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Based on interviews, reviews of the Emergency Room (ER) patient Triage Assessment Sheets, emergency department (ED) medical records, Medical Staff Rules and Regulations, and a review of policies and procedures, the facility's dedicated ED did not act in accordance with the special responsibilities of Medicare hospitals to patients presenting to the ER between July 2011 and January 2012, and failed to:

1. Ensure that individuals presenting to the Emergency Department were provided appropriate medical screening examinations and documented medical screening examination findings by the appropriate qualified medical personnel to determine whether or not an emergency medical condition existed for nine (9) patients of thirty-two (32) patients in the sample ( PI #13, PI #15, PI #18, PI #19, PI #20, PI #22, PI #25, PI#26 and, PI #28). Refer findings under A 2406 / 489.20(r)(3) Medical Screening Examination.

These deficient practices have the potential to effect any patient presenting to the hospital's dedicated ED for treatment.

Based on interviews of facility staff, review of the Emergency Room patient Triage Assessment Sheets and medical records, review of the Medical Staff Rules and Regulations and review of policies and procedures, the facility failed to provide documentation that appropriate Medical Screening Examinations (MSE) that were within the capability of the hospital's Emergency Department were provided by the Physician or designated qualified medical personnel on each patient to determine if an emergency medical condition existed on patients who presented to the ED between July 2011 and January 2012.



This deficient practice effected nine (9) patients of thirty-two (32) sampled ER patients Patient Identifier (PI), PI#13, PI #15, PI # 18, PI 19#, PI #20, PI #22, PI #25, PI # 26, and PI #28 and has the potential to effect all patients who present to the dedicated emergency department (ED).

The findings include:

1. MEDICAL STAFF RULES & REGULATIONS
The Medical Staff Rules and Regulations approved by MEC (Medical Executive Committee) on 03-22-2011 were reviewed on 01-11-12. The following information was taken from 7.0 Emergency Department / Evaluation Center, 7.1 Physician Requirements.

"7.0 EMERGENCY DEPARTMENT / EVALUATION CENTER
7.1 PHYSICIAN REQUIREMENTS
A physician or advanced practice registered nurse, with appropriate clinical privileges, will perform a medical screening examination, based on the patient's presenting signs and symptoms, to determine the existence of an emergency medical condition. If an advanced practice registered nurse performs the medical screening examination, he/she must review the examination findings with the physician and the physician must sign the patient's medical record."

2. POLICIES AND PROCEDURES

*The following information was taken from the Administrative Policy Manual titled "EMTALA PROCESS. Revised: 10/11."

"DEFINITIONS: Medical Screening Examination - the process required to reach, with reasonable clinical confidence the point at which it can be determined whether the individual has an emergent medical condition or not.
MEDICAL SCREENING EXAMINATION
For individuals seeking treatment on hospital property, the facility will provide a medical screening exam conducted by qualified medical personnel to determine if an emergency medical condition exists...
Evaluation Center (ER): A physician or advanced practice registered nurse, with appropriate clinical privileges will perform a medical screening examination, based on the patient's presenting signs and symptoms, to determine the existence of an emergency medical examination, he/she must review the examination findings with the physician and the physician must sign the patient's medical record..."

3. REVIEW OF ER PATIENTS' TRIAGE ASSESSMENT SHEETS

The following patients' Triage Assessment Sheets were reviewed and include the following information.


PI #13: Review of the "Triage Assessment Sheet" revealed a, 20 month old, was triaged (evaluation to determine order of treatment) on 8/25/11 at 16:10 (4:10 p.m.) with the chief complaint of "Poss (possible) ingestion... Hx (history)Illness/Injury: Found c (with) pill in mouth.. . Narrative: Possible vitamin." In ER physician's handwriting "Fireplace rocks...not vitamin. No threat to patient." Triage category is marked as urgent. Signatures present on the bottom right corner of this form are the triage nurse, parent, and ER physician(Physician consulted for medical screening ). There is no documentation on the "Triage Assessment Sheet" or the Evaluation Record of a MSE (Medical Screening Examination) or MSE findings being performed by the physician. An ER medical record was initiated, however, "Cancel chart" was written across the page titled "Evaluation Record." The section on this evaluation form titled HPI (History of present illness) was left blank. Additionally, the area for physician signature "Attend signature (treating MD (medical doctor) was also left blank. Further review indicated the only treatment orders were for a pulse oximetry ( A device, usually attached to the earlobe or fingertip, that measures the oxygen saturation of arterial blood) were performed. There was no further treatment orders documented for the ingestion or that poison control was called for this 20 month old toddler. The facility failed to ensure that an appropriate MSE was provided that was within the capability of the University of South Alabama Children's and Women's Hospital's ED to determine if an EMC existed on 8/25/2011 for PI #13.

PI #15: Review of the hospital's "Triage Assessment Sheet" dated 9/17/2011 indicated that patient #15 a 24 year old was triaged at 22:00 (10:00 p.m.). The patient' "Chief Complaint" was Chest pain ... Hx (History) Illness/Injury: "Chest hurts & (and) arm on L (left) going numb. "Further review revealed in the Narrative section," Pain to (l) chest-pain last night & get better then started again tonight (1 hr (hour) ago). The patient was triaged as (Non-Urgent). The patient ' s Vital Signs were listed as B/P 145/69 (normal <120/80); Respirations 16; Pulse 103 (normal-60-100); and Temperature 98.4; pain level 9 (Pain scale of 0-10 with being the worst pain). Signatures were present on the bottom right side of this form are the triage nurse and ER physician. During review of the "Emergency Department Standing Orders" form indicated that an EKG (Electrocardiogram- is a test that checks for problems with the electrical activity of the heart) was ordered at 22:05 (10:05 p.m.). The results of the EKG indicated "sinus tachycardia (fast heartbeat) otherwise normal." There was no documented evidence on the "Triage Assessment Sheet" or the in the medical record to indicate that a medical screening examination was completed by the physician. The facility failed to ensure that an appropriate MSE was provided that was within the capability of the hospital's ED to determine whether or not an EMC existed on 9/17/2011 for PI #15.

PI #18: A review of the "Triage Assessment Sheet " indicated that patient #18, an 18 year -old presented to the ED on 9/12/2011 at 18:01 (6:01 p.m.). The patient's chief complaint was "Sore throat"...Hx Illness/Injury: c (with) Body aches & fever... Narrative: All weekend (+) (positive) pus pockets (white/yellow spots in back of throat) to throat. The patient's Vital signs were listed as Pulse; 109 (norm 60-100); Respiration (18); Blood Pressure: 126/66; Temperature: 103 (normal ; 98.6 Fahrenheit -99.4 Fahrenheit); Pain Level 7 (on a pain scale of 0-10 with 10 being the worst pain). The Pt care need/Prob (problems) identified were listed as, Potential for infection, pain, and Fever. Signatures present on the bottom right corner of this form are the triage nurse, patient and ER physician. The only documentation on patient #18 was a triage assessment that was completed by the triage nurse for patient #18, but no documentation that a MSE was completed by the physician or that MSE findings were documented by the physician. There was no documentation to indicate whether or not an EMC existed. The facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's ED to determine whether or not an EMC existed on 9/12/2011 for PI #18.

PI #19: Review of the "Triage Assessment Sheet" revealed that a 24 year old presented to the ED on 10/15/2012 at 22:25 (10:25 p.m.). The Chief complaint was "Assault"...HX/Illness/Injury: Boyfriend came to house...and jumped on her & her sister. C/O (complain) neck/back/eye hurting. happened 7:30 - 8p." The patients Vital Signs were all within normal limits and Pain was listed as 6 (On a pain scale of 0-10 , with 10 being the worst pain). Triage category is marked as non urgent. Signatures present on the bottom right corner of this form are the triage nurse and ER physician. There is no documentation on the Triage Assessment Sheet of a MSE or MSE findings was completed/performed by the physician on PI #19 after being assaulted, to determine if an EMC existed. The facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospitals' ED on 10/15/2012.

PI #20: Review of the "Triage Assessment Sheet " dated 9/11/2011 revealed that a 56 year old presented to the ED and was triaged at 9:18 a.m.. The patient's "Chief Complaint" was "Foot Pain (R) (right) foot since about Wed (Wednesday)/Thursday. Swelling of (R) foot... C/O of pain on on the dorsal aspect of the right foot + TP (tenderness). No h/o (history/of) injury trauma. The triage category is marked as "Non-Urgent." Signatures present on the bottom right hand corner of this form are the triage nurse, patient and ED physician. There is no documentation on the Triage Assessment Sheet to indicate that a MSE was performed by physician or documentation of MSE findings by the physician, to determine whether or not an EMC existed for PI #20. . The facility failed to ensure that a MSE was provided that was within the capability of the hospital's ED for PI #20 on 9/11/2011.

PI#22: A review of the "Triage Assessment Sheet" dated 7/10/2011, indicated that a 52 year old was triaged at 18:20 (6:20 p.m.). PI #22 arrived via wheelchair with a chief complaint was"difficulty breathing... HX/Illness/Injury: House c(with) black mold & gas leak. PMH (Past Medical History): migraines, anxiety, breast cancer, bipolar, psychosis, mood swings, schizophrenia... Narrative: Having SOB (Shortness of Breath) and difficulty breathing, Pt. very anxious, word salad, Dry ice. Stops c (increased) WOB (work of breathing) to talk, C/O joint aching." PI#22 Triage category marked as "Urgent."... Further review indicated that the ED nurse identified a "Pt. Care Need/Prob (problem)" checked off was Alteration in Neurological Status" (A state of awareness that is different that the person's normal baseline level of behavior). Documented by the Registered Nurse on the top left side of the Triage Assessment Sheet " revealed "Pt refuses transfer. Pt left triage area." PI #22, presented to the ED with a possible acute psychiatric condition and/or acute medical condition, and was told he/she was being transferred before a MSE was even performed. There was no documentation in the medical record to indicate that the ED physician was notified by the triage nurse that PI #22 had presented to the ED with the presenting signs and symptoms of possible psychiatric disturbance and/or an acute medical condition. The facility failed to ensure that a MSE was performed that was within the capability of the ED to determine whether or not if a psychiatric emergency condition ,or an emergency medical condition existed for PI #22 on 7/10/2011.

PI #25: Review of the Triage Assessment Sheet revealed that an 18 year old, was triaged on 12/11/11 at 14:55 (2:55 p.m.), with the chief complaint of "Vomiting, HA (headache). Pt c/o vomiting x 6 and diarrhea, fever earlier today. HA x 2 days." Triage category is marked as non urgent. Signatures present on the bottom right corner of this form are the triage nurse, patient, and ER physician. There is no documentation on the Triage Assessment Sheet of a MSE being performed by a physician, or MSE's findings. The facility failed to ensure that a MSE was performed that was within the capability of the ED to determine if an EMC existed for PI #25 on 12/11/11.

PI#26: The review of the "Triage Assessment Sheet" dated 11/7/11 indicated that PI #26 was triaged at 21:15 (9:15 p.m.). The patient's chief complaint was "Passed Out... Hx/Illness/Injury: was helping uncle with taxidermy & passed out. Hands, mouth, and nose tingling, Heart beating fast. Vomited x (times ) 3." Triage category is marked as non urgent. The patient's temperature, respirations oxygen saturation were wihtin normal limits. PI #26's heart rate was 102 (normal heart rate 60-100) and Blood Pressure 123/90(normal < 120/80). Further review indicated the ED nurse identified a "Pt Care need/Prob. (problem), "Potential Alteration in Neurological Status." Signatures present on the bottom right former of this form are the triage nurse and the ED physician. There is no documentation on the Triage Assessment Sheet of a MSE being performed or MSE findings by the physician. The facility failed to ensure that a MSE was performed that was within the capability of the ED to determine if an EMC existed for PI #26 on 11/7/11.

PI # 28: Documentation on the "Triage Assessment Sheet" by the triage nurse revealed that PI #28 presented to the ED on 12/1/11. The patient was triaged at 10:15 a.m. with the chief Complaint of "Face Numb... c/o woke up Mom (Monday) am (morning) c (L) side of face numb, (L) hand numb yest (yesterday). Seen @ (at) ...ER. Had tests run told nothing was wrong. Pt denies numbness/tingling at present. Face =(equal) and symmetrical (Everything on face looks equal on each side). Hand strength equal bilaterally, Pt c/o of (L) shoulder pain + (positive) (decreased ROM (range of motion-Limited range of motion is a term meaning that a specific joint or body part cannot move through its normal range of motion).Pt denies injury to shoulder. Triage category is marked as non urgent. Signatures present on the bottom right corner of this form are the triage nurse, patient and ER physician. There is no documentation on the "Triage Assessment Sheet" of a MSE being performed by the physician. The facility failed to ensure that a MSE was performed that was within the capability of the ED to determine if an EMC existed for PI #28 on 12/1/11.
4. INTERVIEWS WITH FACILITY STAFF AND PHYSICIANS

*EI #6 (Interim EC/ER Medical Director) was interviewed on 1-11-12 at 9:15 AM stating "They (EC/ER patients) receive MSE by the (EC/ER) physician. CNP (certified nurse practitioner) can do MSE but the (EC/ER) physician is consulted and signs off. Adult non OB/GYN non urgent patients receive a MSE and are sent to (Adult Hospital) with COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) papers (Transfer to Acute Care/Specialty Facility Summary which includes a MSE for transfer)... 'Triage out' is a semantic issue, sorting versus assessment. Nothing (EC/ER patient) leaves the building without a MSE."
EI #6 was interviewed a second time on 1-12-12 at 9:30 AM to review EC/ER Patient Triage Assessment Sheets with an EC/ER physician's signature but lacked the documentation of the MSE was completed (see above PI's). EI #6 acknowledged the lack the documentation or evidence that a MSE was performed on the patients other than the EC/ER physician's signature.

*EI #7 (EC/ER physician) was interviewed on 1-11-12 at 10:43 AM stating "I look at the patient before I sign off (on Triage Assessment Sheet) on the patient. All patients receive a MSE. If they (patient) go to (Adult Hospital) or other facility, I complete the COBRA form (Transfer to Acute Care/Specialty Facility Summary which includes a MSE for transfer). If the patient is unstable we see and treat the patient back here... then transfer the patient to another facility if the patient is an adult with non OB/GYN complaints..."

The facility failed to ensure that that their policies and procedures were followed, as evidenced by failing to ensure that appropriate MSE's were provided and documented MSE findings by the Qualified Medical Personnel to determine if an emergency medical condition existed for PI #'s 13, 15, 18, 19, 29, 22, 25, 26, & 28.



These citations were written as the result of the investigation of complaint/report AL00025770.