HospitalInspections.org

Based on a review of the Emergency Department (ED) log, medical record review, a review of Medical Staff Bylaws, facility's policy and procedures, and interviews with staff, the facility failed to document discussion regarding the risks and benefits against leaving prior to the hospital providing stabilizing treatment as required, that was within the capabilities of the staff and facilities available at the hospital for one (Patient #1) of 20 sampled patients who was not stabilized prior to discharge.

Findings were:

Refer to findings at Tag -2407.

Based on a review of the Emergency Department (ED) log, medical record review, a review of Medical Staff Bylaws and the facility's policy and procedures, and interviews with staff, it was determined the facility failed to discuss and document the risk verses benefits of staying for a medical screening exam (MSE) leading to stabilizing treatment for one out of 20 patients sampled (Patient #1).

Findings were:

A review of the ED log dated 5/1/21 to 11/15/21 revealed that P#1 presented to the ED on 11/15/21 at 5:45 p.m. for a complaint of left eye pain.

A review of the P#1's medical record revealed an ED visit dated 11/5/21 at 5:45 p.m. P#1 presented to the ED with a chief complaint of left eye pain. A review of a Nursing Triage form dated 11/5/21 at 6:10 p.m. revealed that P#1 stated he woke up with pain in his left eye, redness around the eye, and yellow discharge. P#1 explained to the nurse (Registered Nurse - RN DD) that the pain felt "like someone punched me in the eye." He further said that warm compresses exacerbated the pain. P#1 was observed to be stressed with a tense expression. He had guarded movements and was grimacing. P#1's pain level was a six out of ten. His vital signs were: blood pressure 133/89, pulse 91, respirations 17, temperature 98.2, and pulse oxygenation of 94% on room air. A Suicide Screen was completed. P#1 denied any suicidal or homicidal ideations. P#1's triage was completed at 6:12 p.m. A continued review of P#1's medical record revealed a Nursing Note at 7:10 p.m., which stated that P#1 was informed that a provider would be with him shortly and P#1 replied to the nurse (RN EE) that he would follow up with his physician. P#1 left the ED before being seen by a provider. P#1's ED disposition was documented as Left Without Being Seen at 7:10 p.m. A review of the ChartLink Physician Entered Orders revealed that a wood lamp, Dacriose eyewash, Alcaine 0.5%, and Fluor-I-Strips 2% strips were ordered by a provider (Medical Doctor - MD FF) at 7:13 p.m.

A review of the Medical Staff Bylaws and Rules and Regulations, Article 5, Emergency Call Coverage Requirements Article 5, Medical Screening Examinations (MSE), approved 11/19/2018, revealed that all individuals who came to the facility requesting an examination or treatment to determine the presence of an EMC would be performed.

A. Members of the medical staff with clinical staff privileges in Emergency Medicine, other active staff members, resident physicians, and appropriately credentialed allied health professionals.
Labor and Delivery

A review of facility's policy entitled, "Emergency Department Medical Screening/EMTALA," no number, last reviewed 2/1/2019, revealed the following:

Procedure:
1. If an individual comes to the emergency department:
a. The hospital would provide an appropriate medical screening (MSE) within the capability of the Hospitals

Dedicated Emergency Department, including ancillary services routinely available, to determine if whether an emergency medical condition (EMC) exists.

4.Refusal of Treatment:
a.If the facility offered further examination and treatment and informed the individual or the person acting on the individual's behalf of the risk and benefits of the examination and treatment, but the individual did not consent to the examination or treatment, the facility had to take all reasonable steps to have the individual acknowledge their refusal of further examination and treatment in writing. The medical record had to contain a description of the examination, treatment, or both if applicable, that was refused; the risk and benefits of the examination and/or treatment; the reasons for the refusal; and if the individual refused to acknowledge their refusal in writing, the steps taken to secure the written informed refusal. The facilities personnel involved with the individual's care or witnessing the individual refusing consent had to document the patient's refusal in the medical record.

During a telephone interview with the contracted agency Registered Nurse (RN) EE on 11/16/21 at 10:00 a.m., in the facility conference room, RN EE stated that she worked as a nurse for the past eight years. She continued to say that she typically worked in the ED. RN EE stated she recalled P#1 because, he was the only patient she can remember leaving before receiving their medical screening since working at the facility. She recalled walking into P#1's room to introduce herself, and he seemed irritated. RN EE stated that he had only been in a treatment room for about 15 minutes. She explained to P#1 that a provider had not been assigned to him yet but, it wouldn't be much longer until he was seen. He was adamant that he did not want to stay and wanted to leave. She left P#1's room to document in his medical record and noticed that MD FF had been assigned to P#1. She said that she immediately informed MD FF that P#1 wanted to leave, and MD FF instructed her to let P#1 know that he was on his way to P#1's room. She returned to P#1's room to inform him, but P#1 had already left the ED. RN EE explained that she would have had P#1 sign an Against Medical Advice (AMA) form if he had been seen by a provider. She added that as P#1 had not been seen by a provider, she did not have him sign any forms. RN EE said that she had EMTALA training annually.

During an interview with the Registered Nurse (RN) DD on 11/16/21 at 10:30 a.m., in the facility conference room, RD DD stated that she had been a nurse for 11 years. She had worked at the facility's ED for the past five years. She did not recall P#1, even after reviewing P#1 MR during the interview. She explained that if a patient wanted to leave the ED before receiving an MSE, she would encourage them to stay and inform a provider. She would ask them to sign a Refusal of Medical Screening Examination Form. She explained that the Refusal of Medical Screening Form was more often used when a patient was in triage and wanted to leave. If a patient refused to sign the form, RN DD stated that she occasionally would document the refusal in the medical record. She always tries to have patients sign an AMA form if they have been seen by the provider. She receives EMTALA training annually and understands what EMTALA means.

During an interview with the ED Medical Director (MD) BB on 11/16/21 at 10:55 a.m., in the facility conference room, MD EE stated that he had worked as the Medical Director for the past six years. He explained that all physicians were contracted. MD BB continued to stay that the ED physicians worked solo, meaning they were the only physician working in the ED during their shift. The ED mid-levels worked from 11:00 a.m. to 11:00 p.m. He explained that the mid-levels would see lower acuity patients with physician oversight. The physician would see the higher acuity patients, as well as any admissions or transfers. MD BB said that a physician and mid-levels would see patients based on their acuity level. The acuity level would be assigned to a patient during the nurse triage process. MD BB stated that physicians and mid-levels could not pick and choose patients that they wanted to see. All patients would be seen, and no one would be refused treatment. If a patient wanted to leave before receiving an MSE, he expected the provider to be notified, and the provider would personally speak with the patient. MD BB confirmed that he had EMTALA training annually. He further stated that he frequently educated his ED staff on EMTALA.

During an interview with the ED Nurse Manager (NM) GG on 11/16/21 at 11:15 a.m., in the facility conference room, NM GG stated that he had worked as the Nurse Manager for the past four years. NM GG continued to say that he worked eight-hour shifts Monday through Friday. He further stated that he had been a Registered Nurse for eight years. NM GG explained that the Refusal of Medical Screening Examination Form was initially used by ED Registration. They would ask a patient to sign the form if they wanted to leave before being placed in a treatment room. Over time, some of the ED nurses started to use the form when patients requested to leave prior to being placed in an exam room. He explained that having the document signed was not a requirement, but he would expect his medical staff to try to have a patient sign the form before leaving. He further stated he didn't feel it was necessary to document the refusal to sign in the patient's MR. However, he did say that he expected that the nurse document in the patient's MR that they wanted to leave. He added that it was also his expectation to always have an AMA form signed if the patient had seen the provider and was leaving AMA. NM GG stated that he received EMTALA training annually.

There was no discussion or documentation regarding the communication of risks and benefits documented in the medical record.