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Based on medical record review and interview, the facility failed to provide an appropriate medical screening examination (MSE) that was within the capability and capacity of the hospital's emergency department (ED) to determine whether or not an emergency medical condition existed for 1 patient (Patient #2) of 21 sampled patients for emergency treatment. Refer to findings in A2406.

Based on review of medical records, the Electronic Central Log, in-service training, and interviews, the facility failed to accurately maintain the central log for an individual who comes to the emergency department seeking medical assistance for 1 patient (Patient #2) of 21 sampled patients.

The findings included:


A record review on 11/25/13 revealed documentation for Patient #2 of a late entry dated 11/4/13 for an evaluation that took place on 11/3/13 at 2:00 p.m. The evaluation by the physician documented her primary discharge diagnosis as facial swelling. The treating physician documented, "The patient reports a fall and facial injury 2 days ago for which she was seen and evaluated here at hospital. She states since she is taking anticoagulants, that she had CT head/brain done at that time, which was negative for any intracranial injury.
She states that the swelling on her chin has gotten larger since that time and 'isn't sure what to do about it.' She denies any/all other complaints/symptoms at the time of the initial H & P (History & Physical), specifically denying any changes in visual acuity or neurological changes/symptoms." The patient was discharged home.

During an interview on 11/25/13 at 5:13 p.m., the Director of the Emergency Department (ED) stated, "I sent out a bullet list about EMTALA about how they should approach patients coming to the ED. I explained the situation that we are self-reporting,... I explained about completing the entry into the Central Log and to include all individuals that came to the ED seeking assistance. I reminded them that it must be accurate, that anytime a person requested medical care they must be added to log, every individual coming to the ED even if they leave should be recorded into the log as 'John/ Jane Doe' if they don't give identifying information. ED providers will not advise patients in the lobby or provide any type of exam to any individual in the lobby who has not been logged into the system. Education for EMTALA is done every 2 years. I sent this out to everybody in nursing to be done, and the Medical Director sent out a notice to his providers to do the education on-line."

During an interview on 11/26/13 at 2:24 p.m., Employee A stated, "The niece and the patient (#2) came in with papers in her hand. She said 'I was here on Friday.' When I saw what her face looked like, I offered her a wheelchair; the niece kept saying 'she doesn't need to be here.' The patient said she didn't need to be here but wanted to know if the swelling is what the doctor had said she could expect. I told her to go ahead to sit in the chair and I would register her. She refused to be registered and then said she just wanted to validate what the doctor said. She showed me the discharge papers. I then went to the back and asked the doctor to come and talk to her. I was just asking the physician to validate the instructions by the physician who discharged her, so I asked him to come up. I am not allowed to bring a person back that isn't registered. The ED physician came up to the triage area. I was standing there, but I wasn't observing what he was doing; I was speaking with the niece. I was physically standing in the entrance, but I was turned to the niece. I have since received education, if they refused to be registered I will put them in as John/Jane Doe; every patient will be registered. I would then complete an incident report and get in touch with my supervisor. Now everybody will be registered."

On 11/25/13 review of the Electronic Central Log revealed Patient #2 was logged in on 11/1/13 (her original visit). The electronic central log documented on 11/3/13 for Patient #2 "recheck - late entry" at 1400. Documentation of the Electronic Central Log revealed that on 11/3/13 at 2209 Patient #2 was admitted with a subdural hematoma.

A medical record review on 11/25/13 revealed documentation for Patient #2 as a late entry dated 11/4/13 at 12:50 p.m., for an evaluation by the ED physician that took place on 11/3/13 at 2:00 p.m. Patient #2 was originally seen and evaluated by a physician for this medical issue on 11/1/13. According to interview with Employee A, Patient#2 was seen on 11/3/13 at 2:00 p.m., in the triage area and not was registered in the Electronic Central Log.

The surveyor checked the Electronic Central Log for accuracy, completeness, gaps in entries or missing information in the records. The second encounter for Patient #2 was documented as a late entry and there was no documentation of a disposition for the 11/3/2013 2:00 p.m. visit. There was no record of registration or collection of required information at the time Patient #2 presented in ED at 2:00 p.m. on 11/3/13. Interviews with facility staff revealed the patient was seen in the ED without documenting the encounter.

A review of the hospital records finds the ED nursing staff was provided in-service training on the requirement to document all patient visits to the ED on 11/15/13. All hospital nursing staff received an in-service on 11/7/13, including information on EMTALA requirements and the requirement to initiate a record for all patients presenting at the ED. The medical staff department minutes for emergency physicians documented Employee F had a department meeting with the ED physicians on Tuesday, 11/19/13 and reviewed the requirement to document all patient encounters.

Based on record review and interview, the facility failed to provide an appropriate medical screening examination (MSE) that was within the capability and capacity of the hospital's emergency department (ED) to determine whether or not an emergency medical condition existed for 1 patient (Patient #2) of 21 sampled patients for emergency treatment.

The findings included:

A record review on 11/25/13 revealed documentation for Patient #2 of a late entry dated 11/4/13 at 12:50 p.m. for an evaluation that took place on 11/3/13 at 2:00 p.m. The evaluation by the physician documented her primary discharge diagnosis as facial swelling. The treating physician documented, "The patient reports a fall and facial injury 2 days ago for which she was seen and evaluated here at hospital. She states since she is taking anticoagulants, that she had CT head/brain done at that time, which was negative for any intracranial injury.
She states that the swelling on her chin has gotten larger since that time and 'isn't sure what to do about it.' She denies any/all other complaints/symptoms at the time of the initial H & P (History & Physical), specifically denying any changes in visual acuity or neurological changes/symptoms." The patient was discharged home.

The facility failed to ensure that on 11/3/13 at 2:00 p.m., Patient #2 received a formal medical screening examination. An informal medical screening examination for patient #2 was not documented until 11/4/13 at 12:50 p.m. Further review of the medical record indicated that Patient #2 returned to the ED on 11/3/13 at 22:09 for continued facial swelling, confusion, and vomiting. Review of the History and Physical dated 11/4/13 revealed in part, Patient #2 " had an emergent CT scan of the brain, which showed a large subdural hematoma (a collection of blood outside the brain usually caused by severe head injury). By the time the patient came out of the CT scanner, back to the emergency room, he/she was rapidly becoming obtunded and could not maintain her airway and therefore he/she was electively intubated by the ER physician ... The patient expired shortly before I saw her on the Medical Surgical Department, but had been discussed with the patient's family and been made a DNR (do not resuscitate) and comfort measures. Cause of death is from the subdural hematoma with a midline shift and intracranial pressure."

During an interview on 11/25/13 at 5:13 p.m., the Director of the Emergency Department (ED) stated, " ED providers will not advise patients in the lobby or provide any type of exam to any individual in the lobby who has not been logged into the system.

During an interview on 11/25/13 at 5:50 p.m., Employee B stated "I am aware of her (Patient #2) swelling and she was taking Coumadin (an anti-coagulant). She had questions about her facial swelling; she wanted to know what she could to make it go down faster. I gave her a brief exam and found her to be neurologically intact. I didn't think the CT (computed tomography) scan needed to be repeated based on focal exam, neurologically intact and given the clinical picture; it just wasn't warranted."