HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to provide a Medical Screening Examination. See deficiency at A-2406.

Based on document review and interview it was determined the Hospital failed to provide a Medical Screening Examination for 1 of 20 patients (Pt. #9) presenting to the emergency department for medical care. This failure has the potential to affect all patients seeking care at the emergency department (ED) that treats approximately 60 patients per day.

Findings include:

1. On 11/12/2020 at 3:15 PM, the hospital policy titled, "ED Triage Guidelines (Effective January 2020) was reviewed. The Policy states "When a level 2 condition is identified, the triage process is complete, the patient is taken directly to a treatment area, a complete primary assessment is initiated and immediate physician intervention is requested."

2. On 11/13/2020 at 9:30 AM, the document titled,"Emergency Severity Index (triage training for emergency department registered nurses" was reviewed. The document states "NEUROLOGICAL: Patients with severe headache associated with ...high blood pressure...should be considered high risk and assigned ESI (emergency severity index) level 2. TRAUMA: Any mechanism of injury associated with a high risk of injury should be categorized ESI level 2...head injured patient returning/presenting with symptoms of increased intracranial pressure (headache or vomiting)...should be triaged as a level 2. PAIN: All patients who have a pain rating of 7/10 or greater should be considered for meeting ESI level-2 criteria".

3. On 11/12/2020 at 11:00 AM, the Emergency Department Log from 10/10/2020 through 11/10/2020 was reviewed. The log stated Pt #9 presented on 10/24/2020 at 1:13 PM with a chief complaint of "Head injury: HEAD INJURY, FELL 10FT."

4. On 11/13/2020 at 11:00 AM the clinical record of Pt #9 was reviewed. Pt #9 arrived to the ED (emergency department) on 10/24/2020 at 1:13 PM. Pt #9 was triaged 10/24/2020 at 1:21 PM. Triage documentation states "(Pt #9) was putting a roof on yesterday and fell, 10 feet. (Pt #9) reports headache, right flank pain, and right knee pain". Triage vitals taken at 1:22 PM were temperature 98.2, blood pressure 218/110, and pain rating at 7. Home medications were not verified. No MSE (medical screening exam) was done. Only other nursing note stated on 10/24/2020 at 6:41 PM "rounded on patient in waiting room, discussed wait time and (Pt #9) decided to leave". Documentation shows Pt #9 LWBS (left without being seen) on 10/24/2020 at 6:41 PM. Pt #9 was in the ED for 5 hours and 28 minutes without a Medical Screening Exam.

5. On 11/13/16 at 11:30 AM an interview was conducted with the Chief Nursing Officer (E #2). E #2 stated, "I would expect that a patient with headache, a blood pressure that high, and a fall from the day before would have been seen immediately and not have sat for that long." E #2 agreed, Pt #9 was inappropriately assigned a level 3 on the ESI score and "should have been assigned ESI level 2. An ESI level 2 would have went straight back to a treatment room to have a medical screening exam completed."