HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to provide a medical screening exam (MSE) within the hospital's capability and capacity, when one patient (Patient #21) presented to the Emergency Department (ED) seeking care for abdominal pain with a history of blood in his stools, out of a sample of 32 records selected for review from 05/01/21 to 10/31/21. The hospital failed to perform a test to determine if Patient #21 was bleeding from his gastro-intestinal tract, or obtain any further laboratory tests or imaging studies to determine if the foreign body the patient had ingested had migrated causing an obstruction or other type of an emergency medical condition (EMC, an illness, injury, symptom, or condition so serious one should seek care right away to avoid severe harm or serious impairment).

The hospital's ED had an average of 1,899 emergency visits per month over the past six months.

Based on interview, record review and policy review, the evidence showed that the hospital failed to provide Patient #21 with an appropriate medical screening exam (MSE) on the third presentment, out of 32 Emergency Department (ED) records reviewed from May 2021 through October 2021. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC, an illness, injury, symptom, or condition so serious one should seek care right away to avoid severe harm or serious impairment). The hospital's average monthly ED census over the past six months was 1,899.

Findings included:

Review of the hospital's policy titled, "EMTALA," dated 02/23/21, showed that the purpose of a MSE is to determine if an individual has an EMC. A MSE is not an isolated event. It is an ongoing process that begins, but typically does not end, with triage. A qualified medical professional (QMP) performs the medical screening.

1. Review of Patient #21's first presentation to Hospital A ED, showed that the 32 year old patient arrived on 09/19/21 at 5:59 PM, by ambulance, after he swallowed a piece of metal. Patient #21's history which included multiple psychiatric diagnoses, suicidal ideation (SI, thoughts of causing one's own death), and he had a court appointed guardian (a person appointed by a judge to take care of and manage the property and rights of a person who is considered incapable of administering his or her own affairs). The ED physician documented that patient was "well known" to the ED, that the ingestion was not a suicide attempt, and that the patient reported feeling "mad" and ingested the metal to "feel better." An x-ray was ordered. At 7:04 PM, Staff R, ED Registered Nurse (RN), documented that the patient was irritable, refused treatment and began to leave. Security returned the patient, the ED nurse called the patient's guardian, and the guardian "agreed" that the patient was ok to leave against medical advice (AMA). The x-ray was not completed, and the patient left the ED with group home staff at 7:10 PM.

2. Review of Patient #21's second presentation to Hospital A ED showed that the patient arrived on 09/19/21 at 8:08 PM. The patient presented with an ingested foreign body, a swallowed piece of metal, because he was mad at his staff (patient staff at group home) and where he lived. The patient denied abdominal pain. Risk factors consist of he frequently swallowed foreign objects. He stated that he was not trying to hurt himself. He had no symptoms and no significant exam findings. There was a small piece of metal observed on x-ray. He clearly denied SI. The general surgeon on call was contacted, the surgeon recommended observation management. The patient was discharged in stable condition at 9:11 PM.

3. Review of Patient #21's third medical record showed that on 09/20/21 at 11:41 PM, the patient presented to the ED with abdominal pain and was discharged on 09/21/21 at 4:15 AM.

Review of the ED triage note, dated 09/20/21 at 11:53 PM, documented that the chief complaint was generalized abdominal pain after swallowing a sharp metal object yesterday, and he had blood in his stool yesterday but no bowel movement or flatus today. His aching, stabbing pain was rated as a ten, which equals the worst possible pain.

Review of the physician medical decision making documentation on 09/21/21 at 11:49 PM, documented that the patient presented with abdominal pain. The location of the pain was mid epigastric and was minimal. The last time he ate a foreign object was yesterday. The associated symptoms were nausea. On exam he had no generalized tenderness. His pain was only in the upper abdomen and was minimal. He was inconsistent with any signs of acute abdomen.

During an interview on 11/03/21 at 2:25 PM and on 11/18/21 at 7:23 AM, Staff K, ED Physician, stated that:
- He examined the patient and there was no abdominal tenderness.
- He had consulted the general surgeon the day before and it was his recommendation to observe the patient.
- The patient did not tell him that he had blood in his stools.
- He had asked the patient as part of his exam, and he would have documented it in his assessment if the patient had reported to him that he had blood in his stool.
- He was not aware that the triage nurse had documented that the patient had blood in his stool.

Review of the physician on call schedule showed that a general surgeon was on call 09/20/21 and 09/21/21.

During a telephone interview on 11/03/21 at 3:42 PM, Staff M, General Surgeon, stated that he was on call for the ED on 09/21/21 and had not received a call about Patient #21 on 09/21/21.

During an interview on 11/03/21 at 2:25 PM, Staff K, ED Physician, stated that every patient should receive a MSE to determine if an EMC existed.

During a telephone interview on 11/03/21 at 3:10 PM, Staff L, ED Medical Director, stated that every patient gets an MSE to rule out any EMC.

The medical record did not contain evidence that Patient #21 received an appropriate MSE sufficient to determine if an EMC existed. Patient #21 reported he had severe pain and blood in his bowel movement the day before but the hospital did not perform a test to determine if Patient #21 was bleeding from his gastro-intestinal tract, or obtain any further laboratory tests or imaging studies to determine if the foreign body the patient had ingested had migrated causing an obstruction or other type of EMC.

4. Review of Patient #21's fourth medical record face sheet showed that on 09/21/21 at 2:14 PM, the patient arrived to the ED and Left Without Being Seen (LWBS) on 09/21/21 at 2:59 PM.

5. Review of Hospital C's medical record showed that Patient #21 presented to the ED on 09/21/21 at 4:10 PM with complaints of SI, stated that he tried to jump off of a bridge on 09/19/21, and that he had swallowed a piece of metal. Further documentation showed Hospital C admitted Patient #21 to stabilize his EMC.