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A. Based on reviews of medical records, policies and procedures, central log, and the facility's "Chronology of Events from ED (Emergency Department) date of Event: 6/27/2010" and staff interviews, the facility failed to provide a medical screening examination that was within the capability of the hospital's emergency department to determine whether or not an emergency medical condition exists , when a request was made on the individual ' s behalf with for examination and treatment of a medical condition for one (1) lf twenty ( 20 ) sampled patient records (#1). Refer to findings in tag A-2406.

B. Based on review of Policies and procedures, "Chronology of Events from ED (Emergency Department) event date: June 27, 2010" and staff interviews, it was determined that the facility failed to provide stabilizing treatment within the capability of the hospital's ED, for one (1) of twenty (20) sampled patient records (#1). Refer to findings in tag A-2407.

Based on reviews of medical records, policies and procedures, central log, and the facility's "Chronology of Events from ED (Emergency Department) date of Event: 6/27/2010" and staff interviews, the facility failed to provide a medical screening examination that was within the capability of the hospital's emergency department to determine whether or not an emergency medical condition exists , when a request was made on the individual's behalf with for examination and treatment of a medical condition for one (1) lf twenty ( 20 ) sampled patient records (#1).


Findings:


Review of the facility's policy entitled "Emergency Medical Treatment and Active Labor Act (EMTALA)" effective 9/15/08 stated that "Any individual who comes to the hospital's dedicated Emergency Department (ED) and on whose behalf a request is made for an examination or treatment for a medical condition will be provided with a) an appropriate medical screening examination (MSE) within the emergency's department capabilities, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. "

The facility's investigation entitled "Chronology of Events from ED Event date: June 27, 2010" was reviewed. The review of this investigation indicated that the night shift 7p to 7a on the 26th of June that the staffing pattern revealed in part, "3 (three) ED RNs (Registered Nurses), 1 M/S (Medical-Surgical) RN to assist with patient care, and 1 ED tech (technician). This staffing plan is above the standard set for the ED night shift. Further review indicated the Clinical Director for the ED, the Chief Nursing officer, and the Associate Relations Director met with the staff member (7/27/2010) that worked on the night that patient #1 presented to the ED on 6/27/2010. This investigation document specified in part, "(______ ED staff member) admitted to letting waiting room patients know it was busy in the back and they (patients in the ED waiting room) could wait or go."


Review of the facility's Central Log revealed that the patient presented to the facility's emergency department on 6/27/2010 at 4:21 a.m., where the patient's information for insurance, name, date of birth, age, date, time and chief complaint of "had something like an epilepsy spell" was noted. The central log revealed that the patient left without being seen at 5:20 am. The facility failed to ensure that a medical screening examination was provided for patient #1 on 6/27/2010 to determine if an emergency medical condition existed. This was evidenced by a hospital staff member informing patients in the ED waiting area to either " wait or go " , as this resulted in patient #1 and her caregiver leaving East Georgia Regional Medical Center ED waiting room without receiving a medical screening examination that was within the capability of the ED to determine if an emergency medical condition existed. Patient #1 was taken to another hospital by her caregiver for the needed care.


The medical record from the hospital where patient #1 presented after leaving East Georgia Regional Medical was reviewed. The medical record revealed that on 6/27/2010 at 5:54 a.m. Patient#1 presented to the ED with her daughter (power of Attorney) with complaint of "Seizure." The patient's triage acuity level was listed as "Urgent." Documentation by the physician on the The Emergency Department Report dated 6/27/2010 revealed in part, " 75- year old with a history of diabetes, hypertension, dementia (is a general term for decline in mental ability severe enough to interfere with daily life), and gastroesophageal reflux (stomach contents (food or liquid) leak backwards from the stomach into the esophagus), and Hyperlipidemia (abnormally high concentration of fats or lipids in the blood), who now presents with a seizure. The patient was allegedly sitting on the foam recliner when she had a shaking episode. She started shaking and foaming at the mouth. She thought she had a seizure. She felt this was a generalized tonic-clonic seizure. The patient had another one of these. They were concerned. They allegedly went to another hospital and was told to come here ....The patient wanted to be evaluated. . . REVIEW OF SYSTEMS: . . . She denies any trauma. She has never had a seizure before. . .PHYSICAL EXAMINATION:. . . Cardiovascular: Regular rate and rhythm ....Neurological: The patient is alert and active. The patient is moving all extremities without difficulty . . . I went ahead and got CAT scan (a computerized axial tomography- used to describe normal and abnormal structures in the body) of the head, which showed nothing acute. CPK (cardiac enzymes- the abnormal elevation of these enzymes in the blood stream can occasionally be the indicators that a heart attack has occurred) was 354 (High) (Hospital reference range (35-230), Troponin Level (blood test ordered to see if it is suspected someone has had a heart attack) 5.99 (High) (hospital reference range: 0.-..09), CPK-MB (diagnostic for heart attack) was 21.0 (high) (Hospital reference range: 0.6-.3) ... BNP (B-type natriuretic peptide- a blood test helps doctors to diagnose and treat congestive heart failure) 325 (high) (hospital reference range: 0-99) ... An EKG (electrocardiogram) was performed. This showed a normal sinus rhythm.. .. The patient was given an aspirin 325 mg by mouth. The patient had nitropaste placed applied to the chest wall... I was concerned about the symptoms ...complaints... elevated Troponin. The fact that the patient was potentially acute. She did not have any EKG changes, but she did elevated Troponin and was concerned about ruling in obviously for myocardial infarction (heart attack)...The patient was in the room on the monitor. The patient subsequently had a generalized tonic seizure and went out... she had respiratory arrest... the patient had CPR (Cardiopulmonary resuscitation life saving emergency technique useful in emergencies, including heart attack) ongoing in progress ... I told them to stop CPR and the seemed to be breathing on her own ....seemed to have good pulse ... EKG was ordered stat... we set her up for intubation ...and intubation will be performed ...The patient was given heparin (blood thinner medication). . . the patient seemed to have ST segment elevation (type of heart attack) after her alleged seizure activity. The patient (#1) will be taken immediately to the catheterization (specialized study of the heart). " The patient was admitted to the hospital.


During interview #1 on 8/2/10 at 9:50 a.m. in the conference room, the Director of Nursing stated that he/she was aware of patient #1 leaving without being seen by a medical professional. The director explained that corrective action had been initiated concerning the incident and that the person (s) responsible was no longer working at the facility. The director stated that the nursing and medical staffs were retrained on EMTALA policies. The director further stated that the emergency department had the required staffing that the facility required per policy and that an additional registered nurse was pulled from the floor to help with the emergency room the day patient #1 presented to the facility. The director stated that the central log indicated that the patient had come to the facility and was not seen by a qualified medical professional and was not triaged by a registered nurse. The director explained when patients present to the ED and are not triaged and have not received a MSE, they would not generate a medical record for them. The director stated that the patient signed in the emergency room but because the patient was not triaged and had not received a medical screening examination, the facility would have not generated a record. The director verbalized that the patient was entered into the computer and as a result showed up on the facility's central log. The director stated that the nurse (employee #2) received EMTALA training but was not available for interview due to the corrective action of the facility. The director also stated that the employee was terminated because of failure to meet job performance standards related to emergency room policies.

During interview #3 on 8/2/10 at 1:15 p.m. in the conference room, the Patient Registration Clerk stated that when the patients presented to the emergency room that he/she was the one to greet them. The clerk explained that when the patients presented to the emergency room, he/she would get personal information on the patients and their chief complaint. The clerk stated that depending on the severity of the complaint, the nurse would be notified to do a quick visual assessment. The clerk also stated that he/she did not remember patient #1. The clerk further stated that he/she had training for EMTALA and was aware of the policy. The clerk explained that no one was turned away without being seen but that sometimes patients would leave. The clerk stated that the nurse and physician were notified and if the patients made their concern known, the staff would try to get the patients to stay. He/she also stated that if the patient had been seen by the physician, the patient needed to sign an AMA (against medical advice) form before leaving the facility. The clerk also stated that they called the patients a few times to ensure that the patient was not there before removing them from the presentation board.

During interview #4 on 8/02/2010 at 1:40 p.m., the emergency department medical director, stated that when a patient presents to the ED and are triaged, the name comes upon the MD screen and the "category" levels are present. According to the emergency room medical director, if the ED is busy, we would see the patient as soon as possible. No one would ever ask a patient to leave.


During interview #6 on 8/3/10 at 8:30 a.m., the emergency room nurse who was pulled from the floor to assist the emergency department staff, stated that he/she worked on the medical-surgical area the day that patient #1 presented to the emergency room and that he/she had not seen and was not aware of the patient that had presented. The registered nurse explained that when he/she was pulled to work the ED, he/she would not do triage but assisted the staff as needed with other tasks. The nurse stated that he/she was not aware that any patient was turned away without being seen if they wanted treatment.

During an interview #7 on 8/3/10 at 9:30 a.m. in the conference room, the hospital administrator explained that the facility was contacted by another area hospital regarding patient #1. The administrator stated that they were disappointed to hear that information and that the patient was not treated at the facility. The administrator also stated that the facility took immediate action upon receiving the information and initiated a plan of correction to address that very important issue. The administrator stated that it was not the facility's policy to turn any patient away, ever.

Based on review of Policies and procedures, "Chronology of Events from ED (emergency department) event date: June 76, 2010" and staff interviews, it was determined that the facility failed to provide stabilizing treatment within the capability of the hospital's ED, for one (1) of twenty (20) sampled patient records (#1).(See tag -A-2406 for additional information regarding patient #1's medical record).

Review of the facility's policies and procedures entitled "Emergency Medical Treatment and Active Labor Act (EMTALA)" effective 9/15/08 specified in part that, "b) any necessary treatment to stabilize an emergency medical condition within the capabilities of the staff and facilities, including ancillary services routinely available to the emergency department, prior to discharge or transfer; and/or c) an appropriate transfer, if necessary."

The facility's investigation entitled "Chronology of Events from ED Event date: June 27, 2010" was reviewed. The review of this investigation indicated that the night shift 7p to 7a on the 26th of June that the staffing pattern revealed in part, " 3 (three) ED RNs (Registered Nurses), 1 M/S (Medical-Surgical) RN to assist with patient care, and 1 ED tech (technician). This staffing plan is above the standard set for the ED night shift. Further review indicated the Clinical Director for the ED, the Chief Nursing officer, and the Associate Relations Director met with the staff member (7/27/2010) that worked on the night that patient #1 presented to the ED on 6/27/2010. This investigation document specified in part, " (______ ED staff member) admitted to letting waiting room patients know it was busy in the back and they (patients in the ED waiting room) could wait or go. "
Review of the facility's Central Log revealed that the patient presented to the facility's emergency department on 6/27/2010 at 4:21 a.m., where the patient's information for insurance, name, date of birth, age, date, time and chief complaint of "had something like an epilepsy spell" was noted. The central log revealed that the patient left without being seen at 5:20 am.

During interview #1 on 8/2/10 at 9:50 a.m. in the conference room, the Director of Nursing stated that he/she was aware of patient #1 leaving without being seen by a medical professional. The director explained that corrective action had been initiated concerning the incident and that the person (s) responsible was no longer working at the facility. The director stated that the nursing and medical staff were retrained on EMTALA policies. The director further stated that the emergency department had the required staffing that the facility required per policy and that an additional registered nurse was pulled from the floor to help with the emergency room the day patient #1 presented to the facility. The director stated that the central log indicated that the patient had come to the facility and was not seen by a qualified medical professional and was not triaged by a registered nurse. The director explained when patients present to the ED and are not triaged and have not received a MSE, they would not generate a medical record for them. The director stated that the patient signed in the emergency room but because the patient was not triaged and had not received a medical screening examination, the facility would have not generated a record. The director verbalized that the patient was entered into the computer and as a result showed up on the facility's central log.

During interview #2 on 8/2/10 at 11:15 a.m. in the conference room, the Risk Manager stated that he/she was unaware of a complaint for patient #1. The risk manager explained that the patient's name was not listed on the facility's grievance log and was not aware that a complaint was filed in behalf of the patient. The manager stated that the facility has patient rights information posted in the elevators and in the emergency department. The manager explained that patients were given a booklet with the patient right's information when they were admitted and that the facility had policies that acknowledged patient rights.



During interview #4 on 8/02/2010 at 1:40 p.m., the emergency department medical director, stated that when a patient presents to the ED and are triaged, the name comes upon the MD screen and the "category" levels are present. According to the emergency room medical director, if the ED is busy, we would see the patient as soon as possible. No one would ever ask a patient to leave. He/she has not had any complaints about patients not being seen.

During interview #5 on 8/2/10 at 3:30 p.m. in the emergency room, the registered nurse stated that he/she has worked at the facility for over 10 years. The emergency room nurse reported that it was required during the night shift that at least two licensed registered nurses are on duty. The nurse stated that no patients were turned away without a medical screening. The nurse explained that payment was asked after the patient was seen and was ready for discharge. The nurse stated that all patients that came to the ED were to be seen and treated. The nurse also stated that he/she was trained in EMTALA and recently took review training.

During an interview #7 on 8/3/10 at 9:30 a.m. in the conference room, the hospital administrator explained that the facility was contacted by another area hospital regarding patient #1. The administrator stated that they were disappointed to hear that information and that the patient was not treated at the facility. The administrator also stated that the facility took immediate action upon receiving the information and initiated a plan of correction to address that very important issue. The administrator stated that it was not the facility's policy to turn any patient away, ever.

The facility failed to ensure that their policy and procedure was followed as evidenced by not providing stabilizing treatment that was with the capability of the hospital and staff on 6/27/2010 for patient #1.