HospitalInspections.org

Based on record review and interview the facility failed to enforce their policy to ensure compliance with the requirements of ?489.24 in 2 of 20 sampled patients(SP) #1 and # 15.

Findings include:

1. Review of the facility policy and procedure regarding Emergency Care Services, Title: Provisions for Access to Care revealed that all individuals seeking emergency care will be provided an appropriate medical screening examination (MSE) within the capability of this department. " It was determined the facility did not complete an appropriate screening exam for SP #1 and #15.
Refer to A2406.

2. The facility failed to provide the necessary stabilizing treatment in 2 out of 20 Sample Patients (SP) (SP#1 and SP#15).
Review of the facility policy and procedure Code No. 209; Section 100-200 (Administration); Subject: Patient Transfer between Hospital and another Hospital; IV General Procedures A.(1.) If the medical screening examination reveals that the individual has an emergency medical condition, the hospital staff must provide either: (A.) for such further medical examination and treatment as may be required to stabilize or resolve the emergency medical condition within the service capability and service capacity of the hospital.(3.) If the hospital staff determines, after completing the screening examination, that the individual does not have an emergency medical condition, then appropriate referral or other treatment may be provided.
Refer to A2407.

Based on record review and interview, the facility failed to ensure that an appropriate medical screening examination within the capability of the hospital's Emergency Department was provided in 2 out of 20 Sampled Patients (SP) (SP#1 and SP#15).

The findings include:

Review of the facility policy and procedure regarding Emergency Care Services, Title: Provisions for Access to Care revealed that all individuals seeking emergency care will be provided an appropriate medical screening examination (MSE) within the capability of this department. "


(1) Record review conducted on 07-02-13 to 07-03-13 of sample patient (SP) #1, revealed SP#1 was seen in the facility ' s Emergency Department on 05/29/2013 from approximately 11:06 A.M. to 15:18 P.M. and was discharged the same day. Review of the facility ' s face sheet states reason for the visit was pregnant cramping/dysuria. Review of the " Emergency Services Triage Encounter Form " filled out by SP#1 states that SP#1 wrote " Stomach pain, very painful." Review of the electronic Assessment Forms completed by the Triage Nurse (sample employee (SE#8) on 05/29/2013 at 11:45 A.M. states the chief complaint description was a [positive] + home pregnancy test, LMP [last menstrual period] in April. The forms also stated that the pt [patient] c/o [complaining of] lower abd. [abdominal] pain x 1 day, and denies any bleeding. The record review also stated under the section primary pain intensity: " 6 "on a scale of 0 to 10. The location as " abdomen, " abdomen quadran," left lower quadrant, right lower quadrant " . Under O.B./G.Y.N. (Obstetrics/Gynecology) the nurse documented that SP#1 ' s is gravida " 3 " , para " 1 " , spontaneous abortion " 1 " , and the last last menstrual period was noted as " 04/27/2013 ". Under the gastrointestinal section, the nurse documented that the abdomen description as " pregnant ", abdomen palpation " soft, non-tender". The nurse also noted that the bowel sounds as present in all 4 quadrants. The nurse also has the Recommended ESI (Emergency Severity Index) level = 4.

Review of the Clinical Laboratory form dated 05/29/2013 at 11:53 A.M. shows the urine human chorionic gonadotropin (pregnancy test) was positive. The urinalysis test was within normal limits.

Review of the Admission/Discharge/Transfer Notes documented by the Physician Assistant (sample employee (SE) #2) showed SP#1 was seen by the P.A. on 05/29/2013 at 12:44 P.M. The Menstrual-pregnancy history shows: currently pregnant. The history of present illness documented was that the patient who presents with a complaint of dysuria and the patient comes to ER (complaining of )c/o dysuria (painful urination) and states that she has had this since this morning. She states that she is pregnant at this time. Duration lasting 1 day(s). The course is constant. The degree of severity is moderate. The exacerbating factor is urination. The mitigating factor is negative. The risk factor is negative. Prior episodes: negative. Under Associated Symptoms, the P.A. documented " Constitutional symptoms: chills, Fever: subjective, Gastrointestinal symptoms: Negative, Genitourinary symptoms: Dysuria, Genitourinary pain: Mild, Urine output: within normal limits, Vaginal discharge: Negative, Vaginal bleeding: Negative. Review of Physical examination done by P.A. states under " abdominal: soft non tender". Under the section Medical Decision Making, the P.A. documented the Differential diagnosis as Dysuria, Cystitis, Urinary Tract Infection, and the impression and plan diagnosis as " new onset pregnancy". The Discharge plan states the " patient was given the following educational materials: pregnancy, new dx [diagnosis], prenatal care. Follow up with: [name of O.B./G.Y.N.]".
Review of the Admission/Discharge/Transfer Notes (date and time unknown) documented by the E.D. Physician stated I have participated in this patient's care as follows: Evaluation and management services. Personally performed: Medical history, physical exam, medical decision making. Case discussed with physician assistant/nurse practitioner: yes. I agree with the evaluation and management services provided by the physician assistant/nurse practitioner with the following exceptions: none. I agree with the interpretation of studies documented by the physician assistant/nurse practitioner with the following exceptions: none". Further review of the note revealed an addendum by the E.D. Physician on June 17, 2013 stating a correction: case reviewed with me by Physician Assistant and the referral made to OB (Obstetrics), and that patient was not physically examined by me.

A Review of SP#1 ' s discharge instructions given by the facility ' s P.A. on 05/29/2013 states, " Your exam today shows that you are pregnant " and SP#1 was instructed to follow-up with Obstetrics/Gynecology (O.B./G.Y.N.) and return promptly if: Vaginal bleeding, Moderate or severe abdominal or back pain, excessive vomiting, unable to keep any fluids down for six hours, burning with urination, headache, dizziness or rapid weight gain. Review of the discharge instructions showed SP#1 signed the form on 05/29/2013. Review of the record showed no additional assessments were documented by nursing or intermediate care.

Interview with the mid-level provider (P.A.)(SE#2) who evaluated SP#1 on 05/29/2013 was conducted on 06/10/2013 at 11:50 A.M. The Associate Chief Medical Officer, Peer Review Coordinator, Associate Administration of E.D., SE#4 and second surveyor were also present. The Physician Assistant (SE#2) confirmed evaluating and treating SP#1 on 05/29/2013. When the surveyor asked SE#2 if she was aware of SP#1's complaint of lower abdominal pain, SE#2 stated the patient didn't tell me. I write what the patient tells me. She told me she was pregnant. Surveyor also asked SE#2. if she was aware of the nursing documentation also stating that SP#1 was complaining of left/right lower quadrant pain. SE#2 showed surveyors her assessment which stated abdomen was soft, non-tender and re-stated that SP#1 was complaining of Dysuria. Surveyor asked SE#2 when the E.D. Physician sees cases. SE#2 replied, sometimes he does, sometimes he doesn't. If patient is a lower acuity we just discuss the case with the doctor. Then, surveyor asked about signs/symptoms of ectopic pregnancy. The E.D. Medical Director responded "vaginal bleed, severe abdominal pain in early pregnancy." Additionally, the Emergency Department Medical Director also verbalized that SP#1 didn't present with severe abdominal pain and her complaint was dysuria and she was treated for it.

Interview with the Risk Manager in the presence of the Associate Administrator of Quality Management conducted on 07-03-13 at 11:25 am confirmed the interview with the mid-level provider (sample employee (SE) #2), ED Physician (SE#3)and ED Medical Director on 06-10-13.

(2) Record review conducted on 07-03-13 of sample patient (SP) #15 revealed that the patient was seen in the ED on 01-02-13 at 11:29 am with a complaint of pelvic pain.

Review of the Triage Nurse assessment note showed that sampled patient #15 had lower abdominal (suprapubic) pain for 2 weeks with primary pain intensity of level 10 in a scale of 0-10. Recommended ESI (Emergency Severity Index) level = 3. Further review of the Triage Nurse progress notes (01-02-13 at 2:15 pm) showed: " Pt. (patient) pain free at this time. Pt. given discharge instructions with orders to follow up with OB. Pt. verbalizes understanding. Ambulates out of ED unassisted with no distress.

On 01/02/2013 at 12:19 P.M. Review of the Laboratory results revealed the urine human chorionic gonadotropin (pregnancy test) was positive. Results of the urinalysis revealed that the protein level was 20 ( normal range (Negative), the Urobilinogen was 2.0 (normal range (0.2-1.0) and Leukocyte Esterase 75 (normal range (Negative).

Review of the Admission/Discharge/Transfer Notes (01-02-13 at 1:34 pm) done by the Physician Assistant (PA) (SE) #3 showed: The patient came to ER (emergency room) c/o (complaint) pelvic pain and came to ER to see if she is pregnant. Duration lasting an unknown period of time. The onset was gradual. The course is episodic. Episodes not applicable. Quality: crampy. The degree of pain is minimal. Location lower. Radiating pain: none. History of prior episodes: negative. The exacerbating factor is negative. Fetal movement: negative. Risk factor for pregnancy negative. Sexual intercourse: single partner. Contraception: negative. Physical examination showed abdominal: Soft. Nontender. Discharge plan: patient given educational materials: pregnancy, new diagnosis.

(3) Review of sampled patient # 11 medical records revealed that the patient also presented with abdominal pain, and an OB Pelvic Ultrasound was completed.
Review of sampled patient #14 medical records also revealed that the patient presented with pregnant- abdominal pain, and an Pelvic Ultrasound was completed.

On 06/10/2013 at 05:40 P.M., an interview was conducted with the Med. Dir. of E.D. During the interview, the surveyor asked if there
were any protocols related to patient care who presented to E.R. with abdominal pain or if specific standards of practice were being followed for such patients. The Med. Dir. stated the standards of practice are based upon their own assessment, history/physical and there were no specific protocols in the facility.

Interview with the Associate Chief Medical Officer conducted on 07-03-13 at 12:40 pm confirmed above findings after he reviewed the SP#1 and SP#15 sampled patients records that he determined that these patients should have been examined further based on the documentation on the charts.

Based on the patients record reviews for sampled patients #1 and #15, it was determined the medical screenings provided to the patients were incomplete to determine whether or not an emergency medical condition existed.

Based on record review and interview, the facility failed to ensure that an individual with an Emergency Medical Condition (EMC) will be provided with the necessary stabilizing treatment in 2 out of 20 Sample Patients (SP) (SP#1and SP#15).

The findings include:

Review of the facility policy and procedure Code No. 209; Section 100-200 (Administration); Subject: Patient Transfer between Hospital and another Hospital; IV General Procedures A.(1.) If the medical screening examination reveals that the individual has an emergency medical condition, the hospital staff must provide either: (A.) for such further medical examination and treatment as may be required to stabilize or resolve the emergency medical condition within the service capability and service capacity of the hospital.(3.) If the hospital staff determines, after completing the screening examination, that the individual does not have an emergency medical condition, then appropriate referral or other treatment may be provided.

(1) Record review conducted on 07-02-13 to 07-03-13 of sample patient (SP) #1, revealed SP#1 was seen in the facility ' s Emergency Department on 05/29/2013 from approximately 11:06 A.M. to 15:18 P.M. and was discharged the same day. Review of the facility ' s face sheet states reason for the visit was pregnant cramping/dysuria. Review of the " Emergency Services Triage Encounter Form " filled out by SP#1 states that SP#1 wrote " Stomach pain, very painful." Review of the electronic Assessment Forms completed by the Triage Nurse (sample employee (SE#8) on 05/29/2013 at 11:45 A.M. states the chief complaint description was a [positive] + home pregnancy test, LMP [last menstrual period] in April. The forms also stated that the pt [patient] c/o [complaining of] lower abd. [abdominal] pain x 1 day, and denies any bleeding. The record review also stated under the section primary pain intensity: " 6 "on a scale of 0 to 10. The location as " abdomen, " abdomen quadran," left lower quadrant, right lower quadrant " . Under O.B./G.Y.N. (Obstetrics/Gynecology) the nurse documented that SP#1 ' s is gravida " 3 " , para " 1 " , spontaneous abortion " 1 " , and the last last menstrual period was noted as " 04/27/2013". Under the gastrointestinal section, the nurse documented that the abdomen description as " pregnant " , abdomen palpation " soft, non-tender". The nurse also noted that the bowel sounds as present in all 4 quadrants. The nurse also has the Recommended ESI (Emergency Severity Index) level =4.

Review of the Clinical Laboratory form dated 05/29/2013 at 11:53 A.M. shows the urine human chorionic gonadotropin (pregnancy test) was positive. The urinalysis test was within normal limits.

Review of the Admission/Discharge/Transfer Notes documented by the Physician Assistant (sample employee (SE) #2) showed SP#1 was seen by the P.A. on 05/29/2013 at 12:44 P.M. The Menstrual-pregnancy history shows: currently pregnant. The history of present illness documented was that the patient who presents with a complaint of dysuria and the patient comes to ER (complaining of )c/o dysuria (painful urination) and states that she has had this since this morning. She states that she is pregnant at this time. Duration lasting 1 day(s). The course is constant. The degree of severity is moderate. The exacerbating factor is urination. The mitigating factor is negative. The risk factor is negative. Prior episodes: negative. Under Associated Symptoms, the P.A. documented " Constitutional symptoms: chills, Fever: subjective, Gastrointestinal symptoms: Negative, Genitourinary symptoms: Dysuria, Genitourinary pain: Mild, Urine output: within normal limits, Vaginal discharge: Negative, Vaginal bleeding: Negative . Review of Physical examination done by P.A. states under " abdominal: soft non tender". Under the section Medical Decision Making, the P.A. documented the Differential diagnosis as Dysuria, Cystitis, Urinary Tract Infection, and the impression and plan diagnosis as " new onset pregnancy". The Discharge plan states the " patient was given the following educational materials: pregnancy, new dx [diagnosis], prenatal care. Follow up with: [name of O.B./G.Y.N.] " . Review of the Admission/Discharge/Transfer Notes (date and time unknown) documented by the E.D. Physician stated I have participated in this patient ' s care as follows: Evaluation and management services. Personally performed: Medical history, physical exam, medical decision making. Case discussed with physician assistant/nurse practitioner: yes. I agree with the evaluation and management services provided by the physician assistant/nurse practitioner with the following exceptions: none. I agree with the interpretation of studies documented by the physician assistant/nurse practitioner with the following exceptions: none". Further review of the note revealed an addendum by the E.D. Physician on June 17, 2013 stating a correction: case reviewed with me by Physician Assistant and the referral made to OB (Obstetrics), and that patient was not physically examined by me.

A Review of SP#1 ' s discharge instructions given by the facility ' s P.A. on 05/29/2013 states " Your exam today shows that you are pregnant " and SP#1 was instructed to follow-up with Obstetrics/Gynecology (O.B./G.Y.N.) and return promptly if: Vaginal bleeding, Moderate or severe abdominal or back pain, excessive vomiting, unable to keep any fluids down for six hours, burning with urination, headache, dizziness or rapid weight gain. Review of the discharge instructions showed SP#1 signed the form on 05/29/2013. Review of the record showed no additional assessments were documented by nursing or intermediate care.

Review of the Sp #1 medical records and EMS report provided by Facility #3 revealed that SP#1 was transported to facility #3 via EMS on 06/04/2013) with sharp abdominal pain with a pain level of 10 of 10. She underwent a laparoscopic right salpingectomy.

Interview with the mid-level provider (P.A.)(SE#2) who evaluated SP#1 on 05/29/2013 was conducted on 06/10/2013 at 11:50 A.M. The Associate Chief Medical Officer, Peer Review Coordinator, Associate Administration of E.D., SE#4 and second surveyor were also present. The Physician Assistant (SE#2) confirmed evaluating and treating SP#1 on 05/29/2013. When the surveyor asked SE#2 if she was aware of SP#1's complaint of lower abdominal pain, SE#2 stated the patient didn't tell me. I write what the patient tells me. She told me she was pregnant. Surveyor also asked SE#2. if she was aware of the nursing documentation also stating that SP#1 was complaining of left/right lower quadrant pain. SE#2 showed surveyors her assessment which stated abdomen was soft, non-tender and re-stated that SP#1 was complaining of Dysuria. Surveyor asked SE#2 when the E.D. Physician sees cases. SE#2 replied, sometimes he does, sometimes he doesn't. If patient is a lower acuity we just discuss the case with the doctor. Then, surveyor asked about signs/symptoms of ectopic pregnancy. The E.D. Medical Director responded "vaginal bleed, severe abdominal pain in early pregnancy." Additionally, the Emergency Department Medical Director also verbalized that SP#1 didn't present with severe abdominal pain and her complaint was dysuria and she was treated for it.
Interview with the Risk Manager in the presence of the Associate Administrator of Quality Management conducted on 07-03-13 at 11:25 am confirmed the interview with the mid-level provider (sample employee (SE) #2), ED Physician (SE#3)and ED Medical Director on 06-10-13.



(2) Record review conducted on 07-03-13 of sample patient (SP) #15 revealed that the patient was seen in the ED on 01-02-13 at 11:29 am with complaint of pelvic pain.

Review of the Triage Nurse assessment note showed that sampled patient #15 had lower abdominal (suprapubic) pain for 2 weeks with primary pain intensity of level 10 in a scale of 0-10. Recommended ESI (Emergency Severity Index) level = 3. Further review of the Triage Nurse progress notes (01-02-13 at 2:15 pm) showed: " Pt. (patient) pain free at this time. Pt. given discharge instructions with orders to follow up with OB. Pt. verbalizes understanding. Ambulates out of ED unassisted with no distress. " Review of the Clinical Laboratory form dated.


Review of the Admission/Discharge/Transfer Notes (01-02-13 at 1:34 pm) done by the Physician Assistant (PA) (SE) #3 showed: The patient is a 19 year old female who comes to ER (emergency room) c/o (complaint) pelvic pain and come to ER to see if she is pregnant. Duration lasting an unknown period of time. The onset was gradual. The course is episodic. Episodes not applicable. Quality: crampy. The degree of pain is minimal. Location lower. Radiating pain: none. History of prior episodes: negative. The exacerbating factor is negative. Fetal movement: negative. Risk factor for pregnancy negative. Sexual intercourse: single partner. Contraception: negative. Physical examination showed abdominal: Soft. Nontender. Discharge plan : patient given educational materials : pregnancy, new diagnosis.

On 01/02/2013 at 12:19 P.M. shows the urine human chorionic gonadotropin (pregnancy test) was positive. Results of the urinalysis revealed that the protein level was 20 ( normal range (Negative), the Urobilinogen was 2.0 (normal range (0.2-1.0) and Leukocyte Esterase 75 (normal range (Negative).

(3) Review of sampled patient # 11 medical records revealed that the patient also presented with abdominal pain, and an OB Pelvic Ultrasound was completed.
Review of sampled patient #14 medical records also revealed that the patient presented with pregnant- abdominal pain, and an Pelvic Ultrasound was completed.

On 06/10/2013 at 05:40 P.M., an interview was conducted with the Med. Dir. of E.D. During the interview, the surveyor asked if there were any protocols related to patient care who presented to E.R. with abdominal pain or if specific standards of practice were being followed for such patients. The Med. Dir. stated the standards of practice are based upon their own assessment, history/physical and there were no specific protocols in the facility.

Interview with the Associate Chief Medical Officer conducted on 07-03-13 at 12:40 pm confirmed above findings after he reviewed the SP#1 and SP#15 sampled patients records that he determined that these patients should have been examined further based on the documentation on the charts.

Although, sampled patients #1 and #15 entered the facility with similar symptoms as patients #11 and #14, these two patients weren't provided additional treatment and services to ensure the emergency medical condition was stabilized.