HospitalInspections.org

Based on review of facility policies and procedures, video surveillance footage, Urology On-Call Coverage Agreement, Free Standing Emergency Department (FED) Call Schedule, medical records (MR) and interviews, it was determined Medical West, an Affiliate of UAB (University of Alabama in Birmingham) Health System failed to:

1. Ensure Employee Identifier (EI) #4, physician on-call Urologist, presented to the Emergency Department (ED) to provide further evaluation and treatment to Patient Identifier (PI) #1.

2. Determine if a medical emergency existed through the medical screening exam (MSE) for one of 21 MRs reviewed including PI # 1 and had the potential to affect all patients presenting to the FED.

3. Provide stabilizing treatment or transfer for a patient prior to discharge. This affected one of three MRs reviewed with urinary retention and did affect PI # 1 and had the potential to affect all patients presenting to the FED.

4. Provide a transfer or treatment without delay for a patient presenting to the FED with urinary retention. This affected one of three MRs reviewed with urinary retention and did affect PI # 1 and had the potential to affect all patients presenting to the FED for treatment.

Refer to tags A2404, A2406, A2407, and A2409.

Based on Free Standing Emergency Department (FED) urology on-call schedule, medical record review, and interview, Employee Identifier (EI) #4, physician on-call Urologist, failed to present to the Emergency Department (ED) to provide further evaluation and treatment to Patient #1 (PI #1). This affected one of three medical records reviewed of patients presenting with urinary retention and had the potential to negatively affect all patients presenting with urinary retention.

Findings include:

PI # 1 presented to the FED on 5/5/23 at 8:13 PM with a chief complaint of unable to urinate.

Review of the Triage Assessment by the nurse dated 5/5/23 at 8:13 PM revealed PI # 1 complained of difficulty urinating and last void was at 2:00 PM 5/5/23. ESI (Emergency Severity Index) Level 3.

Review of PI # 1's Emergency Department (ED) record dated 5/5/23 revealed catheterization was attempted by the nurse and Employee Identifier (EI) # 2, FED Physician without success. EI # 4, Urologist On-Call was consulted and PI # 1 was instructed to go to Hospital A's ED for treatment.

Review of the Discharge Summary dated 5/5/23 at 10:52 PM revealed PI # 1 was discharged with instructions to go to Hospital A's ED by POV (Privately Owned Vehicle) as per patient discussion with EI # 2.

Review of the MR from Hospital A dated 5/5/23 revealed PI # 1 arrived by car on 5/5/23 at 11:15 PM.

The May 2023 call schedule was reviewed. On 5/5/23, the day Patient #1 presented to the dedicated emergency department, Employee Identifier (EI) #4, Urologist, was listed as the physician on call for urology services.

An interview conducted on 5/24/23 at 5:15 PM with EI #4, Urologist on-call on 5/5/23, revealed she told PI #1 to go to Brookwood Hospital ED which was a closer drive for her and the patient.

Cross Refer to 2406, 2407 and 2409.

Based on review of facility policies and procedures, medical records (MR), video surveillance footage, and interviews, it was determined the hospital failed to ensure an appropriate Medical Screening Examination (MSE) was performed, to include the use of on-call urology services, for a patient who presented to the Free Standing Emergency Department (FED) with urinary retention to determine if an emergency medical condition existed.

This deficient practice affected one of three MRs reviewed of patients presenting with urinary retention including Patient Identifier (PI) # 1 who presented at the FED and had the potential to negatively affect all patients presenting with urinary retention

Findings include:

Facility Policy: Emergency Medical Treatment and Active Labor Act (EMTALA) Policy

Policy Number: None
Date Issued: 4/1/21

Policy:

It is the policy of this hospital that all persons presenting to the Hospital Campus for unscheduled procedures or evaluation shall receive a MSE by a Qualified Medical Professional (QMP) to determine if an Emergency Medical Condition exists.

Procedure:

4.1. ...all persons presenting to the Hospital Campus requesting treatment or examination shall be provided a Medical Screening Examination.

4.6.2 The purpose of the MSE shall be to determine whether the individual has an Emergency Medical Condition.

1. PI # 1 presented ambulatory to the FED on 5/5/23 at 8:13 PM with a chief complaint of unable to urinate.

Review of the Triage Assessment by the nurse dated 5/5/23 at 8:13 PM revealed PI # 1 complained of difficulty urinating and last void was at 2:00 PM 5/5/23.

Review of the ED (Emergency Department) Note dated 5/5/23 at 9:01 PM by Employee Identifier (EI) # 2, FED Physician revealed, at 2:00 PM, patient was urinating when the flow of urine suddenly stopped...unable to void since...uncomfortable appearing.

Review of the ED Patient Order Summary dated 5/5/23 9:09 PM revealed orders to insert a Coude Foley Catheter once. Lidocaine 2% (Percent) Urojet 10 ml (Milliliters) now.

Review of the ED Visit Summary by the nurse dated 5/5/23 at 9:47 PM revealed, "unable to insert 16 FR (French) coude catheter", EI # 2 notified.

Further review of the ED Note dated 5/5/23 at 9:01 PM by EI # 2 revealed, ED Procedures: Foley Catheter, Type: Coude, Complications: unable to pass catheter. Consulted with EI # 4, Urologist On-Call at 10:42 PM regarding the patient's case and inability to pass the Foley catheter. EI # 4 stated PI # 1 needed to go to another ER (Emergency Room) where they had urology supplies. EI # 4 recommended Hospital A. At 10:48 PM, EI # 2 contacted Hospital A's ED Physician who informed EI # 2 a bed would be open for PI # 1 and the Urology supplies would be ready for EI # 4 who was also covering urology at Hospital A. PI # 1 instructed to, "Go directly to [Hospital A] Emergency Department!"

There was no documentation the MSE by the physician determined whether PI # 1 presented with an emergency medical condition or not and there was no documentation EI # 4 visited the patient in the FED to stabilize the patient.

Review of the Discharge Assessment Comments dated 5/5/23 at 10:52 PM revealed PI # 1 was discharged with instructions to go to Hospital A's ED per POV (Privately Owned Vehicle) as per patient discussion with EI # 2.

Review of the video footage from the FED dated 5/5/23 revealed PI # 1, identified by EI # 1, Chief Quality Officer, entered the FED at 8:11 PM and exited the FED ambulatory at 10:50 PM which was 2 hours and 39 minutes later.

An interview conducted on 5/25/23 at 9:20 AM with EI # 1 confirmed the MSE completed by EI # 2 on 5/5/23 did not include a determination of whether an emergency medical condition existed.

Cross Refer to 2404, 2407 and 2409.

Based on review of facility policies and procedures, video surveillance footage, Urology On-Call Coverage Agreement, Free Standing Emergency Department (FED) Call Schedule, medical records (MR) and interviews, it was determined the hospital failed to provide necessary stabilizing treatment or a transfer for a patient presenting to the FED with urinary retention.

This deficient practice affected one of three MRs reviewed of patients presenting with urinary retention including Patient Identifier (PI) # 1 who presented at the FED and had the potential to negatively affect all patients presenting with urinary retention

Findings include:

Facility Policy:

Emergency Medical Treatment and Active Labor Act (EMTALA) Policy
Policy Number: None
Date Issued: 4/1/21

Standards:

It is the policy of this hospital that all persons presenting to the Hospital Campus for unscheduled procedures or evaluation shall receive a Medical Screening Examination...

Procedure:

4.7 Treatment and Stabilization

4.7.1 Necessary definitive care to stabilize the individual's condition shall be rendered...

Urology On-Call Coverage Agreement
Effective Date: 3/1/2017

...Hospital, which operates an acute care hospital and a free-standing emergency department...desires to maintain urology services at each facility 24 hours a day, seven days per week, and hospital desires to assure physician coverage at the facilities for such services...

(i) Urologist shall be on-call to provide the professional services in the Specialty to patients who present at the Facilities...

1. PI # 1 presented to the FED on 5/5/23 at 8:13 PM with a chief complaint of unable to urinate.

Review of the Triage Assessment dated 5/5/23 at 8:13 PM revealed PI # 1 complained of difficulty urinating and last void was at 2:00 PM 5/5/23.

Review of the ED (Emergency Department) note signed by Employee Identifier (EI) # 2, FED Physician dated 5/5/23 at 9:01 PM revealed, "At 2:00 PM, patient was urinating when the flow of his/her urine suddenly stopped...unable to void since...uncomfortable appearing."

Review of the ED Patient Order Summary dated 5/5/23 9:09 PM revealed orders to insert a Coude Foley Catheter Once. Lidocaine 2% (Percent) Urojet 10 ml (Milliliters) now.

Review of the ED Visit Summary by the nurse dated 5/5/23 at 9:47 PM revealed, "unable to insert 16 FR (French) coude catheter", EI # 2 notified.

Further review of the ED Note dated 5/5/23 at 9:01 PM by EI # 2 revealed, ED Procedures: Foley Catheter, Type: Coude, Complications: unable to pass catheter. At 10:42 PM, consult with EI # 4, Urologist On-Call regarding the patient's case and inability to pass the Foley catheter. EI # 4 stated PI # 1 needed to go to another ER (Emergency Room) where they had urology supplies. EI # 4 recommended Hospital A. At 10:48 PM, EI # 2 contacted Hospital A's ED Physician who informed EI # 2 a bed would be open for PI # 1 and the Urology supplies would be ready for EI # 4 who was also covering urology at Hospital A. PI # 1 was instructed to, "Go directly to [Hospital A] Emergency Department!"

There was no documentation EI # 4 visited the patient in the FED to stabilize the patient.

Review of the Discharge Summary dated 5/5/23 at 10:52 PM revealed PI # 1 was discharged with instructions to go to the receiving hospital ED per POV (Privately Owned Vehicle) as per patient discussion with EI # 2. The discharge diagnosis was Acute Urinary Retention.

There was no documentation the patient was stabilized prior to being discharged and no documentation the patient was offered and refused a transfer to another facility for
stabilization.

Review of the video footage from the FED dated 5/5/23 revealed PI # 1, identified by EI # 1, Chief Quality Officer, entered the FED on 5/5/23 at 8:11 PM and exited the FED ambulatory at 10:50 PM which was 2 hours and 39 minutes later.

An interview conducted on 5/25/23 with EI # 1 confirmed there was no documentation the patient was stabilized prior to discharge, no documentation the consulting urologist visited the patient at the FED to stabilize PI # 1, and no documentation the patient was offered and refused a transfer to another facility.

The May 2023 call schedule was reviewed. On 5/5/23, the day Patient #1 presented to the dedicated emergency department, Employee Identifier (EI) #4, Urologist, was listed as the physician on call for urology services.

Cross Refer to 2404, 2406, and 2409.

Based on review of facility policies and procedures, medical records (MR) from the FED (Free Standing Emergency Department), Hospital A and interviews, it was determined the hospital failed to provide necessary stabilizing treatment or a transfer for a patient presenting to the FED with urinary retention.

This deficient practice affected one of three MRs reviewed of patients presenting with urinary retention and did affect Patient Identifier (PI) # 1 who presented at the FED and had the potential to negatively affect all patients presenting with urinary retention

Findings include:

Facility Policy:

Transfer of Patients in Accordance with EMTALA (Emergency Medical Treatment and Active Labor Act)
Policy Number: None
Date Issued: 5/15/14

Standards:

4.2. The hospital shall not delay providing emergency medical services...

Procedure:

5.2. Appropriate Transfer:

5.2.1.4....A private vehicle shall not be utilized unless the patient or their representative has signed a written refusal of ambulance including a statement of risk.

5.3.1.1. Include in the medical record a description of the proposed transfer that was refused by or on behalf of the individual; and

5.3.1.2. Take all reasonable steps to secure the individual's ... written informed refusal to consent to transfer.

1. PI # 1 presented to the FED on 5/5/23 at 8:13 PM with a chief complaint of unable to urinate.

Review of the Triage Assessment by the nurse dated 5/5/23 at 8:13 PM revealed PI # 1 complained of difficulty urinating and last void was at 2:00 PM 5/5/23. ESI (Emergency Severity Index) Level 3.

Review of PI # 1's Emergency Department (ED) record dated 5/5/23 revealed catheterization was attempted by the nurse and Employee Identifier (EI) # 2, FED Physician without success. EI # 4, Urologist On-Call was consulted and PI # 1 was instructed to go to Hospital A's ED for treatment.

Review of the Discharge Summary dated 5/5/23 at 10:52 PM revealed PI # 1 was discharged with instructions to go to Hospital A's ED by POV (Privately Owned Vehicle) as per patient discussion with EI # 2.

Review of the MR from Hospital A dated 5/5/23 revealed PI # 1 arrived by car on 5/5/23 at 11:15 PM.

There was no documentation the patient was offered and refused a transfer to another facility for treatment.

An interview conducted on 5/25/23 at 9:20 AM with EI # 1 Chief Quality Officer confirmed PI # 1 was discharged from the FED and there was no documentation the patient was offered and refused a transfer to another facility for treatment.

Cross Refer to 2404, 2406, and 2407.