HospitalInspections.org

Based on medical record review, facility policy review, and interview, the facility failed to provide a medical screening examination prior to transfer for one patient (#20) of twenty-seven patients reviewed.

The findings included:

Patient #20, a pediatric patient, presented to the Emergency Department (ED) on October 19, 2014, at 10:52 a.m., for an alleged sexual assualt reported to the grandmother by patient #20. Continued medical record review revealed Registered Nurse (RN) #1 triaged the patient at 11:35 a.m., as a level 3 (urgent) patient on the Emergency Severity Index (ESI).

Medical record review of an ED physician patient assessment form for Patient #20 revealed there was no documentation of a medical screening exam by the ED physician.

Medical record review of a nurse's note dated October 19, 2014, at 11:37 a.m., completed by RN #1 revealed "...[Physician #1] called and advised of situation...[Physician #1] advises...will be there shortly..." Continued review of the nurse's note revealed, at 11:50 a.m., Physician #1 called and advised the patient needed to go to (hospital #2) for an evaluation. Further review revealed Physician #1 advised RN #1 "...I will call over there and call you back..." Continued review of the nurse's note revealed, at 12:30 p.m., "...pt [patient] accepted...by [Physician #2] per [Physician #1]..."

Review of the physician on call schedule for the facility revealed Physician #1 was on call for pediatric patients on October 19, 2014.

Medical record review of a facility Transfer Authorization Form dated October 19, 2014, revealed "...medical condition...alleged sexual assault...a medical screening examination has been performed on this patient...based on that examination, the following condition of the patient...stable [box checked]...reason for transfer...medically indicated...services which are not available at this facility...Pediatrics Specialist..." Continued review revealed the Transfer Authorization Form was completed and signed by RN #1.

Medical record review revealed Patient #20 was discharged "...in no distress..." by RN #1 from the facility on October 19, 2014, at 12:42 p.m., with discharge instructions given to the patient's grandmother to take the child to the pediatric facility (hospital #2) for an evaluation by Physician #2.

Review of facility policy, Emergency Medical Treatment and Patient Transfer, last reviewed on August 15, 2014, revealed "...it is the policy...provide an appropriate MSE [Medical Screening Exam]...all individuals who present to a DED [dedicated emergency department] for examination or treatment of any medical condition...a QMP [Qualified Medical Personnel]...shall assess the patient and perform the MSE..."

Medical record review of an ED record for Patient #20 from hospital #2 revealed the patient arrived at the hospital on October 19, 2014, at 1:40 p.m., and received a medical screening exam from a physician and a Forensic Nurse Examiner (FNE).

Interview with the corporate Risk Manager and the facility Risk Manager on February 10, 2015, at 1:00 p.m., in the conference room, confirmed "...there doesn't appear to be a medical screening...didn't know about this...there is a pediatrician on call everyday...always have coverage..."

Interview with ED Director on February 10, 2015, at 2:10 p.m., at the ED nurses' station, confirmed patient #20 did not have a Medical Screening Examination (MSE).

Interview with Physician #3 on February 10, 2015, at 2:30 p.m., in the ED physician's office, revealed "...normally with young kids we notify the pediatrician and they come to see them...don't remember if they came or not...with patients this young we contact the pediatrician because they are more qualified...don't know for sure if she came and examined...don't see any documentation...don't know why my name is on the chart...I didn't see her [patient]...per our guidelines we contact pediatrician and they come over...I didn't even go in the room from what I see here...they [registration] just select a doctor and put a name on the record..."

Telephone interview with RN #1 on February 10, 2015, at 2:56 p.m., revealed "...she [patient] came to the ER [Emergency Room] and I called the pediatrician...per [Physician #3] request...we have a policy about possible rape of a child to call pediatrician...[Physician #3] did not see...[Physician #1] did not see...[Physician #1] called [hospital #2] and arranged a transfer...told [Physician #3] that I talked to [Physician #1] and what [Physician #1] said and what the plan was...[Physician #3] was in agreement...can't remember who signed the transfer paper...it's a procedure we follow...not a policy...just something we do...it's up to the ED doctor..."

Telephone interview with Physician #5 on February 10, 2015, at 4:00 p.m., revealed "...we see all patients that come into the ED...no special procedure for pediatric sexual assault patients...ED physician does the medical screening...we can call the pediatrician but the ED physician needs to screen..."

Interview with the ED Director on February 11, 2015, at 8:10 a.m., in the Risk Manager's office, revealed "...we don't have a written policy for children under a certain age...if you have a child under a certain age...contact their pediatrician and give opportunity to come in and see the patient...every patient should have a medical screening...that's a federal law...ER doctor should have seen the patient...should have documented a medical screening..." Further interview confirmed "...there is not a medical screening...[RN #1] has not had any special training to be able to complete a medical screening..."

Telephone interview with Physician #1 on February 11, 2015, at 9:00 a.m., revealed "...I believe I got a call from the nursing folks..." Further interview confirmed Phyisician #1 "...did not see her [patient]...ER docs [physicians] didn't see her...ER doc preferred a pediatrician see the patient...we prefer a doc at [hospital #2] see a child and a pediatric sexual assault exam be done there...she [RN #1] called me back and told me they were sending by private vehicle...I had called [hospital #2] and talked to the ED physician...told them I preferred she [patient] be seen by them...they accepted her...they did call me later and tell me their findings...she [grandmother] was in agreement for the child to go to [hospital #2]..."