HospitalInspections.org

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the medical screening exam was competed on one out of 22 medical records reviewed (MR1).

Findings include:

Review on May 20, 2016, of the facility's "Assessment/Reassessment" policy, last reviewed January 5, 2016, revealed "Policy: Qualified individuals initially assess each patient's need for care by systematically collecting and analyzing specific data relative to the patient's physical, psychological, and social status. These assessments continue throughout the patient's hospital stay. Procedure: When the patient enters the setting or service, information is gathered to identify the reason(s) that brings him or her to the Hospital. The information gathered at the first patient contact can indicated the need for more data regarding the patient's physical, psychological, or social status. The need for such further assessment is determined by the care the patient is seeking, his or her condition, his or her consent to treatment, the patient's emergent needs, and the setting in which he or she seeks care. Assessing the status and identifying the needs of the patient are the basis for determining the care to be provided. Each assessment includes appropriate screening, observation, and/or examination procedures with regard to the patient's physical, psychological, and social status, as well as, considering his or her nutritional, functional, and educational needs. ... A licensed independent practitioner with appropriate clinical privileges is responsible for determining the degree of assessment and care or treatment provided to any patient who comes or is brought into the Emergency Department. ..."

Review on May 20, 2016, of MR1 revealed the patient presented to the Emergency Department (ED) on May 5, 2016 at 21:18. The diagnosis was chronic pain syndrome. There was no documentation of a medical screening examination. The patient presented to the ED on May 6, 2016, at 09:39. The diagnosis was back pain and neck pain. A nursing assessment was completed. A physician history and physical was completed. The condition on discharge was stable, and the patient was provided with a prescription for pain medication.

Interview with EMP1 on May 20, 2016, at approximately 9:45 AM revealed MR1 presented to the facility's ED on May 5, 2016, with a complaint of back pain. The patient was requesting a prescription for a pain medication. The patient's personal physician (CF1) was the ED physician on duty. EMP1 confirmed CF1 told MR1 to go to the office first thing in the morning and this physician would provide MR1 with a prescription for a pain medication. EMP1 confirmed MR1 did not receive a medical screening.

EMP1 revealed CF1's relief called off ill, and CF1 was required to remain in the ED on the morning of May 6, 2016. MR1 presented to the ED on May 6, 2016, with continued back. MR1 was assessed, a medical screening was completed, and the patient received a prescription for pain medication.

Interview on May 20, 2016, at approximately 1:00 PM with EMP6 revealed the following: EMP1 informed EMP6 on Monday May 9, 2016, of a possible EMTALA violation in the ED for a patient who left without treatment (LWOT) on May 5, 2016. When the patient returned on May 6, 2016, they noted it was their second visit to the ED for pain management. EMP1 reviewed the patient's May 5 ED record. A medical screening examination was not completed. The ED manager interviewed the registered nurse (RN) on duty at the time. EMP6 interviewed the ED physician on duty at the time of the patient's presentation. It was identified that the ED physician also has a private practice, and the patient presented to the ED, as they knew the physician was working in the ED. The patient was requesting a refill of their pain medication. The ED physician requested that the patient come to their private office the next day for a new subscription. EMP6 noted the facility has several physician working in the ED who also have private practices in the town, and this has been an ongoing issue with their private patients presenting to the ED when they are working. EMP6 confirmed that both the physician and the RN were provided with counseling and re-education regarding the EMTALA obligations.

EMP6 confirmed the EMTALA event and regulatory requirements were provided the following day to all management staff during the AM "Safety Moment." The management staff were to provide this information to each of their employees in their departments. EMP1 was re-educating all ED staff. The information will be shared with the Board, the Medical Executive Committee and all medical staff members at the next scheduled meetings.

Review on May 20, 2016, of "The Berwick Hospital Center's Board of Trustees Agenda" for May 17, 2016, revealed a section labeled "Safety Moment" - EMTALA discussed. Physician and RN re-educated. CF3 requested education on EMTALA be provided to the medical staff and Board at the next monthly meeting and to provide the information to the Medical Executive Committee.

Review on May 20, 2016, revealed "The Medical Executive Committee Agenda" and packet were discussed May 20, 2016, at 9:45. There was a PowerPoint presentation entitled "Demystifying EMTALA - Part 1". The PowerPoint included the requirements for a medical screening examination.

Interview on May 20, 2016, at approximately 9:30 AM with EMP6 and EMP2, revealed no other patients were identified during the facility's investigation of other patients who presented to the Emergency Department and a medical screening examination was not provided.

Review on May 20, 2016, revealed an EMTALA attestation was signed by CF1 noting they spent one hour reviewing EMTALA requirements with CF2.

On May 20, 2016, EMP1 provided documentation noting EMP7 was provided with employee counseling on May 13, 2016, related to the EMTALA violation.

The facility identified the deficient practice that occurred on May 5, 2016. Corrective action was initiated following their investigation. The corrective action includes staff re-education. This was initiated prior to the unannounced onsite on May 20, 2016.