HospitalInspections.org

1. Based on medical record reviews, review of the hospital's emergency room logs, and review of EMTALA training records and hospital's policy and procedures and interviews, the hospital failed to ensure that 1 of 30 patient charts reviewed received an appropriate medical screening examination that was within the capability of the hospitals' emergency department, including ancillary services routinely available to the emergency department upon presentation to the hospital's emergency department to determine whether or not an emergency medical condition existed. (Patient 1). Cross Reference to A 2406.


2. Based on medical record reviews, review of the hospital's emergency room log, interviews, and review of the hospital's policy and procedure, the hospital failed to provide an appropriate transfer of an individual by failing to provide medical treatment that was within the capacity to minimize the risks to the individuals health for 1 of 30 patients who presented to the emergency department with an emergency medical condition prior to the patient's transfer (Patient 1). Cross Reference to A 2409.

Based on observations and interview, the hospital failed to ensure signs explaining the rights of the individual with respect to examination and treatment of emergency medical conditions and women in labor were posted in places likely to be noticed by all individuals presenting to the emergency department.

The findings are:

On 10/03/16 from 11:20 a.m. - 11:37 a.m., random observations in the hospital's emergency department revealed one sign posted on the wall by the triage/waiting room area specifying the rights of individuals with respect to examination and treatment of emergency medical conditions and women in labor. There were no signs posted in the hospital's entrance area, admitting area, and/or any other patient treatment areas. On 10/03/16 at 11:37 a.m., the Chief Compliance Officer revealed, "I thought we had more signs posted, but the walls were renovated. They don't know where the signs are."

Based on review of the hospital's emergency department's central log, interview, and review of the hospital's policy and procedures, the hospital failed to ensure the emergency department's central log was completed with disposition information for individuals who presented to the emergency department (ED) for care and services.
The findings are:
On 10/4/16 at 9:10 a.m., reviewed of the hospital's emergency department's "Daily Log" dated 4/1/16 - 9/30/16 revealed missing data for:
April 2016: missing data for emergency identification and patient disposition on 4/1/16, 4/2/16, 4/13/16, 4/19/16, 4/22/16, 4/23/16, and 4/27/16.
May 2016: missing data for emergency identification and patient disposition on 5/2/16, 5/4/16, 5/5/16, 5/8/16, 5/10/16, 5/11/16, 5/12/16, 5/13/16, 5/14/16, 5/16/16, 5/18/16, 5/19/16, 5/24/16, 5/26/16, and 5/27/16.
June 2016: missing data for emergency identification and patient disposition on 6/6/16, 6/8/16, 6/9/16, 6/11/16, 6/14/16, 6/23/16, and 6/25/16.
July 2016: missing data for emergency identification and patient disposition on 7/5/16, 7/7/16, 7/8/16, 7/9/16, 7/12/16, 7/22/16, 7/23/16, 7/25/16, 7/26/16, 7/27/16, 7/28/16, 7/29/16, and 7/30/16.
August 2016: missing data for emergency identification, level, and patient disposition on 8/4/16, 8/8/16, 8/10/16, 8/29/16, and 8/30/16.
September 2016: missing data for emergency identification, level, departure date, and patient disposition on 9/2/16, 9/7/16, 9/8/19, 9/19/16, 9/22/16, 9/24/16, 9/26/16, 9/27/16, 9/28/16, 9/29/16, and 9/30/16.
On 10/5/16 at 12:29 p.m., the Emergency Department Nursing Director verified the findings.

Based on medical record reviews, review of the hospital's emergency room logs, and review of EMTALA training records and hospital's policy and procedures and interviews, the hospital failed to ensure that 1 of 30 patient charts reviewed received an appropriate medical screening examination that was within the capability of the hospitals' emergency department, including ancillary services routinely available to the emergency department upon presentation to the hospital's emergency department to determine whether or not an emergency medical condition existed. (Patient 1)


The findings are:


On 10/04/16 at 2:00 p.m., review of the Emergency Medical Services (EMS) run report revealed the EMS crew was called on 8/19/2016 at 2:02 p.m. for a 77 year old patient in cardiac arrest. When the EMS crew arrived to the patient's location, a bystander was performing Cardiopulmonary Resuscitation (CPR) on the patient. The EMS crew assumed the CPR procedure and an oral airway was initiated. Patient had a large amount of vomit that was removed with suction. The EMS crew report stated Hospital A's (an acute care hospital) emergency department was notified that the EMS crew was in transport with a male patient status post cardiac arrest with an unsecured airway. The EMS crew report stated Hospital A's emergency department informed the EMS crew to bypass Hospital A and go to Hospital B. The EMS crew report showed the EMS crew stated to Hospital A's emergency department staff that the EMS crew was uncomfortable with transporting the patient to Hospital B due to the unsecured airway and irregularities on the cardiac monitor. The EMS crew report showed the EMS crew advised the physician in Hospital A's emergency department that the EMS crew was looking for assistance in securing the patient's airway with an Endotracheal Tube (ETT) and needed to transport patient to Hospital A's emergency department. The EMS crew's transport sheet revealed when the patient was placed in the hospital's emergency department, the physician in Hospital A's emergency department informed the EMS crew that the King airway ( a single use device intended for airway management-used for RMT's in pre-hospital setting) in the patient was good enough, and the EMS crew were to remove the patient from his hospital. The EMS crew report showed the EMS crew removed the patient and transported the patient to Hospital B.

On 10/04/16 at 2:10 p.m., review of Patient 1's chart revealed the patient presented to the hospital's emergency room via ambulance on 08/19/16 at 2:29 p.m., unresponsive, with STEMI (ST elevation (a particular pattern on an electrocardiogram (EKG) heart tracing showing Myocardial Infarction).
Hospital's A's emergency department notes dated 8/19/2016 at 14:29 p.m. read, "PT (Patient) presents via EMS to Room 1. PT is showing STEMI on EKG performed by EMS, which is confirmed by the physician (Physician 1 in Hospital A) who is in the room upon PT's arrival. PT has IO (Intraosseous-route for delivery of fluid, blood or medication through a needle inserted directly into the marrow of long bones) in place, on monitor, has ROSC (return of spontaneous circulation- a palpable pulse which is present after clinically documented cardiac arrest). PT has patient airway placed by EMS and is being bagged. PT is stable per Physician (1). PT to be transferred to Hospital B so he/she can go to cath(catheter) lab immediately. Hospital B called and cath lab called. On 8/19/2016 at 14:40 p.m., the note reads, "PT back in ambulance, being transferred per STEMI protocol.

On 10/4/2016 at 3:00 p.m., review of an addendum dated 08/30/2016 at 08:09 a.m. by Physician 1 from Hospital A, which reads, in part, "Upon arrival, patient is obtunded, unresponsive, Airway - King airway in place with symmetrical breath sounds with bagging, Cardiac regular rate and rhythm with strong femoral pulse, Neuro patient is unresponsive Glasgow Coma Scale (common scoring system used to describe level of consciousness in a person following traumatic brain injury) is 3, Medical decision making, This is a 77- year- old male status post cardiac arrest with return of spontaneous circulation, EKG reveals STEMI. Patient has multiple predictors a primary cardiac event including history of coronary artery disease, complaining of chest pain prior to collapse, Initial rhythm of V. tach/fib(ventricular Tachycardia/fibrillation), and a witnessed arrest, bystander CPR (cardiopulmonary resuscitation) return of spontaneous circulation at less than 30 minutes, less than 85 years old, and no history of chronic renal failure. The patient's airway appears to be in place and functional, there is a strong pulse, and EKG reveals diffuse ST elevation consistent with STEMI. Patient will be transported directly to the catheter lab, contacted Dr.....who is aware of. Will transfer patient with additional nursing staff for further resuscitation be required."

On 10/4/16 at 3:00 p.m., review of the documentation in the Patient 1's emergency department chart at Hospital A failed to show a medical screening examination was performed on Patient 1 after the patient presented to Hospital A's emergency department via emergency transport.

Review of Hospital A's emergency room log showed the patient's disposition as "left without treatment." Further review of the hospital "EMS (Emergency Medical Services) call log" showed EMS was "advised per Medical Doctor to go to ..... Hospital (Hospital B). Per EMS, pt (patient) too unstable."

On 10/05/16 at 10:20 a.m., interview with Physician 1 revealed that he/she had placed an "addendum" in the patient's chart dated 08/30/16 at 8:09 a.m. which was the patient's assessment for the 08/19/16 emergency department visit. Physician 1 reported,"We evaluated the patient. The patient had vital signs and was evaluated by the nurse. EMS was nervous, and we asked them if they felt comfortable transporting the patient. EMS was here between 5-10 minutes, and I called the cardiologist on alert at the cath (categorization) lab and spoke to them....".

On 10/04/16 at 3:51 p.m., Registered Nurse 2 revealed the EMS crew stated they were concerned about the rhythm. So, they said they would be there shortly. Physician 1 was in the room to greet them, and I was in the doorway (of the room). Physician 1 said, "Do not take the patient off the stretcher. (The patient) was stable enough to go to Hospital B, and the patient had STEMI....".

On 10/03/16 at 2:43 p.m., Emergency Medical Transport Crew Member 1 revealed, "No direct examination was done. I had given pass on to the registered nurses and staff, and then, Physician (1) entered the room being rude and stated we needed to load the patient back into the truck and take (the patient) to another hospital. (Hospital B). The physician (Physician 1) was adamant of placing the 12 lead EKG in my face and asking me if I knew what I was doing.....? I stated it wasn't safe or in the best interest of the patient. Then, we (EMS crew) decided to transport the patient to the other hospital( Hospital B)."

On 10/05/16 at 1:42 p.m., review of Hospital A's EMTALA training records revealed Physician 1 had no documentation that he/she had received EMTALA training. On 10/5/16 at 2:50 p.m., the Associate Vice President of Operations revealed the hospital had a new process for EMTALA training which just started 03/2016 for new physicians, and the older physicians probably haven't done it either (EMTALA training) in awhile. So there's no documentation for them(physicians)."

On 10/5/16 at 11:00 a.m., review of Hospital A's policy, titled, STEMI Alert Activation, index number 12-21 dated 10/13/2011 with an effective date of 10/24/2011, reads, " Purpose: To ensure that all members of the STEMI Alert team are activated in an efficient and timely manner. Policy: To establish a collaborative interdepartmental team of continuous improvement in the quality and safety of emergent interventional cardiac care for each patient, every time. There is a flow chart labeled ... (Hospital B) STEMI Alert and WCH (Hospital A) STEMI Alert. The next section is "Patient reports chest pain/pressure suspicious for MI (Myocardial Infarction - heart muscle dies)." Next section states to get an ECG stat, and read by medical doctor stat. Next section reads, "STEMI determined by ED MD(Emergency Department Medical Doctor)." Next section of flow chart directs the ED MD to notify the ED Operator who calls "STEMI Alert". The next section of the flow chart reveals, " ED Operator activates STEMI Alert team and Interventional Cardiologist via Group Pager Call (telephone number) and enter code). " There was no documentation that Hospital A's emergency department physician followed the hospital's STEMI protocol for Patient 1.

Hospital policy, titled, "Emergency Medical Treatment and Labor Act (EMTALA) (including Medical Screening Exam)" reads, ".... Policy: Whenever an individual comes to the Emergency Department of the hospital, the hospital must provide for an appropriate Medical Screening Examination (MSE) by Qualified Medical Personnel, within the capacity of the hospital's Dedicated Emergency Department, including ancillary services routinely available to the Dedicated Emergency Department to determine whether an emergency medical condition (EMC) exists, or with respect to a pregnant woman having contractions, whether the woman is in labor. The MSE must be the same MSE that the hospital would perform on any individual coming to the hospital with those signs and symptoms, regardless of diagnosis (e.g., labor, AIDS (acquired immune deficiency syndrome)), financial status e.g., uninsured, Medicaid), race, color, national origin, disability, etc.... 5. All patients should have an MSE performed as soon as possible. If the patient is triaged as non-acute or urgent and the MSE is not immediately available, then the patient may be directed to the appropriate registration area and will receive periodic re-evaluation, in the waiting room for priority status change. Under no circumstances should the provider pursue obtaining a pre-authorization from an insurance plan for conducting a medical screening examination, nor should the patient be asked to sign an Advanced Beneficiary Notice (ABN) prior to MSE completion and stabilization....10....d). If the MSE indicates that an EMC exists, action must be taken as medically indicated, regardless of ability to pay....".

The facility failed to ensure that their policies and procedures were followed as evidenced by failing to ensure that an appropriate medical screening examination was provided which was within the capability of the hospital's DED for patient #1 on 8/19/2016 by the Qualified Medical Personnel (ED physician 1) who was available and in the ED when the EMT's brought the patient into the DED seeking emergency medical assistance for an identified emergency medical condition.

Based on medical record reviews, review of the hospital's emergency room log, interviews, and review of the hospital's policy and procedure, the hospital failed to provide an appropriate transfer of an individual by failing to provide medical treatment that was within the capacity to minimize the risks to the individuals health for 1 of 30 patients who presented to the emergency department with an emergency medical condition prior to the patient's transfer (Patient 1).

The findings are:

On 10/04/16 at 2:00 p.m., review of Patient 1's chart revealed the patient presented to the emergency room via ambulance on 08/19/16 at 2:29 p.m. unresponsive with STEMI (ST elevation (a particular pattern on an electrocardiogram (EKG heart tracing) for Myocardial Infarction). Review of Hospital A's physician emergency room progress note indicated the physician ordered the Emergency Medical Transport crew to place the patient back in the ambulance and transfer the patient Hospital B on 08/19/16 at 2:30 p.m.. The emergency department log showed the patient's disposition as "left without treatment". Further review of the emergency room documentation revealed there was no signed certification of the medical benefits of treatment or benefits and risks to the individual for transferring. On 10/04/16 at 3:51 p.m., Registered Nurse 2 revealed, "I was in the doorway when Physician 1 said, "Do not take the patient off the stretcher. Physician 1 stated the patient was stable enough to go to Hospital B's cath lab....".

Review of Hospital A's emergency room log showed the patient's disposition as "left without treatment." Further review of the hospital "EMS (Emergency Medical Services) call log" showed EMS was "advised per Medical Doctor to go to ..... Hospital (Hospital B). Per EMS, pt (patient) too unstable."

On 10/03/16 at 2:43 p.m., Emergency Medical Transport Crew Member 1 revealed, "No direct examination was done. I had given pass on to the registered nurses and staff, and then, Physician (1) entered the room being rude and stated we needed to load the patient back into the truck and take (the patient) to another hospital. (Hospital B). The physician (Physician 1) was adamant of placing the 12 lead EKG in my face and asking me if I knew what I was doing.....? I stated it wasn't safe or in the best interest of the patient. Then, we (EMS crew) decided to transport the patient to the other hospital( Hospital B)."

Hospital policy, titled, "Emergency Medical Treatment and Labor Act (EMTALA) (Including Medical Screening Exam),....Stabilization and Transfers 1)", reads, "If it is determined that an EMC(Emergency Medical Condition) exists, the ED (Emergency Department) physician will stabilize the condition (with the assistance of the on-call physician when necessary) or effect an appropriate transfer. The hospital will assure that patients developing EMC's will be stabilized or appropriately transferred without regard to the patient's ability to pay, method of payment or insurance status....3) Physicians certifying the transfer should state reasons for transfer and risks and benefits; a copy of which should be included in the medical record, and a copy of which should be sent to the receiving facility....".

On 8/19/2016 The hospital failed to ensure and appropriate transfer of Patient #1 as evidenced by failing to ensure the receiving hospital was contacted to ensure the hospital had available space and qualified personnel for treatment of the patient EMC; failed to ensure the receiving hospital agreed to accept the patient in order to provide appropriate treatment ; and failed to complete and sign a written certification of transfer indicating the reasons for transfer and the risks and the benefits; and also failed to send copies of all medical records related to the emergency medical condition which the patient presented that were available at the time of the transfer. As this resulted in an inappropriate transfer of patient #1 on 8/19/2016 with an identified EMC and was unstable.

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