HospitalInspections.org

26611

Based on observation, interview, and record review, the hospital failed to ensure that it was in compliance with the Emergency Medical Treatment and Labor Act (EMTALA) as evidenced by the following:


1. Failure to perform an adequate medical screening examination for one of 24 sampled patients. (Patient 31) Refer to C 2406, finding 1.

2. Failed to perform a triage assessment (the process of determining the priority of patients' treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. Triage may result in determining the order and priority of emergency treatment, the order and priority of emergency transport, or the transport destination for the patient) and a medical screening examination for three of 24 sampled patients. (Patients 39, 40, and 43) Refer to C 2406, findings 2a-c.

3. Failed to accurately assign the appropriate triage class to five of 24 sampled patients. (Patients 30, 31, 33, 34, 47, and 48) Refer to C 2406, findings 3a-f.

4. Failed to ensure that two of 24 sampled patients, who were a danger to themselves or others, were provided protective supervision which resulted in Patients 40 and 41 eloping from the facility. Refer to C 2407, findings 1 and 2.

5. EMTALA postings contained the incorrect name, address, and phone number of the state agency for receiving complaints. Refer to C 2402


These failures have the potential for patients to have delays in receiving needed care and appropriate supervision which can result in adverse outcomes including death.

Based on observation, interview and review of posted information, the facility failed to post the correct contact information for the state licensing agency. This failure could potentially prevent patients, staff or any individual from the general public from being able to contact the state licensing agency with complaints, questions or concerns.

Findings:

On 2/11/14 at 9:15 am, the posted information in the Emergency Department lobby that was available for the public was reviewed with Administrative Staff B. She confirmed that the department name, address, and phone number posted were not the current address of the state licensing agency and this could prevent people from being able to contact them with their complaints.

26611

Based on interview and record review the hospital failed to ensure that that an appropriate screening exam was provided for nine of 24 sampled patients as evidenced by:

1. Failure to perform an adequate medical screening examination for one of 24 sampled patients. (Patient 31)

2. Failed to perform a triage assessment (the process of determining the priority of patients' treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. Triage may result in determining the order and priority of emergency treatment, the order and priority of emergency transport, or the transport destination for the patient) and a medical screening examination for three of 24 sampled patients. (Patients 39, 40, and 43)

3. Failed to accurately assign the appropriate triage class to five of 24 sampled patients. (Patients 30, 31, 33, 34, 47, and 48)

These failure have the potential for an emergency condition to go undetected and result in an adverse patient outcome.

Findings:

1. On 2/11/14, Patient 31's record was reviewed. Patient 31 came to the emergency department (ED) on 1/29/14 at 1528 (3:28 pm) for vaginal bleeding and back pain which was rated as a level 4 of 10. Patient 31 reported she was 17 weeks pregnant. Patient 31's record contained triage notes, performed at 3:39 pm, which indicated that Registered Nurse (RN) D was unable to find fetal heart tones. Patient 31's record did not contain evidence that Patient 1's physician was notified of the lack of fetal heart tones. Patient 31's triage notes further indicated that Patient 31's last menstrual period was 10/5/13, the expected date of delivery was 7/12/14, and 16 weeks gestation (pregnancy).

Patient 31's medical screening examination (MSE), performed from 4:15 to 4:20 pm by ED Physician E, indicated that Patient 31 had a family history of miscarriage. Patient 31's MSE did not contain evidence of assessments of prenatal medical history or prenatal labs if no prenatal care, fetal heart tones, ultrasound (method to visualize structure under the skin), or a pelvic examination. Patient 31's Obstetric (study of pregnancy, labor, and aftercare) Doctor was not notified of the visit to ED or contact Hospital F for further advice. The MSE indicated that Patient 31 had no pain at the time of examination.

On 2/12/14, Web MD online listed the following information related to miscarriage:
A miscarriage is the loss of a fetus before the 20th week of pregnancy. The medical term for a miscarriage is spontaneous abortion but the condition is not an abortion in the common definition of the term.
According to the March of Dimes, as many as 50% of all pregnancies end in miscarriage -- most often before a woman misses a menstrual period or even knows she is pregnant. About 15% of recognized pregnancies will end in a miscarriage.
More than 80% of miscarriages occur within the first three months of pregnancy. Miscarriages are less likely to occur after 20 weeks gestation; these are termed late miscarriages.
Symptoms of a miscarriage include:
· Bleeding which progresses from light to heavy;
· Severe cramps;
· Abdominal pain;
· Fever;
· Weakness; and
· Back pain.

Patient 31 was discharged with back pain rated as a 5 of 10.
Patient 31's previous medical records contained an ultrasound assessment of the fetus conducted on 12/6/13 which indicated that the baby was 8 weeks, 0 days based on the ultrasound measurements.

On 2/11/14, the hospital policy, titled, "ED Care of the Patient," dated 12/19/13, read, "Obtain related history:...name of current obstetrician/any pre-natal care.. As part of the R.N.'s Triage, and/or the Medical Screening Exam done by the physician, pregnant women will receive the following screening for symptoms of: ...vaginal discharge or bleeding...Required testing...fetal heart tones."

On 2/11/14 at 11 am, RN D stated he had tried to get a fetal heart tone but was unable to do so. RN D stated he had asked ED Physician E if he would obtain fetal heart tones. RN D stated ED Physician E declined. RN E further stated that he had not followed up on the inconsistencies in Patient 31's stated weeks of gestation and the weeks as calculated using her last menstrual date. RN D stated he had not followed the hospital procedure for using the pregnancy calculator (wheel) to determine weeks of gestation nor had he reviewed Patient 31's previous visits to the hospital. RN D related that Patient 31 was quite anxious when fetal heart tones were not able to be found but that he reassured her. RN D acknowledged that he knew that Patient 31 did not have pre-natal care and had neglected to document this. RN D stated that upon discharge at 4:36 pm, he knew that Patient 31 was planning to seek an obstetrical evaluation at another hospital as the ultrasound department closed at 4 pm and was not available to assist with the fetal heart tones assessment.

On 2/11/14 at 11:20 am, ED Physician C stated he had reviewed Patient 31's record and found that the MSE lacked information regarding the prenatal care, the fetal heart tones, review of previous visits at the hospital for information such as gestational age, and a lack of a vaginal/pelvic examination which was indicated. ED Physician C was also concerned regarding the inconsistencies in documentation with ED Physician C's pain evaluation versus the nursing assessment, and whether the Patient 31 was sent to Hospital F for further evaluation (ultrasound). ED Physician C acknowledged that he thought this inadequate MSE was an EMTALA violation.

On 2/11/14 at 10:30 am, ED Manager A acknowledged that despite extensive education of nursing staff and physicians, an adequate MSE was not completed for Patient 31.

On 2/12/14, Hospital F's record indicated that Patient 31 was seen for the above complaints and fetal heart tones were present indicating a live fetus.

2a. On 2/12/14, Patient 39's record was reviewed. Patient 39 presented to the ED on 1/14/14 at 1:55 pm for infection spreading to her cheek and ear following the removal of an infected tooth. Patient 39 rated her pain as a 10 on scale of 1 to 10 on a chief complaint form. Patient 39's record indicated that she left without being seen at 4:27 pm, greater than 2.5 hours later. Patient 39's record contained no triage assessment or MSE.

Patient 39's record further contained a second visit to the ED on 1/14/14 at 8:14 pm for the same complaint as above. Patient 39 described the pain as shooting in her cheek and rated the pain again as a 10. Patient 31's record indicated that she left without being seen at 9 am, 45 minutes later. Patient 39's record contained no triage assessment or MSE.

On 2/12/14 at 11:15 am, Patient 39 was contacted via telephone, and stated that she had waited 3 to 4 hours in the waiting room and during that time no one had assessed her. Patient 39 reported that she left and returned later and was told by the blonde registration clerk that the ED was full with elderly people and that they couldn't move patients out. This clerk further told her to go to Hospital F to get seen.

On 2/12/14 at 1:40 pm, ED Manager A reviewed Patient 39's record and could not account for why Patient 39 had two visits to the ED for the same complaint without receiving a triage assessment and a medical screening exam. ED Manager A stated that this was not appropriate care. ED Manager A further stated it was unacceptable that the registration clerk (later identified as Clerk G) told Patient 39 to seek care elsewhere.



28650


2b. The ED record for Patient 40 was reviewed on 2/12/14. Patient 40 presented to the ED on 1/15/14 at 4:56 pm with the chief complaint noted as 5150 Hold for Mental Health (5150 is the California Welfare Institution Code allowing for the 72-hour involuntary detention for evaluation and treatment of persons dangerous to themselves or others or who are gravely disabled as a result of a mental disorder).

Patient 40's record did not contain evidence that an initial triage evaluation, nursing assessment, or medical screening examination had taken place, prior to him leaving the ED (left without being seen) at 6:30 pm, over 1.5 hours later.

During a concurrent interview and record review with ED Manager A and HIM Manager at 2/12/14 at 2:15 pm, both confirmed that Patient 40's ED record contained no evidence that an initial triage evaluation, nursing assessment or medical screening examination had been completed. ED Manager A stated that her expectation would be that the patient should have been triaged in a more timely manor and that waiting over 90-minutes to be seen by anyone was unacceptable.

On 2/12/14 at 2:40 pm, ED Physician C reviewed Patient 40's record and confirmed that he had not examined or seen Patient 40 prior to his departure.

2c. The ED record for Patient 43 was reviewed on 2/12/14. Patient 43 presented to the ED on 1/23/14 at 5:27 pm with the chief complaint noted as right big toe bleeding following nail removal surgery.

Patient 40's record did not contain evidence that an initial triage evaluation, nursing assessment or medical screening examination had taken place, prior to him leaving the ED (left without being seen) at 7:06 pm, over 1.5 hours later.

During a concurrent interview and record review, with ED Manager A at 2/12/14 at 3:10 pm, she confirmed that Patient 43's ED record contained no evidence that an initial triage evaluation, nursing assessment or medical screening examination had been completed. ED Manager A stated that her expectation would be that the patient should have been triaged in a more timely manor, preferably within 10 minutes,and that waiting over 90-minutes to be seen by anyone was unacceptable.

3a. The ED record for Patient 33 was reviewed on 2/11/14. Patient 33 presented to the ED on 1/28/14 at 12:10 pm with the chief complaint noted as thirteen weeks pregnant and vomiting.

On 2/12/14, the hospital policy, titled, "Triage Standards and Guidelines," dated 9/1/97 and reviewed on 1/31/14, had nausea and vomiting listed as an example of triage level 3.

Patient 33's ED record showed that she had been triaged at 12:20 pm, and had been assigned a triage/acuity level of 4.

During an interview and concurrent record review with ED Manager A on 2/11/14 at 3 pm, she stated that Patient 33 had been assigned an incorrect triage/acuity level based on her presenting complaints.

3b. The ED record for Patient 30 was reviewed on 2/11/14. Patient 30 presented to the ED on 2/5/14 at 3:38 pm with the chief complaint noted as eight weeks pregnant with spotting (intermittent bleeding) and cramping.

Patient 30's ED record showed that she had been triaged at 4:20 pm, and had been assigned a triage/acuity Level of 4.

The triage policy indicated gynecological complaints such as bleeding and cramping as an example of triage Level 3.

During an interview and concurrent record review with ED Manager A on 2/11/14 at 10:30 am, she stated that Patient 30 had been assigned an incorrect triage/acuity level based on her presenting complaints.

3c. The ED record for Patient 47 was reviewed on 2/12/14. Patient 47 presented to the ED on 1/31/14 at 10 am, with the chief complaint noted as falling off her bicycle with possible head trauma.

Patient 47's ED record showed that she had been triaged at 10:45 am, and had been assigned a triage/acuity Level of 5.

During an interview and concurrent record review with ED Manager A on 2/12/14 at 3:10 pm, she stated that Patient 47 had been assigned an incorrect triage/acuity level based on her presenting complaints and should have been either Level 2 or 3.

3d. Patient 31 came to the ED for vaginal bleeding and back pain rated as a level of 4 of 10. Patient 31 was 17 weeks pregnant. Patient 31's ED record showed that she had been triaged at 3:39 pm, and had been assigned a triage/acuity Level of 5.

On 2/11/14 at 11 am, RN D stated that he did the triage level determination at the end of the ED stay and tried to give the lowest score so patients would not have excessive charges.

The triage policy indicated gynecological complaints such as bleeding and cramping as an example of triage Level of 3.

During an interview and concurrent record review with ED Manager A on 2/12/14 at 3:10 pm, she stated that Patient 31 had been assigned an incorrect triage/acuity level based on her presenting complaints and that although RN D had passed a recent triage education examination, he had not demonstrated accurate knowledge of the triage level classifications and their purpose.

3e. The ED record for Patient 34 was reviewed on 2/11/14. Patient 34 presented to the ED on 1/28/14 at 1:55 pm with the chief complaint of 14 weeks pregnant with vomiting and dehydration.

Patient 34's ED record showed that she had been triaged at 2:17 pm, and had been assigned a triage/acuity Level of 4.

During an interview and concurrent record review with ED Manager A on 2/12/14 at 1:40 pm, she stated that Patient 34 had been assigned an incorrect triage/acuity level based on her presenting complaints and should have been at a Level of 2.

3f. The ED record for Patient 48 was reviewed on 2/12/14. Patient 48 presented to the ED on 1/31/14 at 9:50 am with the chief complaint of a stroke.

Patient 48's ED record showed that he had been triaged at 9:53 am, and had been assigned a triage/acuity level of 3.

The triage policy listed stroke as an example of triage level 2.

During an interview and concurrent record review with Admin Staff A on 2/12/14 at 3:10 pm, she stated that Patient 48 had been assigned an incorrect triage/acuity level based on her presenting complaints.

28650

Based on interview and record review, the hospital failed to ensure that two of 24 sampled patients, who were a danger to themselves or others, were provided protective supervision. This failure resulted in Patients 40 and 41 eloping from the facility and could result in harm to themselves or others.

Findings:

1. The Emergency Department (ED) record for Patient 41 was reviewed on 2/12/14. Patient 41 presented to the ED on 1/16/14 at 1:30 pm with the chief complaint noted as medical clearance for mental health placement. This refers to the medical evaluation of patients in the ED, whose symptoms appear to be psychiatric in origin. The objective is to determine whether serious underlying medical illness exists, which would render admission to a psychiatric facility unsafe or inappropriate.

Patient 41's record indicated that he was triaged at 1:40 pm and had received a medical screening examination by the physician at 1:35 pm.

Patient 41's record contained a document titled, "Physician ED Record", which indicated that his chief complaints were alcohol intoxication and suicidal thoughts. The physician who examined Patient 41 had documented the following diagnosis; alcohol intoxication, depression with suicidal ideation and absconded (to leave hurriedly and secretly, typically to avoid detection) from the ED.

The ED nursing notes for Patient 41 indicated:
2:10 pm, Mental health staff member was present at bedside with patient;
3 pm, Patient resting quietly at this time;
3:53 pm, Patient out to smoke;
4:00 pm, Patient back in room;
4:57 pm, Patient out to smoke;
5:10 pm, Patient back in room;
5:30 pm, Patient gone. IV catheter (needle used to give medication and fluids into the vein) intact laying on the ground with IV tubing. Mental health agency notified. They state that they will notify the police department.

During an interview and concurrent record review with ED Manager A on 2/12/14 at 1:30 pm, she confirmed that according to the record that Patient 41 eloped (left without permission) from the ED. ED Manager A confirmed that it is not their facility's policy or practice to allow any patient who had been identified as being suicidal to go outside to smoke without adequate supervision. ED Manager A also acknowledged that proper suicide precautions had not been taken per facility's policy.

The facility's policy titled, "Suicide Precautions in the Medical Setting," dated 8/07, indicated that each patient identified as a risk for self-harm, suicidal ideation or homicidal ideation will be assessed and assigned to a level of care and precautions based on the patient's medical needs and ability to maintain control and safety... Suicide precautions include having the patient within visual contact of the staff at all times and those patients may only leave the unit for tests with staff escorts... The observing staff member will document continuous observation of the patient every 15-minutes.

Registered Nurse (RN) H was interviewed by phone on 2/13/14 at 3:40 pm, she stated that Patient 41 had been supervised each time he left the ED to smoke and was in a room situated across from the nurse's station for close observation. RH H recalled that multiple critical patients arrived that took her immediate attention off of Patient 41 and at which point he took the opportunity to elope from the ED.

2. The Emergency Department (ED) record for Patient 40 was reviewed on 2/12/14. Patient 40 presented to the ED on 1/15/14 at 4:56 pm with the chief complaint noted as 5150 Hold for Mental Health (5150 is the California Welfare Institution Code allowing for the 72-hour involuntary detention for evaluation and treatment of persons dangerous to themselves or others or who are gravely disabled as a result of a mental disorder).

Patient 40's record did not contain evidence that an initial triage evaluation, nursing assessment or medical screening examination had taken place, prior to him leaving the ED (left without being seen) at 6:30 pm.

During a concurrent interview and record review, with ED Manager A and HIM Manager, at 2/12/14 at 2:15 pm, both confirmed that Patient 40's ED record contained no evidence that an initial triage evaluation, nursing assessment or medical screening examination had been completed. ED Manager A stated that her expectation would be that the patient should have been triaged in a more timely manor and that waiting over 90-minutes to be seen by anyone was unacceptable. ED Manager A confirmed that it is not their facility's policy or practice to allow any patient who had been identified as 5150 status to be allowed to leave on there own. ED Manager A also acknowledged that proper precautions had not been taken per facility's policy.

The facility's policy titled, "Mentally Disordered/Suicidal Patients: 5150 Hold (72 hour Detention)," dated 8/11, indicated that patients that are a danger to self or others will be provided with appropriate safety interventions based on the patient's needs, patient rights and the least restrictive intervention.