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 three of 24 sampled patients. (Patients 107, 115, and 116)

2. Failed to accurately assign the appropriate triage class to one of 24 sampled patients. (Patient 101)

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 interview and record review, for those patients presenting to the hospital's Emergency Department (ED), the hospital failed to maintain a central log in which each patient presenting for emergency care was listed along with all of the information required by CFR 489.24 for 11 patients. The specific information missing from some pages of the ED log were:

1. Patients 103, 109, 110, 113, 122, 125, 128, and 129 log entries were blank for disposition, and discharge date and time. Patients 105 and 111's log entries were incomplete for chief complaint.

2. Patient 127 had an inaccurate admission time.

These failures had the potential for miscommunication and the inability to assess the compliance with CFR 489.20- 489.24 requirements.

Findings:

1. On 5/27/14, the ED logs for 5/1 through 5/27/14 were reviewed. The log entries for Patients 103, 109, 110, 113, 122, 125, 128, and 129 did not contain evidence of the disposition, and discharge date and time. Patient 105's log entry stated "Unknown." Patient 111's log entry only stated "Altered."

On 5/28/14 at 4 pm, Administrative (Admin) Staff A reviewed the above ED log entries and acknowledged that the ED log was not completed with all the required elements.



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2. On 5/28/14, Patient 127's record was reviewed. Patient 127's record listed the arrival time on 5/4/14 as 19:24 (7:24 pm).

On 5/28/14, the ED log listed Patient 127's arrival time as 07:24 (7:24 am).

On 5/28/14 at 4 pm, Admin Staff A reviewed the ED logs and Patient 127's record and acknowledged that the log was not correct.

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Based on interview and record review, the hospital failed to ensure that an appropriate screening exam was provided for four of 29 sampled emergency room (ED) patients as evidenced by:

1. Failure to perform an adequate medical screening examination for three of 24 sampled patients. (Patients 107, 115, and 116)

2. Failed to accurately assign the appropriate triage class to one of 24 sampled patients. (Patient 101)

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

Findings:

1. On 5/28/14, Patient 107's record was reviewed. Patient 107 came to the ED on 5/20/14 complaining that she was 20 weeks pregnant, had not felt fetal (baby) movement for two days, had intermittent pelvic pain, and was experiencing nausea and vomiting. Patient 107 record did not contain any evidence of a medical screening examination by a physician or mid level practitioner (a Nurse Practitioner or Physician Assistant).

On 5/28/14, the hospital policy, titled, "Medical Screening," dated 1/31/14, read "Persons presenting ... to the ED shall receive a medical screening examination within the capabilities of the department..."

On 5/28/14, the hospital contract for ED coverage, effective 4/2/14, read, "The group (ED physicians) shall require prompt submittal ... of written reports of all examinations, treatments and procedures performed..."

On 5/28/14, the hospital Medical Staff Rules and Regulations, dated 11/29/12, read under Emergency Services, "An appropriate record shall be kept for every patient receiving emergency service...The record shall include:...c) pertinent history of the injury or illness... d) description of significant clinical, laboratory and radiological findings, e) Diagnosis, f) treatment given, and g) Condition of patient on discharge or transfer..."

On 5/28/14 at 4 pm, Administrative (Admin) Staff A reviewed Patient 107's record acknowledged that the record did not contain a medical screening examination.

2. On 5/28/14, Patient 101's ED record was reviewed. Patient 101 presented to the ED on 5/1/14 at 1:38 am with the chief complaint of a fever, nausea, vomiting after a recent episode of pneumonia. Patient 101's ED record showed that he had been triaged at 1:38 am, and had been assigned a triage/acuity level of 4.

On 5/28/14, the hospital policy, titled, "Triage Standards and Guidelines," dated 9/1/97, presented examples of Level 3 patients including nausea, vomiting, and fever.

During an interview and concurrent record review with ED Nurse A on 5/28/14 2:30 pm, she stated that Patient 101 had been assigned an incorrect triage/acuity level based on his presenting complaints.



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3. On 5/28/14, Patient 115's record was reviewed. Patient 115 came to the ED on 5/21/14 complaining of a body rash. Patient 107 record did not contain any evidence of a medical screening examination by a physician or mid level practitioner.

On 5/28/14 at 4:45 pm, Admin Staff A reviewed Patient 115's record and acknowledged that the record did not contain a medical screening examination.

4. On 5/28/14, Patient 116's record was reviewed. Patient 116 came to the ED on 5/21/14 for sharp pain in the abdomen. Patient 116's record contained a form titled, "Physician ED Record" which was blank for the ED course of care and diagnosis. Patient 116's record did not contain a record of the medical decision making or final diagnosis. The record did not contain a medical screening examination. Patient 116 was discharged home with a prescription and instructions to follow up with the local clinic in one week.

On 5/28/14, the hospital policy, titled, "Medical Screening," dated 1/31/14, read, "If the Medical Screening Examination determines that a patient has an emergency medical condition, the care provider will provide further medical examination and treatment required to stabilize the medical condition, within the capabilities of the hospital."

On 5/28/14 at 4:40 pm, Admin Staff A reviewed Patient 116's record and acknowledged that Patient 116's record failed to have a documented medical screening examination. The record failed to demonstrated the medical decision making and diagnosis or any other evidence to determine that an emergency medical condition existed or if one did existed was appropriately stabilized.



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