HospitalInspections.org

Based on observation and interview, the hospital failed to ensure a sign was posted in a conspicuous place in the ED or in any place or places likely to be noticed by all individuals entering the ED specifying the rights of individuals under section 1867 of the EMTALA with respect to examination and treatment for emergency medical conditions and women in labor and to post conspicuously information indicating whether or not the hospital participated in the Medicaid program.

Findings:

Observation on 06/28/16 at 10:40 a.m. in the ED, waiting area of the ED, and the ambulance entrance to the ED revealed no observation of signs posted specifying the rights of individuals under section 1867 of the EMTALA as stated above.

In an interview on 06/28/16 at 10:45 a.m. during the above observation, S2DON confirmed there were no signs posted in the ED, waiting area of the ED, and the ambulance entrance to the ED specifying the rights of individuals related to the EMTALA.

Based on record reviews and interviews, the hospital failed to follow hospital policy by ensuring a central log was maintained on each individual who comes to the ED seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged as evidenced by failure to have Patient #1 who presented for ED services on 06/18/16 included on the ED log.

Findings:

Review of the policy titled "Emergency Department Log", contained in the policy and procedure manual presented by S2DON as the hospital's current ED policies and procedures, revealed that the ED will maintain a log of all patients presenting to the ED for treatment, including individuals dead on arrival and those leaving without being seen by the ED physician. Information will include identification (name, address, age, sex), date, time, and means of arrival, nature of complaint, disposition, time of departure, and diagnosis. Further review revealed no documented evidence that the policy addressed whose responsibility it was to document patient information into the log and the process for doing so.

Review of the "ED Activity Log" for 06/18/16 from 12:00 a.m. to 11:59 p.m. revealed no documented evidence of Patient #1's name, date, time, and means of arrival, nature of complaint, disposition, time of departure, and diagnosis.

In a telephone interview on 06/28/16 at 2:15 p.m., S6PBXO indicated she worked as the registration clerk in the ED on 06/18/16. She further indicated Patient #1 presented to the ED with her mother and two deputies. S6PBXO indicated when the deputy and mother began to tell her the presenting problem, she asked the deputy to go into the ED treatment area and speak with a nurse about Patient #1. She further indicated when the deputy returned to her window, he said "they don't do that here, we're going to go to Hospital A." When S6PBXO was informed by the surveyor that Patient #1's name was not listed on the ED log, she indicated she did a "quick reg", which she described as the process of entering the patient's name and date of birth in the log. She further indicated since Patient #1 left without being seen, she called her supervisor to ask what to do, and S9BOS, her supervisor, deleted Patient #1's name from the "quick reg."

In an interview on 06/28/16 at 2:33 p.m., S5RN indicated Patient #1 and her mother were starting to register, and the next thing she knew, they were gone. She further indicated the nurse has nothing to do with the ED log.

In an interview on 06/29/16 at 11:50 a.m., S9BOS indicated when a patient presents with a report of sexual assault, the ED clerk will go to the ED treatment area to speak with the nurse, rather than speak with the nurse by phone with the patient standing there. She further indicated that what S6PBXO meant when she said that S9BOS deleted the "quick reg" was that S9BOS removed Patient #1's name from the board listing patients who are waiting to be seen in the ED. S9BOS indicated the ED log isn't completed until the patient is triaged, so if the nurse had documented that the patient left without being seen, Patient #1's name would have appeared on the ED log.

Based on record reviews and interviews, the hospital failed to ensure each individual who comes to the ED is provided an appropriate MSE within the capability of the hospital's ED to determine whether or not an EMC exists as evidenced by failure to provide a MSE for Patient #1 who presented to the ED on 06/18/16 with a chief complaint of alleged sexual assault for 1 (#1) of 21 sampled patients.

Findings:

Review of the hospital policy titled "EMTALA - AKMH ER Admission Process", contained in the policy and procedure manual presented by S2DON as the hospital's current ED policies and procedures, revealed that emergency service facilities are available at the hospital 24 hours a day. Further review revealed when a patient (or someone on their behalf) presents to the ED and requests examination or treatment, the hospital will provide for an appropriate MSE within the capability of the hospital's ED to determine whether or not an EMC exists. The MSE and determination of an EMC will be done by the on-duty ED physician. Upon presentation of the patient or attendant, the operator will begin the intake process by asking the patient's age and chief complaint. After the name and chief complaint are collected, the operator will notify the ED nurse that the patient is present and give the age, sex, and chief complaint. The nurse will perform a rapid triage on the patient and determine whether or not the patient is stable enough to give demographic information or if the patient should go back into the ED at that moment. If the patient is stable enough to give demographic information, then the operator will take the information and print a face sheet, labels, and a bracelet. The operation will place the bracelet on the patient and have the patient sign the Conditions of Admission & (and) Privacy policy, if necessary.

Review of the hospital policy titled "AKMH Triage Process", contained in the policy and procedure manual presented by S2DON as the hospital's current ED policies and procedures, revealed that the process described in the "EMTALA - AKMH ER Admission Process" policy would be followed. Further review revealed the ED nurse will assign a triage level on the ED record in order to classify the intensity of their chief complaint.

Review of the hospital policy titled "EMTALA Responsibilities - ER", contained in the policy and procedure manual presented by S2DON as the hospital's current ED policies and procedures, revealed that hospitals with a dedicated emergency department are required under EMTALA to provide an appropriate MSE to any individual who comes to the ED, or elsewhere on hospital property, or presents to the Outpatient Department for non-ED related testing who have not yet begun the registration process and requests examination or treatment for an EMC, or if a prudent layperson observer would believe that the individual may have an EMC.

Review of the hospital policy titled "Alleged Rape", contained in the policy and procedure manual presented by S2DON as the hospital's current ED policies and procedures, revealed that the actual examination and treatment of any patient must depend upon the physician's judgement of the patient's needs as well as the patient's wishes.

Review of the "ED Activity Log" for 06/18/16 from 12:00 a.m. to 11:59 p.m. revealed no documented evidence of Patient #1's name, date, time, and means of arrival, nature of complaint, disposition, time of departure, and diagnosis.

There was no documented evidence of an ED medical record for Patient #1 presented when it was requested by the surveyor.

In a telephone interview on 06/28/16 at 2:15 p.m., S6PBXO indicated she worked as the registration clerk in the ED on 06/18/16. She further indicated Patient #1 presented to the ED with her mother and two deputies. She further indicated one of the deputies said that Patient #1 needed an evaluation, and her mother said she was raped. S6PBXO indicated when the deputy and mother began to tell her the presenting problem, she asked the deputy to go into the ED treatment area and speak with a nurse about Patient #1. She further indicated when the deputy returned to her window, he said "they don't do that here, we're going to go to Hospital A." S6PBXO indicated she didn't know what was meant by "they don't do that here", and she didn't ask the deputy what he meant. When S6PBXO was informed by the surveyor that Patient #1's name was not listed on the ED log, she indicated she did a "quick reg", which she described as the process of entering the patient's name and date of birth in the log. She further indicated since Patient #1 left without being seen, she called her supervisor to ask what to do, and S9BOS, her supervisor, deleted Patient #1's name from the "quick reg."

In an interview on 06/28/16 at 2:33 p.m., when S5RN was asked what she would tell a patient or their parent who presented to the ED and reported that they had been raped or sexually assaulted and needed to see a physician, she indicated she would register the patient and triage them "like normal." She further indicated she would do whatever the physician needed done, and if completing a rape kit was needed, she would do it. She further indicated if the hospital didn't have a rape kit in stock, they would contact the sheriff's office or police department to bring a kit to the ED. S5RN indicated they have done rape kits in the ED. She indicated she remembered a deputy came into the ED treatment area on 06/18/16 and spoke with her about Patient #1. S5RN indicated she told the deputy that the patient would have to be seen by the doctor who would determine if a rape kit was needed. S5RN indicated she never told the deputy that they don't do rape kits at the hospital. She further indicated Patient #1 and her mother were starting to register, and the next thing she knew, they were gone. S5RN confirmed Patient #1 was never triaged by the RN and brought into the ED for a MSE.

In an interview on 06/29/16 at 8:55 a.m., S7MD indicated there were no patients in the ED on 06/18/16 when Patient #1 arrived. He further indicated he was in the on-call room and did not see Patient #1. He further indicated he was not called by the nurses to come to the ED to examine Patient #1. S7MD indicated he does do physical examinations for alleged sexual assault and completes rape kits if needed.

In an interview on 06/29/16 at 9:00 a.m., S8RN indicated she worked the ED on 06/18/16 when Patient #1 presented to the ED. She further indicated she works as a contract nurse with Company A. S8RN indicated she never saw Patient #1 or her mother on 06/18/16. She further indicated a deputy came into the treatment area of the ED and said a young girl was coming with possible sexual assault. She indicated she asked the other RN present, S5RN, what their protocol was related to alleged sexual assault patients. S8RN indicated S5RN told her they bring the patient to the back, let the doctor examine the patient, and get a rape kit from the police or coroner's office. She further indicated Patient #1 came and began to register, and she doesn't know what happened after that. S8RN confirmed she did not triage Patient #1, and Patient #1 did not receive a MSE.

In a telephone interview on 07/01/16 at 1:16 p.m., S10SGT indicated he arrived at the hospital at the same time as Patient #1 and her mother. He further indicated he went to the ED clerk to let her know that they possibly needed to get a rape kit done. S10SGT indicated he didn't remember if he asked to go to speak with the nurse, or if the ED clerk told him to go to speak with the nurse, but he went into the ED and spoke with 2 nurses. The nurses informed him that they didn't "have the ability to do the rape kit." One of the nurses texted the Assistant Coroner who told the nurse she (Assistant Coroner) wasn't qualified to do a rape kit on a child under the age of 8 years old. S10SGT indicated the nurses gave him other options by naming other hospitals who had SANE nurses who could do a rape kit. He further indicated he contacted his office who told him another deputy was at Hospital A with the perpetrator and told S10SGT to go to Hospital A with Patient #1. S10SGT indicated he went back to the waiting area, where Patient #1's mother was registering her. He indicated he told the mother the hospital didn't have the capability to do a rape kit, and they needed to go to Hospital A. S10SGT indicated at this point they left to go to Hospital A.