HospitalInspections.org

Based on policy and procedure review, medical record review, hospital document review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

Based on policy and procedure review, medical record review, hospital document review and staff and physician interviews the hospital failed to ensure a timely Medical Screening Examination (MSE) was provided within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 20 sampled patients (Patient #5).

~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A2406.

Based on policy and procedure review, medical record review, hospital document review and staff and physician interviews the hospital failed to ensure a timely medical screening examination (MSE) was provided within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 20 sampled patients (Patient #5).

The findings include:

Review of hospital policy "EMTALA (Emergency Medical Treatment and Labor Act) Policy" last revised 7/29/2019 revealed "Procedure...1. Any individual who comes to the Emergency Department requesting examination or treatment shall be provided an appropriate medical screening examination 2. The medical screening examination shall include use of ancillary services available to the Emergency Department..."

Review of closed medical record for Patient # 1 revealed a 55-year-old female who presented to the Hospital's DED (Dedicated Emergency Department) on 10/23/2020 at 1429 for a stated complaint of chest pain (CP) and shortness of breath (SOB). Review revealed triage timer began at arrival at 1429. Review revealed triage assessment began at 1534 (1 hour 5 minutes after arrival). Review revealed "ED Triage Assessment" by Registered Nurse (RN) #1 at 1534 "Chief Complaint Triage: General Medical Problem; ...This morning she woke up and had chest pain as well and has not been able to get the pain to go away. States the pain radiates to her jaw." Review revealed vital signs were documented as: blood pressure 118/72; pulse 59; respiratory rate 20; oxygen saturation 100% on room air. Review revealed no pain score documented on triage assessment. Review revealed EKG (electrocardiography) completed at 1546 which displayed "Inferior infarct, possibly acute." Review revealed MSE by Medical Doctor (MD) # 2 began at 1550 (1 hour 21 minutes after arrival). Review of "ED Physician Report" at 1550 revealed "Stated Complaint: CP/SOB; HPI narrative: 55-year-old female presents to the ER with complaints of epigastric and upper chest pain. For the past 2 days. She states about 1 week ago she passed a kidney stone. States she was started on Cipro (antibiotic) and believes this may have started an ulcer in her stomach. She was seen at her PCP (primary care physician) and was started on Carafate (used to treat and prevent ulcers). States she woke up and had chest pain as well and has not been able to get the pain to go away. States the pain radiates to her jaw. Symptoms have improved somewhat since this morning. Physical Exam- General appearance- alert, in distress ... Reevaluation #1: 10/23/2020 at 1638 Lab called with a critical value troponin at 26 ... Consultations #1: Discussed with (named MD) at cardiology at named hospital he accepted the patient to transfer he recommends that she gets Lovenox (blood thinner), nitrates and a beta blocker given her symptoms .... Disposition; Clinical Impression: NSTEMI (non-ST elevated myocardial infarction); Disposition: Transfer to Tertiary Hospital ..." Review revealed Patient #1 was transferred to tertiary hospital via critical care ambulance at 1837.

A review of ED Staffing Assignments on 10/23/2020 revealed no nurse was assigned to triage. Review revealed ED Charge Nurse to cover triage.

Review of the Emergency Department Summary for 10/23/2020 revealed a patient census of 24 when Patient #1 arrived to the hospital's DED. Review of census revealed patients with prior arrival times to triage of 1342, 1416, 1418 and 1422 (Patient #1 was the DED 25th patient when she arrived at 1429).

Interview on 05/05/2021 at 0850 with Front Desk Coordinator # 3 on duty in DED revealed if a chest patient presented to the ED, she would call the charge nurse immediately.

Interview on 05/05/2021 at 0935 with the Front Desk Coordinator #4 revealed she previously worked in the DED and would check patients in. Interview revealed she would enter stated complaints and enter names and date of birth into the EHR (electronic health record). Interview revealed she would perform a respiratory questionnaire which would trigger the triage timer. Interview revealed when a patient presents with chest pain and shortness of breath symptoms, she would call the charge nurse. Interview revealed the charge nurse would have a CNA (certified nursing assistant) perform an EKG on the patient.

Interview on 05/05/2021 with MD #2 revealed he was the MD who performed the MSE on Patient #1. Interview revealed Patient #1 should have had an EKG within 10 minutes of arrival with a complaint of chest pain. Interview revealed MD #2 is also the DED's Medical Director. Interview 10 minutes is an expectation, which has not been measured. Interview revealed door to EKG times are going to be measured as an ongoing expectation.

Interview on 05/05/2021 with RN#1 revealed she triaged Patient #1. Interview revealed she had a patient care assignment (rooms 19-22). Interview revealed she saw a patient in the waiting room who had a complaint of chest pain who needed to be triaged and went and triaged her when she was caught up with patient care. Interview revealed she helps in triage when she is able. Interview revealed when there is no assigned triage nurse, the charge nurse is responsible, but everyone pitches in. Interview revealed if an urgent patient arrives, registration calls and notifies the charge nurse.

Interview on 05/05/2021 at 1445 with RN #5 revealed he was the charge nurse on 10/23/2021. Interview revealed the charge nurse is responsible for triage. Interview revealed with a census of 24-25 he does not recall what could have happened to delay Patient #1 being triaged in a timely manner or performing an EKG. Interview revealed he should have sent a CNA to perform the EKG. Interview revealed "this is a perfect example of why they need a triage nurse at all times."

Interview on 05/05/2021 at 1505 with the ED Director revealed after review of census on 10/23/2021 during Patient #1 arrival time and staffing, there were no acute patient care issues that would cause a delay in triage. Interview revealed census did not reveal any sudden influx of walk in or ambulance patients that would cause a triage delay.