HospitalInspections.org

Based on record review and staff interviews it was determined the hospital failed to have the Emergency Department (ED) patient sign a refusal for medical treatment and discharged the patient without receiving a proper medical screening in one (1) of one (1) medical record reviewed (patient #1). This failure has the potential for all patients who seek care in the ED to not receive proper medical care.

1. Review of the medical record for patient #1 revealed the patient arrived at the ED via ambulance on 03/23/19 at 4:52 a.m. She was triaged by Charge Nurse #1 with documentation of patient's skin cold to touch and heated blankets applied. Temperature upon triage was documented at 97.5 degrees Fahrenheit. Documentation by physician #1 is as follows: "Complaint of altered mental status that a few minutes later she stated, "Fell off a porch." EMS states the patient was running from the police...No loss of consciousness from her fall per EMS. The patient repeatedly states that she is dehydrated and wants put on life support. Full history of present illness is unobtainable from patient secondary to altered mental status and unwillingness to talk. Full review of systems is unobtainable from patient secondary to altered mental status. History: Bipolar disorder, post-traumatic stress disorder (PTSD) and schizoaffective disorder, bipolar type. A normal head to toe assessment is completed as normal. Electrocardiogram (EKG) is documented as bradycardia. Review of old records available with a note from psychiatry...doing well. 5:24 a.m. Patient is agreeable to treatment plan at this time. 5:43 a.m. Patient is refusing all evaluation and care that I was trying to offer. Does not appear to be any sign of emergent medical condition. I will let patient leave. Patient is to return here to the ED if she changes her mind or if new or worsening symptoms appear. The patient is in stable condition at the time of discharge." 5:25 p.m. Registered Nurse (RN) #1 documented "patient awake and talking nonsense. States she wants placed on life support... Demanding critical care because she is a critical patient. Physician is at bedside attempting to assess patient. States she wants on life support so she can talk to her son. States she fell off porch and broke multiple bones...Patient has stopped talking to us. Heart rate between 40-50. Walked into room to draw blood and patient keeps talking to her lord saying we are the devil and she will not allow us to do anything to her. Doctor in room. Patient continues to refuse treatment. Patient is ready for discharge. 6:03 a.m. Patient refuses to leave room...Security called to escort patient to waiting room. Called her father who is on her contact list and unable to get in contact with him. Left a message. Patient in waiting room." There was no written documentation in the medical record of refusal of treatment from patient or patient representative.

2. An interview was conducted with the Chairman of the ED on 04/02/19 at approximately 10:15 a.m. He concurred that he had reviewed the medical record for patient #1 and no refusal of medical care or leaving against medical advice form were signed.

Based on record and document review, interviews and video review it was determined the hospital failed to allow one (1) of one (1) patients (patient #1) to register for emergency medical treatment when asked by triage nurse and initially by Corporal #1. This failure has the potential for all patients seeking emergency medical treatment to be refused to be seen that may result in permanent damage or their death.

1. Review of medical record for patient #1 revealed the patient arrived at the Emergency Department (ED) via ambulance on 03/23/19 at 4:52 a.m. She was triaged by Charge Nurse #1 with documentation patient skin cold to touch heated blankets applied. Temperature upon triage is documented at 97.5 degrees Fahrenheit. Documentation by physician #1 is as follows: Complaint of altered mental status that a few minutes later she stated, "Fell off a porch." EMS states the patient was running from the police...No loss of consciousness from her fall per EMS. The patient repeatedly states that she is dehydrated and "wants put on life support". Full history of present illness is unobtainable from patient secondary to altered mental status and unwillingness to talk. Full review of systems is unobtainable from patient secondary to altered mental status. History: bipolar disorder, post-traumatic stress disorder (PTSD) and schizoaffective disorder, bipolar type. A normal head to toe assessment is completed as normal. Electrocardiogram (EKG) is documented as bradycardia. Review of old records available with a note from psychiatry...doing well. 5:24 a.m. patient is agreeable to treatment plan at this time. 5:43 a.m. Patient is refusing all evaluation and care that I was trying to offer. Does not appear to be any sign of emergent medical condition. I will let patient leave. Patient is to return here to the ED if she changes her mind or if new or worsening symptoms appear. The patient is in stable condition at the time of discharge. 5:25 p.m. Registered Nurse (RN) #1 documented patient awake and talking nonsense. States she wants "placed on life support... demanding critical care because she is a critical patient. Physician is at bedside attempting to assess patient. States she "wants on life support so she can talk to her son."...States "she fell off porch and broke multiple bones"...patient has stopped talking to us. Heart rate between 40-50. Walked into room to draw blood and patient keeps talking to her lord. Saying we are the devil and she will not allow us to do anything to her. Doctor in room. Patient continues to refuse treatment. Patient is ready for discharge. 6:03 a.m. patient refuses to leave room...security called to escort patient to waiting room. Called her father who is on her contact list unable to get in contact with him. Left a message. Patient in waiting room. No written documentation in the medical record of refusal of treatment from patient or patient representative.

2. Review of medical record for patient #2 revealed she was triaged at 7:54 a.m. A medical screening was conducted at 8:08 a.m. by physician #2. Complaints of altered mental status and fall. Documentation by physician #2 is as follows: Patient was seen earlier for a fall that occurred last night. She states, "My body is broken." She presents in a wheelchair and does not answer questions appropriately. Her medical history includes bipolar disorder, PTSD and schizoaffective disorder. She has been waiting outside the ED since her discharge earlier this morning. She was discharged after refusing treatment. 8:14 a.m. Initial evaluation is complete.. Patient clearly lacks capacity to make decisions... CT of head, neck, chest and abdomen/pelvis ordered. CT impression: There are extensive fractures involving pelvic bone. There are bilateral superior and inferior pubic rami fractures. There is an extensive fracture involving the sacrum on the left side with the fracture line through the neural framina of S3, S4 and S5. The vertically oriented fracture extends to the sacrococcygeal junction. There is a large pelvic hematoma measuring 6.7 x 4.7 x 3.2 centimeters in the greater sciatic notch with extension along the pyriformis muscle. 9:23 a.m. Ruby Memorial Hospital contacted for a life-flight. Unavailable to fly due to weather. 9:35 a.m. Inova Hospital contacted, patient accepted. 10:15 a.m. Patient transported to helicopter for transfer to Inova.

3. Review of investigative notes taken per the Director of the ED reveals a statement from Charge Nurse #2 that states in part, "Called by lobby staff regarding patient's suitability for discharge." She stated, "She was discharged, let her go."

4. An interview was conducted with Charge Nurse #2 on 04/02/19 at 9:04 a.m. When asked if she had refused to allow patient #1 and #2 to check back in to the ED to be seen after her initial discharge she stated in part, "I don't remember if I did...The police did come to pick the patient up and asked to talk to me and when they told us she had a visual fall of two stories we re-seen her in the ED."

5. An interview was conducted with registration clerk #1 on 04/02/19 at 12:15 a.m. When asked if she remembered the patient she stated in part, "Yes, I do. I felt so sorry for her. They discharged her and she clearly needed help. Security escorted her to the waiting room and she was scaring the other patients so I called back to see if she could be re-seen and they said no, she was already seen and discharged and that I needed to call the police for a pick up. When the police came they still wouldn't see her when he asked. He told us if he had to arrest her to get a medical screening he would because she obviously needed medical treatment. The triage nurse on dayshift even called back twice to see if the patient could be re-seen and she was told no, she was discharged."

6. An interview was conducted with RN #2 at 12:15 p.m. on 04/02/19. When asked if she remembered the patient, she became tearful and stated in part, "Yes, I came in to work and we were told she had been seen on nightshift and she was still sitting in the lobby. The triage nurse called back and insisted the patient be re-seen and the dayshift charge nurse told her she had already been seen and she wasn't coming back." When asked if she heard that for herself or was told that information, she stated in part, "I was standing right beside of her when she told the triage nurse she has already been evaluated and discharged, she's not coming back here." The triage nurse called back again and asked the Charge Nurse to go to the waiting room and talk to the police.

7. An interview was conducted on 04/02/19 at 4:20 p.m. with Corporal #1. When asked if he remembered the patient and if he did, could he explain his contact with the patient. He stated in part, "Yes, I got a call to come pick up the patient for disturbance. I was going to take her home. When I arrived at the ED I initially went to see where the patient was and when I went to the patient, she was cold to touch and unresponsive to me touching her and talking to her. I remember thinking this patient has died in their ED and no one even knows. I went to the desk and asked for the patient to be seen. They said they were told she refused to be examined and they won't let her back in the ED. I took the patient outside to put her in my car to take her home and another officer helped me stand her up and she screamed "I am broken." I looked at her body and her left hip was bulged. I took her back into the ED and demanded she be seen. The nurse called back to the ED and was told the patient was already discharged and that she wasn't getting re-seen. I told them if I had to arrest her to get medical clearance I would because something was clearly wrong with the patient and she needed medical treatment. I asked to speak to the Charge Nurse and when she came out I told her the patient was going to be examined. She initially told me she had already been discharged and wasn't going to be seen. I then told her the patient had a two story fall in the presence of another officer and she needs at least X-rays because she clearly has a medical problem. The nurse stated they didn't know it was a two-story fall and then took the patient back into the ED."

8. When the patient arrived at 04:42 a.m. EMS gave verbal report to the Charge nurse, which included the patient had been out in the cold since 12:30 a.m., was running from the police and fell.
A review of a telephone recording on 03/23/19 of emergency medical personnel calling a report to the ED, 20 minutes after the patient's arrival, revealed she had hypothermia and suffered a two (2) story fall and was not upgraded to a P2 trauma at that time.

9. A review of the body cam video of Corporal #1 from 03/23/19 was reviewed on 04/04/19 at 1:45. The video was received from Martinsburg Police Department after exit of the survey, based on the interview with Corporal #1. The body cam video revealed the officer arrived at the hospital at approximately 9:40 a.m. and went to the triage station. This part of the video had no voice recording. He then went to the patient and tried to talk to her but the patient does not move. He continues to talk to the patient and takes the wheelchair outside to his police car. The patient begins to talk in religious overtones. Eleven (11) minutes and nine (9) seconds into the video the officer, with the help of another officer, stands the patient up and she screams, "My leg is broken." She will not move. He sits the patient back down and takes her back into the ED waiting room. He tells the people at the desk that the patient needs to be re-seen and is told they have tried, and they refuse to see her. The triage nurse picks up the phone and makes a phone call and then tells the officer that they say she has already been seen and discharged. Thirteen (13) minutes and forty (40) seconds into the video the Corporal tells the desk staff, "You either check her in as a patient or as a prisoner, but one way or another she is going to be seen. She obviously needs medical attention." The staff still are telling him there is nothing they can do as the ED refuses to see her. He asks for the Charge Nurse. The Charge Nurse arrives in the waiting room at seventeen (17) minutes into the video. She is telling the Corporal the patient has already been seen and discharged. The officer states to the nurse, "When I arrived she was cool to touch and unresponsive. I thought she was dead in your ED and you didn't even know it. She had a two story fall last night that was visualized by another officer. She needs medical attention and if I have to handcuff her to a bed we aren't leaving until she gets it." The patient is taken into the ED at eighteen (18) minutes into the video.

10. An interview was conducted on 04/02/19 at approximately 8:30 a.m. with the Director of Compliance. Although she did not have access to the recordings of the medical communication center or the body camera of Corporal #1, she did concur the patient was refused treatment.