HospitalInspections.org

Based on medical staff by-law rules and regulations, facility policy, record review and interview, the hospital (Hospital #1) failed to ensure all patients presenting to the Dedicated Emergency was provided an appropriate Medical Screening Examination (MSE) was provided by an emergency room physician, to include ancillary services routinely available in the emergency department to determine whether or not an emergency medical condition existed for one (#4) of 20 sampled patients who presented to the Emergency department with head injuries from a fall.
The hospital also failed to identify or define Medical Personnel (QMP) who could perform MSEs in their By-laws

Refer to A2406.

Based on facility document review, medical record review and interview, the hospital failed to maintain a central log that included each individual presenting to the hospital's Dedicated Emergency Department (DED) seeking emergency medical attention for 1 of 20 (Patient #4) sampled patients.

The findings included:

1. Review of a facility document dated 2/21/2019 at 2:17 a.m., written by Physician #2, revealed that the incident involving Patient #4 was reported to a higher up authority within the hospital. The facility document revealed on 2/20/19 Patient #4's father, who is an Emergency Medical Tech (EMT) with the hospital's operated Emergency Medical Services (EMS), presented to the hospital's DED (Visit #1) with his 7 year old son, who is identified as Patient #4. The child/patient presented with a scalp laceration. Physician #2 documented, "...the father came to the ER [DED] and treated the child, putting two staples in his scalp wound...The father and one of the male ER nurses "discharged" the patient to the mother, although the child had not yet been registered and had not been seen by the ER MD or a nurse practitioner...". There was no documentation on the hospital's central log the patient had been seen and treatment had been provided to the patient on 2/20/19 during this visit. Physician #2's document revealed on 2/20/19, "The mother brought the child back to the Emergency Department..., about 6 hours later, stating she wanted him to be seen by a doctor..."

2. Medical record review revealed Patient #4 was a 7 year old male who presented to Hospital #1's DED on 2/20/19 at 8:48 PM (Visit #2) with a Scalp Laceration. The minor patient was accompanied by his mother.

Review of the 2/20/19 DED notes during the 8:48 PM visit (Visit #2) revealed the patient's EMT father placed staples to the patient's scalp laceration. The notes revealed, "...per mother was stapled here [in Hospital #1's DED] earlier today..."

Review of the 2/20/19 DED physician notes for Visit #2 revealed at 11:08 PM Physician #2 documented, "...Slipped on wet cement steps and fell, striking back of ...head and sustaining a laceration. His father (an EMT) and another EMT put two staples in the laceration. The mother has brought him to the ER for further evaluation..."

Review of the hospital's central DED log for 2/20/19 revealed Patient #4's name was only listed for Visit #2 at 8:48 PM. Visit #1 (initial visit) on 2/20/2019 for Patient #4 was not listed on the hospital's DED central log.

Based on medical record review, Summary review documents, medical staff by-law rules and regulations, facility policy, record review and interviews, the hospital (Hospital #1) failed to ensure all patients presenting to the Dedicated Emergency was provided an appropriate Medical Screening Examination (MSE) was provided by an emergency room physician, to include ancillary services routinely available in the emergency department to determine whether or not an emergency medical condition existed for one (#4) of 20 sampled patients who presented to the Emergency department with head injuries from a fall. The hospital also failed to identify or define Qualified Medical Personnel (QMP) who could perform MSEs in their By-laws.

The findings included:

1. Review of the "Transfer of Patients to Another Healthcare Facility, Policy and Procedure for" revealed, "...Procedure...Medical Screening...Anyone who arrives at the hospital and/or the Emergency Department and requests or requires an examination or treatment for a medical condition will be provided an appropriate medical screening examination to: 1. Determine whether an emergency medical condition exists. The term 'emergency medical condition' means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: a. placing the patient's health in serious jeopardy, b. serious impairment of bodily functions, or c. serious dysfunction of any bodily organ or part...If...the above conditions exist [Henry County Medical Center - Hospital #1] Emergency Department will provide:1. Further medical examination and treatment necessary to stabilize the medical condition within our capabilities...".

Review of the "Corporate Compliance Plan" policy revealed, "...The plan contains organizational conduct requirements that are intended to address pertinent compliance issue and the overall scope of conduct...EMTALA Compliance...[Name of Hospital #1] personnel or agents shall comply with all federal and state regulations and laws regarding the evaluation, admission and treatment of patients with emergency medical conditions...regardless of the nature of the medical condition...Personnel and agents shall provide initial medical screening examinations to all potential patients..."

2. Medical record review revealed Patient #4 was a 7 year old male that presented to Hospital #1's DED on 2/9/19 at 8:48 PM with a Scalp Laceration. The minor patient was accompanied by his mother. This was the second ED visit for Patient #4 at this hospital on 2/9/19.

Review of the DED nurse's notes revealed on 2/20/19 at 9:53 PM RN #3 documented, "...per mother hasn't been acting right since hitting head on concrete earlier today. states pt been more drowsy than usual...per mother was stapled here [the child's laceration was stapled in Hospital #1's DED] earlier today [Visit #1]..."

Review of the DED physician notes revealed on 2/20/19 at 11:08 PM (Visit #2) Physician #2 documented, "...Slipped on wet cement steps and fell, striking back of ...head and sustaining a laceration. His father (an Emergency Medical Technician (EMT)) and another EMT put two staples in the laceration. The mother has brought him to the ER for further evaluation. No LOC [loss of consciousness] or vomiting. The patient has been less active than usual this evening and has no appetite. She is concerned he may have a serious head injury..." The physician exam revealed, "...3 cm horizontal laceration of occiput, properly closed with two staples..." A Computerized Tomography Scan of the head was performed and the results revealed, "...No acute intracranial process..." The patient was discharged home in stable condition.

There was no documentation Patient #4 received a MSE by an ED Physician during DED Visit #1 on 2/20/19.

Review of documents provided by the hospital revealed the following:
A summary provided by EMT #3 revealed EMT #4 was on duty for the hospital operated EMS, and treated his own son in the DED on 2/20/19 as described below:
On 2/20/19 EMT #4 brought his son to the DED after his son had fallen and sustained a laceration to his head. EMT #4 did not want his child to wait in the DED waiting room so he took the child to DED exam room M-1. The summary revealed EMT #4 treated the child and placed 2 staples in his child's head laceration.

Two (2) summaries were provided by RN #4:
Summary #1 revealed EMT #4 came to the DED with his son on 2/20/19. EMT #4 placed 2 staples in his child's head laceration. The summary revealed a DED male nurse assisted EMT #4. The child did not receive a MSE for this initial visit.
Summary #2 revealed on 2/20/19 EMT #4 took his child to DED room M-1 and placed 2 staples in the child's head laceration. The summary revealed that EMT #5 and RN #1 both gave medical advice that the child's head laceration needed staples. EMT #5 assisted EMT #4 place the staples in EMT #4's child's head laceration.

In an interview on 5/7/19 at 2:30 PM in the conference room RN #7 stated on 2/20/19 they witnessed EMT #4 enter through the ambulance area with his son/Patient #4. EMT #4 asked DED RN #1 to come look at his son and they went into the DED exam room M-1.

In an interview on 5/8/19 at 10:20 AM in the conference room RN #1 stated, "I was triaging [working in the DED performing assessments] on 2/20. [Name of EMT #4] asked me 'come look at my boy's head.' He took me in M-1. I couldn't see good. There was matted blood on the back of his head. I said you need to come check in and it [laceration] needs staples. [Name of EMT #5] was with him. Not sure what time they came in, maybe between 2 and 5 [PM]. Didn't see him put staples in."

In an interview on 5/8/19 at 11:10 AM in the conference, EMT #5 stated that on 2/20/19 "My partner and I brought a patient to the ED. [Name of EMT #4] and his child were in M-1 [room]. [Name of EMT #4] called me in the room to look at his son's head. I told him it probably needs some staples or something. I left and didn't see what happened after that. Only heard after the fact that he stapled his son's laceration."

In a telephone interview on 5/8/19 at 12:30 PM EMT #4 stated, "My ex called and said my son fell and hit his head. She met me a the ER and he [his son] had a 1 inch laceration. I carried him to M-1 [DED exam room]. I asked a couple of people to look at it."
EMT #4 confirmed he asked RN #1 and EMT #5 to look at his son's laceration. EMT #4 stated, "The wait time was too long and the waiting room was full of flu. I put 2 staples in his head [his son's head], no one else helped me do it. They [RN #1 and EMT #5] advised me it [laceration] needed staples..." EMT #4 stated he used his own personal staple gun and that EMT #5 was present when he stapled his son's head laceration.

The hospital DED staff failed to ensure Patient #4 received an appropriate MSE on Visit #1, when the EMT father presented the patient in the DED and treated the patient's head laceration.
The facility failed to ensure that their Corporate Compliance Plan was followed as evidenced by failing to ensure that on 2/202019 patient #4, who presented to the ED with a head injury, received an initial medical screening examination by an emergency department physician. As this posed and immediate and serious threat and safety to the patients' health.

3. Review of the Medical Staff Bylaws rules and regulations revealed, "...The Department of Emergency Medicine shall consist of all members of the emergency room staff...It shall be the responsibility of this committee to review the care delivered in the emergency department. In addition, it shall recommend policies and procedures for governing the provision of patient care in this area..." The Medical Staff By-Laws rules and regulations failed to define who were Qualified Medical Personnel approved by the board to perform medical screening examinations (MSEs).

In an interview on 5/8/19 at 11:15 AM in the hospital's conference room the CEO verified all EMTALA policy and procedures had been provided to the surveyor. The CEO verified there was not a hospital policy or medical staff By-Law defining the qualifications of the person who was competent to be a QMP to perform the MSEs.