HospitalInspections.org

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Based on observation, interview, record review and review of hospital policies and procedures, the hospital failed to develop and implement policies and procedures for evaluation and treatment of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure patients receive a comprehensive medical screening examination by a qualified medical professional and stabilizing treatment prior to transfer or discharge risks poor health care outcomes, injury, and death.

Findings included:

1. The hospital failed to provide a comprehensive medical screening examination for 1 patient who was discharged from the Emergency Department and told to return the following day to have an ultrasound to rule out deep vein thrombosis.

Cross Reference: C 2406
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Based on interview, document review, and review of hospital policies and procedures, the hospital failed to provide a comprehensive medical screening examinations for 1 of 25 records reviewed.

Failure to ensure patients receive a comprehensive medical screening by a qualified medical professional risks poor health outcomes injury, or death.

Findings included:

1. Review of the hospital's medical staff bylaws rules and regulations, revised 03/10/21, showed that in the Emergency Department, physicians and advanced practice clinicians are authorized to perform medical screening examination.

2. Review of the hospital's policy titled, "Transfer of Emergency Medical Patients, " no number, reviewed 06/21/22, showed that an Emergency Medical Condition is manifested by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonable be expected to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy. All patients who present themselves to KVH for treatment will be given a screening exam by a qualified medical person to determine whether an emergency medical condition exists.

3. Review of the hospital's policy titled, "Ultrasound Afterhours Call," no number, revised 04/10/23, showed that the KVH ultrasound staff would be on call and available to be called in to perform acute, urgent ultrasounds for Inpatients and Emergency Room patients. On Call hours would be subject to change based on sonographer staffing levels. The following list of exams had been developed in partnership with providers and the radiologists and is a guideline to use to determine whether or not to call in the ultrasound staff. Ultrasound staff should be called in for:

a. Testicular Torsion
b. Ovarian Torsion
c. Ectopic Pregnancy
d. Placental Abruption
e. Fetal Demise

Ideally, stable patients with the following diagnoses would be medically managed by the Emergency Department Provider, Hospitalist, Orthopedic Surgeon and/or General Surgeon and have the ultrasound performed the following morning:

a. Appendicitis
b. Cholecystitis
c. High clinical suspicion of DVT

4. Review of the medical record for the complaint subject patient showed that the patient arrived in the Emergency Department on 09/04/23 at 10:12 AM with concern about a possible deep vein thrombosis (DVT) (blood clot) in their right leg. The patient complained of calf pain 5 out of 10. The nursing triage note showed that the patient had been sedentary for about 6 weeks related to shortness of breath from a maxillary sinus fungal infection. In triage the patient's respiratory rate was 20 per minute and heart rate was 112 beats per minute. The provider note showed that the patient was seen at 10:20 AM and was given a dose of Xarelto 20 mg (a blood thinner). The patient was discharged at 10:59 AM and was told to return in the morning for an ultrasound. Documentation showed that there was no clubbing, cyanosis, edema, or pallor of the extremities; atraumatic with full range of motion, neurovascular intact and strength 5 out of 5 in all extremities. Documentation showed that there was no comparison between the patient's two legs, measurements of the patient's calves, and there was no laboratory testing ordered. The patient was given discharge instructions for musculoskeletal pain (Patient #14).

The patient returned to the hospital on 09/05/23 for their scheduled 8:30 AM ultrasound.

The 09/04/23 Emergency Department record showed an addendum dated 09/05/23 9:18 AM that showed that the radiologist called to notify the ED provider that the patient had a positive DVT study that morning. The ED provider contacted the patient to return to the ED for further evaluation. The patient stated that they were feeling dizzy and lightheaded. The provider stated that they may have a pulmonary embolism (blood clot in the lungs). The patient was told that they had received Xarelto at the time of their ED visit. The documentation showed that the patient told the provider that they may come in the afternoon, but that they wanted the provider to send a prescription to their pharmacy.

Documentation showed that the patient returned to the ED on 09/05/23 at 9:30 AM and told the triage nurse that they had been referred back to the ED for reevaluation following an ultrasound of the right lower extremity that morning (Patient #15). Triage documentation at 9:33 AM, showed that the patient reported increased shortness of breath, and that the patient was mildly distressed while in Triage. In Triage the patient's respiratory rate 30 per minute and heart rate 114 beats per minute. The provider note showed that the patient had a positive ultrasound for DVT that morning, and had been given a loading dose of Xaralto the day prior in the ED. Orders during this ED visit included, a complete blood count, a comprehensive metabolic panel (CMP which tests 14 different substances in the blood), Prothrombin time and international normalized ratio (tests to measure if blood is clotting normally and if anticoagulant therapy is working), as well as COVID-19, influenza and respiratory syncytial virus (RSV) testing. The provider note showed that the hospital's computerized tomography (CT) scan machine was unable to accommodate the patient's weight, so the patient would be transferred for evaluation of their dyspnea (shortness of breath). The patient was accepted for admission to Swedish First Hill hospital and the patient was given Eliquis 10 mg prior to leaving the hospital. The patient requested to go by private vehicle and stated that they would go directly to Swedish First Hill hospital for further evaluation and treatment. The Patient Transfer Order Form showed that at the time of discharge the patient's respiratory rate was 22 per minute and heart rate was 98 beats per minute. The form showed that the risks and benefits of the transfer were explained to the patient and that the patient may be at risk for deterioration from or during transport. The patient signed consent for transfer.

5. On 11/07/23 at 10:52 AM, during an interview with the investigator, the Emergency Department physician (Staff #1) stated that patients are triaged and then moved to a room for a medical screening examination. If a patient needed an ultrasound, but it wasn't available and the provider had a high suspicion for a DVT, they would treat prophylactically and have the patient come back in for an ultrasound when ultrasound was available. If a patient wasn't comfortable with that plan, they would consider transferring the patient to another hospital.

6. On 11/07/23 at 10:47 AM, during an interview with the investigator, the Physician's Assistant on duty, (Staff #3) stated that if a patient emergently needed a test that the hospital did not have available, they would follow their transfer process to find a facility and provider that accepted the patient. Occasionally, a patient with deep vein thrombosis might be reasonably treated with a first dose of Lovenox (a blood thinner), and told to come back the next day when ultrasound was available, but only if the patient was able to safely take blood thinners.

7. On 11/07/23 at 11:32 AM, during an interview with the investigator, the Director of Imaging (Staff #2) stated that the ED provider decides if an ultrasound is needed to be done by the on-call person, or if it could wait. There are openings left in the ultrasound schedule specifically for anyone that didn't meet on call call-in criteria. The hospital has a policy that ultrasound is not called in for DVT studies.

8. Document review of the hospital's imaging staff schedule showed that there was an ultrasound technologist on call on 09/04/23, but there were no ultrasound technologists scheduled to be working onsite in the department at the time of the patient's initial ED visit.