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Tag No.: A2405
Based on policy review, review of ED logs, review of incident reports, and staff interviews, it was determined the hospital failed to ensure patients who came to the ED were documented in the ED central log for 2 of 18 patients arriving via ambulance on 6/06/22. This caused a lack of documentation of 2 patients who presented to the hospital seeking emergency care but were turned away. Findings include:
Policy # 61645.1 titled: EMTALA-RM-PMC, effective date: 11/10/2019 was reviewed. It included a section titled: Signs and Records. It reads: "Portneuf Medical Center will maintain the following signs and records:...
iv) Central log. Portneuf Medical Center will maintain a central log on each individual who comes to Portneuf Medical Center 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..."
An incident report dated 6/06/22, stated: "I had to have 4 ambulances take their patients out to the waiting room...[EMS]...walked their patient to the waiting room and a few minutes later they walked her back to their ambulance and left...called [EMS] to confirm that they took them to [another local hospital ED]. One of the other patients that came in by ambulance that had to go to the waiting room had her family come and get her after about an hour...they made it to...one of the gas stations and called for an ambulance to take her to [another local hospital ED}...."
A phone interview was conducted on 8/18/22 beginning at 11:15 AM with the ED charge nurse on duty 6/06/22. He confirmed he had written this incident report. When asked if he had a record of these patients' names referred to in the incident report of 6/06/22, he stated: " I don't know their names"; he stated that he "had to call [EMS] to find out what happened."
The ED physician on duty 6/06/22 was interviewed 8/17/22, beginning at 9:00 AM. When asked if the ED was on diversion he stated: "the ER [emergency room] doesn't divert." When asked why patients presenting to the ED via EMS would have been taken out to triage in the lobby, he stated: "We were absolutely destroyed that night, we had 30 patients come in in 8 hours and 2 gunshot wounds..." When asked if he felt staffing is adequate in the ED, he replied: "I don't think staffing is adequate anywhere in the country."
Surveyor attempted to obtain the names of these patients brought in by ambulance by referencing run sheets. No ambulance run sheets were provided. Surveyor called [EMS] to obtain ambulance run sheets. The [EMS] is part of tribal services and information access was denied. [Another local hospital ED] was contacted for patient names but information was not provided.
The hospital failed to maintain an accurate log of all patients who presented to the ED requesting a MSE.
Tag No.: A2406
Based on record review, policy review, and staff interview, it was determined the hospital failed to provide a timely MSE to 4 of 21 patients whose records were reviewed. (Patient #6, Patient #7 Patient #8, and Patient #18). Findings include:
Policy # 61645.1, titled: EMTALA-RM-PMC, effective date: 11/10/2019, was reviewed. Within this policy,the definition of "Qualified medical personnel" is defined as such: "Hospital's governing body hereby designates the following as medical personnel qualified to perform a medical screenng examination on emergency department patients as required by EMTALA: (1) physicians, (2) midlevel providers (e.g., PAs, NPs, and other advance practice nurses) acting within the scope of their licensure; and (3) registered nurses (RNs), if and only to the extent that the nature of the patient's request for examination and treatment is within the scope of practice of the RN (e.g., a request for a blood pressure check and that check reveals that the patient's blood pressure is within normal range). In the case of RNs, if the nature of the patient's request for examination and treatment involves independent medical diagnosis or treatment outside the RN's scope of permissible practice, the RN shall contact the physician or midlevel to complete the examination and/or arrange for an appropriate transfer of the patient to another facility consistent with EMTALA requirements and this policy.
39430
The facility failed to provide a MSE to all patients seeking care in the emergency room. Examples include:
1.Policy #60359.1, Title: EMTALA Medical Assessment Screening OB Patient-NS-PMC, effective date: 11/03/19, was reviewed. The Procedure states: "All patients presenting for obstetrical conditions 18 weeks or greater, other than scheduled procedures, or trauma patients go directly in the Labor and Delivery unit." This policy was not followed.
Patient #18 presented to the ED at 2:54 PM and was not assessed in L&D until 5:34 PM, 2 hours and 40 minutes after being triaged in the ED. Patient #18 was a 23 year old female triaged and registered in the ED on 6/06/22. ED triage note written at 2:54 PM states: "Pt presents to ED with R [right] sided lower back pain that started this morning. Pt is 22 weeks pregnant..." Patient #18 was triaged as "urgent" and pain score was documented as "7-severe pain." No further ED documentation was found in the patient record.
Reviewed Patient #18's record with ED Supervisor and ED Director on 6/17/22, beginning at 11:00 AM. When asked to find the MSE, the ED Supervisor stated: "I don't see one. It looks like she was admitted to ED, triaged, and never had a MSE in the ED." The ED Director concurred that there was no MSE documented in the patient record.
Patient #18's medical record indicated on 6/06/22 at 5:34 PM, she was admitted to 2nd floor Labor and Delivery. Assessment was completed by Labor and Delivery physician with a note stating: "the patient....presents with new onset right lower back pain, dysuria/urgency." A urine analysis was negative and a pelvic ultrasound was negative. A renal ultrasound was completed as well as lab work.
Patient #18 was discharged with instructions from Labor and Delivery on 6/06/22 at 9:47 PM. No documentation was found to indicate how or when the patient was transported to Labor and Delivery 2nd floor. No documentation was found to indicate there was communication between the ED and Labor and Delivery.
The ED Charge nurse was interviewed by phone on 8/18/22 beginning at 11:15 AM. When asked about the protocol for a pregnant patient presenting in the ED, he stated: "if they are greater than 20 weeks pregnant and if they are pregnancy related, we would take to Labor and Delivery and not register them, we would call up to L&D. If it is not pregnancy related we would do a MSE here."
Patient #18 presented to the ED at 2:54 PM and was not assessed in L&D until 5:34 PM, 2 hours and 40 minutes after being triaged in the ED.
2. Patient #6 was a 54 year old female who presented to the ED via private vehicle on 6/6/22 at 10:44 AM. Her chief complaint was left ankle pain.
Patient #6's medical record included a triage note documented by an RN. It stated: "Pt reports left ankle pain. Pt reports that she was walking apprx[approximately] 3 days ago and has noticed swelling since then. Pt reports pain in left ankle. "
Patient #6's medical record included that she rated her pain at an 8 on a 0-10 score with 10 being the worst pain. The medical record included Patient #6's vital signs.
Patient #6's medical record did not include a MSE. At 12:08 PM it is documented that Patient #6 was not in the waiting room.
The ED supervisor was interviewed 8/17/22 beginning at 11:00 AM and Patient #6's medical record was reviewed in his presence. He confirmed Patient #6's record did not include a MSE.
3. Patient #7 was a 66 year old female who presented to the ED via ambulance on 6/5/22 at11:21 PM. ED clerk documented: "Ambulance Report: [EMS] transporting female patient that fell out of her chair Wednesday and is still experiencing left foot pain with bruising. Patient also reports a bump in the middle of her chest she would like checked out. No recent trauma. Patient a/o [alert and oriented]."
Patient #7's next ED note documented on 6/6/22 at 12:22 AM by RN is "Pt left ED prior to triage assessment."
The ED supervisor was interviewed 8/17/22 beginning at 11:00 AM and Patient #7's medical record was reviewed in his presence. He confirmed Patient #7's record did not include a MSE.
4. Patient #8 was 51 year old male who presented to the ED via private vehicle on 6/01/22 at 12:04 PM. His chief complaint was bilateral eye burning.
Patient #8's medical record included a triage note documented by an RN at 12:12 PM. It stated "Patient presents to the ED with bilateral eye burning that started around 10am this morning. Patient denies environmental exposer[sic]. No erythema noted to sclera. Patient denies vision changes."
Patient #8's medical record included a pain rating of 8 on a 0-10 score with 10 being the worst pain. The medical record included Patient #8's vital signs.
Patient #8's medical record did not include a MSE. At 12:48 PM the physician documented patient was discharged, and that Patient #8 left without being seen after triage.
The ED supervisor was interviewed 8/17/22 beginning at 11:00 AM and Patient #8's medical record was reviewed in his presence. He confirmed Patient #8's record did not include a MSE.
The facility failed to ensure all patients seeking care in the ED were provided a MSE.
46933
Tag No.: A2409
Based on record review, policy review, and staff interview, it was determined the hospital failed to ensure an appropriate transfer for 2 of 7 patients (patient #1, patient #14 ) whose records were reviewed and transferred out of the ED to a higher level of care. This had the potential for an adverse patient outcome. Findings include:
1. Patient #1 was a 22 month old female seen in the ED twice on 8/06/22. The first encounter was at 2:36 AM. Patient was brought in by family with reported abdominal pain. Record states: "Mom states pt has been grabbing her belly and saying ow. Reports of diarrhea, nausea, fever." ED midlevel ordered urinalysis and nasal swab culture. Patient was discharged at 4:50 AM with discharge instructions to follow up with pediatrician and return if symptoms worsen. Clinical Impressions documented as rhinovirus.
Patient #1 presented to the ED again on 8/06/22 at 10:21 PM via ambulance. The EMS run sheet reported a seizure and uncontrolled fever for 2 days. Ultrasound of abdomen was ordered by ED physician.
Events documented in patient #1's record:
8/06/22, Saturday night:
- 10:08 PM: EMT assessment in home: Temp: 105.6F; HR: 205; BP: 110/56
- 10:21 PM: arrival to ED; initial assessment in room 19; Temp: 104.6F; HR: 208; BP: 100/75
8/07/22, Sunday morning:
- 1:53 AM ultrasound of abdomen results relayed to ED physician.
- 3:34 AM: a physician note stated: "spoke with...a midlevel at [receiving hospital]. They recommend a CT scan of the patient's abdomen.."
- 6:21 AM: a physician note stated: "again spoke with [midlevel at receiving hospital] who agrees to accept the patient. Patient will be transferred via private vehicle."
"Clinical Impressions: Acute appendicitis"
- 6:17 AM: EMTALA transfer form states: "The accepting facility has agreed to accept transfer..." "...transport mode: POV (Patient's own vehicle)..."
- 6:20 AM: ED disposition in patient record by ED physician: "condition: Stable"; "Comment: [Patient #1] should be transferred out to [receiving hospital]
- 6:26 AM: transfer consent signed by parent of Patient #1
- 6:30 AM: vitals: Temp: 100.3F; HR: 122; BP: none
The ED physician who cared for Patient #1 was interviewed 8/17/22, beginning at 9:00 AM. When asked why the patient was transferred, he replied: "she was transferred to the highest level of care, they have pediatric surgeons." When asked why the patient could not be treated at this hospital, the ED physician replied: "I talked to our surgeon here, [surgeon name], she was not comfortable with the case." When asked if this conversation with the surgeon was documented, he stated that it was not.
When the ED physician was asked if he had physician to physician contact at receiving hospital he replied: "I did not speak to an MD, [midlevel at receiving] relayed to MD." When ED physician was asked about the decision to transport via private auto, he stated: "we had ground transport available with a 2 hour delay, I discussed with them the ground versus air versus private auto and they chose private auto." There was no documentation in patient record to confirm this conversation.
The section on the transfer form titled: "PHYSICIAN ASSESSMENT AND CERTIFICATION" was signed by the physician but the "BENEFITS: RISKS: " was left blank. When the ED physician was asked if this section should have been filled out, he stated: "ya, it should have been."
Patient #1 was taken by private auto across state lines to the receiving hospital which was a distance of 166 miles. Per MapQuest inquiry 8/23/22, this was a 2 hour and 39 minute drive. Patient #1 was a 22 month old female with an IV intact, documented as stable by the sending physician. When asked how patient was stabilized, the ED physician stated: "she was given fluids, antipyretics and antibiotics." When ED physician was asked if he would expect an RN to RN communication note giving report to the receiving hospital, he stated: "yes." Surveyor was unable to find any nurse to nurse communication note.
Medical records for patient #1 were further reviewed in the presence of the ED Supervisor, the ED Director, the VP of Quality, and the Director of Regulatory Compliance 8/16/22, beginning at 11:00 AM. The ED Supervisor was unable to locate any documentation of physician to physician communication or nurse to nurse report documentation. When asked if there was a documented discussion with parents regarding the risks and benefits of the transfer and the transfer options, he replied: "I can't answer cuz I don't know." When the ED Supervisor was asked if Patient #1 was a transfer or a discharge, he confirmed it was a transfer. The ED Supervisor also confirmed the transfer form was incomplete. When asked if it is typical to transfer via private auto to a receiving hospital in another state, the ED Supervisor replied: "No." The ED Director was also asked if this is typical to transfer via private auto and he replied: "No."
The current charge RN on duty was interviewed on 8/17/22, beginning at 10:30 AM. He was asked if the charge nurse is involved in transfers and he replied: "somewhat". When asked if a transfer requires a nurse to nurse documented handoff, he replied: "Yes." When asked if he recalled the case of patient #1, he replied: "I vaguely remember the conversation of the transfer." When asked if this transfer via private auto is common, he replied: "no, it is an outlier. We had a form once for private vehicle transport but it was so uncommon we did away with it."
Patient #1 was transferred via private auto with acute appendicitis, requiring a 2 hour and 39 minute drive across state lines. This had the potential for an adverse outcome.
39430
2. PT #14 was a 9 month old female seen in the ED on 5/15/22. She presented to the ED with a chief complaint of a fever after chemotherapy within the past week.
Patient #14's medical record included the following provider notes.
5/15/22 at 11:36 PM, the physician documented: "Patient is a 9 month old female with a history of neuroblastoma who presents to the emergency department today with a fever after chemotherapy within the past week. I received a phone call from [oncologist name] oncology fellow at [reciving hospital]. that I be prepared for the patient arrived[sic] in the emergency department." The child's oncologist recommended lab work and antibiotics for Patient #14 and that Patient #14 may need a hospital admission.
5/16/22 at 12:06 AM, the physician documented: "Did sign out from [previous physician] pending laboratory workup. The patient was noted to have an absolute neutrophil count of 1.3 down from earlier the patient does look well I did speak with oncology fellow [Patient #14's oncologist] at [receiving hospital]. Plan is to give cefepime[antibiotic] and admit I spoke with pediatrics who will admit the patient. [sic]"
5/16/22 at 12:57 AM, "Patient and family change their mind wanted to go to the [receiving hospital]. I spoke with the transfer center and [Patient #14 oncologist] who accepted the patient in transport."
There was no documentation in Patient #14's record on how Patient #14 was transported to [receiving hospital]. Additionally, there was no documentation the ED physician discussed risks and benefits of the transfer.
The ED supervisor was interviewed 8/17/22 beginning at 11:28 AM. When asked if Patient #14 was transferred or discharged he stated, "technically it's a transfer." When asked for the transfer form he was unable to provide it, he stated a transfer form should have been filled out. When asked for documentation of the transfer risks and benefits explained to Patient #14's parents, he confirmed there was no documentation that risks and benefits of the transfer were discussed with the parents. When asked how the patient was transferred to [receiving hospital], he stated there was no documentation on how Patient #14 was transported.
The hospital failed to ensure risks and benefits of transfer were documented. Additionally, the hospital failed to ensure all transfer information was included in the medical record.