HospitalInspections.org

Based on observation, interview and record review, the hospital failed to conspicuously post required signage when:

1. The Emergency Department (ED) did not have signage at the ED lobby entrance.
This failure had the potential for individuals to be unaware of the Emergency Department location

2. The Emergency Treatment Notice in the Labor and Delivery (L&D) waiting room was obstructed (blocked). This failure had the potential for individuals to be unaware of their emergency services and care rights.

Findings:

1. During a concurrent observation and interview on 11/18/21, at 9:15 AM, with Emergency Department Director (EDD), outside of the Emergency Department (ED), there was no ED sign present. The EDD stated, "A lady hit the wall and sign. It was an accident, and happened pre-Covid (prior to 3/11/20)." EDD pointed to a blue post, and stated "It (sign) was there."

During an interview on 11/18/21, at 10:53 AM, with Facilities Director (FD) and Quality and Risk (Q & R 2), The FD stated, "I didn't know about it until October 2019 when I started here. Nothing is being done, and with the transition all signs are being updated. The sign is not scheduled to be replaced." Q & R 2 stated, "I know there's a sign at the street." Q & R 2 stated, she was not aware of issues with the sign.

During a review of the facility's Security Department incident report, dated 7/15/19, the incident report indicated, "Visitor (V 1) was parked in the ER (Emergency Room) parking space north of the blue sign at 0852 hours when her truck accelerated and drove up onto the ER lobby entry curb knocking over the Emergency blue sign out of its foundation. . . The blue sign fell over landing in the handicap parking space. The blue sign was removed from the location and the active wires were cut and capped by Facilities staff. . ."

During a review of the facility's policy and procedure (P & P) titled, "EMTALA - Posting of Signs," revision date 6/5/19, the P & P indicated, "Policy: Compliance - Key Elements 1. Location of Signage. Each Dedicated Emergency Department of the Hospital will post signage in places likely to be noticed by all individuals entering the Dedicated Emergency Department, including the entrance. . . 2. Visibility. The signage must be visible from a distance of least twenty (20) feet or the expected location of persons in the Dedicated Emergency Department. 5. Maintenance. The Hospital will ensure that the signage is in good repair. . ."


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2. During a concurrent observation and interview on 11/18/21, at 2 PM, with Labor and Delivery Interim Manager (L & D IM) and Regulatory Specialist (RS) 2, in the Labor and Delivery waiting room, several signs were noted on the walls in both English and Spanish. On the wall, near the door, leading to the patient care area, were two large signs, each approximately 18 inches by 24 inches titled "Emergency Treatment Notice" which contained the required information about the hospital's emergency services, including women in labor (about to give birth), regardless of ability to pay for services, care is not based upon. . .participation in the Medi-Cal program and the Department's address and telephone number. A blue and white banner, approximately four inches taller than the signage, indicated Leapfrog Safety (hospital rating program) Grade A was in front of the English "Emergency Treatment Notice." L & D IM stated, the banner was blocking the Emergency Treatment signage.

During a review of the facility P&P titled, "EMTALA - POSTING OF SIGNS," revision date 6/5/19, the P&P indicated, "Maintenance. The Hospital will ensure the signage is. . .conspicuously [easy to notice] posted. . ."

Based on interview and record reviews, the hospital (Hospital 1) failed to provide a Medical Screening Examination (MSE) within the capability of the hospital's dedicated emergency department, to determine whether an Emergency Medical Condition (EMC) existed for 1 of 25 sampled patients (Patient 25). This failure resulted in Patient 25 experiencing a delay of care when the ambulance was diverted 42.4 miles (51 minutes) to another hospital (Hospital 2).

Findings:

During an interview on 11/16/21, at 10:30 AM with Vice President of [ambulance company] (VP), VP stated, "all our ambulances are on GPS [global positioning system, a U.S. Government navigation system]. We know where they [ambulances] are, and how fast they are going. We have maps and it shows the ambulance on the [hospital] premises. They (the ambulance with the patient) were in the [Hospital 1's name] parking lot."

During an interview on 11/16/21, at 11 AM, with Emergency Medical Technician (EMT), EMT stated, on 11/10/21, Emergency Medical Service (EMS, ambulance) picked up a 40-year-old male with symptoms of gastrointestinal (GI, refers to stomach and intestines) bleeding. EMT stated, the patient requested to be taken to [hospital name (Hospital 1)]. EMT stated, when the ambulance was four to five minutes from the hospital, he made the first courtesy call to inform the hospital a patient was on the way with a "non-stat (non-emergency)" GI bleed. EMT stated, when the ambulance was one to two minutes from the hospital, he received a call back from a female Registered Nurse (RN) who said they did not have GI specialist at the facility. Please do not bring that patient here, We have had a GI Consult [patient needing a GI specialist] waiting already for 47 hours. Ask the patient (Patient 25) where he wants to go. EMT stated, while the hospital RN was speaking, the ambulance arrived at the hospital.

During a review of the Patient 25's "EMS Care Summary" (shows care provided by ambulance crew with times), dated 11/10/21, the EMS Care Summary indicated, EMS arrived at 1:48:39 PM, to Patient 25's residence. Patient 25 was sitting on his couch with no obvious signs of distress or trauma. Patient 25 showed no signs of active bleeding, no shortness of breath, no chest pain. Patient 25 complained of abdominal (stomach pain), nausea, vomiting, coffee ground emesis (vomit). Patient 25's vital signs (heart rate, breathing rate, blood pressure, pain, oxygen level) were within normal limits. Patient 25 received intravenous (IV, in the vein) fluids during transportation. Patient 25 was "initially transported to [hospital name (Hospital 1)] ER [emergency room], but per [Hospital 1's name] ER (-) [no] GI pt's [patients] are being accepted. EMS diverted [route patients to another facility] to [Hospital 2's name]." Arrived at Hospital 2 at 14:21:30 (2:21:30 PM).

During a review of the ambulance company's "FleetEyes" GPS Map, dated 11/10/21, at 1:32:51 PM, the map indicated Ambulance 753-525 LST (ambulance identification number) was at Hospital 1.

During a review of ED Note Physician [MSE] from Hospital 2, dated 11/10/21, at 2:29 PM, the MSE indicated, Patient 25 reported vomiting immediately after eating his last meal two to three hours ago and having his last bloody bowel movement a few hours ago. The MSE indicated, Vital Signs Temperature 36.8 degrees Celsius (oral) (Celsius, a unit of measurement, normal temperature 36.2 to 37.6 degrees), Heart Rate 88 Respirations 19, Blood Pressure 125/73 and Oxygen Saturation of 96% (all values within normal limits), The MSE indicated, Patient 25 had a low red blood cell count (3.48), low hemoglobin (8.5) and a low hematocrit (25.5) (tests indicating blood counts). The MSE indicated, "Medical Decision Making ...43M [43 year old male] with Hx [history] of Seizure disorder presents with signs/symptoms suspicious for upper GI bleed, admits to alcohol use. . .Hemodynamically [blood pressure and heart rate within normal limits] stable. Mild tremors concerning for withdrawal. Extended wait for beds/diagnostics/treatments due to ED census/staffing in setting of ongoing COVID-19 pandemic. TEAM Lead notified of concerns regarding patient and inability to wait in WR [waiting room]. Patient placed in wheelchair to intake area to initiate labs/orders. Staff aware of need for bed for which none available at present. . .Ativan (medication to reduce impact of withdrawal symptoms) ordered for potential withdrawal. . . Patient falling from wheelchair per staff, no seizure event...Hgb low but not meeting criteria for transfusion (addition of blood) ..."

During an interview on 11/19/21, at 11:37 AM, with Hospital 1's Emergency Department (ED) Medical Director, ED Medical Director stated, the facility does not have a gastroenterologist (specialist in digestive disease) consultant, however, one general surgeon (Surgeon 1) does GI. ED Medical Director stated, when a patient with GI issues, arrived at the ED, the ED physician would call Surgeon 1, if he was the on-call physician. ED Medical Director stated, since Surgeon 1 was not the on-call physician on 11/10/21, the facility did not have the ability to assess and stabilize a patient with a GI bleed. The facility informed the EMTs they did not have the service available and suggested the ambulance take the patient elsewhere.


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During an interview on 11/19/21, at 1:50 PM, with Hospital 1's Registered Nurse Charge (RNC), RNC stated, a Travel Nurse picked up a call from EMS, and hung up. I was told there was a patient with three days of coffee ground emesis. RNC stated, she asked the doctor if there was GI coverage, and the doctor said we did not have GI. RNC stated "The doctor told me to ask EMS if they can divert. I asked EMS staff to please let the patient know we don't have GI, and the care can be delayed. The EMS staff said they were three minutes out (away). I informed the EMS staff that we had a patient that had been here for three days, and we did not want to delay care." RNC stated, on 11/10/21, the Emergency Department was not on diversion. When asked why the patient was not seen in the ED, RNC stated "Well, we asked them to divert." RNC stated, they have protocols to divert, but was unable to provide the facility protocols.

During an interview with the Hospital 1's ED Director (EDD), on 11/19/21, at 2:05 PM, the EDD stated, according to the Director of Kern County EMS it was understood that the ED can ask about consults and divert. EDD confirmed the patient (Patient 25) was not seen or evaluated, "We told them (EMS) it could be a delay in care."


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During an interview on 11/22/21, at 12:20 PM, with ED Medical Doctor (MD, scheduled provider at Hospital 1), MD stated, when a patient arrived at the ED, the physician did a "work-up (thorough medical exam, includes patient history and physical, laboratory work, x-rays, intravenous fluids in order to arrive at a diagnosis and treatment plan)." After the examination, if the physician determined a patient required a specialty or level of care not available at the facility, the facility provided stabilizing treatment and monitoring. MD stated, this facility had the capability to administer intravenous fluids, blood, and oxygen. MD stated, we do not divert. MD stated, the assessment process for a patient's blood loss was the same regardless of the source. MD stated, the ED had performed MSE on other patients with GI bleeds.

During an interview on 11/22/21, at 12:20 PM, with EDD, EDD stated, we did not want to bring him (Patient 25) in, perform an assessment and delay his care.

During a review of the facility policy and procedure (P&P) titled, "ER I-1 Definition and Objectives," revision date 9/21/20, the P&P indicated, "Compliance - Key Elements A. Emergency services (E.R.) is a separate but integral part of [facility name] which has facilities to provide services requiring basic to advanced treatment ...B. All patients desiring Emergency Services treatment shall be seen by an ER physician/nurse practitioner/physician assistant or their private physician if so requested ..."

During a review of the facility P&P titled, "EMTALA - Medical Screening Examination (MSE) and Stabilization," revision date 6/5/19, the P&P indicated, "A. Performance of the Medical Screening Examination. The Dedicated Emergency Department. . .must provide for an appropriate Medical Screening Examination within the Capability of the Dedicated Emergency Department, including ancillary services routinely available to the Dedicated Emergency Department, to determine whether or not an individual has an Emergency Medical Condition. . .in the following circumstances. . .2. On Hospital Property. The individual has presented on Hospital Property other than a Dedicated Emergency Department, and requests or has a request made on his/her behalf for examination or treatment for what may be an Emergency Medical Condition ...4. In a Non-Hospital-Owned Ambulance. The individual is in a non-hospital owned ground or air ambulance that is on Hospital Property for presentation for examination or treatment for a medical condition at the Hospital's Dedicated Emergency Department. . .F. Examination and Treatment after the Initial Medical Screening Examination. 1. If the Treating Physician. . .determines that an individual has an Emergency Medical Condition, the Hospital, within its Capability, will provide (1) further examination and Stabilizing treatment for the individual. . ."