HospitalInspections.org

Based on review of Emergency Department (ED) policies, Medical Staff By-laws, Medical Records, and staff interview, the critical access hospital (CAH) failed to comply with their provider agreement to provide a medical screening examination (MSE) sufficient to determinine the presence of an emergency medical condition (EMC) within its capacity and capability for one 20 patients' ED records reviewed (Patient #1) from November 2016 to April 2017. The hospital's failure to comply with their provider agreement and provide a MSE had the potential to affect all patients seeking ED services.



Findings include:


- Policy titled "Emergency Room Policy" reviewed on 4/10/2017 at 3:00 PM directed Providers "...To provide and appropriate medical screening examination of ALL patients requesting treatment. The purpose of the examination is to determine the presence or absence of an emergency medical condition or active labor. The extent of the examination is to be determined by the capability of the hospital's emergency department. To determine that an "emergency medical condition" does exist which may be performed by a D.O., M.D., or Midlevel ...Physician or MLP coverage will be available within 30 minutes, relative to the patient's illness or injury if necessary ..."


- "Medical Staff Rules and Regulation of Ashland Health Center Ashland, Kansas reviewed on 4/10/2017 at 3:00 PM directed Providers "..."Medical Screening Examination" is the process, conducted by qualified medical personnel (QMP), that is required to reach the determination with a reasonable degree of clinical confidence, as to whether the patient has an emergency medical condition. A medical screening examination typically begins with a nursing assessment and is a spectrum ranging from a very simple to a more complex process. It may consist of as little as brief history and physical to the full use of ancillary services depending upon the situation. It is an on-going process; not an isolated event. This screening must be universally applied to all patients complaining of the same condition. "Qualified Medical Person (nel)" means any Practitioner, emergency room Physicians, qualified Mid-Level Practitioner (including Physician Assistant (PA), Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife (CNM) or other qualified advanced practice nurse), emergency room registered professional nurses and labor and delivery registered professional nurses.


- Patient #1 (a one year old) presented to the ED on 3/29/2017 at 1:01am carried by a family member with a chief complaint that the child had a fever and was fussy. The family member indicated that they had sought medical care earlier the previous day at the clinic and the patient was receiving fluids and alternating tylenol and ibuprofen. The child had been having symptoms for three days. The child currently had a temperature of 100.8 (normal 98.6). A late entry nurses' note by RN Staff I dated 3/29/2017 at 9:58pm read in part: Family member is concerned about fever, decreased urine output (3 wet diapers and 2 bottles of fluid for the day). The family member also reported that the patient was twitching (twitching is characterized when your leg or arm or eyelid starts pulsing, and you have no control over it; lack of water in our system can wreak havoc in strange ways, and an annoying repetitive muscle spasm can be one of them). RN Staff I indicated she called APRN Staff F and notified her of the findings of her assessment including the patient arriving to the ED with a fever, decreased urinary ouptut, twitching and fussiness. APRN Staff F related that she had seen the child earlier in the day at the clinic and the child had a viral illness and there wasn't much more to do. APRN Staff F provided RN Staff I with discharge instructions over the phone for Patient #1. RN Staff I discharged the patient with the family member to home.


The facility failed to provide an appropriate MSE within their capacity and capability by a QMP to determine whether Patient #1 had an emergency medical condition.

Based on observation, staff interview and policy review, the critical access hospital (CAH) failed to post any EMTALA (Emergency Medical Treatment and Labor Act) signage in one of two hospital entryways (Emergency Department (ED) Walk in/Ambulance Bay entrance). This deficient practice had the potential for patients seeking examination and treatment and women in labor to not understand their right to receive an appropriate medical screening exam and treatment.


Findings Include:


- ED walk in/Ambulance Bay entryway observed on 4/10/2017 at 9:55 AM lacked evidence of EMTALA signage for patient viewing.

Chief Nursing Officer (CNO) Staff B interviewed on 4/10/2017 at 9:55 AM acknowledged there is not an EMTALA sign at the ED patient walk in entrance/Ambulance bay. Staff B was surprised there was not a sign because there use to be one. Staff B found a broken EMTALA sign in the corner of ED room 1. Staff B stated we needed to get a replacement one and repost it.


- Medical Staff Rules and Regulation reviewed on 4/10/2017 directed facility "...EMTALA Compliance...a sign specifying individual rights under EMTALA with respect to examination and treatment for emergency medical conditions and women in labor..."

Based on medical record review, staff interview, Medical Staff By-laws review, and policy review, the critical access hospital (CAH) failed to provide an appropriate medical screening exam (MSE) for 1 of 20 sampled patients (Patient #1) presenting to the Emergency Department (ED) in the last six months from November 2016 to April 2017. A qualified medical personnel (QMP) failed to come to the CAH to perform the required MSE to determine whether Patient #1 had an emergency medical condition. The CAH's failure to provide an appropriate medical screening exam placed all patients seeking services at risk for harm and/or death.

Findings include:

- Patient #1's medical record review on 4/10/2017 at 12:00 PM revealed RN Staff I noted in their Emergency room nursing documentation notes: Patient #1 presented to the ED on 3/29/2017 carried by a family member at 1:01am, urgent. Chief complaint: fever and fussy. Patient #1 has been given fluids, ibuprofen and Tylenol at home and their symptoms started "three days prior to arrival to ER". Patient #1 received medical care earlier that previous day in a clinic. RN Staff I performed their nursing assessment with the findings as follows: Temperature 100.8 (normal 98.6). No other Vital signs taken. Eyes opening response: spontaneous, obeys command, verbal response: oriented, respiratory system clear bilaterally, cardiovascular system capillary refill <3 seconds (a test used to monitor for sypmtoms of dehydration and good blood flow; in a normal person with good cardiac output and digital perfusion, capillary refilling should take less than 3 seconds). Psychosocial affect: appropriate, moves all extremities, skin pink/warm/dry. Patient sitting quietly with eyes open on family member's lap.

- RN Staff I completed a late entry addendum to her nurse's notes on 3/29/2017at 8:58pm (approximately 19 hours and 38mins after patient#1 was dismissed.) that read in part: Family member is concerned about fever, decreased urine output (3 wet diapers and 2 bottles of fluid for the day). The family member also reported that the patient was twitching (twitching is characterized when your leg or arm or eyelid starts pulsing, and you have no control over it; lack of water in our system can wreak havoc in strange ways, and an annoying repetitive muscle spasm can be one of them). RN Staff I indicated she called APRN Staff F and notified her of the findings of her assessment including the patient arriving to the ED with a fever, decreased urinary ouptut, twitching and fussiness. APRN Staff F related that she had seen the child earlier in the day at the clinic and the child had a viral illness and there wasn't much more to do. APRN Staff F provided RN Staff I with discharge instructions over the phone for Patient #1. RN Staff I discharged the patient with the family member to home at 1:18am.

RN Staff I interviewed on 4/10/2017 at 2:40 PM indicated that she had only been with the facility since last summer (2016) and her background was telemetry (a telemetry nurse monitors patient's vital signs with an electrocardiogram (tracing of the patient's heart rhythm) or other life sign-measuring device) with no previous ED experience and so she was not a designated QMP to provide a medical screening exam. Patient #1 presented with a fever, was fussy, and twitching. The family member was trying to put Patient #1 to bed at home and could not pacify the child. The family member was alternating Tylenol and ibuprofen for the fever as they had taken Patient #1 and their twin earlier in the day to the health clinic and saw (Physician Assistant) PA Staff G and APRN Staff F. Staff I notified the on call APRN Staff F by phone about Patient #1. Staff F stated they saw the patient earlier in the day and there is not much else we can do for Patient # 1 since they have a viral infection. Staff F instructed me to provide education to the family member about giving the medications and fluids to Patient #1. Staff I stated it did not register at that time that the Staff F should have come in to see and assess Patient #1 to complete an appropriate MSE.

APRN Staff F interviewed on 4/11/2017 by phone at 11:30 AM indicated Staff G and they saw the twins together that afternoon (3/28/2017) at the clinic. I saw one of the twins and Staff G saw the other. The twins had fevers of 104 (normal 98.6) and the family member was given a teaching sheet on how to alternate Tylenol and Ibuprofen. I explained to the family member that babies can go bad quickly. At the clinic, Patient #1 was acting well; no respiratory infection; teething; chewing on fingers and not dehydrated as they had lots of saliva from their mouth when chewing on their fingers. The family member brought in Patient #1 to ED because Patient #1 had only 2 wet diapers and a temperature. RN Staff F reported to me that night (3/29/17) that Patient #1 was active; she never told me that Patient #1 had any twitching. I asked the family member if she wanted Patient # 1 seen that night and they indicated no, they just wanted to make sure Patient #1 was ok.

Physician Assistant (PA) Staff G interviewed on 4/11/2017 at 10:35 AM stated the twins came in to the clinic on 3/28/2017 with a fever and it was viral in nature. APRN Staff F gave instructions to the mother before leaving clinic about fluids and alternating medications to treat the fever. PA Staff G mentioned they do not do telephone assessments and don't allow an RN to perform a MSE. As stated in our bylaws, they (RNs) would have to have lots years of ED experience to be considered a QMP.

Chief Nursing Officer (CNO) Staff B interviewed on 4/11/2017 at 11:00 AM indicated Certified Nursing Assistant (CNA) Staff J reported to me that morning (3/29/2017) that a Provider (APRN Staff F) did not come to see the patient during the night. Staff J registered Patient #1 and had the family member sign the consent for treatment. The family member came in because patient #1 was still running fever and not voiding (urinating) much. Staff B stated that CNA Staff J told me they got the patient's temperature but had to get more Pediatric oxygen sensors (a device for measuring the amount of oxygen in the bloodstream). By the time CNA Staff J came back with the oxygen sensors, RN Staff I had already spoken with APRN Staff F on the phone and had discharge orders. CNO Staff B stated the Provider (APRN Staff F) should have come to see the patient to complete a MSE.

Medical Director Doctor of Osteopathy (D.O.) Staff E interviewed on 4/10/2017 at 3:50 PM indicated they have a long relationship with this family member. My impression of the situation was that the family member had a question and came to the ED for an answer. APRN Staff F did not perceive that the patient was being addressed as an emergency room patient. When D.O. Staff E spoke with APRN Staff F, she stated that she assessed the patient over the phone and the exam had not change since the clinic visit earlier that day. We (Providers) usually come to the ED to see patients to complete a MSE.

- Policy titled "Emergency Room Policy" reviewed on 4/10/2017 at 3:00 PM directed Providers "...To provide and appropriate medical screening examination of ALL patients requesting treatment. The purpose of the examination is to determine the presence or absence of an emergency medical condition or active labor. The extent of the examination is to be determined by the capability of the hospital's emergency department. To determine that an "emergency medical condition" does exist which may be performed by a D.O., M.D., or Midlevel ...Physician or MLP coverage will be available within 30 minutes, relative to the patient's illness or injury if necessary ..."


- "Medical Staff Rules and Regulation of Ashland Health Center Ashland, Kansas reviewed on 4/10/2017 at 3:00 PM directed Providers "..."Medical Screening Examination" is the process, conducted by qualified medical personnel (QMP), that is required to reach the determination with a reasonable degree of clinical confidence, as to whether the patient has an emergency medical condition. A medical screening examination typically begins with a nursing assessment and is a spectrum ranging from a very simple to a more complex process. It may consist of as little as brief history and physical to the full use of ancillary services depending upon the situation. It is an on-going process; not an isolated event. This screening must be universally applied to all patients complaining of the same condition. "Qualified Medical Person (nel)" means any Practitioner, emergency room Physicians, qualified Mid-Level Practitioner (including Physician Assistant (PA), Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife (CNM) or other qualified advanced practice nurse), emergency room registered professional nurses and labor and delivery registered professional nurses.