HospitalInspections.org

1. Based on review of video recordings, facility policies and procedures, Medical Record (MR) reviews, Patient Registration Logs, Emergency Department (ED) Log, ED beds and Care Unit bed census, Emergency Medical Services (EMS) run report, and interviews it was determined the facility failed to ensure an appropriate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 (Patient Identifier (PI) # 1) of 21 sampled patients ED medical records.

This deficient practice had the potential to affect all patients presenting to the hospital ED for treatment.

Refer to tag A 2406 for findings.

PI # 1 was brought by ambulance 1/22/23 to Dale Medical Center (Hospital A) per patient request with complaints of shortness of breath and respiratory distress. During transport the paramedic called and spoke with the ED physician and gave the report of a patient who was short of breath with a history of Pulmonary Embolism. The ambulance arrived at Hospital A ambulance bay at 10:04 AM. PI # 1 was not taken from the ambulance into the ED. The paramedic entered the ED to discuss the patient with the ED physician. A decision was made to transport PI # 1 to Hospital B, which was twenty five miles from Hospital A, receiving hospital. There was no documentation a Medical Screening Examination (MSE) was conducted and no documentation PI # 1 was registered in the ED Log. PI # 1 was transported via ambulance to Hospital B where he/she was evaluated, treated, and admitted to Hospital B.

2. Based on medical record reviews, and staff interviews facility policy review, and facility staff interview it was determined the facility failed to ensure that if an individual has an emergency medical condition the hospital must provide within its capabilities of the staff and facilities available at the hospital for further medical examination and treatment as required to stabilize the medical condition. As the facility staff allowed the patient to leave the emergency department knowing the patient did not have the mental capacity to understand or make decisions because he had an identified psychiatric emergency medical condition.

This deficient practice affected one (1) of twenty- one (21) medical records reviewed including Patient Identifier (PI) # 5, and had the potential to affect all patients presenting to this hospital.

Refer to findings in Tag- A 2407

Based on review Hospital A (Dale Medical Center) Patient Registration logs, Emergency Department (ED) logs, facility policy and procedure, review of medical record (MR) from Hospital B (receiving hospital), Emergency Medical Services (EMS) Pre-Hospital Care report, Hospital A video recordings, and interviews, it was determined Hospital A failed to ensure a patient with an emergency medical condition was entered in the patient registration or ED logs.

This deficient practice affect one of twenty one medical records reviewed and did affect Patient Identifier (PI) # 1 and had the potential to affect all patients presenting to this hospital.

Findings include:

Facility policy: EMTALA Policy

Policy number: 12786819

Revised date: 01/2023

1.1. General Information:

...iv. It is the policy of this hospital that all employees and Medical Staff shall comply with provisions of this law...

1.3. Procedure:

...iii. Persons presenting by ambulance shall be taken directly to an Emergency Department treatment room or designated area...

20.2 Central Logs

20.2.1 A presentation log will be maintained for all persons presenting in emergency care areas of the facility...

1. Review of the EMS Pre-Hospital Run Report dated 1/22/23 revealed EMS arrived at the address of PI # 1 on 1/22/23 at 9:44 AM. Further review of the EMS Pre-Hospital Run Report revealed the ambulance left the scene on 1/22/23 at 9:50 AM.

Review of video recordings from the ambulance bay in front of the main ED entrance revealed at 10:03.47 AM the ambulance arrived at Hospital A. At 10:03.57 AM an EMS crew member (EI # 6, Paramedic) exited the rear of the ambulance and entered the ED main entrance door. When ambulance door opened, a patient was lying on the stretcher in the ambulance. At 10:04.59 EI # 6 exited the ED and opened the rear door of the ambulance. At 10:05.43 the ambulance left the ambulance bay and hospital with emergency lights on.

Review of Hospital A electronic and paper Registration logs dated 1/22/23 revealed no documentation of PI # 1 arriving at the ED.

In an interview conducted on 1/31/23 at 2:27 PM, EI # 11, Registration Specialist, if he/she remembered the patient who came in by ambulance on 1/22/23. EI # 11 responded, "... I remember the ambulance coming in and stopping. I did not know there was a patient in the ambulance. They come in a lot to get blankets, supplies, or just to get things signed. I was not given any information to log them in or anything. Unless they tell me there is a patient, I don't know there is one..."

In an interview conducted on 1/31/23 at 3:50 PM, EI # 13, Registered Nurse (RN), was asked if he/she remembered a patient coming in by ambulance on 1/22/23 complaining of shortness of breath. EI # 13 responded "I do, I was in room two with a patient, (EI # 12, ED physician), was in there when the call came in. I remember (him/her) telling them it was in the patient's best interest to go somewhere else. I saw the fire medic when (he/she) came in. (He/She) stood outside of the room...I was not aware the patient was in the ambulance...".

In an interview conducted on 2/2/23 at 2:36 PM, EI # 1, Director of Quality, confirmed a patient arrived by ambulance on the hospital property on 1/22/23 at 10:03 AM and was not entered in the Patient Registration Log nor in the ED log.

Based on review Hospital A (Dale Medical Center) video recordings, facility policy, review of medical record (MR) from Hospital B (receiving hospital), Emergency Medical Services (EMS) Pre-Hospital Care Report, Emergency Department Beds and Intensive Care Unit bed census, and interviews, it was determined Hospital A failed to ensure that an appropriate medical screening examination (MSE) was provided within the capability of the hospital emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists.

This deficient practice affected one (1) of twenty-one (21) medical records reviewed including Patient Identifier (PI) # 1 and had the potential to affect all patients presenting to this hospital.

Findings include:

Facility policy: EMTALA (Emergency Medical Treatment and Labor Act) Policy

Policy number: 12786819

Revised: 1/2023

...General Policy Statement

...Patients shall not be denied evaluation, screening...on the basis of their presenting complaint, condition, or lack of physician on the medical staff of the hospital...

1.3. Procedure:

i. ...all persons presenting at the Emergency Department or any other department of the hospital and requesting treatment or examination shall be provided a Medical Screening Examination in the Emergency Department of this Hospital...

iii. Persons presenting by ambulance shall be taken directly to an Emergency Department treatment room or designated area...

v. The physician or licensed nurse practitioner providing the medical screening examination shall physically examine the patient and, where necessary to rule out any potential emergency medical condition ...

xiii. ...ambulance patients shall be provided a medical screening examination prior to others in order to make treatment facilities and capabilities available more rapidly...

1. Review of the EMS Pre-Hospital Run Report dated 1/22/23 revealed EMS arrived at the address of PI # 1 on 1/22/23 at 9:44 AM. Review of the EMS Pre-Hospital Run Report Narrative revealed Employee Identifier (EI) # 7, Advanced Emergency Medical Technician (AEMT), documented "...arrived on scene to find (PI # 1) in tripod position on couch with a chief complaint of difficulty breathing...respirations are tachypneic, shallow, and labored with accessory muscle use and retractions noted...states history of PE (Pulmonary Embolism) approximately (two and one half) weeks prior...EMS crew chose non-emergent transport to (Hospital A), the closest appropriate facility, per patient request..." Further review revealed "Pt states extensive history of COPD with exacerbation ...Patient speaks in 3-4 word sentence with noted dyspnea."

Further review of the EMS Pre-Hospital Run Report revealed the ambulance left the scene on 1/22/23 at 9:50 AM. Review also revealed in part," Upon arrival to Hospital A, and on ambulance ramp, (name of Fire Department) EI #7 NRP (National Registry Paramedic) exited the ambulance to speak with the ED Physician. After a brief absence, he returned, and EMS crew was advised that patient needed to be transported to Hospital B per EI#7 conversation with EI #12, ED physician. EMS crew diverted to Hospital B."

Review of video recordings from the ambulance bay in front of the main ED entrance revealed at 10:03.47 AM the ambulance arrived at Hospital A. At 10:03.57 AM an EMS crew member (EI # 6, Paramedic) exited the rear of the ambulance and entered the ED main entrance door. When ambulance door opened, a patient was lying on the stretcher in the ambulance. At 10:04.59 AM EI # 6 exited the ED and opened the rear door of the ambulance. At 10:05.43 AM the ambulance left the ambulance bay and hospital with emergency lights on. There was no video of the patient or other crew exiting the ambulance and no video of a Dale Medical Center employee entering the ambulance. PI # 1 was transported to Hospital B by EI # 7, AEMT, and an EMT driver.

EI # 6, Paramedic remained at Hospital A and did not accompany the ambulance to Hospital B.

A review of the video recordings from the ED hallway between the nurses station and ED room # 2 revealed interaction between EI # 6 and EI # 12, physician. Further review of the video revealed on 1/22/23 at 10:04.15 AM EI # 6 walked down the hallway and entered ED room # 2. At 10:04.39 AM EI # 6 exited ED room 2 and walked down the hallway out of camera view. At 10:05.44 AM EI # 6 re-entered the hallway and stops at the nurses desk in front of ED room 2 and opens a laptop. At 10:16.17 AM an ED staff member in green scrubs, (identified by EI # 1, Director of Quality, as EI # 12, ED physician), exited ED room 2, greeted EI # 6 then walked over to the laptop of EI # 6. This was the only video evidence of the interaction between EI # 6 and EI # 12, ED physician.

Review of the ED and Intensive Care Unit (ICU) bed census from 1/22/23 from 9:30 AM through 10:30 AM revealed three ED beds were available and four ICU beds were available when PI # 1 arrived at Hospital A.

Review of Hospital B ED Provider Notes dated 1/22/23 at 10:43 AM revealed PI # 1 presented to the ED via ambulance with "past history of COPD (Chronic Obstructive Pulmonary Disease), asthma, CHF (Congestive Heart Failure), hypertension who presents with shortness of breath since last night....". Further review of the medical record revealed the patient presented to Hospital B with worsening shortness of breath and acute hypoxic respiratory failure (acute or chronic impairment of gas exchange between the lungs and the blood causing hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) hypercapnia (blood is too acidic). Patient #1 received an appropriate MSE. Continued review or the medical record revealed that in-patient medicine was consulted and agreed to admit Patient #1 to their services for further care and management.


In an interview conducted on 1/31/23 at 9:34 AM, EI # 6 stated when he/she arrived on the scene PI # 1 was showing signs of respiratory distress, had recently had a PE and also had CHF and COPD. EI # 6 stated he/she called report in to Hospital A and gave report of the patient having difficulty breathing and PE. He/she stated the ER physician (EI # 12) said "if she is having a PE, we cannot treat (him/her) here. I told (him/her) we were enroute and would have to transport to the ED". EI # 6 stated when he/she got to the ED he/she went in to talk to the physician (EI, # 12), "I told (him/her) I am not sure if she had a PE. I told (him/her) if (he/she) did not feel safe treating this patient I could take (him/her) somewhere else...the doctor said since the patient recently had a PE and may be having another, (he/she) did not have what was needed to treat the patient."

EI # 6 was asked if PI # 1 received any examination or treatment at Hospital A. EI # 6 responded, "no, they never made contact with the patient.

In an interview conducted on 1/31/23 at 2:47 PM, EI # 12 ED physician stated "the call came, I was really presented a question, not so much a report. (He/she) told me about a patient who was recently treated for a PE and wanted to know if they needed to come here or go to (Hospital B)...I told (him/her) we did not necessarily have the equipment to treat a PE. (He/she) said do you want me to go on to (Hospital B), I said if you can then yes...I did not talk to them face to face that morning". EI # 12 was asked if PI # 1 received an MSE at Hospital A. EI # 12 responded, "no treatment at (Hospital A), the patient never came here".

An interview was conducted with the ED Medical Director on 2/2/2023 at 7:45 a.m. The ED Medical Director stated in part, "If SOB or other serious complaints they come straight ...I try to get them back as soon as possible. Regardless of what is going on. I lay eyes on them and do what is needed to stabilize them." The surveyor asked the question regarding the process of when a patient arrives to the hospital via ambulance. The ED Medical Director stated in part, "I am (Name of EMS) Medical Director when a call goes out. They send me a detailed text message to me on the phone. They give me a report and bring the patient in. They come up the ramp, usually the person at the front desk sees them come up and opens the door for them." The ED Medical Director summarily stated that Patient #1's history was explained to him. He stated that if the patient was here on 1/22/23 the patient should have been treated. He also stated the hospital had the capability and capacity to treat patient #1.

In an interview conducted on 2/2/23 at 2:36 PM, EI # 1, Director of Quality confirmed PI # 1 did not receive a MSE and the hospital had the capability and capacity to treat the patient and the ED was not on diversion on 1/22/23, when PI # 1 presented on the hospital's property via ambulance.

Based on medical record reviews, and staff interviews facility policy review, and facility staff interview it was determined the facility failed to ensure that if an individual has an emergency medical condition the hospital must provide within its capabilities of the staff and facilities available at the hospital for further medical examination and treatment as required to stabilize the medical condition. As the facility staff allowed the patient to leave the emergency department knowing the patient did not have the mental capacity to understand or make decisions because he had an identified psychiatric emergency medical condition.

This deficient practice affected one (1) of twenty- one (21) medical records reviewed including Patient Identifier (PI) # 5, and had the potential to affect all patients presenting to this hospital.

Findings include:

Facility policy: EMTALA (Emergency Medical Treatment and Labor Act) Policy

Policy number: 12786819

Revised: 1/2023

...1.3. Procedure:

...iii. Persons presenting by ambulance shall be taken directly to an Emergency Department treatment room or designated area.

...vi. Necessary definitive care...to stabilize the patient's condition shall be rendered in the hospital...

Facility policy: Prescreen of Psychiatric Patients in the Emergency Department

Policy number: 9851168

Revised: 12/2021

...Procedure

...If medical stability is determined, the Emergency Department notifies the New Day Social Services Department to request a psychiatric evaluation.

...Every effort shall be made to protect the patient's safety and safety of others while the patient is in the Emergency Department. If the patient is violent, hostile, or a danger to self or others and cannot be easily controlled, hospital security or the Dale County Sheriff's Department may be called for assistance.

For patients requiring admission but refuse, are a danger to themselves or others, or lack the capacity to give consent, Emergency Detention/commitment procedures may be instituted...

Facility policy: Patient Elopement from the Emergency Department

Policy number: 897849

Revised: 07/2011

Definition: Any patient who has been seen by the Triage Nurse but left prior to an evaluation by the Emergency Department physician, or who has been seen by the Emergency Department physician but left before treatment or disposition, is deemed as an elopement...

PI # 5 presented to the ED (Emergency Department) on 1/3/2023 at 2:32 PM with a chief complaint of psychiatric problem.

Review of the ED Nursing Chart dated 1/3/23 revealed PI # 5 arrived by ambulance and placed in ED room # 11. The triage time was at 2:32 PM and Assessment time was at 2:38 PM. The vital signs were blood pressure 130/83, heart rate 100, respirations 20, and oxygen saturation was 97 %. Further review of the ED Nursing Chart dated 1/3/2023 revealed the nurse documented PI # 5 was having homicidal ideations, stated people were pushing (him/her) and (he/she) doesn't have anything else to lose, "the devil is going to cause me to murder someone". Patient stated he/she had been off psychiatric medications for one and a half years and could "feel the demons out on the streets". Further review revealed in part, "Mental Health Screening: Depression Screening: The patient admits to having felt down, depressed, or hopeless in the last 2 weeks. Over the 2 weeks, have you felt little interest or pleasure in doing things? No. The patient admits to suicidal and /or homicidal Ideation. The patient admits to previous suicide attempts. Notes; A sitter is at the bedside ...Physician was notified ...Psychiatric Evaluation Consultation order obtained."


Review of the Physician Chart dated 1/3/23 at 2:32 PM revealed the provider, EI # 16, Certified Registered Nurse Practitioner, documented "...currently presents with depression, anxiety, unclear thinking, and violent behavior. The patient currently admits to homicidal ideation". The section of the Physician chart titled Physical Examination revealed in part, "Neurological: The patient was oriented to person, place and time. The patient was awake and alert: Psychiatric: thought was paranoid and with rambling conversation. Thought was coherent, not delusional and with flight of ideas. Affect was anxious. Affect was not appropriate. There were visual hallucinations. There were no auditory hallucinations. Insight was below average. Judgement was below average. Additional findings: disorganized thoughts." Further review of the Physician Chart dated 1/3/2023 revealed EI # 16 documented at 2:57 PM "called (New Day Counselor) and notified (him/her) of needed psychiatric evaluation. Documentation in the section of the Note titled MDM (Medical Decision Making) also revealed upon examination EI #5 was willing to be admitted. PI#5's disposition was listed as "AMA." At 4:10 PM EI# 16 called the city's police regarding the patient leaving the department due to his homicidal ideations. Continued review of the Physician Chart, Provider Treatment Notes, dated 1/3/2023 revealed EI # 16 documented at 3:50 PM, "(EI # 19), Security Guard) reports that (EI # 15) attempted to enter the room when the patient became hostile yelling at (EI # 15) and states that (he/she) was just here to get into the a named hospital in Tuskegee for help, (EI # 19) reports that the patient wanted to leave and left the department at this time because the patient was not a court order...".

Review of the New Day Behavioral Pre-Hospital Screening Form dated 1/3/2023 at (no time on record) revealed EI # 15, Counselor, documented "Pt. (patient) appeared agitated. Pt. was informed that I'm here to do an evaluation. Pt. responded, "if you can't get me to the (named Hospital) get the (exploitative) out of my face. I'll call my mom to take me. Pt. proceeded to get dressed and asked this writer to leave because (he/she) was about to leave...Pt. left ER (Emergency Room) AMA (Against Medical Advice)".

Review the medical record revealed the patient was suicidal and homicidal, and experiencing visual hallucinations, and required stabilizing care. There was no documentation PI # 5 was determined to be deemed reliable, safe, and appropriate to refuse treatment and be allowed to leave the ED.

There was no documentation in the medical record to indicate that PI #5 had the capacity to understand or make a decision regarding the risks and benefits of the examination and treatment and/or both.

There was no documentation in the medical record of any attempts by hospital security staff or facility ED staff tried to prevent or stop PI#5, (who was at risk to harm others) from leaving the ED in an unstable condition.

Additionally, there was no documentation in the medical record as to why further treatment and or interventions, such as medications or obtaining a 72-hour hold was implemented to keep the patient from leaving the hospital's ED, when staff identified on 1/3/2023 that PI#5 had an emergency psychiatric medical condition.

There was no video available for review of the location near room # 11.

In an interview conducted on 2/1/23 at 3:06 PM, EI # 15 (Social Worker) stated "I was called to go to the (ED) for an evaluation. When I approached (PI # 5's) room, the security guard (EI # 19) was at the door. The patient said are you here to take me to the VA? If you are not going to send me to the VA you can get the ... out of here. I left the room briefly to allow (him/her) to calm down. (He/she) did not want to hear anything I had to say. When I came back, about three to five minutes, (EI # 19) was at the door and the patient was gone.

In an interview conducted on 2/1/23 at 3:26 PM, EI # 16 stated "(EI # 15) the social worker had come down to evaluate (him/her). I was doing a typical psych work up. (EI # 15) went in the room and came out shortly after. Next I saw (EI # 19) at the desk and he said the patient had left. (EI # 19) said the patient did not have a court order to hold (him/her), so (he/she) had to let (him/her) leave.

EI # 16 was then asked if PI # 5 was deemed safe for discharge and not a threat to himself or others. EI # 16 responded "no, not with (his/her) threats and behavior".

In an interview conducted on 2/2/23 at 11:50 AM, EI # 19 stated "(PI # 5) started cursing and said he would get (his/her) stuff and get his mother to take (him/her) to Tuskegee. (He/she) left out of the side door and left AMA (Against Medical Advice). We were not allowed to stop (him/her) since we did not have a hold order on (him/her). He told the nurse (he/she) was trying to get to Tuskegee. When EI # 15 came in to evaluate (him/her) (he/she) did not want to hear anything and left...".

In an interview conducted on 2/2/23 at 7:45 AM with EI # 18, ED Medical Director, was asked if he/she was familiar with PI # 5. EI # 18 responded "I was not here for this, but in my opinion (he/she) should have been put on a 72-hour hold. If (he/she) was agitated like this, I would have given (him/her) Geodon or the concoction to calm (him/her) down.

In an interview conducted on 2/2/23 at 2:36 PM, EI # 1, Director of Quality, confirmed no attempts were made on 1/23/2021 to prevent PI # 5, who was at risk for harm to others, from leaving the ED. The facility failed to ensure that stabilizing treatment was provided as required for PI #5 on 1/3/2023 when the ED staff identified that patient #1 had and identified emergency psychiatric condition.