HospitalInspections.org

Based on review of facility policy, medical record review, review of a security video recording, and interviews, the facility failed to provide a medical screening examination for one patient (#3) of 25 Emergency Department patients reviewed.

Refer to 2406 for failure to provide a medical screening examination.

Based on policy reviews, record reviews, observations of video recordings, and interviews, the facility failed to complete an appropriate medical screening exam (MSE) for 1 patient (#3) of 25 Emergency Department (ED) patients reviewed.

The findings included:

Review of the facility's Medical Screening Examination and Stabilization Policy effective date 2/1/16, revealed, "...hospital must provide an appropriate MSE...The MSE must be completed by an individual (i) qualified to perform such an examination..."

Review of Patient #3's medical record from Facility A revealed the patient was registered at 10:21 PM on Sunday 9/11/16. Further review of the medical record revealed the patient was triaged at 10:28 PM, and assigned an acuity level of 3 (urgent). Further review revealed the patient presented to the ED with a complaint of "...Just got out of the hospital for pericarditis and this is the same pain and symptoms...Pain in left upper chest to shoulder...moaning in triage...hunched over..." Continued review revealed the patient's vital signs at triage were: blood pressure 117/70, Pulse 122, Respiration Rate 20, Oxygen Saturation (O2 Sat) 96% (Oxygen Saturation the amount of oxygen in the blood, normal is 92% or above), and Pain Level was 10 on a scale of 1-10 (1very mild pain and 10 severe pain). Continued review of a triage note at 11:34 PM revealed "...pt [patient] sitting in wheelchair moaning...patient experiencing any pain or discomfort...yes..disposition: waiting room..."

Medical record review of an Electrocardiogram (EKG a measurement of electrical activity and function of the heart) was performed at 10:26 PM with interpretation of sinus tachycardia and possible left atrial enlargement.

Medical record review of Provider Triage form dated 9/11/16 at 10:26 PM revealed the MSE was initiated by a Nurse Practitioner (NP #1), who obtained a history and physical and a physical exam. Continued review at 10:50 PM revealed NP #1 ordered diagnostic laboratory tests and a chest x-ray.

Medical record review of the chest x-ray results dated 9/11/16 at 11:18 PM revealed "...overall improved aeration of both lungs. The right sided atelectasis is nearly resolved with small effusion remains...the intracardiac opacity has also improved...Persistent left basilar atelectasis and small bilateral pleural effusions...".

Medical record review revealed no documentation the laboratory tests specimens or the diagnostic tests were completed prior to the patient leaving.

Medical record review of an "Elopement Note" written by NP #1 on 9/11/16, not timed, stated "...This patient left the emergency department or waiting room with no communication to myself, nursing or administrative staff. There was no opportunity to discuss the patient's decision to leave, provide medical advice or discuss alternatives to leaving. The staff has made efforts to locate the patient without success..."

Medical record review of a nurse's note dated 9/12/16 at 1:04 AM revealed "...Pt left AMA [against medical advice] from WR [waiting room]. No papers signed..."

Review of the medical record from Facility B revealed Patient #3 presented to the ED on 9/12/15 at 1:00 AM. Further review of the medical record revealed the patient was triaged at Hospital #2 on 9/12/16 at 1:12 AM with vital signs: Blood Pressure 122/67, Pulse 121, Respirations 16, O2 Sat 99%, and Pain Level 10/10. Further review of the medical record revealed the patient was admitted to Facility B with a diagnosis of Pericarditis and Pleural Effusion on 9/12/16 and remained there as an impatient until discharged on 9/15/16.

Observations of a security video recording of Facility A's ED Waiting room revealed Patient #3 walked into the ED accompanied by an unknown man on 9/11/16 at 10:21 PM and walked directly to the nurses' desk, where she appeared to present for treatment. Further review of the video revealed the following timeline for Patient #3's ED visit on 9/11/16 to 9/12/16:
10:21 PM Patient #3 entered ED and presented at nurses desk.
10:23 PM Patient #3 was taken by a nurse in a wheelchair to triage.
10:32 PM Patient #3 was returned to the waiting room by the nurse and sat in wheelchair in waiting room.
10:55 PM Patient #3 was taken to x-ray by wheelchair.
11:04 PM Patient #3 was returned from x-ray and was left sitting in the wheelchair in the waiting room.
11:38 PM Patient #3 was taken by wheelchair to the registration office.
11:41 PM Patient #3 was taken back to the waiting room in the wheelchair.
12:37 AM Patient #3 was observed walking out of ED waiting room (2 hours and 16 minutes after arrival) with a male and did not return.

Telephone interview with NP #1 on 9/27/16 at 8:25 AM on 9/27/16, confirmed Patient #3 left Facility A's ED prior to completion of the MSE. Continued interview confirmed the patient left before the laboratory specimens were obtained and before a re-assessment and a cardiology consult was provided.

Telephone interview with RN #1 on 9/26/16 at 3:45 PM confirmed Patient #3 left Facility A's ED on 9/11/16 before the nurse drew the blood specimens for laboratory tests. Continued interview confirmed the laboratory tests were not completed prior to the patient leaving the ED.



.