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Based on review of medical records, review of the hospital's policies and procedures and staff interviews, it was determined that the hospital failed to enforce their policies to ensure compliance with the requirements under 489.24 in regard to providing medical screening and stabilizing treatment. This was found in 1(Patient 2) of 26 patients' medical records reviewed who had presented to the emergency department for care.

Findings include:
Please refer to A2406 and A2407 for the details.

Based on review of medical records, policy review and staff interviews, it was determined that the hospital failed to ensure a patient received appropriate emergency medical treatment. This was found in 1(Patient 2) of 26 patients' medical records reviewed who had presented to the emergency department for care.


Findings include:

The medical record for Patient 2 was reviewed on 05/11/11. Patient 2 presented to the Emergency Department (ED) on 05/07/11 at 1:19 AM with a chief complaint of a bite injury. The triage documentation written by Staff G (registered nurse) stated that the patient complained of a snake bite to the right foot, but the patient was unsure as to the type of snake. Staff G documented at the time of triage that Patient 2 complained of burning and constant pain which the patient rated at a level of 7 (with 0 being no pain and 10 the worst pain of your life). Vital signs were obtained and were within normal limits. There was no documentation that an assessment of the condition of the patient's right foot was completed in regard to evidence of a bite or any appearance of swelling or discoloration. Based on the information that was obtained during triage, Patient 2 was given a triage ESI of 4, (Emergency Severity Index; gives a number value to assess the severity of the patient's medical needs in which 1 indicates the need for life saving intervention and 5 as the least severe), and was placed back in the waiting room.

At 2:12 AM Staff G documented that Patient 2 got up from his/her wheelchair, was cursing loudly, and walked out the entrance with a brisk and steady gait. There was no documentation that the patient was reassessed after this incident.

At 3:35 AM Staff H (registered nurse) documented that the patient's spouse had stopped at the triage desk and inquired about how much longer the wait would be. Patient 2's spouse was told that they were seeing patients as fast as they can but are unable to give him/her an exact time as to when the patient will be seen. Further review of the medical record revealed documentation at this time that Patient 2 was lying in a chair in the waiting room with his/her foot propped up on the chair, that no distress was noted, his/her breathing was non labored, and the patient's skin was warm and dry. There was no documentation that Patient 2 was reassessed for pain, vital signs, or changes in the condition of the patient's right foot. The patient's spouse then told Staff H that he/she would take Patient 2 somewhere else to be seen. Staff H stated that Patient 2 left the hospital walking with a steady gait on the injured foot without difficulty.

On 05/11/11 at 2:30 PM the complaint/grievance files were reviewed with Staff F. Staff F was questioned in regard to the grievance that was logged on 05/09/11 by Patient 2. The complaint/grievance log stated that on 05/09/11, the ETC (Emergency Trauma Center) Director reviewed the medical record and contacted the patient for follow up. It was also documented that wait times were clarified with the patient and that an investigation is in process. Staff F stated that he/she has 26 years of experience and felt it was appropriate that the patient had been triaged at an ESI level of 4 and that the triage nurse who had worked the during the time of Patient 2's visit had been questioned and stated that he/she had doubted that the patient had been bitten by a snake. Staff F stated that when he/she had called the patient on 05/09/11, patient 2 told him/her that at the time of the call they were admitted in the hospital for the snake bite. Staff F stated that he/she believes this to be untrue because a car noise was heard in the background during the call which led him/her to believe Patient 2 was not actually in the hospital.

Review of the medical record from the hospital emergency department that Patient 2 went to after leaving Atrium Medical Center revealed that Patient 2 did present to the emergency room on 05/07/11 at 4:18 AM, with a chief complaint of snake bite. Documentation in the medical record revealed that the patient had "2 small punctures over fifth metacarpal area with mild swelling and ecchymosis...". Investigation by the hospital revealed that the bite to Patient 2's right foot was from a brown snake and that the snake was non-venomous and the patient was treated and released.

The hospital's policy titled "PATIENT CARE: ASSESSMENT, PLAN OF CARE AND DOCUMENTATION" Policy #PCS 320 was reviewed on 05/11/11. On page 3 of this policy, in tandem with the Emergency Trauma Center unit, it describes the initial assessment as "Triage evaluation upon arrival; focused assessment based on patient presentation and clinical acuity". The "reassessment" portion states "Focused reassessment according to level of acuity"; however, there are no guidelines on how this is to be acheived.

The hospital's policy titled "Triage of Emergency Patients and Use of Optional Medical Directives" Policy #20.45 was reviewed on 05/11/11. This policy states that "The Emergency Department will have an established system of sorting and classifying patients to determine priority of care, location for treatment, and identify an emergent conditions. In addition, the Emergency Department should have an established system for the use of Optional Medical Directives with patients presenting for care". This policy did not include guidelines for managing patients that did not fit under the list of conditions for the Optional Medical Directives.

The hospital's EMTALA policy and procedure titled " EMTALA Requirements for Off-Campus Departments and On-Campus Departments of the Hospital ", policy #PCS 147 effective January 2011 was reviewed on 05/11/11. This policy states if an individual comes to the emergency department, as defined in this policy the hospital must: "Provide an appropriate medical screening examination 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 exists".

Based on review of the medical record, review of the hospital's policies and procedures, and staff interviews it was determined that the facility failed to ensure a patients that refused medical examination and/or treatment was inform of the risks and benefits of not accepting treatment and the facility failed to attempt to obtain a signed informed consent for refusal of treatment. This was found in 1(Patient 2) of 26 patients' medical records reviewed who had presented to the emergency department for care.


Findings include:

The medical record for Patient 2 was reviewed on 05/11/11. Patient 2 presented to the Emergency Department (ED) on 05/07/11 at 1:19 AM with a chief complaint of a bite injury. The triage documentation written by Staff G (registered nurse) stated that the patient complained of a snake bite to the right foot, but the patient was unsure as to the type of snake. Staff G documented at the time of triage that Patient 2 complained of burning and constant pain which the patient rated at a level of 7 (with 0 being no pain and 10 the worst pain of your life). Vital signs were obtained and were within normal limits. There was no documentation that an assessment of the condition of the patient's right foot was completed in regard to evidence of a bite or any appearance of swelling or discoloration. Based on the information that was obtained, Patient 2 was given a triage ESI of 4, (Emergency Severity Index; gives a number value to assess the severity of the patient's medical needs in which 1 indicates the need for life saving intervention and 5 as the least severe), and was placed back in the waiting room.

At 2:12 AM Staff G documented that Patient 2 got up from his/her wheelchair, was cursing loudly, and walked out the entrance with a brisk and steady gait. There was no documentation that the patient was advised of the risks and/or benefits of leaving the emergency room without treatment.

At 3:35 AM Staff H (registered nurse) documented that the patient's spouse had stopped at the triage desk and inquired about how much longer the wait would be. Patient 2's spouse was told that they were seeing patients as fast as they can but are unable to give him/her an exact time as to when the patient will be seen. The patient's spouse then told Staff H that he/she would take Patient 2 somewhere else to be seen. Staff H stated that Patient 2 left the hospital walking with a steady gait on the injured foot without difficulty. There was no documentation that Patient 2 was counseled prior to leaving the ED on the morning of 05/07/11 or asked to sign a refusal for treatment.

The hospital's EMTALA policy and procedure was reviewed on 05/11/11. This policy titled " EMTALA Requirements for Off-Campus Departments and On-Campus Departments of the Hospital ", policy #PCS 147 effective January 2011. The policy does not address the need for a written informed refusal of an examination, treatment or an appropriate transfer in the case of an individual who refuses the examination, treatment and transfer.