HospitalInspections.org

Based on review of hospital EMTALA (Emergency Medical Treatment and Labor Act) policies; staff interview and record reviews; the facility failed to ensure staff followed their policies to maintain compliance with EMTALA. The hospital failed to ensure that each individual who presented to the Emergency Department and requested services was provided a medical screening examination and timely reassessment for 8 of 20 sampled patients (Patients # 1,2,3,8,9,17,19, and 20).

Findings included:

Refer to A2406.

Based on observations, staff interviews, Emergency Department Activity Log review, Central Log review, policy review, and medical record review the hospital failed to ensure that the Emergency Log accurately recorded the time patients presented to the Emergency Room (ER) requesting treatment. All patients who present to the ER should be included in the log. The currently in place process potentially excludes patients who present to the ER but leave after waiting but before registration, resulting in an incomplete Emergency Log and ER daily census.

A review of the central log revealed that for 5 of 20 patients sampled (Patients # 1, 2, 3, 9, 20), the discharge deposition was incorrectly documented. The facility failed to accurately record patient dispositions in the central emergency room log.

Findings included:

On 8/30/2021 at 9:35 am, the triage process in the ED was observed with Staff A. Patients were observed presenting to ER for treatment and were not allowed to register upon their arrival until the triage Nurse was ready to perform the triage assessment. Upon entering the facility, patients first undergo security screening. Property and body screening was conducted inside the entrance and when cleared patients were directed to sit and wait in chairs located in front of the reception desk. Patients were observed not being allowed to register until they were ready to be triaged by the nurse and the nurse is available and ready.
On 8/30/2021 at 9:45 am, Nurse K was observed working in the waiting room as the triage nurse. During this process it was observed that patients' registration was delayed while they waited for Staff K to complete her triage of another patient.
Interview with staff members A,K, L, and M confirmed this to be the process and it was stated that was standard practice for the department and was implemented in March 2021.
Review of the Emergency Department Activity Logs for 8/12/2021, 8/30/2021, 8/31/2021 and 9/1/2021 records the arrival date/time, discharge date/time and length of stay. The arrival time logged does not accurately reflect the patient's true arrival times and the arrival time record is in fact the registration time. The registration time may be after a significant wait. Patients who leave the ER after waiting without triage would not be shown on the ER log, resulting in an inaccurate central log.
An interview was conducted on 08/31/2021 at 2:40 pm with the Quality Manager and the Emergency Department (ED) Manager at which time they confirmed the above triage process has been implemented since March 2021 and confirmed this to be the process.
Facility policy titled "Emergency department - Left Without Treatment (LWOT)." Last approved on 5/2021 documents, " The purpose of this policy is to define documentation of patients that present to the emergency department (ED) but leave without treatment.
Leaves without treatment - patients notifies staff of intent
1. If a patient chooses to withdraw request for examination or treatment and the staff is made aware the patient intent to leave the nurse: informs the patient of the risks of leaving prior to receiving the examination and treatment.
2. If the patient remains insistent on leaving, the nurse; explain leaving without a medical screening.
3. Document the circumstances surrounding the patient's decision to leave without treatment.
4. The depart process is completed with the disposition of "Left Without Treatment." (LWOT).
Leaves without treatment - patient does not notify staff of intent
1. Documents circumstances surrounding the discovery of patient's departure and attempts made to verify patient not in waiting room areas.
2. The depart process is completed with the disposition of "Left Without Treatment." (LWOT).
Facility policy titled "Discharge of patients against medical advice (AMA)." Last approved on 4/2021 documents, "when a patient makes a decision to leave against medical advice, the physician or another healthcare provider explains, the risks associated with leaving against medical advice and reasons for continuing care. The healthcare provider records the events in the medical chart.

A review of the medical records and the central log revealed:

On 8/12/2021 at 4:09 pm, Patient 1 left without receiving medical treatment, but it was documented in the patient's record by a Registered Nurse (RN) that the patient "refused to sign AMA paperwork and walked out ER entrance ambulatory." Review of the central log revealed that the patient left Against Medical Advice. Patient did not have a medical screening examination. Patient should have been correctly logged in as Left Without Medical Treatment (LWOT).

On 8/12/2021 at 5:29 pm, Patient 2 left without receiving medical treatment, but it was documented in the patient's record by an RN, "No answer from patient. x2." Review of the central log revealed that the patient left Against Medical Advice. Patient did not have a medical screening examination. Patient should have been correctly logged in as Left Without Medical Treatment (LWOT).

On 8/12/2021 at 6:02 pm, Patient 3 left without receiving medical treatment, but it was documented in the patient's record by RN, "Unable to locate patient. x2. AMA." Review of the central log revealed that the patient left Against Medical Advice. Patient did not have a medical screening examination. Patient should have been correctly logged in as Left Without Medical treatment (LWOT).

On 8/12/2021 at 4:53 pm, Patient 9 left without receiving medical treatment, but it was documented in the patient's record by an RN, "AMA narrative notes, patient. educated and instructed multiple times to remain in ER lobby ..." Review of the central log revealed that the patient left Against Medical Advice. Patient did not have a medical screening examination. Patient should have been correctly logged in as Left Without Medical Treatment (LWOT).

On 8/12/2021, Patient 20 left without receiving medical treatment. A copy of the facility BC 2970 release form "responsibility from AMA" was signed by the patient on 8/12/2021 at 6:31 pm. Review of the central log revealed that the patient left Against Medical Advice. Patient did not have a medical screening examination. Patient should have been correctly logged in as Left Without Medical Treatment (LWOT).

Interview with Staff (A), RN Manager of Emergency Department on 09/01/21 at 12:30 PM verified the above findings.

Based on review of medical records, policy review, and staff interviews it was determined the facility failed to ensure that each individual who presented to the Emergency Department (ED) and requested services was provided a medical screening examination (MSE) and timely reassessment for 8 of 20 sampled patients (Patients # 1,2,3,8,9,17,19, and 20).

Findings included:

Review of the facility policy titled "Assessment/reassessment of adult patients" last approved 6/2021 documents, ED patient timeframe until initial assessment is upon arrival and the time frame for reassessment is every 2 hours and as needed for intervention and treatment intervention.

Review of facility policy titled "Emergency Medical Treatment and Labor Act", last approved 05/2021 states under the section titled " Medical Screening Procedures" that patients are entitled to a Medical Screening Exam (MSE). The policy states that "Any individual who comes to the hospital campus requesting examination or treatment for a medical condition must be provided with an appropriate medical screening examination to determine if he/she is suffering from an emergency medical condition." The policy further states that "A medical screening examination will be completed on any individual who presents at the hospital campus requesting examination or treatment to determine if an emergency medical condition exists." The policy also states that "If an emergency medical condition is determined to exist, the hospital provides treatment, including ancillary services routinely available in the emergency department, until the individual is stable or transferred to another hospital that can provide the necessary care. If an emergency medical condition is determined to exist by a qualified medical person (QMP), the appropriate treatment, and ancillary services routinely available in the emergency department will be provided. No individual suffering from an emergency medical condition will be denied further evaluation or treatment required to stabilize the condition."

Review of the facility policy titled "Intake and initial assessment of the patient in the emergency department" issued on 3/2021 states, this policy is intended to reduce the risk to all patients seeking care from, or whilst in the care of, the ED. The policy further states that based on the patient's emergency severity index (ESI) acuity level designation, and the triage nurse's overall clinical impression, place the patient in the appropriate location to assure that a medical screening examination (MSE) by qualified medical personnel is completed in a timely manner. In the event of increased patient census and lack of treatment area availability, lower acuity patients may need to wait in the ED lobby to be seen by a qualified medical person (QMP). If this occurs, the patients are re-evaluated for changes in condition, new onset of symptoms, and vital signs at a minimum occurrence of every 2 hours.

(Patient #1) Review of the medical record for Patient #1 revealed the patient presented to the facility ED on 8/12/2021 at 11:54 am for a complaint: going to travel and needed a COVID test. Review of the record revealed the patient was triaged by an RN (registered nurse) at 12:02 pm. The patient's vital signs were blood pressure 249/111, temperature 98.7, pulse 95 beats per minute (bpm), respiratory rate 20, oxygen saturation 99% on room air and pain level not documented.
Review of the triage assessment revealed the RN assigned the patient an acuity level of 5 - non urgent. The Emergency Severity Index (ESI) is a five-level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs. Review of the record revealed at 12:34 pm the vitals were reassessed, and blood pressure was 234/105, the patient was reassigned an acuity level of 2- emergent and doctor notified. The patient was sent back to the lobby to wait.
Review of the record reveals no further assessment of the patient. Review of the record revealed the patient was not reassessed for more than 4 hours.
Review of the record reveals no medical screening examination was done and at 4:09 pm the patient left without receiving medical treatment.

(Patient #2) Review of the medical record for patient #2 revealed the patient presented to the facility ED on 8/12/2021 at 12:10 pm. The patient's complaint was chest pain, dizzy pain, radiating to left arm and neck, sent by urgent care. Review of the record revealed the patient was triaged by an RN (registered nurse) at 12:15 pm. The patient's vital signs were blood pressure 132/88, temperature 98.0, pulse 76 bpm, respiratory rate 17, oxygen saturation 100% on room air and pain level not documented.
The RN assigned the patient an acuity level of 3 - urgent. At 12:18 pm an EKG (electrocardiogram) was completed which reflected Abnormal EKG, normal sinus rhythm with sinus arrhythmia. Review of the record reveals the patient was sent back to the lobby to wait. At 1:24 pm orders for an EKG, cardiac labs and a chest x-ray were placed. No further assessment of the patient was documented until 5:29 pm, more than 5 hours after the patient was triaged, that stated, "no answer from patient x 2." Further review revealed the patient did not receive any of the orders for EKG, cardiac labs and chest x-ray and left without receiving any medical screening examination and medical treatment.
Review of the record reveals no further assessment of the patient. Review of the record revealed the patient was not reassessed for more than 5 hours.
Review of the record reveals no medical screening examination was done and at 5:29 pm the patient was noted not to be in the waiting room. The patient left without receiving medical treatment.

(Patient #3) Review of the medical record for Patient #3 revealed the patient registered to the facility ED on 8/12/2021 at 12:44 pm. The patient's complaint was congestion and shortness of breath, 21 weeks pregnant. Review of the record revealed the patient was triaged by an RN (registered nurse) at 12:47 pm. The patient's vital signs were blood pressure 111/75, temperature 98.1, pulse 107 bpm, respiratory rate 20, oxygen saturation 100% on room air and pain level documented 0. The RN assigned the patient an acuity level of 3 - urgent. Review of the record reveals the patient was sent back to the lobby to wait. At 1:32 pm, orders for a COVID-19 swab were placed.
Review of the record reveals no further assessment of the patient. Review of the record revealed the patient was not reassessed for 6 hours.
Review of the record reveals the orders where not completed and no medical screening examination was done and at 6:02 pm the patient left without receiving medical treatment.

(Patient #8) Review of the medical record for Patient #8 revealed the patient presented to the facility ED on 8/29/2021 at 8:13 pm. The patient's complaint was bilateral leg swelling. Review of the record revealed the patient was triaged by an RN (registered nurse) at 8:33 pm. The patient's vital signs were blood pressure 125/75, temperature 98.2, pulse 65 bpm, respiratory rate 16, oxygen saturation 98% on room air and pain level documented at 5/10. The RN assigned the patient an acuity level of 3 - urgent.
Review of the record revealed the patient was not reassessed for 7.5 hours after 11:19 pm on 8/29/2021.
Review of the record revealed the patient did not receive a MSE.
The following day on 8/30/2010 at 7:48 am, RN notes, "called pts name multiple times to take vitals. Pt was nowhere to be found in the lobby."

(Patient #9) Review of the medical record for Patient #9 revealed the patient presented to the facility ED on 8/12/2021 at 12:22 pm The patient's complaint was not feeling well since last week, has a cough, sinus pressure, sore throat, and fever. The patient's vital signs were blood pressure 115/74, temperature 101.1, pulse 99 bpm, respiratory rate 18, oxygen saturation 98% on room air and pain level documented 7/10. Review of the record revealed the patient was triaged by an RN (registered nurse) at 12:34 pm. The RN assigned the patient an acuity level of 4 - semi urgent.
Review of the record revealed the patient was not reassessed for the duration of 4.5 hours.
Review of the record revealed the patient did not receive COVID swab as ordered at 1:25 pm.
Review of the record reveled the patient did not receive an MSE.
The patient left without receiving medical treatment at 4:53 pm.

(Patient #17) Review of the medical record for Patient #17 revealed the patient presented to the facility ED on at 8/30/2021 at 1:17 am. The patient's complaint was shortness of breath, chest pain and COVID. Review of the record revealed the patient was triaged by an RN (registered nurse) at 1:46 am. The patient's vital signs were blood pressure 146/86 , temperature 99, pulse 92 bpm, respiratory rate 19, oxygen saturation 98% on room air and pain level documented 7/10. The patient left before receiving treatment 8 hours later at 7:39 am.
Review of the record revealed the patient did not receive a medical screening exam after waiting 8 hours.

(Patient #19) Review of the medical record for Patient #19 revealed the patient presented to the facility ED on 8/30/2021 at 5:20 am. The patient's complaint was worsening shortness of breath and cough. Review of the record revealed the patient was triaged by an RN (registered nurse) at 5:24 am. The patient's vital signs were blood pressure 133/82 , temperature 99.9, pulse 105 bpm, respiratory rate 19, oxygen saturation 98% on room air and pain level documented 7/10.
Review of the record revealed the patient did not receive a medical screening exam.
Review of the record revealed the patient's orders for a COVID swab were not completed.
Review of the record revealed the patient was not reassessed.
Review of the record revealed the patient left before receiving treatment at 8:28 am.

(Patient #20) Review of the medical record for Patient #20 revealed the patient presented to the facility ED on 8/12/2021 at 12:10 pm. The patient's complaint was shortness of breath, and increased weakness. Review of the record revealed the patient was triaged by an RN (registered nurse) at 12:10 pm. The patient's vital signs were blood pressure 119/84 , temperature 98.1, pulse 95 bpm, respiratory rate not documented, oxygen saturation 97% on room air and pain level documented 8/10.
Review of the record revealed the patient did not receive a medical screening exam.
Review of the record revealed the patient was reassessed at 2:48 pm and 6:31 pm, more than two hours in between.
Review of the record revealed the patient left before receiving treatment 6 hours later at 6:31 pm.

The hospital failed to ensure patients were examined in a timely manner. The facility does not have a specific policy defining timeliness of a Medical Screening Exam (MSE) but has a quality goal in place of 20 minutes. ER Department is 50 beds. On 8/12/2021, the census had 232 patients, hospital was not on bypass or diversion at any time. 44 of the 232 patients left without seeing a provider on that date after waits of up to 12 hours.

Interview was conducted on 8/30/2021 at 2:00 pm with the risk manager, quality manager, director of quality and the ED managers at which time they confirmed the above findings.