HospitalInspections.org

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Based on observation, interview, record review, and review of hospital policies and procedures and medical staff bylaws, the hospital failed to develop and implement policies and procedures for evaluation and treatment of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure patients receive a comprehensive medical screening examination by a qualified medical professional and stabilizing treatment prior to transfer or discharge risks poor health care outcomes, injury, and death.

Findings included:

1. The hospital failed to post signs notifying patients waiting in emergency department (ED) treatment areas that they had a right to a medical screening examination (MSE) and necessary stabilizing treatment regardless of ability to pay for services; and whether or not the hospital participated in the Medicaid program.

2. The hospital failed to ensure that the physician on duty in the ED performed a MSE to determine if stabilizing treatment could have been provided for a patient who was brought to the ED by an ambulance on 06/21/19.

3. The hospital did not analyze the event above to determine if system changes were needed to ensure all patients who come to the ED receive a MSE prior to discharge, admission to the hospital, or transfer to another hospital for care.

4. The hospital did not have a process for monitoring for lapses in providing MSE's, stabilizing treatment, and patient transfers to other hospitals through the hospital's quality program.

Cross Reference: Tags C-2402, C-2406
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Based on observation, interview, and review of hospital policies and procedures, the hospital failed to post signs notifying patients waiting in emergency department treatment areas that they had a right to a medical screening examination (MSE) and stabilizing treatment; and whether or not the hospital participated in the Medicaid program.

Failure to post this information risked violation of the patient's right to receive a medical screening examination, stabilizing treatment, and/or transfer regardless of ability to pay for services.

Findings included:

1. Review of the hospital's policy titled, "COBRA - Medical Screening Exam," policy #C-5e reviewed 12/08, read: "Individuals presenting to Lourdes Health Network for the purpose of an emergency examination or treatment shall be advised that, regardless of their ability to pay, Lourdes Health Network is willing to conduct a medical screening examination to determine if an emergency medical condition exists..."

2. On 09/25/19 at 8:30 AM during a tour of the emergency department (ED) with the Director of Quality and Risk Management (Staff #1), the investigator observed there were no posted signs in the ED treatment rooms notifying patients of their right to a MSE and stabilizing treatment regardless of ability to pay; and that the hospital participated in the Washington State Medicaid program.

3. During an interview at the time of the observation, the Director of Quality and Risk Management confirmed that there was no such signage.
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to 1) ensure that the physician on duty in the emergency department (ED) performed a medical screening examination (MSE) to determine if stabilizing treatment could have been provided for a patient who was brought to the ED by ambulance on 06/21/19 (Patient #1); 2) analyze the event to determine if system changes were needed to prevent recurrence; and 3) monitor for potential EMTALA violations through the hospital's quality program.

Failure to ensure patients receive a comprehensive medical screening examination and stabilizing treatment prior to transfer or discharge risks poor health care outcomes, injury, and death.

Findings included:

1. Review of the hospital's medical staff bylaws, effective 12/18, showed that each medical staff member would "Comply with all aspects of the Emergency Medical Transfer and Active Labor Act."

2. Review of the hospital's emergency department policies and procedures showed the following:

a. The policy titled, "Standards and Regulations of Operations," Policy #E-2 approved 11/20/18, read: "Any individual who comes to the hospital for emergency medical evaluation or initial treatment shall be properly assessed by qualified individuals and appropriate services rendered."

b. The undated policy titled, "Medical Staff Coverage," Policy #M-5, showed that the hospital would provide a MSE and immediate intervention of life threatening conditions on a 24-hour basis.

c. The policy titled, "Re-Routing or Diversion of Patients," Policy #P-16 approved 01/30/19, showed that patients who presented to the hospital's ED would not be diverted to other hospitals prior to stabilization.

3. On 09/24/19 at 4:00 PM, the investigator interviewed the complainant and obtained the following information:

On 06/21/19 at 12:56 AM, the 22 year-old patient, who had been stabbed in the left side of his chest near the town of Milton-Freewater, Oregon, was taken by ambulance to Providence St. Mary Medical Center (PSMMC) in Walla Walla, Washington. Medical staff diagnosed the patient as having an injury to his heart or aorta. At 1:23 AM, PSMMC staff arranged for transfer of the patient to Kadlec Regional Medical Center (KRMC) in Richland, Washington, for cardiovascular surgery.

The patient left PSMMC by ground transport at 2:09 AM. At 2:28 AM while in route to KRMC, the patient became unresponsive. His wound was "pulsating with blood". Ambulance personnel initiated cardiovascular resuscitation (CPR), advanced cardiovascular life support (ACLS), and blood transfusions. Ambulance personnel decided to re-route to the closest hospital, Lourdes Medical Center (LMC) in Pasco, Washington.

On arrival, LMC ED staff told the ambulance personnel to continue on to KRMC. They drove to KRMC and arrived at 3:10 AM, CPR and ACLS still in progress. KRMC staff continued CPR and performed an emergency thoracotomy. Resuscitation efforts were not successful, and the patient was pronounced dead at 3:25 AM.

4. Review of the patient's medical records from the ambulance service provider confirmed the ambulance crew left PSMMC with the patient on 06/21/19 at 2:09 AM. The review confirmed the patient became unresponsive and pulseless at 2:28 AM, and that CPR, ACLS, and blood transfusions were started and continued until the patient arrived at KRMC at 3:10 AM. The review confirmed that the ambulance took the patient to LMC when the patient's condition deteriorated and that LMC staff told the ambulance to continue on to KRMC.

5. Review of the patient's medical records from KRMC confirmed the patient arrived at KRMC at 3:10 AM, that CPR and ACLS were continued, and that a cardiovascular surgeon performed an emergency thoracotomy (an emergency procedure to surgically open the patient's chest in order to control bleeding and perform internal cardiac massage). Resuscitation efforts were not successful, and the patient was pronounced dead at 3:25 AM.

6. On 09/25/19 at 8:50 AM during an interview with the investigator, the physician who was on duty in the ED during the night shift of 06/20-21/19 (Staff #2) stated he recalled that an ambulance brought a patient from Walla Walla to the LMC ambulance bay, and that he did not perform a MSE prior to sending the ambulance on to KRMC.

7. On 09/25/19 at 8:50 AM during an interview with the investigator, the Director of Quality and Risk Management (Staff #1) stated that the event above had not been reported to her.

8. On 09/26/19 at 1:00 PM during a subsequent interview with the investigator, the Director of Quality and Risk Management stated an ED staff member had completed an incident report regarding the event. The incident had been closed by the ED department nursing director (Staff #3). The hospital did not analyze the event to determine if system changes were needed to ensure all patients who come to the ED receive a MSE and stabilizing treatment prior to discharge, admission to the hospital, or transfer to another hospital for care. The interview showed the hospital's quality program did not have an effective monitoring process for possible EMTALA violations when providing MSE's, stabilizing treatment, and patient transfers from the ED to other hospitals.
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