HospitalInspections.org

Based on record review, interview, and policy review, the hospital failed to complete a medical screening exam (MSE) for one patient (Patient (P) 4) of 20 Emergency Department (ED) records reviewed when the patient presented to the ED on 06/11/24 seeking emergency care. This failure had the potential to harm all patients who present to the ED seeking emergency care.

Findings include:

Review of P4's electronic medical record (EMR) revealed P4 arrived at the emergency department (ED) on 06/11/24 at 1:56 PM with a chief complaint of "general checkup."

Review of the "ED Triage Note" dated 6/11/2024 at 2:11 PM documented by the Registered Nurse (RN) revealed, "Pt arrived in {sic} triage with co [complaint] of needs {sic} total checkup, requesting CT [Computerized Tomography that is a scan of the body]. Pt states [he/she] moved from New York to Fayetteville one year ago and states [he/she] got assaulted and beat up in New York one year ago, causing [him/her] to have chronic pain / Pt uses cane for ambulation at all times. Pt states central area chronic chest pain and abdominal pain for one year Pt complaints of generalized body aches, lower back pain, wearing sling on right arm. Pt states is painful to raise bilateral arms up x [times] one year. Pt denies any SOB [shortness of breath], nausea, vomiting or dizziness at this time ...Pt ambulatory AXOX4 [alert and oriented times 4]. Pt denies any problems urinating or moving bowels at this time. Pt states taking Advil and pain is not well controlled at this time. Pt with edema on bilateral legs at this time HX [history] of BP [hypertension], diabetes, elevated cholesterol."

Review of P4's EMR dated 06/11/24 at 2:20 PM revealed, "Acuity/Destination Patient Acuity: 3
Triage Complete."

Review of the note documented by ED/Doctor of Osteopathy (ED DO) on 06/11/24 at 2:23 PM located in P4's EMR revealed, "MSE: 68-year-old [sex] presents with generalized pain for over a year after being assaulted in New York. [He/she] is requesting a total checkup and a body scan for this. [He/she] also is complaining of chest pain however this appears to be chronic as well. Protocol orders placed. Nursing in triage, to be further evaluated when [he/she] is roomed."

Review of the "Orders" dated 06/11/24 located in P4's EMR revealed to obtain a CBC (complete blood count) with differential, CMP (basic metabolic panel), Lipase, High Sensitivity baseline Troponin level, electrocardiogram (ECG), and chest x-ray.

Review of the "Orders" dated 06/11/24 located in P4's EMR revealed to administer aspirin chewable tablet 324 milligrams (mg). Review of the EMR revealed aspirin 324mg was administered at 2:24 PM.

Review of the CMP collected on 06/11/24 at 2:41 PM revealed the results were within normal limits except for the random glucose that was 276 mg/dL (milligrams per deciliter) [Reference Range: 74 - 109 mg/dL].

Review of the "ED Quick Updates" dated 06/11/24 at 8:50 PM located in P4's EMR revealed, "Patient came up to RN asking why the wait is so long. RN explains to patient that everyone is waiting for a room in the back to see a doctor. Patient states he/she has not eaten all day and needs something to eat. RN provided patient crackers and water."

Review of the "ED Quick Updates" dated 06/11/24 at 9:30 PM located in P4's EMR revealed, "Patient's [escort] came up to front desk asking, 'what is taking so long'. RN explained to escort that the patient is waiting for a room in the back to talk with the doctor about [his/her] results from lab work and imaging. Escort asks RN 'How do we make this go faster.' RN explained that it is a process and is based on the acuity of the patient and how critical everyone is. RN [not] able to provide an exact time to escort."

Review of the "ED Quick Updates" dated 06/11/24 at 9:54 PM located in P4's EMR revealed, "Patient came up to the front window asking, 'I have been here all day, why are people going back before me.' RN explained that the wait was not based on how long a person has been here but how critically ill based on vitals, lab work, and imaging. Patient states, 'well I am done.' RN explains that the patient is not being held here and was free to go at any point if he/she wants too. Patient leaves front window and has a seat back out in the lobby."

Review of the "ED Quick Update" dated 06/11/24 at 11:24 PM located in P4's EMR revealed, " ...Patient came up to the front window yelling at triage nurse. Patient screams "I need a form to make a complaint!" [name] RN explains to patient that we do not have a form but gave the number to patient relations to have the patient call that number ...RN explains that we [hospital] do not have a form system, and you have to call this number to file complaint. Patient is upset and states that she wants to see an administrator ... called lead charge to have her come up. ..."

Review of P4's EMR revealed, "Disposition- ED Dismiss -Left Before Treatment Complete."

Review of P4's EMR dated 06/12/24 at 12:10 AM, "Patient dismissed."

During an interview on 11/20/24 at 11:00 AM, ED DO stated he/she was the provider scheduled in the triage area when P4 presented to the ED on 06/11/24. ED DO stated he/she evaluated the patient and started the MSE. ED DO stated orders were placed for bloodwork and other tests to determine if immediate placement was necessary. ED DO stated he/she did not complete the MSE because his/her shift ended at 7:00 PM on 06/11/24 and the patient remained in the waiting area and had not been brought back into a room. ED DO stated he/she reviewed the blood work results and the ECG and chest x-ray and did not have any concerns that would expedite moving P4 to a room.

During an interview on 11/20/24 at 11:15 AM, Chief Clinical Officer (CCO) stated the MSE was initiated in the triage area by the assigned provider. The provider assigned was responsible for the patient until they are moved into a room in the back. When a patient is brought back into a room, a different provider is responsible for the patient's care and that provider completes the MSE to determine whether an EMC exists and determine disposition. CCO stated long waits are not the goal of the hospital and if the front line nurses tell the provider the patient complains and states, "That's it I'm going" the provider will speak to the patient and explain the risks/ benefits of leaving without waiting for treatment to be completed. CCO stated although RN5 told the patient he/she is not being held here (hospital) and was free to go at any point if he/she wanted to, he/she felt that was misinterpreted. CCO confirmed the patient left before the MSE was completed and the provider was not notified the patient stated, "Well I am done" so the patient was not seen.

Hospital policy titled, "Refusal to Consent to Treatment or Transfer - Elopement/Walk Out/AMA", effective 08/14/23, defines "Against Medical Advice (AMA): A situation whereby the patient/guardian expresses a desire to refuse further treatment, procedures, transfer from or admission to CFVHS." The policy stated, "Prior to Completion of Medical Screening Examination 1. Staff discusses the situation with the patient/guardian and attempts to dissuade the departure. 2. Staff requests a family member or significant other, when available, to try to convince the patient to stay. 3. If the patient continues to express desire to leave prior to receiving complete MSE, staff requests that the 'Refusal to Consent to Medical Screening Examination/Treatment/Transfer' form (FF#0162) be signed by the patient/guardian. 4. If the patient/guardian refuses to sign the 'Refusal to Consent to Medical Screening Examination/Treatment/Transfer' form, staff completes the form and documents the patient's/guardian's refusal to sign. Staff obtains the signature of two witnesses on the form. Staff offers to provide a copy of the form to the patient/guardian. If the patient 'elopes or walks out' without staff being aware, the nurse documents the medical record what occurred to the best of his/her knowledge. 5. Staff documents in the medical record the specifics as to what was occurring at the time of the patient's refusal of care or departure against medical advice, including: a. Reasons why the patient is leaving. b. Condition of the patient at the time of departure. c. Instruction(s) provided to the patient. d. Care provided to the patient in preparation for leaving, e.g. removal of IV's, discontinuation of monitoring, etc. e. Date and time the patient left the care area. 6. The 'Refusal to Consent to Treatment/Transfer' form remains in the patient's medical record. 7. Staff immediately requests review of the above documentation by the Patient Care Manager or Nursing Supervisor."

There was no documentation in the medical record to show the hospital staff followed its own policy on "Refusal to Consent to Treatment or Transfer - Elopement/Walk Out/AMA".