HospitalInspections.org

Based on policy review, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20(l) and §489.24.

Findings included:

1. The hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 25 sampled patients. (Patient #9)

~cross refer to §489.24(a) & §489.24(c), Appropriate Medical Screening Exam - Tag A2406

Based on policy review, medical record review and staff and physician interviews, the hospital failed to provide an appropriate on-going medical screening examination that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 25 sampled patients. (Patient #9)

Findings included:

Review of the EMTALA policy, review/revised date 05/27/2021, revealed " ...Emergency services and care, including an appropriate Medical Screening Examination, will be provided to individuals who 'come to the Hospital's Emergency Department' at either it (A) Campus ....or its (B) Campus ....and request examination or treatment of a medical condition ....A Medical Screening Examination will be performed to determine if an Emergency Medical Condition exists. If the individual has an Emergency Medical Condition, the hospital will either stabilize the medical condition within its available staff, facilities, and resources, or, if stabilization at the hospital is not possible, appropriately transfer the individual to a qualified receiving facility. ...Medical Screening Exam (MSE): Examinations, tests, studies, monitoring and procedures that are appropriate given the individual's presenting signs and symptoms and reasonably calculated to determine if an EMC is present, including ancillary services routinely available to the emergency department. ..."

1. Review of the DED record for Patient #9 revealed the 60-year-old male arrived at the hospital's main campus (A) via ambulance on 01/07/2022 at 1749 with a chief complaint of AMS (Altered Mental Status) and alcohol intoxication. Record review revealed an ED Triage General Assessment was started by RN (Registered Nurse) #1 at 1757 and revealed vital signs were recorded as Temperature (T) 97.0, Pulse (P) 95, Respirations (R) 16, Blood Pressure (BP) 179/109, Oxygen Saturation (SpO2) 100% on room air and no pain present. Patient #9 was assigned an ESI (Emergency Severity Index) level of 3, urgent. The CSSRS (Columbia Suicide Severity Rating Scale) Screen revealed Patient #9 was unable to be screened due to his AMS. Review of the ED Physician Documentation revealed Patient #9's Medical Screening Exam was started by MD (Medical Doctor) #2 at 1807 and stated, "History is obtained primarily from EMS ...Apparently, the patient has been drinking today with friends, possibly also doing drugs ...Last known normal was yesterday ...found walking down the road, uncooperative and in imminent danger ...Family called EMS ...Patient himself unable to provide any history at this point as he is somnolent (abnormally drowsy) ...Medical Decision Making: Given altered state, will proceed with CT of the head and laboratory work-up ...he has received a liter of LR [Lactated Ringers - type of IV Fluid) ...did receive large dose of sedating medications per EMS. He will need to be reassessed once these medications have worn off. Patient is checked out to [named physician] at change of shift ...Assessment/Plan: 1. Altered mental status 2. Alcohol intoxication ..." Review of an ECG result at 1829 revealed a heart rate of 97 and "Sinus Rhythm with occasional supraventricular premature complexes." Review of Lab Results at 1835 revealed a Total CK (Creatine kinase test, elevated CK may indicate disease of muscles, heart or brain) of 439 [RR 30-375] and Troponin I (blood test, high levels may indicate some heart damage) of 24 [RR less than 20]." The Urine Drug Screen results at 2059 revealed a positive result for Amphetamines, Cocaine and THC [RR Negative]. A repeat Troponin at 2143 revealed a result of 22. Review of the MAR (Medication Administration Record) revealed Patient #9 was administered 1 liter of LR IV fluids at 1905. Record review revealed a final Nurse Rounding Note completed by RN #3 at 0000 that stated, "Pt up to chair, attempting to call family for transport home." Review of the Discharge Flowsheet completed by MD #4 at 0044 revealed, "D/C-Identified EMC [Emergency Medical Condition], STABLE at time of disposition decision." Vital signs taken just prior to discharge at 0050 revealed, Temperature (T) 97.0, Pulse (P) 99, Respirations (R) 15, Blood Pressure (BP) 156/93, Oxygen Saturation (SpO2) 100% on room air and no pain present. Record review of a Discharge Note completed by RN #3 at 0050 (7 hours and 1 minute after his arrival) further revealed, "Pt alert and oriented, vss [vital signs stable], pt understands d/c instructions with follow-up appointment if necessary. Pt ambulated out of facility with steady gait for (named company) to transport home." DED record review did not reveal further testing of cardiac markers. Record review did not reveal Patient #9 was made aware of the abnormal troponins and Total CK. Record review failed to reveal Patient #9 was made aware of the risks of leaving the DED with elevated troponin and CK-Total.

Interview on 03/23/2022 at 1228 with RN #3 (Discharge RN) revealed, she remembered Patient #9. Interview revealed Patient #9 had altered mental status and had a history of drug abuse. RN #3 recalled rounding on Patient #9 throughout the evening and stated that he "sprung up" at midnight to use the urinal. RN #3 stated, "I helped him, he walked around and was steady on his feet. I let the provider know, the patient said he was ready to go home." Interview revealed Patient #9 was no longer altered at that point. RN #3 stated that she spoke with several members of Patient #9's family and none of them were able to pick him up. Interview further revealed RN #3 asked the US (Unit Secretary) to arrange transport and then called Patient #9's family back to advise them that he would be on his way. Interview revealed Patient #9 asked if he was okay to discharge and also wanted to make sure his AMS was related to drugs and not something more serious like a stroke. RN #3 stated, "I think I spoke with family like 10 times" and that they were aware of the testing that had been done on Patient #9. Interview revealed RN #3's usual process was to look at the task list when speaking with family and go over all of the tests that were done and their results. Interview revealed the DED routinely evaluated patients who presented for symptoms related to substance abuse. RN #3 stated that Patient #9 was alert, oriented and understood his discharge instructions.

Interview on 03/23/2022 at 1459 with MD #2 revealed the physician vaguely remembered Patient #9 and reviewed the medical record. Interview revealed MD #2 was unable to assess Patient #9 in the altered mental state that he was in upon arrival, so she ordered his "work-up" and "checked him out to [named MD #4]" for reassessment after his medications wore off. MD #2 stated that the usual process was to do a complete AMS work up on every acutely intoxicated patient to make sure there was nothing else causing them to be altered. MD #2 stated, "We have a pretty robust screening process." Interview revealed that once all the tests resulted, they checked with the patient to what they wanted to do. MD #2 stated, "We often find that once the substance has worn off, they want to go home and if they are not suicidal or homicidal and don't want help, we discharge them." Interview revealed the families of substance abusers often ask if the hospital can hold them, but staff explained to them that they cannot hold someone against their will if they are of sound mind and not a danger to themselves.

Interview on 03/23/2022 at 1527 with MD #4 revealed he remembered Patient #9. Interview revealed, MD #4 assumed care of Patient #9 from MD #2 at shift change. MD #4 stated, "After he woke up, he told me he had been doing meth and cocaine ...I know he walked to the bathroom, but he was sitting up in the chair when I spoke with him. He was alert, oriented and knew where he was. He said he wanted to go home ...he gets to make is own decisions. I cannot keep him there against his will."

2. Review of the closed medical record for Patient #9 revealed the 60-year-old male arrived to the DED (Dedicated Emergency Department) via ambulance on 01/10/2022 at 0839 with a chief complaint of "Seizures". Review of the Medical Screening Exam performed by MD # 5 at 0849 revealed, "per family, was seen last Friday, they presume that he had been partying all weekend, returned yesterday ...mild twitching movements to right side of his head and face. Vitals have been stable aside from some tachycardia, in route to emergency department, patient had a generalized tonic-clonic seizure, lasted approximately 1 minute just prior to arrival ...Per EMS patient's seizure spontaneously resolved ...Medical Decision Making: EKG obtained ...rate of 124 ...No ST segment elevation, depression or T wave abnormality indicating ischemia. Patient given Ativan, Keppra (anti-convulsant) load, twitching ...resolved ...No further seizure activity ...history of methamphetamine abuse, also concern for alcohol withdrawal. Internal medicine evaluated patient, requested intubation. Patient intubated, admitted to the intensive care unit."

Record review revealed Patient #9 was hospitalized for 16 days and was discharged home on 01/26/2022 at 1606.