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Based on interview and document review the facility failed to provide documentation patients had received a Medical Screening Exam (MSE) where the physician explained what his treatment plan was and the patient had been given the opportunity to accept or decline the treatment plan in 20 of 20 (Pt #1 through #20) medical records reviewed.


This deficient practice had the likelihood to effect all patients of the facilities Emergency Department.


Findings included.

On 8/23/2018 in the conference room a copy of patient (Pt/pt) #1's Medical record (MR) was reviewed. The MR inidcated that pt was routinely treated at the Veterans Administration (VA) but had come to the county hospital because he was convinced he had a urinary tract infection (UTI) and it would be quicker to receive treatment there.

Upon admission to the ED, Pt #1 was complaining of chills, and eventually his fever was 101.5. He complained of pain with urination. The ED physician ordered lab to be drawn that included a complete blood count, metabolic panel and blood for cultures, a urinalysis and a computer tomography (CT).

The initial lab revealed an elevated lactic acid and the urinalysis was positive for visible blood and microscopic bacteria in the urine. The initial indication's led the ED physician to suspect pt #1 was septic or near septic from the bacteria count identified in his urine. Pt #1's blood count was low and the physician wanted to admit pt #1. PT #1 refused to be admitted stating his blood count was always low and the VA had been monitoring it for a long time. He just wanted a prescription for an antibiotic for his UTI.

Pt #1 had expected the Community hospital would treat him like the VA treated him and simply provide the antibiotic he needed. Pt #1 was upset that instead the ED physician had ordered lab (blood and urinalysis) and a CT to rule out any other kidney problems and positively identify a urinary tract infection. The ED physician ordered an intravenous antibiotic (ABT) be given and a liter of fluid provided but did not provide the script for a antibiotic. Pt #1 agreed to stay until the IV ABT and fluid were complete then he left Against Medical Advice. Pt #1 promised to visit his VA clinic as soon as possible.

The following day the blood culture returned with a positive bacterial count. The lab result was called to the VA clinic pt #1 identified as the one he visited.



PT #1 was unaware of the plan of treatment the physician suspected was needed and had not been allowed the opportunity to refuse treatment. The physician's course of treatment was not inaccurate but was a surprise to Pt #1.

On 8/23/2018 MR for pt's #1-through #20 revealed the MSE was not identified within the ED record. A discussion of the physician's plan with patient was not identified and no documentation the patient had agreed to the physician's treatment plan was identified.

On 8/23/2018 an interview with the CNO confirmed their electronic MR did not have the MSE built into it. The program did not allow for a "hard stop" where the physician and the patient could discuss the treatment plan. The MR did not reflect if the pt was in agreement or not with the plan of care the physician was recommending.