HospitalInspections.org

Based on policy review, medical record review and interviews the hospital failed to ensure that an adequate medical screening examination was provided for 3 of 24 patients who presented to the hospital's Dedicated Emergency Department (DED) for evaluation (Patients #13, #12 and #15).

The findings include:

The hospital staff failed to ensure a medical screening examination was completed within the capability of the hospital's Dedicated Emergency Department (DED) to determine whether or not an emergency medical condition existed for 3 of 24 patients who presented to the DED (Patients #13, #12 and #15).

~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

Based on policy and procedure review, medical record reviews and staff and physician interviews, the hospital staff failed to ensure a medical screening examination was completed within the capability of the hospital's Dedicated Emergency Department (DED) to determine whether or not an emergency medical condition existed for 3 of 24 patients who presented to the DED (Patients #13, #12 and #15).

The findings included:

Review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) policy effective 05/16/2018 revealed, "... Definitions: Medical Screening Examination: A process of sufficient scope to conclude, with reasonable clinical confidence, whether an emergency medical condition does or does not exist and that utilizes necessary ancillary services that are routinely available to the hospital. ... Procedure: Medical Screening Examination If an individual: 1) presents at (the hospital's) Dedicated Emergency department and requests examination or treatment for a medical condition; ... 3) ... then an appropriate Medical Screening Examination shall be conducted by qualified clinical personnel to determine whether the patient is in active labor or whether an Emergency Medical Condition exists. ... The medical screening examination shall be reasonably calculated to identify critical medical conditions that may be affecting a symptomatic patient and shall be consistent with the screening examination afforded other patients presenting with he same complaints or symptoms. ..."

Review of the facility policy titled "Patients Leaving Before Treatment Complete Policy" effective 02/02/2021 revealed "...Purpose: The intent of this policy is to outline the process to follow when a competent adults decides to leave the Emergency Department (ED) under the following conditions...2. Refuses treatment by leaving after the medical screening examination has begun...Definitions...4. Patient Leaving after Medical Screening Exam (PLAM)- The patients has had at least one contact with the physician...The medical screening examination has begun and the patient has a plan of care...5. Against Medical Advice (AMA)/ Patient Leaving after Medical Screening Exam-The medical exam has been initiated and the patient is refusing recommended treatment. This will include the following...b. Patient informed staff and is refusing to sign AMA...Policy: There is a legal duty to offer every patient who presents to the dedicated ED a medical screening examination, to properly inform patients of the plan of care and the risks and benefits of that care so they can exercise their right to choose to stay to receive care or to leave the hospital...Procedure...2. The following steps will be followed if the patient leaves PLAM/AMA: a. The Emergency Medicine Provider or the primary nurse should make every attempt to provided a thorough explanation of the potential consequences of the patient's actions to the patient...d. It is the responsibility of the Emergency Medicine Provider to initiate the documentation requirement...3. Required documentation of...PLAM, AMA: a. Should be completed on the "Refusal Treatment, Transfer, and Medical Screening" form...or in the...computerized charting system..."

1. Review of a closed Dedicated Emergency Department (DED) record on 11/17/2021 revealed Patient #13 was a 56-year-old female who arrived to the ED on 07/23/2021 at 1556 via EMS with a complaint of chest pain. Medical record review revealed triage vital signs documented at 1600 were temperature 98.6, pulse 120, respirations 18, blood pressure 132/77, pain 8 out of 10 (pain severity scale 0-10). Medical record review revealed the MSE was initiated by Medical Doctor (MD) #5 at 1621. Review revealed MD #5 ordered cardiac monitoring, lab work, EKG, chest X-ray and CT of the chest. Review of an "ED Provider Note" signed by MD #5 at 1628 revealed "...Pt is a 56 y.o. female who presents with complaints of Chest Pain. Ongoing since this morning, dull and tingling sensation with no nausea vomiting, no shortness of breath. No change with nitroglycerin...Given the patient's initial medical screening exam, the following diagnostic evaluation has been ordered. The patient will be placed in the appropriate treatment space, once one is available, to complete the evaluation and treatment. I have discussed the plan of care with the patient. Medical Decision Making...Will need expedited emergent workup for the above here in the emergency department today. Plan for IV (intravenous) access, IVF (intravenous fluids) as needed, analgesia/antiemetics, possible imaging which may include CXR (chest x-ray), CTA (computed tomography angiography) for possible PE (pulmonary embolus), ECG (electrocardiogram), ASA (asaprin), full lab panel, continuous telemetry, and serial exams. Disposition pending ED w/u (work-up) and response to interventions..." Medical record review revealed at 1650, Patient #13 was transferred from Triage Room #7 to the waiting room. Medical record review revealed at 0225, Registered Nurse (RN) #6 discontinued the IV (catheter placed into vein to give medications or fluids) in Patient #13's left antecubitical (arm). Medical record review revealed at 0230, RN #6 documented Patient #13's disposition to LBTC (left before treatment completed). Medical record review failed to reveal evidence the ED staff advised Patient #13 of the benefits of staying versus the risks of leaving the ED against medical advice or before treatment was completed. Medical record review failed to reveal evidence of a signed "Refusal Treatment, Transfer and Medical Screening" form.

An interview was requested with RN #6 who was unavailable for interview.

Telephone interview on 11/17/2021 at 1539 with MD #5 revealed he was the provider assigned to triage on 07/23/2021. Interview revealed he did not recall Patient #13. Interview revealed based on review of the medical record, Patient #13 presented to the ED with a complaint of chest pain. Interview revealed MD #5 initiated the generic order set for patients with chest pain. Interview revealed based on review of the ED record, his shift was over prior to Patient #13 leaving the ED. Interview revealed MD #5 was not made aware that Patient #13 planned to leave the ED before treatment was completed.

Interview on 11/17/2021 at 1100 with the ED Clinical Operations Director revealed a physician is assigned to triage between the hours of 0700 and 2300. Interview revealed after 2300, the triage nurse would request orders from the provider assigned to the "A Pod" of the ED. Interview revealed based on review of Patient #13's DED record, there was no documentation that the ED nurse notified a provider Patient #13 planned to leave the ED before treatment was completed. Interview revealed there was no order to discontinue Patient #13's IV and no order to discharge Patient #13 from the ED. Interview revealed there was no documentation the ED nurse discussed the risks of leaving the ED versus the benefits of staying to receive medical care. Interview revealed the attending physician was responsible to have the ED patient sign the AMA form. Interview revealed "the AMA form would have been initiated if the provider had been engaged."

2. Review of a closed Dedicated Emergency Department medical record on 11/17/2021, revealed Patient #12 was a 74-year-old female who arrived to the DED via EMS (emergency medical service) on 07/18/2021 at 1531 with a complaint of generalized weakness. Medical record review revealed the medical screening exam (MSE) was initiated by MD #1 at 1533. Medical record review revealed at 1533 MD #1 ordered an EKG, chest X-ray, and lab tests to include: complete blood count with Differential (CBC), comprehensive metabolic panel (CMP), Prothrombin time (INR), activated Partial Thromboplastin Time (APTT), urinalysis, and a troponin. Review of an ED triage note written by Registered Nurse (RN) #2 at 1534 revealed "... Here with near syncopal episode while driving this afternoon. Denies dizziness or pain. No vision changes. Reports "vail" over her brain. [sic]" Medical record review revealed 1535 vital signs were: temperature 98.4, pulse 60, respirations 16, blood pressure 171/82 and oxygen saturation 100%. Review of an "ED Provider Note" written by MD #1 at 1537 revealed "Medical Evaluation at Triage...Pt is a 74 (year old) female with complaints of near syncope. States she felt 'like a veil came down over my brain' but not in her vision. She was seen at urgent care who referred her here. Reports chest pain several days ago, but none currently...(Medical Decision Making) and Plan:...The patient will be placed in the appropriate treatment space, once one is available, to complete the evaluation and treatment. I have discussed the plan of care with the patient..." Medical record review revealed at 1636, Patient #12 was transferred from the waiting room to Triage Room #5 for lab draws and EKG and then transferred back to the waiting room at 1649.

Review of an ED note written by RN #2 at 2214 revealed "Patient to NF (nurse first) asking about bed status. Apologies made for wait times. Triage and MSE process explained. Pt denies pain at this time and is ambulating in lobby with steady gait." Medical record review revealed at 2244 Patient #12's peripheral IVs was removed by an ED paramedic (EMT #3). Medical record review revealed documentation of room call #1 at 0045, room call #2 at 0056 and room call #3 at 0101 by RN #4. Medical record review revealed at 0101, RN #4 documented "Patient went home" and set the disposition to LBTC (left before treatment completed). Review of an "ED Note" written by RN #4 revealed "Patient has decided to leave the Emergency Department before their treatment and a complete evaluation could be performed. I have encouraged patient to wait for a complete evaluation. I have recommenced patient promptly follow up with their primary care physician or return to the ED as necessary. I discussed with patient that follow up is important to review the results of labs and/or radiologic studies ordered in the ED that have not been reviewed with the patient by an ED provider due to their decision to leave." Medical record review revealed on 07/19/2021 at 0102 Patient #12's disposition was documented as "Left Against Medical Advice." Medical record review failed to reveal evidence an ED provider was notified before or after Patient #12 left the ED. Medical record review failed to reveal documentation the ED staff advised Patient #12 of the benefits of staying versus the risks of leaving the ED against medical advice or before treatment was completed. Medical record review failed to reveal evidence of a signed "Refusal Treatment, Transfer, and Medical Screening" form.

Interview on 11/17/2021 at 1050 with RN #2 revealed she worked in triage at the time Patient #12 presented to the ED and then worked in the Nurse First area of the ED later on in the shift. Interview revealed based on record review, Patient #12 presented to the Nurse First desk for an update on being taken back in the ED. Interview revealed RN #2 explained the triage and MSE process. Interview revealed RN #2 assessed Patient #12's comfort level and asked if Patient #12 needed anything. Interview revealed she did not recall Patient #12 stating she planned to leave the ED. Interview revealed RN #2 was not aware that Patient #12 left the ED before treatment was completed.

An interview was requested with EMT #3 who was unavailable for interview.

An interview was requested with RN #4 who was unavailable for interview.

Telephone interview on 11/18/2021 at 1415 with MD #1 revealed he was the provider assigned to triage on 07/18/2021 from 1500-2300. Interview revealed based on review of the ED record, he was not made aware that Patient #12 planned to leave the ED before treatment was completed. Interview revealed MD #1 did not write an order to discontinue Patient #12's IV. Interview revealed MD #1 did not write an order to discharge Patient #12 from the ED.

Interview on 11/17/2021 at 1100 with the ED Clinical Operations Director revealed a physician is assigned to triage between the hours of 0700 and 2300. Interview revealed after 2300, the triage nurse would request orders from the provider assigned to the "A Pod" of the ED. Interview revealed based on review of the DED record, there was no documentation that the ED nurse notified a provider Patient #12 planned to leave the ED. Interview revealed there was no physician order to discontinue Patient #12's IV and no order to discharge Patient #12 from the ED. Interview revealed the attending physician was responsible to have the ED patient sign the AMA form. Interview revealed "the AMA form would have been initiated if the provider had been engaged."


16369

3. Review of a closed DED record on 11/17/2021 revealed Patient #15 was a 38-year-old female who arrived to the DED on 09/07/2021 at 1039 with a complaint of generalized weakness and chest pain. Medical record review revealed triage vital signs documented at 1053 were temperature 98.1, pulse 83, respirations 16, blood pressure 166/92, oxygen saturation 98%, denies pain. Review of triage notes documented the patient was "here for dizziness, nausea and palpitations last night after dialysis treatment. This morning symptoms have persisted, reports generalized weakness. Thinks blood pressure may have been low, reports a recent history of same after dialysis. Gets M/W/F dialysis, received a full treatment yesterday. Denies CP (chest pain)/SOB (shortness of breath)/fevers. Alert and calm in triage. Medical record review revealed the MSE was initiated by MD #7 at 1056. Review of an "ED Provider Note" signed by MD #7 at 1100 revealed "...Pt is a 38 y.o. male who presents with weakness after dialysis. No fevers." Review revealed a plan to obtain lab studies and a chest x-ray. MD notes recorded, "I have evaluated the patient and initiated the medical screening exam and diagnostic evaluation. Pt will need ongoing assessment and potentially further workup and treatment. The patient will be placed in the appropriate treatment space, once one is available to complete the evaluation a and treatment. I have discussed the plan of care with the patient." Review revealed MD #7 ordered lab work and a chest X-ray. Review revealed a peripheral IV (intravenous) line was placed at 1107 and blood was collected for lab studies at this time. Review revealed the patient was transferred from Triage Room #5 to the waiting room at 1109. A chest x-ray was initiated at 1122. Review of the record revealed repeat vital signs at 1456 were temperature 98.6, pulse 70, respirations 20, blood pressure 141/107, oxygen saturation 100%. Medical record review revealed at 1813, RN #8 discontinued the IV in Patient #15's right antecubital (arm). Medical record review revealed at 1813, RN #8 set Patient #15's disposition to LBTC (left before treatment completed) and documented the patient was discharged at 1814. Medical record review failed to reveal a discharge order. Medical record review failed to reveal documentation the ED staff advised Patient #15 of the benefits of staying versus the risks of leaving the ED against medical advice or before treatment was completed. Medical record review failed to reveal evidence of a signed "Refusal Treatment, Transfer and Medical Screening" form.

Telephone interview on 11/18/2021 with RN #8 revealed she did not remember Patient #15. Interview revealed if a patient reported they were leaving before treatment was completed she would review the chart, labs and engage the physician. She reported she would encourage the patient to stay. She stated, "If they choose to leave, I would ask the patient to let me know and I will discontinue the IV prior to the patient's departure. I will typically document if the physician was notified. The volume in the waiting room makes it difficult to document everything." The nurse reported that if she was really concerned with a patient leaving, she would put the patient in the triage area and have the physician evaluate them. She reported she would document in the ED record if the patient was moved to a different area.

Telephone interview on 11/18/2021 at 1405 with MD #7 revealed he was the provider assigned to triage on 09/07/2021. Interview revealed he did not recall Patient #15 and was unable to remember what happened with the patient. Interview revealed based on review of the medical record, Patient #15 presented to the ED with a complaint of general weakness after dialysis. Interview revealed MD #7 initiated the workup. He stated he would document updates if there was a change in the patient's condition or treatment. The physician stated he usually doesn't discharge a patient from the waiting room area. He stated that if he was told the patient was leaving he would usually reassess the patient and recommend staying to complete the evaluation. He stated he would tell the patient that risks of leaving could not be assessed until the evaluation was completed. Interview revealed MD #7 was not made aware that Patient #15 planned to leave the ED before treatment was completed.

Interview on 11/17/2021 at 1100 with the ED Clinical Operations Director revealed a physician is assigned to triage between the hours of 0700 and 2300. Interview revealed based on review of the DED record, there was no documentation that the ED nurse notified a provider Patient #15 planned to leave the ED. Interview revealed there was no order to discontinue Patient #15's IV or order to discharge Patient #15 from the ED. Interview revealed there was no documentation the ED nurse or physician discussed risks of leaving the ED versus the benefits of staying to receive medical care with Patient #15.