HospitalInspections.org

Based on observation during a tours of the Hospital's Emergency Department (ED) and the Maternity nursing unit it was determined the Hospital did not conspicuously post signage specifying the rights of individuals with respect to examination and treatment for emergency medical conditions, women in labor, and participation in the State Medicaid Program.

Findings included:

During a tour of the ED, conducted on 6/7/10, at 2:15 PM, it was observed the Hospital had not posted signage that contained the required EMTALA elements other than on one wall opposite the waiting area next to the registration desk. The signage was not observable to all areas in the waiting room. No signage was posted in the main ED treatment rooms or the ambulance entrance bay.

The VP of Patient Care Services said patients presenting to the Hospital reporting they were in labor were sent to the the Maternity Nursing Unit for evaluation.

During a tour of the Maternity Nursing Unit, on 6/7/10 at 4:10 PM, it was observed the Hospital had not posted signage that contained the required EMTALA elements in any area of the Maternity Nursing Unit.

Based on interview and documentation review, it was determined the Hospital failed to ensure that all individuals presenting to the emergency department seeking treatment were provided with an appropriate medical screening examination. It was also determined based on interview and documentation review the Hospital ' s medical staff bylaws, rules and regulations or other document approved by the governing body did not specify the individuals qualified to conduct Medical Screening Examinations (MSEs).

Findings included:

I. The Triage nurse was interviewed in person on 6/4/10 at 7:15 AM. He/She said He/She had brought charts back into the ED treatment area, prior to Patient #1's arrival and while there in the treatment area four ambulances arrived one after the other. Since the Charge Nurse was triaging one of the ambulance patients, He/She triaged another ambulance patient, at 12:33 AM, who was reporting a headache.

The Registration Clerk was interviewed in person on 6/4/10 at 2:00 PM. He/she said He/She was called out into the ED treatment area to register an ambulance patient and while there 3 additional ambulances arrived one after the other.

The Security Guard was interviewed in person on 6/4/10, 10:15 AM. He/She said at 12:27 AM Patient #1 and Patient #1's Family arrive and upon noticing no one was at the registration desk asked me where the staff was as Patient #1 was having trouble breathing and needed to be seen right away. He/She said He/She called the Registration Clerk via cell phone and reported Patient #1 was in the waiting area, was having trouble breathing and needed to be seen right away. The Registration Clerk stated it would be about a 5 minute wait as ambulances had arrived and the ambulance patients were being registered.

The Registration Clerk said while registering the ambulance patients He/She received one call from the Security Guard who reported there was a patient in the ED waiting area who needed to be seen. He/She said He/She did not recall any description of who was waiting to be seen other than " a patient " . He/She told the Security Guard that He/She was registering some ambulance patients and that He/She would be out as soon as possible.

The Security Guard said He/She directed Patient #1's Family with Patient #1 to one of the triage booths to wait. A short time later, one of Patient #1 ' s Family members, who was very upset, approached me and asked why no one had helped them yet. He/She replied that as soon as possible the Registration Clerk would be with them. He/She then called the Registration Clerk a second time and reported it was urgent that Patient #1 be seen. He/She said the Registration Clerk replied He/She was doing the best He/She could and would be out as soon as possible; to have Patient #1 ' s Family and Patient #1 take a seat in one of the triage booths. He/She said one of Patient #1 ' s Family members appeared very agitated and had continued to pace while waiting, a short time later Patient #1's Family with Patient #1 exited the Hospital. Another patient arrived as Patient #1 and Patient #1 ' s Family were leaving and the Registration Clerk was called once again to report the other patient ' s arrival. A short time later the Registration Clerk came out and went over to the triage area to help the newly arrived patient.

The Registration Clerk said it was probably about 5 minutes later He/She went out to the waiting area and there were two patients seated in triage booths waiting.

The Triage Nurse said He/She was concerned that Patient #2 ' s headache could be a bleed and discussed the case with the ED physician who ordered a computed tomography of the head. He/She said it was a very busy night in the ED so I bought Patient #2 to the CT department at 12:40 AM. When I returned to the ED treatment area with Patient #2, from the CT department, I was told at the nurse ' s desk there were people out front in the lobby waiting. He/She said I was never told there was a sick child waiting.

The Security Guard said it was fairly common for both the Triage Nurse and the Registration Clerk to be gone at the same time.

The Triage Nurse said whenever the on duty registration clerk and triage nurse were both back in the ED treatment area and a patient arrived the security guard at the desk in ED waiting area would call the registration clerk by phone to report a patient had arrived and was waiting.

Review of Hospital Policy did not indicate there was a written formal policy to address the process for identifying responsibility for manning the patient registration area or a triage nurse reporting off when leaving the area nor was there any language relative to a backup plan for instances then the triage nurse was occupied with the management of a critically ill patient.

The Hospital provided corrective measures that abated the immediacy of the situation. The corrective actions included the development of a new policy and revision of the plan for staffing the Registration Desk and Triage area. The new policy ensured that the Triage area was attended by a member of the Patient Registration Staff or Emergency Department Nurse at all times. A Patient Registration Associate would be at the Greeter Desk or in the adjacent Triage Area in the ED waiting room at all times. A list of all clinicians phone numbers and emergency response codes would be located in the registration area, triage area and security desk. The Triage Nurse would notify the Patient Registration Associate when he/she left the area to transport a patient into the ED treatment area. The Triage Nurse and the ED Charge Nurse would both carry wireless telephones. In the event the Triage Nurse leaves the area to attend to a patient ' s care need the Registration Personnel who is responsible for greeting the patient will notify the Triage Nurse of the patient ' s arrival by calling the Triage Nurse ' s wireless phone. In the event the Triage Nurse was not available the Charge Nurse would be notified of the patient ' s arrival via wireless phone. In the event the Charge Nurse and Triage Nurse were not immediately available the Registration Clerk would call the Main ED telephone and request to speak with a Registered Nurse. In the Event that the Registration Staff is unable to locate a Registered Nurse, the Nursing Supervisor would be paged.

Review of Hospital documentation indicated the ED staff and Patient Registration staff were provided with education about the new policy the evening and the Policy and new staffing plan was placed into effect on 6/4/10. A copy of the new policy was also posted at the desk in the ED and in the Patient Registration area. The VP of Patient Care Services discussed the Policy changes with the Manager who was responsible for the contracted security staff. The VP of Patient Care Services toured the triage area on Saturday 6/5/10 and met with nursing staff members, confirming that the staff had received copies of the policy. The VP of Patient Care Services also confirmed that information related to wireless phone numbers was in place. In addition the Nurse Manager of ED and Hospital Nursing Supervisors monitored compliance with the new policy and staffing plan and confirmed that on Friday evening/night (6/4/10), Saturday, (6/5/10) and Sunday (6/6/10) the Staff were compliant with the new policy/ revised staffing plan.


II. A review of the Hospital's Medical Staff Bylaws and Rules and Regulations indicated they did not specify individuals qualified to conduct MSEs.

The VP of Patient Care Services was interviewed throughout the survey. The VP of Patient Care Services was unable to identify any document approved by the governing body or any other policy specifying individuals qualified to conduct MSEs.