HospitalInspections.org

Based on review of patient records, hospital policies and procedures and staff interviews, the hospital failed to comply with all requirements of 489.24.

Refer to citations and examples at:

A 2406 (489.24 (a)) Medical Screening Exam - Hospital ED staff failed to provide a medical screening exam for Patient #1 who arrived by ambulance in their Emergency Department on 06/06/18. There was no documentation that the medical screening exam was completed at the time of the patient's arrival, or that the patient did not have an emergency medical condition. A physician's progress note dated 06/07/18, documented the patient had been medically cleared earlier by other ED medical staff.

A 2409 (489.24 (e) (1)-(2)) Appropriate Transfer - Hospital staff failed to ensure that hospital policy was followed when Patient #1's parents and involved state agencies would not accept responsibility for his care upon discharge from the hospital. An ambulance transport to the home of the patient's parents was arranged (130 miles away) but no one answered the door when the ambulance arrived. The ambulance took the patient to the Emergency Department in the local area.

Based on record review, review of hospital policy, and staff interview, the hospital failed to provide documentation that a patient was provided a medical screening exam to rule out an emergency medical condition for 1 of 25 Emergency Department patient records reviewed (Patient #1).

Failure to provide a medical screening exam at the time of the Patient #1's arrival in the Emergency Department potentially put the patient's health and safety at risk, and was a violation of EMTALA requirements.

Findings were:

Patient #1 arrived at the hospital's Emergency Department on 06/06/18. Upon record review, there was no evidence that the patient received a Medical Screening Exam at the time of arrival. There was documentation the patient was monitored and his vital signs were within normal limits. A medical progress note on 06/07/18 documented that the patient had been medically cleared, but there was no evidence of physician documentation of a medical screening exam completed at the time of arrival on 06/06/18.

Review of hospital policy, EMTALA Compliance, last dated 10/17, read that a Medical Screening Exam would be offered to any individual presenting to the emergency department or on hospital grounds, and would be consistent with the same examination the hospital would perform on any individual with similar signs and symptoms.

Interview with senior administrative staff and the medical director of the Emergency Department on 08/15/18 verified that an initial medical progress note demonstrating that a Medical Screening Exam was done, could not be located in Patient #1's electronic medical record.

Based on complaint information, staff interview, record review, and review of hospital policies, the hospital failed to provide a safe patient discharge which resulted in an inappropriate transfer to another hospital's Emergency Department for 1 of 23 Emergency Department patient transfer records reviewed (Patient #1).

Failure to provide an appropriate transfer risked patient health and safety.

Findings were:

Patient #1 was a non-verbal 16 year old male with a history of severe autism, and a bipolar disorder. On 06/06/18, he was living in a Community Crisis Stabilization Services facility administered through the Developmental Disabilities Administration (DDA) and Department of Social and Health Services (DSHS) under a voluntary placement. At approximately 7 P.M., he had a behavioral outburst, assaulted a caregiver, and was taken to the Mary Bridge Children's Hospital ED by ambulance for evaluation of the behavioral problem.

He was evaluated for the behavioral problem and medically cleared for discharge back to the care facility on 06/07/18. By that time, the patient's care facility (administered through DDA and DSHS) refused to take the patient back. Per staff interview on 08/15/18, the care facility failed to return calls from hospital staff to discuss the situation and arrange a safe discharge/return of the patient back to their facility. . The patient's mother refused to take the patient home. Per staff interview on 08/15/18, Child Protective Services (CPS) also had an open case file for this patient and was contacted for assistance. There was no CPS response to the hospital's requests. Staff interview on 08/15/18 indicated that staff initiated an Administrative Discharge for Patient #1.

The Hospital's policy, "Administrative Discharge" (last dated 11/21/17) was reviewed. This policy was to be enacted when a patient was medically capable of being released or transferred, but repeatedly refused any kind of discharge. The policy specified that it was for patients who could demonstrate decisional capacity.

The associated algorithm for the "Administrative Discharge" policy included a step that directed staff when parents/guardians and state agencies (for example, Child Protective Services) refused to take the patient at the time of discharge. The algorithm called for a hospital hold, followed by a legal and executive team review, and then an administrative discharge to the responsible agency (CPS) by ambulance transport if other options failed.

On 06/08/18, a hospital staff and multi-agency phone conference was held with the patient's mother. The hospital had located a qualified bed at Lakeland care facility in Spokane and Lakeland staff were willing to receive the patient. The mother refused placement at Lakeland, and continued to refuse to take the patient home.

The patient did not meet criteria for admission. After 2 days in the ED (06/06-08/18) the hospital notified the parents the patient would be transported to their home in Vancouver (130 miles away). The parents declined to take the patient at discharge.

Interview on 08/15/18 with the medical director of the ED and the director of pediatric care continuum identified a pattern of similar parental refusals of this patient to allow for arranged care, or to agree to provide care for their son at home following other ED visits. (There had been 8 visits in 2018.)

Following hospital team discussion on 06/08/18, the decision was made to implement the hospital's policy, "Administrative Discharge" (last dated 03/18 with an associated algorithm dated 11/21/17) and discharged Patient #1 to his parent's home with the expectation that they would take their son.

The transport was scheduled and implemented on 06/08/18 to best accommodate the patient's highest level of stability and comfort (by ambulance, and in the evening). Upon the ambulance arrival at the home, no one answered the door. The ambulance then took the patient to a Vancouver area hospital's Emergency Department where he remained.

The hospital failed to follow approved policy and hold the patient until an administrative discharge to an authorized agency could be arranged. The failed transport resulted in another hospital receiving the patient without an appropriate transfer.

The failed discharge developed into an inappropriate transfer to another hospital when the patient's family refused to accept the patient's discharge to their home and the only alternative was to take the patient to another hospital's ED.