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Based on review of the hospital's Medical Staff Bylaws, Medical Staff Rules and Regulations, Emergency Department (ED) policies and procedures, and staff interviews, the hospital failed to ensure 1) written policies and procedures were in place that ensured a medical screening exam (MSE) was conducted for each patient who present to the ED seeking treatment; 2) Medical Staff Bylaws and Rules and Regulations clarified who can perform a MSE; and 3) ED policies and procedures were in place that defined the nurses role in triage and MSE. In addition there were no ED policies and procedures regarding patients leaving the ED without being screened. These failed practices potentially denied patients access to being informed about their rights to a MSE and failed to give nursing staff clear direction as to their role in triaging ED patients.


Findings:
Review of the hospital's policies and procedures revealed the following:

-There were no policies or procedures that defined when nurses were to triage patients or if a nurse triage qualified as a MSE;

- No definition of an MSE;

- No ED policies or procedures that defined when an Outpatient Department (OPD) appointment should be made and who would make the appointment;

- No ED policies or procedures on patient's leaving the ED, even for treatment in other departments, prior to being screened; and

- No ED policies or procedures on patient's leaving the ED against medical advice.


During an interview on 12/6/12 at 1:50 pm, when asked where they could find a policy on triaging the ED patients, Licensed Nurse (LN) #s 1, 2, and 3, working in the ED, responded it should be in the new policy program. After 15 minutes, LN #2 was able to find a policy from a different hospital. During the interview LN #s 1, 2, and 3 were unable to find any facility policies pertaining to the ED. Nor was there a policy about offering the ED patients an appointment in the outpatient department.

Review of the Medical Staff Bylaws and the Medical Staff Rules and Regulations revealed no definition of a medical screening exam or any reference to who is qualified to do a medical screening exam.



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Through observation the facility failed to ensure signage informing patients of the Emergency Medical Treatment And Labor Act (EMTALA) was posted at all entrances to the Emergency Department (ED). This failed practice potentially denied patients access to information about their right to a Medical Screening Exam.

Findings:
Observations during a tour of the ED on 12/6/12 at 10:00 am revealed patients, that presented to the ED by ambulance, came in through the downstairs entrance and up to the ED by elevator. Further observations during the tour revealed there was no EMTALA signage that informed patients of their rights located in any of those areas or in the patient treatment rooms located in the ED.








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Based on record review and interview the facility failed to ensure patients (#s 2; 3; 8; 9; 13; 22; and 29) who had presented to the Emergency Department (ED) were provided with medical screening exams (MSE) by a qualified provider (physician or midlevel practitioner) to determine if a medical emergency existed prior to being sent to their appointments in the Outpatient Department (OPD) located in another area of the hospital. In addition, 2 patients (#23) and (#30) were referred back to the ED when the OPD determined they were unable to meet the patient's needs. One patient (#7) presented to the ED, was sent to the OPD, went back to the ED with worsening headaches, and was then referred back to the OPD. These failed practices denied all patients who presented to the ED their rights to a MSE by a qualified provider and placed them at risk for not receiving emergency services. Findings:

I. ED Patients sent to OPD and refered back to ED

Patient #23

Review of the ED log on 12/6/12 revealed the Patient presented to the ED on 11/26/12 at 10:29 am for "bleeding [times] 3 days". Review of the "Emergency Visit Record", dated 11/26/12 at 10:29 am, revealed "Appointment made for OPD for 11:30 this day". There was no evidence the Patient was triaged (a mechanism of rapid evaluation and prioritization of patients presenting for emergency care) by a nurse or received a MSE by a provider prior to being sent to the OPD.

Review of the OPD "Nurse Narrative" dated 12/6/12 revealed, "Pt. was brought from the ER [Emergency Room]but she was referred back to the ER by the provider."

Further review of the ED log on revealed the Patient returned to the ED at 11:40 am. The Patient then received a MSE by the ED provider with a diagnosis of "Early pregnancy bleeding".

Patient # 30

Review of the ED log on 12/6/12 revealed the Patient presented to the ED 11/9/12 at 1:24 pm for "Fractured Ribs". Review of the "Emergency Visit Record", dated 11/9/12 at 1:24 pm, revealed "Outpatient appointment made for [2:00 pm]". There was no information in the record indicating the Patient had been triaged by the nurse or had received a MSE by a provider prior to going to the OPD.

Review of the OPD record, dated 11/9/12 at 2:40 pm revealed "Advised Pt [Patient] to go to ER if he wants anymore extensive pain management to include narcotics. Pt became very irate and aggressive towards me. Spoke with ER Doc about Pt. Pt sent to ER for further pain management."

Further review of the ED log revealed on 11/9/12 at 2:50 pm, the Patient returned to the ED. The problem listed was "Refused Tramadol [anti-inflammatory medication] in OPD/ Seeking Narcotics."

Review of the "Emergency Department Nurse Record", dated 11/9/12 revealed the physician in the ED conducted a medical screening exam and the Patient was discharged home at 7:05 pm with the diagnoses rib fracture and contusion (bruising) of the ribs.

Patient # 7

Review of the ED log on 12/6/12 revealed the Patient presented to the ED on 10/12/12 at 1:58 pm with "cluster headaches". Under the disposition of the Patient were the initials "OPD". The ED medical record contained no evidence the Patient had received a MSE.

Review of the OPD record dated 10/12/12 at 2:11 pm revealed "After leaving the OPD [Outpatient Department] HA [Headache] became severe. Went to the ED for pain and was sent back to the OPC [Outpatient Clinic]..." There was no evidence the Patient had returned to the ED department in the ED log.

II. ED Patients sent to OPD

Patient #2

Review of the ED log on 12/6/12 revealed the Patient had presented to the ED on 9/25/12 at 12:53 pm with a "sore burning throat and chest". Review of the "Emergency Department Nurse Record" revealed, "Pt [Patient] triaged [and] ambulated [walked] to waiting area to await room in ER ...strep completed. To OPD for [3:30 pm] appointment." The ED medical record contained no evidence the Patient had received a MSE.

Patient #3

Review of the ED log on 12/6/12 revealed the Patient had presented to the ED on 11/29/12 at 10:58 am with "Chest Pain". Under the disposition of the Patient were the initials "OPD". The ED medical record contained no evidence the Patient had received a MSE.

Patient #8

Review of the ED log on 12/6/12 revealed the Patient had presented to the ED on 9/11/12 at 2:44 pm with a "cold". Under disposition "OPD" was written. There was no documentation in the record of the Patient leaving the ED and the ED medical record contained no evidence the Patient had received a MSE.

Patient #9

Review of the ED log on 12/6/12 revealed the Patient presented to the ED on 9/24/12 at 9:06 with "belly pain upper right side, short of breath, need inhaler". Under disposition, "OPD" was entered. Review of the " Emergency Department Nurse Record " dated 9/24/12 revealed " Education provided regarding importance of using ED appropriately and having provider in Outpatient [Outpatient Department]. Recommended OPD apt [appointment] today. Patient made decision to go to OPD appointment today." The ED medical record contained no evidence the Patient had received a MSE.

Patient #13

Review of the ED log on 12/6/12 revealed the Patient presented to the ED on 9/11/12 at 9:23 am with a "UTI [urinary tract infection]". Review of the "Emergency Department Nurse Record" revealed the "[Patient] prefers OPD appointment 10:30". There was no documentation in the ED record the Patient had received a MSE.

Patient # 22

Record review of the ED log on 12/6/12 revealed the Patient presented to the ED on 7/6/12 at 1:18 pm for "fell on rocks". Review of the "Emergency Visit Record" revealed "Appointment [at] OPD [at 1:30 pm]". There was no documentation in the ED record the nurse had triaged the Patient or the Patient was provided with a MSE.

Patient #29

Review of the ED log on 12/6/12 revealed the Patient presented to the ED on 8/13/12 with "Pain/check up on arm" at 12:55 pm. Review of the "Emergency Visit Log", dated 8/13/12, revealed "OPD". There was no evidence in the ED record the Patient was triaged by a nurse, nor was there evidence the Patient was provided with a MSE.

During an interview on 12/6/12 at 9:15 am, the Medical Director (MD) was asked about the ED process of sending patients to the OPD. The MD stated the facility did not have a process in place to "fast-track" (a process that streams patients with less urgent complaints into a dedicated area) patients. In addition, the MD stated the OPD was a completely separate department. When asked specifically about Patient #23 being sent to the OPD for an appointment and then having to return to the ED, the MD replied the OPD appointment was inappropriate because the Physician's Assistant (PA) the patient was scheduled to see [in the OPD] was not privileged to do obstetrics. The MD confirmed only a provider would be qualified to perform the MSE.

During an interview on 12/6/12 at 9:50 am, when asked about the process for sending ED patients to the OPD, the OPD Manager replied the decision to start doing it had started at an Electronic Health Record (EHR) meeting last year. It was his understanding patients were to be triaged by a nurse prior to being sent over to the OPD for an appointment. In addition, he added the facility initiated this process to try to get patients to use the ED "appropriately". The OPD Manager stated he was the Acute Care Manager (including the ED) when this process was initiated. During the interview, the OPD Manager stated the nurses were to use the ESI (Emergency Severity Index) method to triage every patient that checked into the ED.

III Licensed Nurse (LN) signing as provider

Futher review "Emergency Visit Record" in the ED records for 14 of the Patients revealed a LN signed off as the provider.

During an interview on 12/6/12 at 4:00 pm The Director of Compliance and Quality Services confirmed LN's should not be signing as providers.

During an interview with the Director of Nursing (DON) on 12/6/12 at 9:30 am, when asked about patients being sent to the OPD without receiving a medical screening exam, the DON replied the ED patients are always triaged by an ED nurse. The DON added the new procedure "It's like a fast-track".

Review of the policies provided by the facility revealed there were no policies that defined when nurses were supposed to perform a triage or if a nurse triage qualified as a MSE. Furthermore, there were no ED policies that defined when an OPD appointment should be made and who should be making those appointments. There were no policies that defined if patients leaving the ED (even for treatment in other departments), prior to being screened, were leaving against medical advice.

During an interview on 12/6/12 at 1:50 pm, when asked where they could find a policy on triaging the ED patients, LN #s 1, 2, and 3, working in the ED, responded it should be in the new policy program. After 15 minutes, LN #2 was able to find a policy from a different hospital. During the interview LN #s 1, 2, and 3 were unable to find any facility policies pertaining to the ED. Nor was there a policy about offering the ED patients an appointment in the OPD.

Review of the Medical Staff Bylaws and the Medical Staff Rules and Regulations revealed no definition of a medical screening exam or any reference to who is qualified to do a medical screening exam.

Review of the Medicaid claim forms provided by the facility on 12/7/12 revealed the ED and the OPD were billed as separate departments.

Review of the facility's policy titled "Patient Rights and Responsibilities", dated 9/29/09, revealed, "If you are in labor or have a medical emergency, you have a right to receive an appropriate medical screening examination necessary stabilizing treatment (including treatment for an unborn child), and if necessary, an appropriate transfer to another facility..."