HospitalInspections.org

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Based on observation, interview, record review and review of hospital policies and procedures, the hospital failed to develop and implement policies and procedures for evaluation, treatment and appropriate transfer or discharge of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure patients receive a comprehensive medical screening examination
by a qualified medical professional and stabilizing treatment prior to transfer or discharge risks poor health care outcomes, injury, and death.

Findings included:

1. The hospital failed to ensure that patients who presented to the Emergency Department for care would receive a medical screening examination for 1 of 20 patients who presented to the emergency department (Patient #16).

Cross Reference: A 2406

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Based on interview, document review, and review of hospital policies and procedures, the hospital failed to provide an appropriate medical screening exam (MSE) for 1 of 20 patients (Patient #16) seeking treatment in the Emergency Department (ED).

Failure to provide appropriate medical screening examinations by qualified medical professionals and stabilizing medical treatment prior to ED discharge or transfer risks poor health outcomes, injury, and death.

Findings included:

1. A review of the hospital's policy titled, "Patient Registration," number 11394086, revised 09/01/22, showed that patients who presented for care in the Emergency Department are greeted upon arrival by an admitting clerk and entered immediately on the Emergency Department Tracker.

A review of the hospital's policy titled, "Triage for Emergency Department Patients including ESI (Emergency Severity Index) Triage System," number 14999689, revised 01/05/24, showed that the condition of each patient arriving in the ED is assessed upon arrival by a registered nurse (RN) for the purpose of determining the nature and urgency of the patient's medical need and the prioritization of the patient's care and treatment.

A review of the hospital's policy titled, "LWBS-Patient Leaving Emergency Department Without Being Seen (Left Without Being Seen)," number 13313222, revised 03/15/23, showed that any patient choosing to leave the ED before receiving a medical screening examination (MSE) will be encouraged to stay and be seen, and the risks of leaving will be explained. If the patient insists on leaving prior to having a medical screening examination, the ED staff will have the patient sign a Refusal of Medical Treatment form.

2. On 07/11/24 at 2:58 PM, during an interview with the investigator, an ED nurse (Staff #1) stated that if a patient wanted to leave before triage, or before receiving a MSE, the nurse would talk with the patient about staying and try to get the provider, if available, to come out and talk to the patient. If the patient receives a MSE and decides to leave before treatment is complete, the provider gives the patient the risks and benefits associated with their decision to leave. Staff will complete and have the patient sign a Refusal of Medical Treatment form. If the patient refuses to sign the form, two people will sign the form and note that the patient refused to sign.

3. A review of the medical records for Patient #16 showed that the patient had 2 visits on 06/12/24. The review showed the following:

a. The patient arrived on 06/12/24 at 11:34 AM, with complaints of chest pain and right hip pain from a fall. Triage was completed at 11:36 AM, and the patient received a MSE at 12:04 PM. Provider documentation showed that the patient was seen in the ED the previous evening with labs drawn and imaging completed but was currently refusing lab draws and x-rays. Documentation showed that the provider reviewed the test results from the previous visit and noted that the patient was medically stable.

Nursing notes showed that staff escorted the patient to the restroom at 12:07 PM, and again at 12:28 PM. During the second visit to the restroom, the patient threw himself on the floor. Nursing notes showed that the patient was informed that he would not be allowed to use the restroom if he continued to throw himself on the floor. At 12:37 PM, Patient #16 refused staff assistance as he walked to the restroom. He continued to throw himself on the floor and refused to follow staff instructions to stay in bed. Patient #16 told staff he was going to throw himself in front of traffic and kill himself. He then walked out of the ED, but remained on hospital property. Staff notified the police and the DCR (DCR -provide comprehensive mental health assessment to the patient in a mental health crisis to determine if a patient needs to be held against their will for the patient's and others' safety). Nursing documentation showed that at 1:25 PM, Patient #16 was seen in the lobby by the DCR and cleared for discharge at 1:50 PM. Nursing documentation showed that at 2:03 PM, the patient's disposition status was changed to eloped. The investigator found no evidence of a Refusal of Medical Treatment form for refusal of testing or completion of medical screening and stabilizing treatment.

b. On 06/12/24 at 2:34 PM, Patient #16 returned to the ED. The admitting clerk documented fall as the patient's chief complaint. At 2:35 PM, Patient #16 signed a consent for treatment, at 2:53 PM Staff #2 was assigned to the patient, and the provider first contact was documented at 2:59 PM. At 3:01 PM, ED charge nurse (Staff #3) documentation showed that the patient arrived due to a fall, that Staff #3 had spoken with the DCR, and that there was a plan in place for the patient. Nursing documentation showed that during prior ED visits, Patient #16 would refuse treatment, fall to the ground on purpose and refuse to follow staff instructions. Staff #3 documented that the patient was looking for a ride home, refused to be seen in the ED, and that the DCR arrived to take the patient home as he requested. Documentation showed the patient's disposition as Left Without Being Seen (LWBS) at 3:10 PM. The investigator found no evidence of documentation showing that the patient was triaged, assessed, or assigned an emergency severity index (ESI) score, and there was no evidence of a Refusal of Medical Treatment form to show that the provider explained the risks of leaving without receiving a MSE or treatment.

4. On 07/11/24 at 3:24 PM, during an interview with the investigator, a hospital supervisor (Staff #2) stated that they were in the triage area working as an ED staff nurse when Patient #16 arrived in the ED waiting room on 06/12/24 at 2:34 PM. The patient was heard telling the admitting clerk that the reason for their visit was because they fell down an embankment. Staff #2 stated that she assigned herself to the patient and asked another staff member to room the patient for triage. Staff #2 stated that before she could triage the patient, the ED charge nurse came out to the waiting room and told her to leave the patient in the lobby because the local DCR was coming and there was already a plan in place. Staff #2 stated that she advised the Charge Nurse that the hospital had to triage the patient and provide an MSE due to EMTALA (Emergency Medical Treatment and Active Labor Act) laws. The Charge Nurse physically blocked Staff #2 to prevent her from bringing Patient #16 into a room to be triaged. At that time Staff #2 removed her name as the assigned nurse for Patient #16. Staff #2 confirmed that Patient #16 was never triaged and did not receive a MSE by a qualified provider during the encounter.

5. On 07/18/24 at 12:26 PM, during an interview with the investigator, the Chief of Patient Care Services (Staff #4) stated that policies and procedures were not followed.

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