HospitalInspections.org

A-2400/489.20(1): Compliance with 489.24

Based on staff interview, hospital bylaws, policy review, and ambulance record, the ED (emergency department) registered nurses failed to follow the hospital ' s EMTALA (Emergency Medical Treatment and Labor Act) policies and Medical Staff Bylaws to provide a MSE (Medical Screening Examination) for 1 of 21 patient's medical records reviewed (patient # 1) for individuals presenting with a request for medical care.

Findings include:

- Hospital EMTALA policy " Definitions ... " dated 11/2012 reviewed on 7/9/13 at 10:00am directed staff " ...all employees shall be familiar with the following definitions used in the EMTALA policies and procedures, and shall be able to identify those persons to whom the hospital owes certain duties and obligations under EMTALA ... covered persons means those persons to whom the hospital owes an obligation to provide a MSE and, if such person is determined to have an EMC (emergency medical condition), stabilizing treatment or an appropriate transfer. Such persons include ...any person present in the ED (Emergency Department), including the reception and waiting areas, adjacent hallways and the ambulance bay if the person requests any type of medical examination or treatment or such a request is made on behalf of the person ... "

Hospital EMTALA policy " Medical Screening Examination " dated 11/2012 reviewed on 7/9/13 at 10:00am directed staff " ...the hospital shall provide each covered person with an appropriate MSE within its capabilities to determine whether the person has an EMC ...The decision whether a covered person has an EMC must be made by the physician or mid-level practitioner who personally examines the covered person ...the ED shall maintain a log of all covered persons ... "

Hospital Medical Staff Bylaws dated 2012-2013 reviewed on 7/8/13 at 4:00pm directed staff to provide an appropriate MSE to determine whether or not an EMC condition exists for any individual arriving by himself or herself or with another person at the ED. The individuals qualified to conduct the MSE included: Physicians, Nurse Practitioners, Physician Assistants and Registered Nurse who shall consult with the physician or APP (Advanced Practice Practitioner) on call. A Physician, or APP, who are on call or an RN in consultation with Physician or APP shall perform a MSE on all patients presenting on hospital property seeking emergency care ...If a physician and/or APP is not on site, the RN will call the provider on call, and will consult with them relative to the patient ' s condition. The on call provider will then decide if an EMC (emergency medical condition) exists and will communicate this to the RN. If an EMC exists, the provider on call will see the patient. If an EMC does not exist, the RN may, after receiving orders from the provider, treat the patient. If, at any time, the RN feels the provider should see the patient, then the provider is obligated to do so immediately.

Review of the Critical Access Hospital Database Worksheet on 7/9/13 at 9:30am revealed the hospital provided the following services:

Anesthesia service, Chiropractic Service, CT Scans, Emergency Department, (dedicated), Laboratory-clinical, MRI (Magnetic Resonance Imaging), Nuclear Medicine services,
Occupational services, operating rooms, outpatient services, pediatric services, pharmacy services, physical therapy services, post-operative recovery, radiology services-diagnostic, respiratory care services, speech pathology services and surgical inpatient and outpatient and social services.

Review of the EMS (emergency medical service) ambulance report for patient # 1 revealed EMS sent an ambulance crew on 6/28/13 at 12:52am to an oil field rig outside of Wakeeney, Kansas for a patient who had suffered a traumatic injury. Patient #1 worked on an oil rig and a pipe that weighed over 1400 pounds fell and struck the patient. The pipe struck the patient ' s left shoulder and left side of their body. The patient complained of pain and told EMS they could not feel anything down their left side. The EMS placed a cervical-collar on the patient ' s neck and placed the patient on a spine board. The EMS crew called to the Trego County-Lemke Memorial Hospital (TCLMH) ED to give the ED nurse report on the patient. The EMS crew documented registered nurse H from the ED called the ambulance and stated the RN gave physician assistant D on call a report on patient #1 who instructed the ambulance to proceed to hospital BB. The EMS crew documented during the transport to hospital BB but while within 2 blocks from the TCLMH the patient ' s blood pressure dropped from 159/124 to 72/47. The EMS brought the patient to the nearest ED which was TCLMH in Wakeeney, Kansas. The EMS transporting the patient lacked certification to start IV fluids which could bring the patient ' s blood pressure back to a normal range. The ambulance pulled into TCLMC Hospital ED entrance and ED nurse staff climbed into the back of the ambulance and started an IV then instructed the EMS crew to resume the transport of patient #1 to hospital BB.

Review of the TCLMH ED log on 7/8/13 at 1:30pm revealed on 6/29/13, the ED nurses failed to document when patient #1 presented by ambulance on hospital property.

Staff A, RN (Registered Nurse)/(Chief Nursing Officer) interviewed on 7/8/13 at 1:15pm verified the ED nurses failed to ensure patient #1 received a MSE per hospital policy when the ambulance presented on hospital property. Staff A, RN/CNO verified the ED staff failed to document in a medical record that patient #1 presented to the ED. Staff A, RN/CNO explained they expected the ED nurses to follow hospital policies regarding EMTALA.

ED nurse E, RN interviewed on 7/9/13 at 9:50am verified they worked the 7pm to 7am night shift on 6/28/13. Staff E indicated the RN ' s take turns with ED services and will help assist each other so patient needs are met. ED nurse E, confirmed on 6/29/13 at 1:10am they overheard on the EMS scanner that EMS was on an ambulance run to a patient with a shoulder injury seven miles outside of Wakeeney. Staff E received a call at 1:35am from EMT (Emergency Medical Technician) staff J who reported a 40 something year old male was injured in the oilfield when struck by a 1457 pound pipe. The patient was screaming out in pain with no visible injuries; however the patient could not feel anything on their left side. EMT staff J reported they secured the patient on the spine board, with a c-collar. The patient ' s B/P was 150/124. ED nurse E, stated EMT staff J asked if there was anything else EMS could do. ED nurse E, RN stated they told EMS to just watch the airway and proceed to the hospital. ED nurse E, RN gave this report to ED nurse H, RN who called the Physician Assistant D and gave a report about patient #1. The Physician Assistant D gave ED nurse H, RN instructions to tell EMS to re-route to hospital BB due to the patient ' s injuries and level of care needed. ED nurse E, RN stated the RN ' s were at the nurses ' station and around 1:52am someone came rushing down the hallway and stated, " The ambulance was at the back door. " ED nurse E, RN stated they stopped in the ED and grabbed an IV start kit, then climbed in the back of the ambulance and found an appropriate place for the IV, placed the tourniquet and inserted the IV. ED nurse E, RN verified they connected the IV tubing and fluids to the patient. ED nurse E, RN stated at 2:01am all the RNs returned to the nurses ' station and briefed the other nurses about the treatment provided.

Physician Assistant (PA) D interviewed on 7/9/13 at 11:05am confirmed on 6/29/13; they received a telephone call from ED nurse H, RN at 1:49am. The ED nurse H, RN called to notify the PA that a 40 year old male was coming to the ED after an oil field accident where a large pipe hit the patient and the patient had no feeling on the left side. Physician Assistant D stated they instructed ED nurse H, RN to tell EMS dispatch to re-route the ambulance to hospital BB because Trego County-Lemke Memorial Hospital lacked services for traumas. Physician Assistant D indicated they waited for a return call from the ED nursing staff but never received further calls with an update of the patient#1 ' s condition or request for care.

Staff C, RN/DON (Director of Nursing) interviewed on 7/9/13 at 1:15pm confirmed staff E, ED RN failed to follow hospital EMTALA policy when they jumped into the rear of the ambulance and started an IV for a patient #1.

ED nurse H, RN interviewed on 7/10/13 at 7:00am verified the interview information obtained from ED nurse E about the hours and duties nurses worked. ED nurse H confirmed the information about patient #1 ' s injury, PA contact, ED arrival and treatment with IV fluids prior to resuming transport to hospital BB. ED nurse H, observed ED nurse E, RN in back of the ambulance inserting an IV catheter and started IV fluids then the ambulance proceeded to hospital BB. ED nurse H acknowledged they and the other ED nurses failed to notify the PA on call the patient arrived on hospital property and EMS requested assistance. ED nurse H verified TCLMH staff did not call hospital BB to tell them the patient had been at the Trego County-Lemke Memorial Hospital ED. ED nurse H, RN verified they failed to document what occurred.

ED nurse G, RN interviewed on 7/10/13 at 7:40am verified they worked the 7pm to 7am night shift on 6/28/13. ED nurse G, RN confirmed the EMS crew brought patient #1 to the ED because the patient ' s blood pressure dropped and needed an IV inserted. ED nurse E, RN climbed into the back of the ambulance and started the IV then the ambulance proceeded onto hospital BB. ED nurse G, RN stated they and the other nurses talked about this and realized they failed to document anything and they discussed the possibility if they had done something " illegal " . ED nurse G, RN indicated the hospital provided annual EMTALA training and " it has been drilled into them that if someone comes onto the hospital property they must be seen in the ED " .

Staff I, CEO (Chief Executive Officer) and staff A, RN/CNO interviewed on 7/10/13 at 11:00am verified the ED nurses who worked the night shift on 6/28/13 failed to follow hospital EMTALA policies and procedures when a patient presented on hospital property.

2406/489.24(a) and 489.24(c): MSE

Based on staff interview, hospital bylaws, policy review, and ambulance record, the hospital failed to ensure 1 of 21 patients (patient #1) received a MSE (Medical Screening Examination) for individuals presenting to the hospital property with a request for emergency medical care.

Findings include:

- Hospital EMTALA policy " Definitions ... " dated 11/2012 reviewed on 7/9/13 at 10:00am directed staff " ...all employees shall be familiar with the following definitions used in the EMTALA policies and procedures, and shall be able to identify those persons to whom the hospital owes certain duties and obligations under EMTALA ... covered persons means those persons to whom the hospital owes an obligation to provide a MSE (Medical Screening Examination) ...Such persons include ...any person present in the ED, including the reception and waiting areas, adjacent hallways and the ambulance bay if the person requests any type of medical examination or treatment or such a request is made on behalf of the person ... "

Hospital EMTALA policy " Medical Screening Examination " dated 11/20/12 reviewed on 7/9/13 at 10:00am directed staff " ...the hospital shall provide each covered person with an appropriate MSE within its capabilities to determine whether the person has an EMC ...The decision whether a covered person has an EMC must be made by the physician or mid-level practitioner who personally examines the covered person ...the ED shall maintain a log of all covered persons ... "

Hospital Medical Staff Bylaws dated 2012-2013 reviewed on 7/8/13 at 4:00pm directed staff that any individual arriving by himself or herself or with another person at the ED shall be provided with an appropriate MSE to determine whether or not an EMC condition exists. The individuals qualified to conduct such a screening included: Physicians, Nurse Practitioners, Physician Assistants and Registered Nurse who shall consult with the physician or APP (Advanced Practice Practitioner) on call. A Physicians, or APP, who are on call or an RN in consultation with Physician or APP shall perform a MSE on all patients presenting on hospital property seeking emergency care ...If a physician and/or APP is not on site, the RN will call the provider on call, and will consult with them relative to the patient ' s condition. The on call provider will then decide if an EMC (emergency medical condition) exists and will communicate this to the RN. If an EMC exists, the provider on call will see the patient. If an EMC does not exist, the RN may, after receiving orders from the provider, treat the patient. If, at any time, the RN feels the provider should see the patient, then the provider is obligated to do so immediately.

Review of the Critical Access Hospital Database Worksheet on 7/9/13 at 9:30am revealed the hospital had the capability to provide the following services:

Emergency Department, (dedicated), Anesthesia service, Chiropractic Service, CT Scans, Laboratory-clinical, MRI (Magnetic Resonance Imaging), Nuclear Medicine services,
Occupational services, operating rooms, outpatient services, pediatric services, pharmacy services, physical therapy services, post-operative recovery, radiology services-diagnostic, respiratory care services, speech pathology services and surgical inpatient and outpatient and social services.

Review of the EMS (emergency medical service) ambulance report for patient # 1 revealed EMS dispatch sent an ambulance crew on 6/28/13 at 12:52am to an oil field rig outside of Wakeeney, Kansas for a patient who had suffered a traumatic injury. Patient #1 worked on an oil rig and a pipe that weighed over 1400 pounds fell and struck the patient. The pipe struck the patient on their left shoulder and down the left side of their body. The patient complained of pain and told EMS they could not feel anything down their left side.

EMT (Emergency Medical Technician) staff J, interviewed on 7/9/13 at 1:55pm confirmed they were the lead EMT on the ambulance crew on the morning of 6/29/13. EMT staff J stated they were BLS (Basic Life Support) trained and was paged to an accident seven miles from TCLMH (Trego County-Lemke Memorial Hospital) in Wakeeney. When EMS arrived at the scene they found a male face down on the ground. EMT staff J stated they were informed the patient was hit with a pipe on the shoulder and down the leg. EMT staff J stated their assessment rated the patient ' s pain level at 10 and the patient was alert/oriented X ' s 3. The patient reported no feeling on their left side. EMT staff J observed the patient not moving their left side. EMS staff applied a c-collar, logged rolled the patient onto the back board and cut off the patient ' s coveralls and clothing. EMT staff J stated the patient had no visual injury, no bruising, or blood was observed; but the patient continued to verbalize severe pain. The patient ' s blood pressure at this time was 196/121. EMT staff J rechecked the B/P after on backboard and determined the patient was stable to transport. EMT staff J notified ED nurse E, RN after the patient was loaded into ambulance that they were en route to TCLMH. EMT staff J explained to ED nurse the patient was a 29 year old who was hit with a fourteen hundred pound pipe on the left shoulder to the ankle and was unable to move their arm or anything down to their feet. EMT staff J stated that when EMS was two blocks away from TCLMH they received instructions to re-route to hospital BB. EMT staff J explained that they could not re-route to hospital BB because the patient ' s blood pressure had fallen to 70/44, and the patient was unstable. EMS stopped at TCLMH because they felt the patient required stabilizing care before proceeding to hospital BB some 30 miles away. EMS pulled into TCLMH ambulance bay and was met by four nurses. EMT staff J stated that ED nurse E, RN entered the ambulance and removed the blood pressure cuff from the patient ' s right arm, moved it to the left arm and started the IV on the right arm while another RN programmed the IV pump and told us to make sure the airway remained open. EMS left TCLMH and continued to hospital BB.

ED nurse E, RN interviewed on 7/9/13 at 9:50am verified they worked the 7pm to 7am night shift on 6/28/13. They received a call at 1:35am from EMT (Emergency Medical Technician) staff J who provided report on a 40 something year old male that was injured in the oil field when a 1457 pound pipe fell and struck their left shoulder and down their left side and leg. The patient was screaming out in pain with no visible injuries; however the patient could not feel anything on their left side. EMT staff J reported they secured the patient on the spine board, with a c-collar and a B/P of 150/124. ED nurse E, RN gave this report to ED nurse H, RN who called the Physician Assistant D and gave a report about patient #1. The Physician Assistant D gave ED nurse H, RN instructions to tell EMS to re-route to hospital BB due to the patient ' s injuries and level of care needed. ED nurse E, RN stated the RN ' s were at the nurses ' station and around 1:52am someone came rushing down the hallway and stated, " The ambulance was at the back door. " ED nurse E, RN stated they stopped in the ED and grabbed an IV start kit, climbed in the back of the ambulance and inserted the IV. ED nurse E, RN verified they connected the IV tubing and fluids to the patient. The ambulance proceeded onto hospital BB.

Physician Assistant (PA) D interviewed on 7/9/13 at 11:05am confirmed on 6/29/13; they received a telephone call from ED nurse H, RN at 1:49am. The ED nurse H, RN called to notify the PA D that a 40 year old male was coming to the ED after an oil field accident where a large pipe hit the patient and the patient had no feeling on the left side. Physician Assistant D stated they instructed ED nurse H, RN to tell EMS dispatch to re-route the ambulance to hospital BB because Trego County-Lemke Memorial Hospital lacked services for traumas. Physician Assistant D shared they waited for a return call but never received any further calls alerting them patient #1 arrived on hospital property by ambulance due to a low blood pressure of 70/44.

Staff I, CEO (Chief Executive Officer) and staff A, RN/CNO (Chief Nursing Officer)interviewed on 7/10/13 at 11:00am verified the ED nurses failed to ensure patient #1 who had presented on hospital property received a MSE.