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Based on reviews of medical records, policies and procedures, and staff interviews the facility failed to provide a medical screening examination to an individual to determine whether or not an emergency medical condition status post head trauma for 1 (#1) of 25 sampled patients. The hospital also failed to ensure that their policy and procedures were followed as evidenced by failing to document the benefits involved in leaving prior to the medical screening examination, and failed to document the description of the examination and treatment that was refused for 1 (#1) of 25 patients. See findings in tag A-2406.

Based on review of the hospital's Central Log Policy and Procedure and a random review of the Central Log, the facility failed to maintain an accurate Central Log on each individual who comes to the emergency room seeking medical assistance.

Findings:
A random review of the Central Emergency Room Log for June and July 2014 revealed 27 occasions where the patients entered into the Central Emergency Room log had no disposition documented.
On 06/06/2014 4 patients had no disposition recorded
On 06/06/2014 2 patients had no disposition recorded
On 06/09/2014 4 patients had no disposition recorded
On 06/11/2014 5 patients had no disposition recorded
On 06/12/2014 3 patients had no disposition recorded
On 06/22/2014 1 patient had no disposition recorded
On 07/01/2014 5 patients had no disposition recorded
On 07/09/2014 2 patients had no disposition recorded
On 07/21/2014 1 patient had no disposition recorded
Review of the EMTALA policy and procedures effective 10/01/2012
Central Log:
Central log is a log that a hospital is reviewed to maintain on each individual who comes to the emergency department seeking assistance that documents whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged.

Based on reviews of medical records, policies and procedures, and staff interviews the facility failed to provide an appropriate medical screening examination to an individual to determine whether or not emergency medical condition exists status post head trauma for 1 (#1) of 25 sampled patients. The hospital also failed to ensure that their policy and procedures were followed as evidenced by failing to document the benefits involved in leaving prior to the medical screening examination, and failed to document the description of the examination and treatment that was refused for 1 (#1) of 25 patients.

Findings:

Review of the policies provided by the hospital titled " Medical Screening Policy " dated 10/1/12 revealed in part, Policy: The hospital with an emergency department must provide to an individual that is not a patient who " comes to the emergency department " an appropriate MSE (medical screening examination) within the capability of the hospital ' s emergency department, including ancillary services routinely available to the emergency department to whether or not an emergency medical condition exists ...2. Leaving DED (dedicated Emergency Department) after triage but before MSE. If an individual presents to the DED and requests services for a medical condition, is triaged ad then indicates a desire to leave prior to the MSE " (LPMSE), the facility should use its best efforts to ... d. discuss with the individual the ...benefits involved in leaving prior to the medical screening and document the same ...h. describe in the medical record, the examination and treatment that was refused. "




Record review for Patient #1 revealed that on 5/15/14 at 7:26 PM the patient, ( 64 year old) was transported to the emergency room by EMS with complaints of syncope (loss of consciousness) with an unwitnessed fall. It was reported that she lost consciousness for 30 seconds. She had a small laceration on her head that was not bleeding at the time of arrival to the ER. The nurse documented that the patient reported that she had 2 drinks of liquor. She has a history of seizures but her husband denies witnessing seizure activity. The onset of the event was 1 hour prior to arrival to the emergency room. On 5/15/14 at 7:26 PM her vital signs were as follows: 98 degrees temperature, 81 pulse, 125/57 blood pressure, 16 respirations and 97% oxygen saturation. At 8:13 PM an EKG (electrocardiogram) was performed which read normal sinus rhythm. Further review of the medical record indicated that the following lab tests were ordered at 8:13 p.m., CBC (complete blood count), Comprehensive Metabolic Panel (once stat-without delay; immediately) It is noted that no laboratory testing was done, but a stat lab was ordered 2 hours and 12 minutes prior to Pt #1 leaving the ED. No diagnostic testing (CT -computerized tomography scan of head) were performed for Patient #1 on 5/15/2014. Patient #1 was not examined by a medical provider (physician, physician's assistant, or nurse practitioner).

On 5/15/14 at 8:30 PM an 18 gauge IV (intravenous) access was started to her left forearm which was capped and flushed. At 9 PM her vital signs were as follows: 124/62 blood pressure, 82 pulse 15 respirations and 99% oxygen saturation on room air. On 5/15/14 at 10 PM Patient #1's vital signs were as follows: 111/59 blood pressure, 84 pulse, 14 respirations and 98% oxygen saturation on room air. On 5/15/14 at 10:25 PM the nurse documented that Patient #1 elected to leave without seen by the provider. The patient stated that she was tired of waiting. She refused to sign the AMA (against medical advice) form. The nurse documented that she instructed the patient's husband to observe the patient closely tonight and return to the emergency room for any deterioration in condition. GCS currently 15 (Glasgow coma scale-scale that is used to assess severity of a brain injury. For a low score (as 3 to 5) indicates a poor chance recovery and for a high score (as 8 to 15) indicates a good chance of recovery). No active bleeding. The nurse documented that she removed the IV and the patient left ambulatory (walking) with her spouse. There was no documentation in the medical record to indicate the benefits of involved in leaving prior to a medical screening examination and treatment; nor a description of the examination and treatment that was refused as stated in the hospital's policy.


Telephone interview by surveyor #1 with the husband of Patient #1 on 5/27/14 at 10:15 AM stated that his wife was transported the emergency room by EMS after a fall at home resulting in her hitting her head. He stated that his wife had a cut on her head after the fall. He stated that the doctors never examined his wife. He stated that after a 4 ? hour wait he and his wife left the hospital. He stated that his wife never had a CT scan of her head to see if there was any injury after the fall. Telephone interview by surveyor #2 with the husband of Patient #1 on 08/18/2014 At 9:50 a.m. He said his wife had a history of seizures but had not had a seizure in 6 years.

Interview with the interim ER Director on 05/27/14 at 2:15 PM stated that there is a communication issue between the nurses and the medical practitioners. She stated that each emergency room area is assigned to be covered by the specific emergency care providers (physicians, physician's assistants and nurse practitioners) on duty.

Interview with the ER Medical Director on 5/27/14 at 2:30 PM he stated that he is investigating what happened during Patient #1's emergency room visit.


An interview with the Risk Manager on 08/04/2014 at 4:20 PM revealed the complainant was contacted by the Medical Director called the spouse said the practitioner forgot to see the pt. The physician was busy with another patient.

An interview conducted with an, ED RN, on 08/04/2014 at 12:15 PM revealed the patients are monitored in the waiting room by the paramedic in the waiting room. Vital signs are hourly. A patient with a head injury is usually a level II and will usually come right back. A CT ordered right away. Protocol for head injury is to order CT. Tests could be ordered while waiting. If there is a paramedic in the ED they can do an EKG and draw blood. If a protocol is ordered, the whole protocol is done. The protocol is already signed off by medical director.
The facility failed to ensure that their policy and procedure was as evidenced by failing to follow their policy an procedure related MSE by failing to provide an appropriate medical screening examination to patient#1 on 5/15/2014, that was within the capability of the hospital ' s emergency department, including ancillary services (Labs) routinely available to the emergency department to determine whether or not an emergency medical condition exists.