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Based on review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) policy and procedure, Medical Staff Bylaws and Rules and Regulations, Emergency Department (ED) medical records (MR), credentialing files, and interviews with staff it was determined the facility Board of Trustees failed to identify and approve Nurse Practitioners and Physician Assistants as qualified to conduct medical screening examinations in the Emergency Department.

Refer to findings in A-2406.

Based on review of the facility EMTALA policy and procedure, ED logs, MR documentation and staff interviews it was determined the facility failed to ensure:

1. Patients who refused consent to treatment and left the ED without being seen were provided a description of the examination and/or treatment being refused.

2. The risk of refusal and benefits of the examination and/or treatment was explained and documented in the MR by the physician or nurse.

3. The ED staff followed the facility EMTALA policy when patients expressed the intent to leave the hospital.

Refer to findings in A-2407.

Based on review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) policy and procedure, Medical Staff Bylaws and Rules and Regulations, medical records (MR), credentialing files, and interviews with staff it was determined the facility Board of Trustees failed to identify and approve Nurse Practitioners (NP) and Physician Assistants (PA) as qualified to conduct medical screening examinations in the Emergency Department (ED).

This affected 5 of 22 ED records reviewed that received a Medical Screening Examination (MSE) including Patient Identifier (PI) # 3, PI # 6, PI # 16, PI # 18, PI # 25 and had the potential to affect all patients presenting to the ED for treatment.

Findings include:

Policy: EMTALA
Reviewed Date: 9-15-19

Policy:
It is the policy of Troy Regional Medical Center to provide an appropriate Medical Screening Examination to individuals who present to the hospital for emergency care...

Procedure:
I. Appropriate Medical Screening Examination (MSE)
...The MSE must be performed by a physician.

Troy Regional Medical Center Medical Staff Rules & Regulations
Article VI Emergency Medical Screening, Treatment, Transfer & on-Call Roster Policy
February 28, 2019

Screening, Treatment & Transfer

6.1 (a) Screening

(3) All patients shall be examined by qualified medical personnel, which shall be defined as a physician trained in emergency medicine...

1. PI # 3 presented to the ED on 6/4/19 at 2:18 PM with a chief complaint of ingestion of Top Job, a glass cleaner with ammonia.

Review of the MR documentation revealed the MSE was conducted at 4:05 PM by a NP and not an ED physician.

2. PI # 6 presented to the ED on 6/8/19 at 4:08 PM with a chief complaint of dog bite.

Review of the MR documentation revealed the MSE was conducted at 4:05 PM by a NP and not an ED physician.

3. PI # 16 presented to the ED on 11/21/19 at 11:25 AM with a chief complaint of flu-like symptoms.

Review of the MR documentation revealed the MSE was conducted at 11:57 AM by a PA not an ED physician.

4. PI # 18 presented to the ED on 11/21/19 at 10:51 AM with a chief complaint of cough.

Review of the MR documentation revealed the MSE was conducted at 11:24 AM by a PA not an ED physician.

5. PI # 25 presented to the ED on 11/21/19 at 10:05 AM with a chief complaint of shoulder/arm problem.

Review of the MR documentation revealed the MSE was conducted at 10:20 AM by a PA and not an ED physician.

Review of the facility's Medical Staff Bylaws and Rules and Regulations revealed the Board of Trustees failed to designate and approve Nurse Practitioners and Physician Assistants as qualified to perform the initial Medical Screening Examination for individuals seeking care in the Emergency Department.

Review of the credentialing files for the NPs and PAs who conducted the MSEs listed above, revealed the Clinical Privileges Sheet Emergency Medicine did not include conducting medical screening examinations for ED patients. Additionally, there was no documentation the NPs and PAs had been deemed competent to perform MSEs.

An interview conducted 12/5/19 at 8:00 AM with Employee Identifier (EI) # 1, Chief Clinical Officer, and EI # 2, Quality Director, confirmed the Medical Staff Bylaws and the Clinical Privileges credentialing did not identify NPs and PAs as qualified by the Medical Staff to conduct the MSE for ED patients and there was no documentation of competency.

Based on review of the facility Emergency Medical Treatment and Labor Act (EMTALA) policy and procedure, ED (emergency department) log, ED staffing schedule, medical record (MR) documentation and staff interviews it was determined the facility failed to ensure:

1. Patients who refused consent to treatment and left the ED without being seen were provided a description of the examination and/or treatment being refused.

2. The risk of refusal and benefits of the examination and/or treatment was explained a physician or nurse and documented in the MR.

3. The ED staff followed the facility EMTALA policy when patients expressed the intent to leave the hospital.

The deficient practice affected 1 of 3 patients identified on the ED log as LWBS (left without being seen). This did affect Patient Identifier (PI) # 22 (complainant) and had the potential to affect all patients that LWBS.

Findings include:

Policy: EMTALA
Reviewed Date: 9-15-19

Policy:
It is the policy of Troy Regional Medical Center to provide an appropriate Medical Screening Examination to individuals who present to the hospital for emergency care...

Procedure:
I. Appropriate Medical Screening Examination (MSE)
...The MSE must be performed by a physician.

...If, prior to completion of the MSE, the patient expresses the intent to leave the hospital, a physician or nurse shall encourage the patient to remain and explain to the patient the risks of leaving and benefits of the MSE.

1. PI # 22 presented to the ED on 11/21/19 at 11:07 AM and left the ED at 11:48 AM without being seen.

Review of the ED log dated 11/21/19 revealed PI # 22 was registered on 11/21/19 with complaint of "Hurts all over".

Review of the MR revealed:

a. General Consent for Test, Treatment and Services form signed by PI # 22 on 11/21/19.

b. Leaving Without Screening/Treatment form signed by an individual other than the patient on 11/21/19 at 11:48 AM and witnessed by the registration clerk.

c. Nursing documentation: Disposition: LWBS - the patient departed the facility on 11/21/19 at 11:48 AM. No attempts were made to contact the patient. NOTES: stated to admissions we are not taking care of her so going to (Hospital B). Electronically signed by the Registered Nurse (RN) on 11/21/19 at 11:51 AM.

There was no documentation in the MR that the physician or the nurse provided a description of the examination and/or treatment PI # 22 refused nor was there documentation of the risks associated with that refusal.

An interview was conducted with Employee Identifier (EI) # 3, ED Registration Clerk, on 12/4/19 at 11:50 AM. When asked "what do you do if a patient comes up and says I am leaving?" EI # 3 responded " I ask - are you sure, I can get a nurse to come talk to you. If they say they are not going to wait I go over the form with them."

EI # 3 verified she witnessed the Leaving Without Screening/Treatment form for PI # 22 on 11/21/19. EI # 3 stated she remembered PI # 22 and stated it was the patient's sister that came to the desk and signed the Leaving Without Screening/Treatment form on behalf of PI # 22. When asked if she remembered why PI # 22 came to the ED EI # 3 stated yes - (patient) said he/she was hurting all over. When asked if a nurse or MD spoke with PI # 22 EI # 3 stated "as far as I know he/she did not talk to a nurse or doctor."

An interview was conducted with EI # 4, ED Registered Nurse (RN), on 12/4/19 at 12:20 PM. EI # 4 verified he functions as the charge nurse on 7 AM to 7 PM shift and verified the ED had 10 beds and 2 hallway beds available if needed. EI # 4 was asked what is considered to be at full capacity? Would you be at capacity with 8 patients in the back? EI # 4 stated "with our staffing - yes they would be at full capacity with 8 patients." EI # 4 reviewed the staffing schedule for 11/21/19 and verified there were 3 nurses on the 7 AM shift with a 4th nurse scheduled to come at 11:00 AM.

EI # 4 was asked "if a patient in the waiting area becomes impatient and the clerk comes back to let you know, what do you do?" EI # 4 responded "go out to speak with them, reassure them, if you speak with them they are usually pacified." During the interview EI # 4 stated he felt confident the ED staff was notified when a patient wanted to leave and did not remember a time when the ED staff did not speak with a patient wanting to leave.

An interview was conducted on 12/4/19 at 12:43 PM with EI # 5, Medical Director of the ED, who was on duty 11/21/19. EI # 5 was asked "are you made aware of patients that come in and leave without being seen?" EI # 5 stated "at the moment I am not aware but at a meeting I am made aware."

An interview was conducted on 12/4/19 at 2:30 PM with EI # 6, ED Director. EI # 6 was asked "what is the process if a patient in the waiting room wants to leave without being seen?" EI # 6 stated "we get AMA or LWBS form, registration has them signed and we come out." The surveyor asked "who discusses the risks and benefits with the patient?" EI # 6 stated "nurse who is available."








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