HospitalInspections.org

Based on review of the hospital EMTALA (Emergency Medical Treatment and Labor Act) policies, staff and provider interviews, and record reviews, the facility failed to ensure staff followed their policies related to provision of a Medical Screening Examination (MSE) and failure to include all patients requesting to be seen in the Central Log. Both these failures related to Patient 20, who was 1 of 20 sampled patients who presented for examination and treatment. Facility provided information of patients presenting to the ED from November 2020 through April 2021 reveal the ED sees on average 26 patients per month. See also 2405 and 2406. Findings are:

A. Record review of facility policy titled "Emergency Medical Treatment and Labor Act (EMTALA) Policy" last revised 7/21/2020 states the purpose of the policy is to "ensure that individuals who come to Genoa Medical Facilities seeking examination or treatment are provided an appropriate medical screening examination as required by law and that any transfer of an individual with an emergency medical condition is appropriate."
The policy further states that any individual who comes to the Dedicated Emergency Department or on hospital property and "on whose behalf exam or treatment is requested for any medical condition, shall receive an appropriate MSE performed by a Qualified Medical Provider [MD, DO, PA, NP] to determine whether an Emergency Medical Condition exists."
The Policy states that the Central log is a record maintained of all individuals who come to the hospital seeking examination or treatment. The policy notes the log should include the patient's name, treatment provided, dates, times, provider and disposition for "those treated and released, admitted, stabilized and transferred and refusal of treatment."

B. Interview with the Director of Nursing (DON) on 5/11/21 at 2:00 PM revealed on 5/3/21 Patient 20 came to the waiting area at the front of the hospital with her parents and requested to be seen stating she was 12 weeks pregnant with a high risk pregnancy and wanted an ultrasound to check the baby. The DON had just done the initial assessment on the patient's significant other (Patient 3). Who had arrived by ambulance, handcuffed with law enforcement present. Review of the record of Patient 3 indicates arrival at 5:40 PM post deployment of police taser. The notes state the Sheriff stated "patient had an altercation with his girlfriend. Sheriff reports he (Patient 3) had slammed her against the wall, choked her, has a head injury."Patient 3 was tased after "coming at us with a hammer and being verbally aggressive and combative."The DON stated the patient had red marks on her face, was anxious and crying. The DON stated she "gave the patient 2 options, we could see her here and assess her, we have no ultrasound or she could go to [Name of location of receiving Hospital B, a critical access hospital that provides Obstetrical (OB) services] or to [Name of location of larger acute care hospital, Hospital C] stating they have ultrasound. Hospital B is a 26 miles away, Hospital C is 27 miles away. The DON stated the parents of the patient asked her to call [hospital B]. The DON called Hospital B and spoke to someone in ED, not sure of a name and said an OB was on their way to be seen telling them no name and that the patient was 12 weeks pregnant with a high risk pregnancy.
The DON related it was not her intention to encourage the patient to leave but to give her options. The DON stated "We should have evaluated her at least. The DON reported she was new in the role having worked in Long Term Care and had not completed EMTALA education yet. The DON also stated she was unsure if the hospital had a Left Without Being Seen or Refusal of MSE form. The form is used to ensure patients are informed of the risks/benefits of failing to have a MSE and is signed by the patient. The patient was not entered into the Central Log. The DON knew the patient's name from Dispatch.

C. Interview with the ED Medical Director, Doctor of Osteopathy (DO) "D" on 5/11/21 at 3:50 PM stated that when a patient is checked in an alert goes to his phone as he oversees the PA's and NP's who cover the ED. Since Patient 20 was not checked in he was unaware she had come to the hospital to be seen. DO D stated that if the patient had been seen given her history of domestic assault and pregnancy they would have put on a C-collar and done imaging (x-rays) as well as Doppler (a small instrument used to detect sound waves through blood vessels and can detect fetal heart tones). If the patient was cramping he would call the patient's OB provider and discus transfer for further evaluation. DO D stated "Probably would not have done an Ultrasound that night, could have done evaluation here and send her on." DO D further stated that Patient 20 had a possible EMC related to domestic abuse with a 12 week high risk pregnancy with red marks on head. Possible EMC until proven not."

D. Interview with ED provider on call on 5/3/21, Nurse Practitioner (NP) "E" on 5/11/21 at 4:0 PM. NP E recalled getting an initial call of a 12 week pregnant pt coming to ER. NP E was on way as boyfriend of patient coming in. She stated they were planning to use the "Covid Room" to keep them separated. The main ED has 2 bays separated by a door. With Covid pandemic the hospital set up a patient room across the hall from the ED room with negative pressure if needed to evaluate possible ED Covid patients. The next call NP E got was that the Patient (Patient 20) was not coming but going to [Name of hospital B location]. NP E never saw Patient 20. The Sheriff told NP E about Patient 20 and said there was "choking etc".

Based on review of the Central log from 5/1-5/10/21, staff interview and review of the facility Emergency Medical Treatment and Labor Act (EMTALA) policy the facility failed to ensure 1 of 20 sampled patients was entered into the Central Log. Findings are:

A. Interview with the Director of Nursing (DON) on 5/11/21 at 2:00 PM revealed on 5/3/21 Patient 20 came to the waiting area at the front of the hospital with her parents and requested to be seen stating she was 12 weeks pregnant with a high risk pregnancy and wanted an ultrasound to check the baby. The patient left without being seen. The DON confirmed the patient was not entered into the Central log.

B. Review of the Central log for 5/3/21 reveals only 1 entry, a male patient.

C. Record review of facility policy titled "Emergency Medical Treatment and Labor Act (EMTALA) Policy" last revised 7/21/2020 states that the Central log is a record maintained of all individuals who come to the hospital seeking examination or treatment. The policy notes the log should include the patient's name, treatment provided, dates, times, provider and disposition for "those treated and released, admitted, stabilized and transferred and refusal of treatment."

Based on medical record review, staff and provider interviews, receiving hospital staff and provider interviews and review of policies and procedures related to EMTALA the facility failed to provide 1 of 20 patient records sampled (Patient 20) with a Medical Screening Examination (MSE) sufficient to determine whether or not an emergency medical condition (EMC) existed. The hospital is a critical access hospital that does not provide inpatient obstetrical services. Failure to provide a MSE has the potential to place all patients presenting to the Emergency Department (ED) at risk of serious harm or death from an untreated EMC. Facility provided information of patients presenting to the ED from November 2020 through April 2021 revealed the ED sees on average 26 patients per month. Findings are:

A. Interview with the Director of Nursing (DON) on 5/11/21 at 2:00 PM revealed on 5/3/21 Patient 20 came to the waiting area at the front of the hospital with her parents and requested to be seen stating she was 12 weeks pregnant with a high risk pregnancy and wanted an ultrasound to check the baby. The DON had just done the initial assessment on the patient's significant other (Patient 3). Patient 3 had arrived by ambulance, handcuffed with law enforcement present. Review of the record of Patient 3 indicates arrival at 5:40 PM post deployment of police taser. The notes state the Sheriff stated "patient had an altercation with his girlfriend. Sheriff reports he (Patient 3) had slammed her against the wall, choked her, has a head injury." Patient 3 was tased after "coming at us with a hammer and being verbally aggressive and combative."The DON stated the patient had red marks on her face, was anxious and crying. The DON stated she "gave the patient 2 options, we could see her here and assess her, we have no ultrasound or she could go to [Name of location of receiving Hospital B, a critical access hospital that provides Obstetrical (OB) services] or to [Name of location of larger acute care hospital, Hospital C] stating they have ultrasound. Hospital B is a 26 miles away, Hospital C is 27 miles away. The DON stated the parents of the patient asked her to call [hospital B]. The DON called Hospital B and spoke to someone in ED, not sure of a name and said an OB was on their way to be seen telling them no name and that the patient was 12 weeks pregnant with a high risk pregnancy.
The DON related it was not her intention to encourage the patient to leave but to give her options. The DON stated "We should have evaluated her at least. The DON reported she was new in the role having worked in Long Term Care and had not completed EMTALA education yet. The DON also stated she was unsure if the hospital had a Left Without Being Seen or Refusal of MSE form. The form is used to ensure patients are informed of the risks/benefits of failing to have a MSE and is signed by the patient. The patient was not entered into the Central Log. The DON knew the patient's name from Dispatch.

B. Interview with the ED Medical Director, Doctor of Osteopathy (DO) "D" on 5/11/21 at 3:50 PM stated that when a patient is checked in an alert goes to his phone as he oversees the PA's and NP's who cover the ED. Since Patient 20 was not checked in he was unaware she had come to the hospital to be seen. DO D stated that if the patient had been seen given her history of domestic assault and pregnancy they would have put on a C-collar and done imaging (x-rays) as well as Doppler (a small instrument used to detect sound waves through blood vessels and can detect fetal heart tones). If the patient was cramping he would call the patient's OB provider and discus transfer for further evaluation. DO D stated "Probably would not have done an Ultrasound that night, could have done evaluation here and send her on." DO D further stated that Patient 20 had a possible EMC related to domestic abuse with a 12 week high risk pregnancy with red marks on head. Possible EMC until proven not."

C. Interview with ED provider on call on 5/3/21, Nurse Practitioner (NP) "E" on 5/11/21 at 4:0 PM. NP E recalled getting an initial call of a 12 week pregnant pt coming to ER. NP E was on way as boyfriend of patient coming in. She stated they were planning to use the "Covid Room" to keep them separated. The main ED has 2 bays separated by a door. With Covid pandemic the hospital set up a patient room across the hall from the ED room with negative pressure if needed to evaluate possible ED Covid patients. The next call NP E got was that the Patient (Patient 20) was not coming but going to [Name of hospital B location]. NP E never saw Patient 20. The Sheriff told NP E about Patient 20 and said there was "choking etc".

D. Phone Interview with Hospital B, receiving hospital, DON on 5/12/21 at 11:00 AM. The DON received a call from the ED RN stating that the ED had gotten a call on 5/3 from Genoa Community Hospital but with no name or details. Patient 20 arrived and stated to staff she was "sent here by staff at Genoa." The patient reported she had not been examined at Genoa hospital. The patient on exam at Hospital B denied loss of consciousness, and stated she had been on bedrest for subchorionic hemorrhage ( bleeding between the placenta and the uterus during pregnancy) prior to the domestic assault. The patients OB is one of "our doctors". Since the patient complained of abdominal cramping she was a rule out EMC until proven otherwise. The patient told them at Genoa she was worried about being safe in ED. They told her they could not secure her safety and encouraged her to go to [name of hospital B or C].

E. Phone interview 5/12/21 at 111:30 AM with ED Physician's Assistant (PA "F") from Hospital B, who performed MSE on Patient 20 on 5/3/20. PA F recalled the patient was anxious, tearful and a ruddy red color. The patient stated she was assaulted by her significant other who hit her head several times on cabinets, he had knocked her head down and she had posterior neck pain. With that mechanism of injury the patient needed examination of the head and neck to ensure there was no injury. On exam the issue was musculoskeletal with full ROM. She had lumps on the scalp. They did neck and spine X-rays. UA found she was dehydrated so IV fluids were given. Due to complaint of cramping and history of subchorionic hemorrhage prior they did a transvaginal ultrasound. Baby was fine, no vaginal bleeding. The patient was sent home with diagnosis of a concussion. PA F stated the patient did not tell her she had been to Genoa Community Hospital first but the nurse did. PA F said no one from Genoa hospital had called her about the patient. PA F stated that on initial presentation Patient 20 had a possible EMC until evaluated via MSE.

F. Record review of ED visit for patient 20 from the receiving hospital B dated 5/3/2 noted the patient arrived at 5:55 PM. Review of PA F's ED notes reveal the patient's chief complaint was "assaulted, 12 weeks pregnant." Patient 20 told the provider her significant other pushed her into some cabinets striking the back of her head "pretty hard.". The patient denied any loss of consciousness. The patient also said the significant other tried to choke her and took her by the hair and banged her head against the cabinets. The patient fell during the assault and scraped the right knee. The pt complained of headache, sore areas to the back of her head and neck as well as "uterine-like cramping." Testing included X-rays to rule out neck injury, Urinalysis and a Transvaginal Ultrasound.
X-rays were normal. The Urine showed the pt had some dehydration. 1 liter of intravenous fluid was administered. The Transvaginal Ultrasound showed normal fetal heart rate and no further pregnancy related concerns. The pt discharged with her parents at 9:03 PM. The MSE did not find the patient had an EMC and was stable for discharge home with instructions.
Hospital B Social Services noted the Patient 20 was called 5/4/21 at 2:10 PM as follow-up to the ED visit. The notes documented the patient reports she sought care in the Genoa Hospital and due to her perpetrator coming there as well and having a divider between the room with him and not being able to do an ultrasound "they encouraged he to go to [Name of hospital B or C].

G. Record review of facility policy titled "Emergency Medical Treatment and Labor Act (EMTALA) Policy" last revised 7/21/2020 states the purpose of the policy is to "ensure that individuals who come to Genoa Medical Facilities seeking examination or treatment are provided an appropriate medical screening examination as required by law and that any transfer of an individual with an emergency medical condition is appropriate."
The policy further states that any individual who comes to the Dedicated Emergency Department or on hospital property and "on whose behalf exam or treatment is requested for any medical condition, shall receive an appropriate MSE performed by a Qualified Medical Provider [MD, DO, PA, NP] to determine whether an Emergency Medical Condition exists."