HospitalInspections.org

Based on policy reviews, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 489.24.

The findings included:

The hospital's Dedicated Emergency Department (DED) failed to provide an appropriate ongoing Medical Screening Examination (MSE) within the capability of the hospital's DED to determine whether an Emergency Medical Condition (EMC) existed for one (1) of 26 sampled DED patients (Patient #7).

~ Cross refer to 489.24(a) and 489.24(c) Medical Screening Examination - Tag A 2406.

Based on policy review, ambulance trip reports, review of the dedicated emergency department (DED) log and staff interviews, the hospital failed to accurately document on its DED central log all patients that presented to the hospital's DED for treatment for four (4) of 26 records reviewed (Patients #6, #27, #13, and #16).

The findings included:

Review of the EMTALA (Emergency Medical Treatment and Labor Act) policy, effective date 09/2023, revealed "...CENTRAL LOG: To identify and document each individual who either comes to the Dedicated Emergency Department seeking treatment for any medical condition or presents on Hospital Property or Premises seeking care for an emergency medical condition. Each hospital that has a Dedicated Emergency Department will maintain a central log to include information on each individual who comes to the Hospital Property or Premises requesting treatment....The log must contain....the name of the individual who comes to the emergency department seeking assistance; and.... whether the individual: ...refused treatment ....was refused treatment .... was transferred ....was discharged. ..."

Review of the EMTALA log for 09/07/2023 (date of the alleged violation) revealed the name of Patient #27 was not listed on the log.

Review of the Emergency Medical Services (EMS) CALL LOG for 09/07/2023 revealed "EMS Unit: (EMS #1); Age: 56; M (male) [circled]; Visit ID: 13 ... Home ... Abd (abdomen) pain x (times) 30 mins (thirty minutes) sharp to back Dialysis pt (patient) ..."

1. Review of the Emergency Medical Services (EMS #1) Report dated 09/07/2023 revealed Patient #27 was transported to Hospital A Campus A's DED arriving at 1718 and call completed at 1758. Review revealed "dispatched to residence ... to a 56-year-old male with breathing problems ... sudden onset of severe abdominal pain that radiates to his back. Patient is in obvious distress due to the pain ... Due to patient being Dialysis ... On arrival at (Hospital A Campus A), patient remained on stretcher without registration, triage or seen by any staff at (Hospital A Campus A) for approximately 45 mins (minutes). Patient noted staff appeared very rude and decided he wanted to leave facility and go elsewhere. EMS advised staff member of same and (CN #3), charge nurse states 'That will be the best thing for him.' Patient then refuses, EMS D/C (discontinues) IV (intravenous) and assisted patient to waiting are with wife ..."

A search on 06/04/2024 in the hospital's electronic medical record system for the name of Patient #27 revealed there was not an electronic medical record for the patient on 09/07/2023.

Interview on 06/04/2024 at 1047 with the Manager of House Supervisors (HS #2) revealed he remembered the incident. When HS#2 arrived to the ED the charge nurse (CN #3) was speaking with the EMS personnel. The EMS personnel seemed upset and the patient decided to leave. The patient felt he would not have to wait if he went to another hospital in the area.

Telephone interview on 06/05/2024 at 1400 with EMS #4 revealed he remembered the incident. Interview revealed toward the end of the afternoon EMS #1 picked up a patient in need of dialysis and a comorbidity was renal failure. The crew arrived onsite at (Campus A) where the charge nurse told them they needed to wait as they (Campus A ED) could not take anymore pts. EMS #4 stated the hospital staff were internally discussing the possibility of going on diversion however they were not on diversion when the EMS crew arrived to hospital (Campus A). The computers in the EMS trucks did not show the hospital was on diversion at the time either.
Interview revealed after arriving to the hospital (Campus A) the charge nurse was not pleasant with the team and instructed the hospital registration staff to "not" register the patient. The EMS crew escalated this to leadership. EMS leadership spoke with the CN at (Campus A) to explain the problem with being on the property, the need to register the patient, and transfer the care of the patient to the ED staff and of the medical provider deemed it necessary, then transfer the patient to another facility. The EMS crew cannot leave with the patient once they have arrived on site at a hospital ED. EMS #4 was asked to speak to the ED Director, which he did and explained the same information to them as he had to the CN. The ED Director was in agreement, however stated she was being overruled by the House Supervisor (HS #2). EMS #4 attempted to contact HS #2 to try to resolve this issue. Interview revealed after about thirty minutes, the patient decided he was going to leave and go somewhere else.

Telephone interview on 06/05/2024 at 1436 with Paramedic #5 revealed they were called to a resident for a patient with side pain similar to kidney stone on a dialysis patient. The patient was transported to Campus A. Upon arrival the nurse told the registration personnel not to register the patient. Paramedic #5 notified her supervisor, who in turn contacted the hospital supervisor (HS #2). The patient got "fed up" because all this was taking place in front of him, and he decided he wanted to leave. We (EMS crew) removed the monitor and IV and walked with the patient out the door.

Telephone interview on 06/06/2024 at 1027 with Charge Nurse (CN #3) revealed the hospital was on diversion, there were patients in every room and in hallway beds. CN #3 acknowledged she told registration to not register the patient when they came in because they would be on the tracker board and it would look like they have not been triaged. HS #2 came to the ED, he said it was not an EMTALA violation, EMS crew said it was. The patient decided he wanted to leave.

Interview on 06/10/2024 at 1319 with Information and Technology personnel (IT #7) revealed she reviewed the account. It appears "short registration was not used." Short registration would have triggered a task for registration to complete once the MSE (medical screening examination) was completed. By not using this it did not put the patient in a pre-registration status and did not put the patient on the ED log. The medical record was created days after the event and still should have followed the normal process to ensure it was captured on the log.

Telephone interview on 06/10/2024 at 1448 with Paramedic #6 revealed they were dispatched to pick up a patient from dialysis. The patient had a complaint of abdominal pain and was a dialysis patient. Arrived at Campus A's ED and they were told they would have to wait. While waiting with the patient they went to register the patient up front. The registration staff would not register the patient as they were told by the CN to not register the patient. We contacted our supervisor about being told had to wait and the hospital staff not allowing the patient to be registered. During this time the hospital's house supervisor came to the ED and he reiterated what the CN had said about having to wait.

In summary, Patient #27 was brought into the DED via EMS, the patient was not registered as the registration staff was told not to register him in the computer. The patient decided to leave. As of date of survey, 06/04/2024, the patient was not on the EMTALA log.

Review of the EMTALA log for 09/07/2023 (date of the alleged violation) revealed there were no "John Doe" patients listed on the log.

2. Review of the medical record created on 09/09/2024 for "John Doe" patient (Patient #6) revealed a 60-year-old male patient admitted to Campus A's DED (dedicated emergency department) 09/07/2023 at 1740. Review of the Patient Profile revealed " ... Patient Details; Admit Complaint: toe pain/missed dialysis ... Service: Emergency Room ... Discharge Date: 09/07/2024 ... Visit Status: Against Medical Advice ..." Review of the Progress Notes Report revealed an entry "Assessment Date; 09/11/2023 1032 This RN (Registered Nurse) arrived in ED at 1734 on 09/07/2023 to find this pt (patient) lying (sic) in an EMS (emergency medical system) stretcher with (EMS #1) present. The ED Charge RN was explaining to the pt and EMS that every room in the ED was currently full and they would need to wait in the hallway until staff was available to evaluate the patient and get him a room. The pt did not want to wait in the hallway and verbalized that he would like to leave. This RN explained to the pt that we would still like to evaluate him, but he was adamant that he would like to leave and be seen at another healthcare facility. Per pt request (EMS #1) then discontinued the pt's IV (intravenous) and disconnected him from oxygen. EMS then walked the pt to the lobby where he was met by his wife. The pt and his wife left in a personal vehicle."

Interview on 06/04/2024 at 1047 with the Manager of House Supervisors (HS #2) revealed he remembered the incident. When HS#2 arrived to the ED the charge nurse (CN #3) was speaking with the EMS personnel. The EMS personnel seemed upset and the patient decided to leave. The patient felt he would not have to wait if he went to another hospital in the area. HS#2 reported he notified the patient they would be happy to see him and would get him in a room as soon as one became available. Interview revealed the patient did not want to wait for a room to become available and to be seen.

Telephone interview on 06/05/2024 at 1400 with EMS #4 revealed he remembered the incident. Interview revealed toward the end of the afternoon EMS #1 picked up a patient in need of dialysis and a comorbidity was renal failure. The crew arrived onsite at (Campus A) where the charge nurse told them they needed to wait as they (Campus A ED) could not take anymore pts. EMS #4 stated the hospital staff were internally discussing the possibility of going on diversion however they were not on diversion when the EMS crew arrived to hospital (Campus A). The computers in the EMS trucks did not show the hospital was on diversion at the time either. Interview revealed after arriving to the hospital (Campus A) the charge nurse was not pleasant with the team and instructed the hospital registration staff to "not" register the patient. The EMS crew escalated this to leadership. EMS leadership spoke with the CN at (Campus A) to explain the problem with being on the property, the need to register the patient, and transfer the care of the patient to the ED staff and of the medical provider deemed it necessary, then transfer the patient to another facility. The EMS crew cannot leave with the patient on they have arrived on site at a hospital ED. EMS #4 was asked to speak to the ED Director, which he did and explained the same information to them as he had to the CN. The ED Director was in agreeance, however stated she was being overruled by the House Supervisor (HS #2). EMS #4 attempted to contact HS #2 to try to resolve this issue. Interview revealed after about thirty minutes, the patient decided he was going to leave and go somewhere else.

Telephone interview on 06/05/2024 at 1436 with Paramedic #5 revealed they were called to a residence for a patient with side pain similar to kidney stone on a dialysis patient. The patient was transported to Campus A. Upon arrival the nurse told the registration personnel not to register the patient. Paramedic #5 notified her supervisor, who in turn contacted the hospital supervisor (HS #2). The patient got "fed up" because all this was taking place in front of him, and he decided he wanted to leave. We (EMS crew) removed the monitor and IV and walked with the patient out the door. No risks and benefits were explained to the patient prior to leaving.

Telephone interview on 06/06/2024 at 1027 with Charge Nurse (CN #3) revealed the hospital was on diversion, there were patients in every room and in hallway beds. CN #3 acknowledged she told registration to not register the patient when they came in because they would be on the tracker board and it would look like they have not been triaged. HS #2 came to the ED, he said it was not an EMTALA violation, EMS crew said it was. The patient decided he wanted to leave. CN #3 thinks HS #2 spoke with the patient prior to the patient leaving. CN #3 stated since the incident there has been re-education about EMTALA and she paid for a class about EMTALA outside of what the hospital provided.

Interview on 06/10/2024 at 1319 with Information and Technology personnel (IT #7) revealed she reviewed the account. It appears "short registration was not used." Short registration would have triggered a task for registration to complete once the MSE (medical screening examination) was completed. By not using this it did not put the patient in a pre-registration status and did not put the patient on the ED log. The medical record was created days after the event and still should have followed the normal process to ensure it was captured on the log.

Telephone interview on 06/10/2024 at 1448 with Paramedic #6 revealed they were dispatched to pick up a patient from dialysis. The patient had a complaint of abdominal pain and was a dialysis patient. Arrived at Campus A's ED and they were told they would have to wait. While waiting with the patient they went to register the patient up front. The registration staff would not register the patient as they were told by the CN to not register the patient. We contacted our supervisor about being told had to wait and the hospital staff not allowing the patient to be registered. During this time the hospital's house supervisor came to the ED and he reiterated what the CN had said about having to wait. These conversations took place in front of the patient. The patient got upset decided he would leave and go somewhere else. No one explained the risks and benefits to the patient and EMS staff walked the patient out of the ED.

In summary, Patient #6 was brought into the DED via EMS, the patient was not registered as the registration staff was told not to register him in the computer. The patient decided to leave. As of date of survey, 06/04/2024, the patient was not on the EMTALA log. Review revealed no evidence or documentation of risks and benefits prior to the patient leaving.



33790


3. Review of the Emergency Department log revealed Patient #13, a 44 year-old, arrived to the DED on 06/03/2024 at 1946 with a complaint of "Flank Pain" and had a discharge time recorded as 2000 for a length of stay of 14 minutes. Further review of the log revealed a visit status documented as "Canceled NoShow."

Documentation, received on 06/10/2024, related to Patient #13's 06/03/2024 DED visit revealed two documents: an "ED Summary Report" and "Patient Details". There were no notes to indicate Patient #13 was triaged or received any medical screening and no documentation to show if the patient was seen leaving the facility. A complaint of flank pain was entered on both documents and Patient #13 was noted to have departed the DED at 2000.

Interview on 06/10/2024 at 1600 with Registration Staff #19 revealed the canceled no show documentation would be entered on the log if a patient had been initially entered incorrectly, for example if the patient arrived as an outpatient, not an ED patient, or if a patient came up and said they did not want to be seen. Follow-up interview on 06/11/2024 at 1620 revealed Patient #13 arrived to the DED, not as a planned outpatient. Registration Staff #19 stated that if a patient came up to registration before triage and stated they were leaving, Registration Staff would call it a cancel, no show to take the patient off the board. Interview revealed nursing entered the LWBS (left before being seen) or AMA (against medical advice), that Registration was taught to use the canceled no show.

4. Review of the Emergency Department log revealed Patient #16, a 38 year-old, arrived to the DED on 04/04/2024 at 1005 with a complaint of "Abdominal Pain." The patient had a recorded discharge time on the log of 1019 for a length of stay of 14 minutes. The status noted on the DED log was "Canceled NoShow."

Documentation, received on 06/10/2024, related to Patient #16's 04/04/2024 visit revealed an "ED Summary Report", "Patient Details", Demographics, and an "Event Log." Review of the documents did not provide any notes to indicate Patient #16 was triaged, received any medical screening, nor any evidence whether the patient was seen leaving the facility. A complaint of abdominal pain was documented and the patient was noted to depart the DED at 1019.

Interview on 06/10/2024 at 1600 with Registration Staff #19 revealed the canceled no show documentation would be entered on the log if a patient had been initially entered incorrectly, for example if the patient arrived as an outpatient, not an ED patient, or if a patient came up and said they did not want to be seen. Follow-up interview on 06/11/2024 at 1620 revealed Patient #16 arrived to the DED, not as a planned outpatient. Registration Staff #19 stated that if a patient came up before triage and stated they were leaving, Registration Staff would call it a cancel, no show to take the patient off the board. Interview revealed nursing entered the LWBS (left before being seen) or AMA (against medical advice), that Registration was taught to use the canceled no show.

Based on policy review, medical record review and physician interviews, the hospital's Dedicated Emergency Department (DED) failed to provide an appropriate ongoing Medical Screening Examination (MSE) within the capability of the hospital's DED to determine whether an Emergency Medical Condition (EMC) existed for 1 of 26 sampled DED patients (Pt #7).

The findings included:

Review of the EMTALA (Emergency Medical Treatment and Labor Act) policy, titled "EMTALA: Medical Screening and Transfer of Patients...PC 103", approved 09/2023, revealed "...L. Medical Screening Examination is the process required to reach with reasonable clinical confidence....whether or not an emergency medical condition exists....The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred. ..."

Review of the Dedicated Emergency Department record revealed Patient #7 arrived to the DED on 11/29/2023 at 1452 by EMS. Review of the Triage Note revealed an acuity of 2 was assigned. A Glasgow Coma Scale (GCS) completed at 11/29/2023 at 1531 revealed a total score of 15 out of 15, noting Patient #7 was alert and oriented to person, place, time and situation and had clear speech. Review of an "ED Provider Scribe Template" date of service 11/29/2023 at 1507, revealed "...Chief Complaint/ HPI .... This is a 74-year-old male with a past medical history of hypertension, diabetes mellitus, and hyperlipidemia brought in by EMS who presents for nausea and vomiting. EMS reported the patient is complaining of nausea/a blood pressure in the 250s/120s and blood sugar level of 234. The patient states he's had nausea and vomiting associated with diarrhea and stomach pain since 1 pm. He notes no appetite for the past two days. Patient denies fever, shortness of breath, extremity weakness, chest pain, dysuria, polyuria or any other associated symptoms. ..." Review revealed a central line was placed for hemodynamic monitoring and IV access (per nursing note this was done at 1746).

Review of the "ED Provider Scribe Template" further revealed "...1850 we are at capacity in terms of PC and ICU (Progressive and Intensive Care) beds. Will attempt to transfer the patient to hospital with capacity. - I contacted (outside Hospital E)....is at capacity for ICU beds in step-down.... Condition: stable....Patient will be signed out to (MD #3) Final Diagnosis .... DKA (Diabetic Ketoacidosis) [space] Hypertensive Urgency. ..."

Review of physician documentation did not reveal any notes made by the oncoming physician (MD #3) at hand-off to show the patient's condition. On 11/29/2023 at 1949, a Nurse Note indicated Patient #7 got up out of bed and pulled out the central line, the physician (MD #3) was made aware and replaced the line. Blood glucose at that time was noted as 289. At 2011, Patient #7 was noted by nursing to have vomited "coffee-ground emesis."

At 2100 (documented at 2333), a RN Neurological Assessment noted that Patient #7 was "Confused" and "Nonverbal". On 11/20/2023 at 0338, Patient #7 was documented to have complained of abdominal pain at a level of 10:10. At 0500, Patient #7 was again noted to be "Nonverbal" but was stated to be alert and oriented. Review did not reveal any physician documentation throughout the night to show if a physician evaluated Patient #7 or noted any change in condition.

DED record review revealed an "ED Assumption of Care Note", dated 11/30/2023 at 0630, that stated "...This patient was signed out to me by the outgoing physician. Please see their initial documentation for further details regarding initial H&P....The patient is currently boarding in the emergency department as there are no beds available for transfer and no ICU beds currently at this facility .... Of note, I consulted GI regarding concern for upper GI bleed. ..." Review of the physician's note did not reveal information on the patient's mental status or pain.

Review of a GI Consult Note, dated 11/30/2023 at 1354, indicated " ...Reason for consult....Coffee Ground emesis ....History of Present Illness: Reviewed; HPI details: 74-year-old male admitted with a hypertensive crisis, DKA with GI being consulted form coffee-ground emesis. Patient is awake but is not conversive, he moves around, does not appear in any distress, but does not answer any questions. As per patient's nurse today, he is not alert and oriented..."

Further review of the "ED Assumption of Care Note" revealed "...The patient is a (Hospital G) patient. I reached out to the (hospital G) to request transfer given no ICU bed availability here. The patient has been accepted for transfer to the (Hospital G). ..." Review of the note failed to reveal if any change in mental status was observed compared to when Patient #7 arrived.

Review of a Nursing Assessment Note on 11/30/2023 at 1610 revealed Patient #7 was being Transferred Out and noted the patient's condition at that time was "Stable" and "Fair" and the LOC was "Responds to painful stimuli." Another note by the same RN, at 1620, indicated the patient was transferred at 1620 and was "...awake, not verbally responsive."

Review of the Transfer Form revealed it was signed by DO #18 and indicated the patient was stable for transfer at 1620. The form was dated and timed at the top of the form but the date/time beside the MD signature was left blank. There were no orders marked on the form to indicate the mode of transport or support orders during transport, however nursing documentation indicated Patient #7 was transferred out by (Hospital E ALS Transport) and remained on Nicardipine, Insulin and Protonix drips. No other notes were found by DO #18 to determine if the physician evaluated Patient #7's mental status and overall condition.

Telephone interview on 06/05/2024 at 1605 with MD #2, the physician who did the initial medical screening on Patient #7, revealed MD #2 did not recall the patient. Interview revealed MD #2's documentation of the medical screening showed that Patient #7 was alert and oriented and talking with the physician at the time of the examination. Interview revealed MD #2 signed off to MD #3 at the end of the shift and did not have further interactions with Patient #7.

Request for interview with MD #3, the ED physician to whom MD #2 signed over Patient #7, revealed that while MD #3 remained on staff, MD #3 had not worked at the hospital recently, had not responded to calls and thus was not available for interview.

Requests to interview two nurses who documented change in mental status and nonverbal status revealed the nurses no longer worked at the hospital and were not available for interview.

Telephone interview on 06/06/2024 at 1640 with DO #18, the physician who signed and certified the benefits exceeded the risks of transfer for Patient #7, revealed DO #18 did not write a note in Patient #7's record, just signed the transfer form. Interview revealed the standard process before signing off a transfer form was to make a quick round on a patient to evaluate him/her before signing out the patient for transfer. Interview revealed DO #18 "almost certainly" saw and evaluated Patient #7. Interview revealed writing a note "probably should have happened." DO #18 stated " ...think I checked and was going to write and probably got called (away)."

Telephone interview on 06/06/2024 at 1658 with MD #4, the day shift ED physician on 11/30/2024, revealed the providers round and see patients during report and sign off bed by bed; they discuss what has been done and how the patient appears. Interview revealed MD #4 would have checked the patient's baseline for that shift and to see if there was a baseline change. Interview revealed the goal was to have everything written down and MD #4 could not say why more was not documented. Interview revealed providers check patients waiting for a bed at the beginning and end of the shift, then throughout the shift would check if requested. MD #4 stated the goal was to continue to treat and stabilize a patient waiting for a bed, and that ideally the patient would have been in an ICU bed. Interview revealed if there had been a substantial change in Patient #7's condition that warranted imaging, there would have been a note. In regards to concern for a stroke, the physician indicated there would be focal deficits. If MD #4 had been concerned for a stroke, interview revealed, a code stroke would have been activated. The MD stated a change in mental status with no laterality was more suggestive of encephalopathy as opposed to a stroke.

Interview on 06/07/2024 at 1030, with MD #13, ED Medical Director, revealed MD #13 had been briefed on Patient #7's case. Interview revealed the expectation for documentation by ED providers was a shift to shift verbal sign-out, with the oncoming physician writing an assumption of care note, and at disposition the provider writing a summary or progress note. Interview revealed if a patient appeared well, a provider might just write "stable" but if there was a change, there should be a note of the change. Interview further revealed all patients in the ED were active ED patients, not boarder patients. Related to this patient, interview revealed, there should have been assumption of care notes from all ED providers when they assumed care and notes with condition changes to show what happened and when.