HospitalInspections.org

Based on a review of clinical records and an interview with staff, the hospital failed to provide an appropriate medical screening exam by a qualified medical person to determine whether or not an emergency medical condition existed for Patients #1 through 23.

Findings were:

During a review of 23 clinical records (Patients #1 through #23), none of the records contained documentation of a medical screening exam by a qualified medical person. The patients were evaluated by a nurse and the care was discussed with a physician. The physician did not perform a medical screening examination. The patients were either transferred to another facility or discharged.

Patient #1 presented on 09-17-16 with a complaint of suicidal ideation. Patient #1 was assessed by a registered nurse and transferred to an area psychiatric hospital due to the lack of an available bed.
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Patient #2 presented on 09-17-16 with a complaint of suicidal ideation. Patient #2 also complained of chest pain. Patient #2 was assessed by a registered nurse and transferred to a nearby medical hospital for clearance.

Patient #3 presented on 09-01-16, requesting substance abuse treatment. Patient #3 was assessed by a registered nurse and transferred to a nearby medical hospital for symptoms of heroin withdrawal.

Patient #4 presented on 07-22-16 with a complaint of depression. Patient #4 was assessed by a registered nurse and was transferred to a nearby medical hospital due to a blood pressure of 180/107.

Patient #5 presented on 07-15-16 with a request for housing, as [patient #5] was homeless. Patient #5 was assessed by a registered nurse and transferred to a nearby group home.

Patient #6 presented on 07-03-16 with a complaint of suicidal ideation. Patient #6 was assessed by a registered nurse and transferred to an area psychiatric hospital due to the lack of an available bed.

Patient #7 presented on 07-02-16 with a complaint of depression and cocaine abuse. Patient #7 was assessed by a registered nurse and transferred to an area psychiatric hospital due the lack of an available bed.

Patient #8 presented on 06-27-16 with a complaint of depression and stated that she had ingested 3 bottles of blood thinner tablets and 1 bottle of blood pressure medication prior to her arrival. Patient #8 was assessed by a registered nurse and transferred to a nearby medical hospital for treatment of her overdose.

Patient #9 presented on 05-21-16 with a complaint of depression. Patient #9 was assessed by a registered nurse and advised to go to a nearby hospital for medical clearance, as the patient appeared to be intoxicated on alcohol.

Patient #10 presented on 05-18-16 with a complaint of having relapsed on heroin. Patient #10 was assessed by a registered nurse and advised to go to a nearby hospital for medical clearance.

Patient #11 presented on 04-27-16 with complaints of being intoxicated. Patient #11 was assessed by a registered nurse and sent to a nearby hospital for medical clearance, accompanied by friends.

Patient #12 presented on 02-05-16 with complaints of dementia. Patient #12 was assessed by a licensed professional counselor and transferred to a nearby medical hospital.

Patient #13 presented on 12-07-15 with complaints of psychotic symptoms and grandiose delusions. Patient #13 was assessed by a registered nurse and transferred to a nearby psychiatric hospital due to legal issues with the physician.

Patient #14 presented on 05-07-16 with complaints of slight paranoia and epigastric pain. Patient #14 was assessed by a registered nurse and transferred to a nearby medical hospital for treatment of her epigastric pain.

Patient #15 presented on 02-10-16. No reason is documented. Patient #15 was assessed by a social worker and advised to seek treatment at an outpatient psychiatric facility.

Patient #16 presented on 01-07-16 with complaints of visual hallucinations. Patient #16 was assessed by a registered nurse and advised to seek treatment at an outpatient psychiatric facility.

Patient #17 presented on 02-04-16. No reason is documented. Patient #17 was assessed by a social worker and admitted.

Patient #18 presented on 02-11-16 with complaints of depression. Patient #18 was assessed by a registered nurse and determined to not meet criteria for inpatient admission.

Patient #19 presented on 03-17-16. No reason is documented. Patient #19 was assessed by a registered nurse and determined to not meet criteria for inpatient admission.

Patient #20 presented on 08-03-16. No reason is documented. Patient #20 was assessed by a registered nurse and determined to not meet criteria for inpatient admission.

Patient #21 presented on 06-18-16 requesting shelter and medical management of his delirium tremens. Patient #21 was assessed by a registered nurse and advised to seek medical treatment for his delirium tremens.

Patient #22 presented on 09-11-15. No reason is documented. Patient #22 was assessed by a registered nurse and determined to not meet criteria for inpatient admission.

Patient #23 presented with complaints of major depression. Patient #23 was assessed by a licensed professional counselor and transferred to a nearby medical hospital for medical clearance.

In an interview with staff #13 on 09-21-16, staff #13 confirmed that no medical screening exam had been performed or documented on any of the 23 patients.

The above was confirmed in an interview with staff #13 on the afternoon of 09-21-16.