HospitalInspections.org

Based on review of patient #1's medical record, facility log, facility's policies and procedures, staff and physician interviews, it was determined that Donalsonville Hospital, Inc., failed to ensure compliance with 42 CFR 489.24, Special Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Findings were:

Cross refer to A2406 as it relates to failure to provide an appropriate medical screening to an individual who presented to the emergency department and a request was made on their behalf for an evaluation.

Cross refer to A2408 as it relates to delay in treatment due to the refusal of the individual to pay for his/her treatment to determine if an emergency medical condition existed.

Based on review of medical records, facility policies and procedures, staff and physician interviews, it was determined that the facility failed to perform an appropriate medical screening (MSE) for a patient who presented and a request was made on their behalf for an evaluation for one of twenty (#1) sampled patient records.

Findings were:

Review of the facility's policy entitled "Emergency Room Triage Policy", effective October 9, 2008 revealed that the facility was: "To ascertain a patient's medical condition and whether his/her condition constitutes a medical emergency. If the patient isn't suffering from a medical emergency as deemed by the hospital, then the hospital will further screen the patient's insurance coverage or request a $100 deposit if the patient decides to seek further treatment in the hospital room." The policy further indicated that "To determine ways to screen out non-emergency medical care, a medical screening evaluation is done on all patients who go to the emergency department. EMTALA (Emergency Medical Treatment and Labor Act) was a federal law that required all patients who came to the hospital with a dedicated emergency room, seeking and requesting treatment, to receive a medical screening evaluation to assure that no emergency medical condition exists. The medical screening cannot be delayed to determine the patient's ability to pay for the exam. Once a medical screening evaluation had been performed and no emergency medical condition exists, the hospital is free of EMTALA obligations. At this point, the hospital may request financial information from the patients and request a cash deposit for this elective visit to the emergency room. Patients unable to pay a deposit needed to register as indigent and complete the necessary paperwork." The policy further stated that the physician and registered nurses who had been approved by the medical staff could perform a medical screening exam.

Review of the facility's policy entitled "Purpose and Rules Of The Emergency Room", effective 6/4/97, revised 6/20/98 approved by the Medical Staff and the hospital's Governing Body stated that "Upon presentation to the Emergency Department, all patients shall be triaged by a Registered Nurse assigned to that area. Based upon criteria, each patient shall be classified according to the E.R. Level. The Nurse shall then notify the on-call physician regarding the patient's presenting complaints, E.R. Level, vital signs and brief history of complaint. The physician shall then be responsible for completing a medical evaluation to determine if a medical emergency exists."

During an interview (#1) on 8/30/10 at 10:30 a.m. in the conference room, the nurse supervisor stated that the medical doctor and registered nurse were qualified to do a medical screening. A Licensed Practical Nurse (LPN) could triage a patient, but the registered nurse was required to complete the assessment. The supervisor stated that the registered nurse was responsible for checking that the LPN had completed duties as per policy. The supervisor explained that, during the triage process, the nurse collaborated with the physician and if it was determined that a patient was not an urgent level, they became a MSO (Medical Screening Out). The registration clerk then came and spoke to patients to inform them of their options. The supervisor stated that if patients wanted continued treatment then the registration clerk informed them that there was a fee of $100 dollars. The nurse explained that the fee was a standard fee that the hospital used for patients that came to the emergency room and needed further treatment but were deemed as non-urgent.

Review of patient #1's medical record revealed that the patient 72 years old presented to the facility's emergency department (ED) on 04/30/2010 at 9:12 a.m. complaining of shortness of breath and chest congestion. The record revealed that the patient was seen by the registration clerk who took the patient's contact information and insurance information. The patient was then seen by the registered nurse (personnel record #2) who triaged the patient as a Level 2 (URGENT- a condition requiring medical attention within one hour, conditions that required prompt attention, but will generally not cause loss of life or permanent severe impairment if treated in an appropriate time frame). This triage category was based on the facility's policy entitled "Assessment of the Emergency Department Patient", effective 9/96 and revised 4/04. The patient's vital signs were taken by the nurse and a brief history of the patient's complaint was obtained, and documented by the nurse, Pt (Patient) c/o (complain) of chest congestion, cough. Productive and@ (at) times; slightly diminished breath sounds in bases ..." According to documentation in the medical record, patient #1's pulse rate was 53 (normal 60-80). The patient provided a list of medications that he/she was taking inclusive of insulin for Diabetes Type 2; Atenolol for high blood pressure; Warfarin ( a blood thinner); and three additional medications. Documentation in the emergency room record revealed that the nurse notified the emergency room doctor (credential file #2) about the patient at 9:40 am. According to documentation in the record, the nurse received a verbal order from the physician for a medical screening out (MSO - being screened out for further treatment after determination that a medical emergency was ruled out) for the patient at 9:40 a.m. According to documentation by the nurse who triaged the patient, patient #1's condition was unchanged, verbal discharge instructions at 9:40 a.m. were given to the patient and the patient was discharged ambulatory. The order was signed by the physician at 1:00 pm the same day. Documentation further revealed that the patient opted to seek care elsewhere and signed the "Medical Screening Disposition for Non-Emergency Care" form, stipulating that the patient's medical condition was evaluated by the ER provider or Nurse Screener and it was determined that the patient's condition was not an emergency and did not require immediate treatment. The information that was communicated to the physician on-call was not documented. Review of the form titled, " Emergency Triage and Physician " Physician Responsibility the Physical Examination and History sections were all left blank. Documentation by the nurse on the " Emergency Triage and Physician Record " form checked off in the Nursing Diagnosis section was airway clearance/effective (abnormal breath sounds, cough) and alteration in comfort (pain). There was no documentation in section of the notes to indicate treatment or intervention to these identified problems. There was no documented evidence that any diagnostic studies were ordered and/or performed. The ED nurse checked off on the " Medical Screening Evaluation Form " dated 4/30/2010, " further evaluation and/or testing is required to determine if an Emergency Medical Condition is present. " The facility failed to ensure that an appropriate medical screening examination was performed on patient #1 to determine if an emergency medical condition exists.

During an interview (#2) on 8/30/10 at 2:05 p.m. in the conference room, the emergency room (ER) physician who worked the day the patient presented to the ER stated that he/she was not familiar with the patient. The physician explained that patients that presented to the emergency room were signed in by the registration clerk or nurse. The physician stated that after patients signed in, patients were triaged by the registered nurse and received a medical screening exam by the nurse. If an emergency condition existed, patients were seen by the physician, depending on the level of urgency. The physician stated that when it was a non urgent condition, the physician may not need to see them. The physician consulted with the registered nurse and they determined when the patient needed to be seen by the physician. The physician stated that patients were discharged according to the non urgent care guidelines. The physician explained that during this MSO process, the physician signed and dated the order but that there was no formal diagnosis given. The physician stated that the nurse explained to patients about receiving further care. Patients could pay the $100 fee for non emergent treatment or seek alternative care. The facility gave some resources to patients concerning were they could be seen. The physician stated that the nurse needed an order from the physician for the MSO and that he/she signed the order later that day if possible.

Based on review of medical records, facility policies and procedures, staff and physician interviews, it was determined that the facility delayed treatment by failing to provide an appropriate medical screening based on method of payment for further medical examination and treatment to determine if an emergency medical condition existed for one of twenty (#1) sampled patient records.

Findings were:

Review of the facility's policy entitled "Emergency Room Triage Policy", effective October 9, 2008 revealed that the facility was: "To ascertain a patient's medical condition and whether his/her condition constitutes a medical emergency. If the patient isn't suffering from a medical emergency as deemed by the hospital, then the hospital will further screen the patient's insurance coverage or request a $100 deposit if the patient decides to seek further treatment in the hospital room." The policy further indicated that " To determine ways to screen out non-emergency medical care, a medical screening evaluation is done on all patients who go to the emergency department. EMTALA (Emergency Medical Treatment and Labor Act) was a federal law that required all patients who came to the hospital with a dedicated emergency room, seeking and requesting treatment, to receive a medical screening evaluation to assure that no emergency medical condition exists. The medical screening cannot be delayed to determine the patient's ability to pay for the exam. Once a medical screening evaluation had been performed and no emergency medical condition exists, the hospital is free of EMTALA obligations. At this point, the hospital may request financial information from the patients and request a cash deposit for this elective visit to the emergency room. Patients unable to pay a deposit needed to register as indigent and complete the necessary paperwork." The policy further stated that the physician and registered nurses who had been approved by the medical staff could perform a medical screening exam.

Review of the facility's policy entitled "Purpose and Rules Of The Emergency Room", effective 6/4/97, revised 6/20/98 approved by the Medical Staff and the hospital's Governing Body specified that "Upon presentation to the Emergency Department, all patients shall be triaged by a Registered Nurse assigned to that area. Based upon criteria, each patient shall be classified according to the E.R. Level. The Nurse shall then notify the on-call physician regarding the patient's presenting complaints, E.R. Level, vital signs and brief history of complaint. The physician shall then be responsible for completing a medical evaluation to determine if a medical emergency exists."

During an interview (#1) on 8/30/10 at 10:30 a.m. in the conference room, the nurse supervisor stated that the medical doctor and registered nurse were qualified to do a medical screening. A Licensed Practical Nurse (LPN) could triage a patient, but the registered nurse was required to complete the assessment. The supervisor stated that the registered nurse was responsible for checking that the LPN had completed duties as per policy. The supervisor explained that, during the triage process, the nurse collaborated with the physician and if it was determined that a patient was not an urgent level, they were categorized as a MSO (Medical Screened Out). The registration clerk then came and spoke to patients to inform them of their options. The supervisor stated that if patients wanted continued treatment then the registration clerk informed them that there was a fee of $100 dollars. The nurse explained that the fee was a standard fee that the hospital used for patients that came to the emergency room and needed further treatment but were deemed as non-urgent.

Review of patient #1's medical record revealed that the patient presented to the facility's emergency department (ED) on 04/30/2010 at 9:12 a.m. complaining of shortness of breath and chest congestion. The record revealed that the patient was seen by the registration clerk who took the patient's contact information and insurance information. Documentation on the "Medical Screening Disposition for Non-Emergency Care" form dated 4/30/2010 at 9:40 a.m., specified in part, " If you choose to continue further treatment in the Emergency Room, a minimum fee of $100 will be required in advance for non-emergency care. " Further review revealed that the patient opted to seek care elsewhere and signed the form stipulating that the patient's medical condition was evaluated by the ER provider or Nurse Screener and it was determined that the patient's condition was not an emergency and did not require immediate treatment. According to documentation in the medical record, patient #1's pulse rate was 53 (normal 60-80). The patient provided a list of medications that he/she was taking inclusive of insulin for Diabetes Type 2; Atenolol for high blood pressure; Warfarin ( a blood thinner); and three additional medications. The information that was communicated to the physician on-call was not documented. The ED nurse checked off on the " Medical Screening Evaluation Form " dated 4/30/2010, " further evaluation and/or testing is required to determine if an Emergency Medical Condition is present. " There was no documented evidence that any diagnostic studies were ordered and/or performed. The hospital failed to ensure that an appropriate medical screening examination and further medical examination and treatment for patient #1 to determine if an emergency medical condition existed based on method of payment.

During an interview (#2) on 8/30/10 at 2:05 p.m. in the conference room, the emergency room (ER) physician who worked the day the patient presented to the ER stated that he/she was not familiar with the patient. The physician explained that patients that presented to the emergency room were signed in by the registration clerk or nurse. The physician stated that after patients signed in, patients were triaged by the registered nurse and received a medical screening exam by the nurse. If an emergency condition existed, patients were seen by the physician, depending on the level of urgency. The physician stated that when it was a non urgent condition, the physician may not need to see them. The physician consulted with the registered nurse and they determined when the patient needed to be seen by the physician. The physician stated that patients were discharged according to the non urgent care guidelines. The physician explained that during this MSO process, the physician signed and dated the order but that there was no formal diagnosis given. The physician stated that the nurse explained to patients about receiving further care. Patients could pay the $100 fee for non emergent treatment or seek alternative care. The facility gave some resources to patients concerning were they could be seen. The physician stated that the nurse needed an order from the physician for the MSO and that he/she signed the order later that day if possible.