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Based on reviews of Facility #1's Emergency Department medical records, document review, staff interviews, family interview, review the bylaws, rules, and regulations of the medical staff, review of the ED policies and procedure manuals and review of hospital policies and procedures, the hospital failed to comply with 489.24 by failing to provide a Medical Screening Exam (MSE) for one (1) of 22 patients reviewed.


Findings include:

Based on Emergency Department (ED) Medical Record review, document review, policy and procedure review, staff interview, family interview, review the bylaws, rules, and regulations of the medical staff, review of the ED policies and procedure manuals, and review of hospital policies and procedures, the hospital failed to provide within the hospital's capabilities (staff and facilities) that were available for a Medical Screening Exam (MSE) for Patient #1, one (1) of 22 ED patient records reviewed.


Findings include:

Mississippi State Department of Health received a written complaint against Hospital #1 from Patient #1's wife. The complaint stated:
"Date of alleged event 02/09/2018 11:00 p.m.
Arrived at the Emergency Room - told staff my husband was having a stroke - that his blood pressure was elevated. Had been having signs/symptoms of weakness. Was told had a lot of patients already and for me to just take him somewhere else. My husband was able to function somewhat with his right side at that point, but was extremely weak and getting weaker. Took him to (Hospital #2) where they diagnosed him with a left side stroke - We were told it was too late to give the "clot bursting" medication. They did not assess my husband, did not check his vital signs. He was stumbling - trying to walk. I explained to them he was having a stroke - the nurse told me "he can sit over there and wait until I have time" - my son came and asked could they not see him and the nurse said they were too busy and we'd have to take him somewhere else. My son and I took him to (Hospital #2). His stroke has caused him to have paralysis on the right side - speech impairment and Dx (diagnosis) of (L) sided CVA (cardiovascular accident). Me and my son watched my husband slowly deteriorate during the time home from getting to (Hospital #1) ER (Emergency Room) til he was admitted to (Hospital #2).
I want the hospital ER investigated and some type of penalty imposed - no one should be turned away while having an active stroke - if he could have gotten the clot bursting medication he may not have lost use of his ® side and we wouldn't be going through the trauma of therapy and recovery. I want the nurse to face the consequences of her actions of not triaging this patient to determine his needs. I want to see her lose her job." Patient #1's wife signed and dated the complaint.



On 02/27/2018 at 10:00 a.m. Hospital #1 was entered. A meeting was held with the Administrator; Compliance Officer; and the Registered Nurse (RN) Emergency Department (ED) Director regarding the reason for the visit. The Administrator stated that he had received a letter of complaint from the patient's wife. He stated that he did not think it happened the way she stated it did. A list of needed items was given and they were told that the ED logs and Nursing Schedules were needed quickly. We were told that the ED Director would handle all of our requests and questions.

At 11:15 a.m. the ED Director presented their ED logs and was told we would need to talk to the RN on duty in the ED the night Patient #1 presented to the ED with signs and symptoms of a stroke. He stated her name was (RN #1) and gave us her cell number and her home number. He also stated that she was out of town on vacation. Review of the ED logs revealed that Patient #1 did not come to their ED on 2/9/18 at 11:00 p.m. as the complaint stated. He presented to their ED on 2/11/18 at midnight.

At 12:04 p.m. RN #1 was called via her cell phone. She was told the purpose of the call. She stated that she was on vacation, but that she remembered the patient and his wife and would be happy to discuss it with us. RN #1 stated that on that night all 18 of the ED rooms were full due to normal flow and a motor vehicle wreck with multi patients brought in at 11:45 p.m. She stated that she had a patient in triage and had stepped out to get another patient when Patient #1's approached her and told her that her husband was having a stroke and needed to go straight back and be seen now. "I told her that we were very full and I had a patient sitting in triage that I needed to finish and I would be right back out to get him. When (Patient #1's wife) was told that her husband could not go straight back she got very upset and stated they were going somewhere else. I finished the patient sitting in triage, but when I went back out to get (Patient #1) they were gone." RN #1 denied that she told them to take him somewhere else because they were too busy to see him. "I would never tell anyone something like that. The wife was the one that said they were taking him somewhere else."

Review of the ED logs for 2/11/18 from 11:30 p.m. to 12/12/18 at 12:30 a.m. revealed all 18 ED rooms stayed occupied, as stated by the ED RN. Six (6) patients arrived during that time frame who were connected with the MVA.


ED record review for Patient #1 revealed this 59 year old male presented via private vehicle to the ED with his wife and son on Sunday 2/11/18 at 12:07 a.m. with a complaint of slurred speech and dizzy. The patient's wife told staff he was having a stroke and became upset because the staff did not take him straight to the back. At 12:23 a.m. the wife and patient walked out of the ED area without being triaged, without a Medical Screening Exam (MSE) and with no Stabilizing Treatment provided.

At 1:24 p.m. the ED was toured with the ED Director. Observation revealed there were approximately 40 chairs in the main ED waiting room and EMTALA signs were noted to be posted on the wall. The ED contained 22 beds - 2 major trauma rooms; 4 minor trauma rooms; 2 cardio rooms; 4 rooms which were not in use at this time; and the remainder 10 rooms were normal ED rooms. All rooms had EMTALA signs posted in them. A Stroke Alert Protocol flow chart was posted on the wall in between the 2 major trauma rooms. When the ED Director was asked what they would do if all of their ED rooms were full he stated that they would move patients with less severe emergencies to observation rooms upstairs.

ED record review for Patient #1 revealed this 59 year old male presented via private vehicle to the ED with his wife and son on Sunday 2/11/18 at 12:07 a.m. (not 2/9/18 at 11:00 p.m.) with a complaint of slurred speech and dizzy. The patient's wife told staff he was having a stroke and became upset because the staff did not take him straight to the back. At 12:23 a.m. the wife and patient walked out of the ED area without being triaged, without a Medical Screening Exam (MSE).


At 2:00 p.m. the ED Director was told we needed to interview the other nurses on duty the night of 2/11/18 as soon as possible. He gave us the names but no numbers of two RNs he thought worked that night.


On 2/28/18 at 9:00 a.m. the ED Director was asked what level trauma center the hospital was. He stated that they are a Level 3 Trauma Center and a Level 3 Stroke Center. At that time he was asked again about the receptionists' name and telephone number. He gave the receptionists' name and phone number that was on duty in the ED the night Patient #1 came to the ED. This number was called multiple times and messages were left for her to return the calls. She failed to return the call.


On 2/28/18 at 9:05 a.m. the facility presented a copy of a CD which showed Patient #1, his wife and their son coming into the ED. They stayed approximately 6 minutes. We again requested interviews with the RNs on duty the night of 2/11/18. At 9:50 a.m. the ED Director came back and stated there was only one other RN on duty that night and gave us her cell phone number. Her number was called and a voice message left for her to return the call. Another attempt was made and another voice message was left. She never returned the call.

At 10:28 a.m. ED RN #2 was interviewed. He stated they had a lot of patients in ED at the moment. He was not working on Sunday 2/11/18 at 12:07 a.m. when Patient #1 came to their ED. When asked if he ever triaged he stated, "I use to. I'm the shift leader now." The emergent and non-emergent levels were discussed. He stated that a patient is put into the system as emergent or as non-emergent when they check in. When it was pointed out to him that most of their patients were entered as non-emergent he stated he was not sure why that was done that way. He stated that the insurance clerk enters that information.

In an interview on 12/28/18 at 10:50 a.m. the ED Director was asked to explain the process of what happens to a patient when they walk in through the ED doors. He stated that ambulatory patients come through the doors and report to the receptionist/insurance clerk. When asked about having a delay in treatment to ask for insurance information he stated, "There is never a delay in triage or treatment to get a patient's insurance information." The emergent and non-emergent levels were discussed. He also stated that a patient is put into the system as emergent or as non-emergent when they check in. When it was pointed out to him that most of their patients were entered as non-emergent (Level 1) he stated he was not sure why that was done that way and that the insurance clerk enters that information. He stated it might be because they get a higher educated level of patients or because of the insurance their patients have or various other reasons.


On 2/28/18 at 11:30 a.m. an Exit Conference was held with the Administrator; the Compliance Officer; and the ED Director. No further information was submitted for review.


On 2/28/18 from 12:01 to 12:13 p.m. a telephone interview was held with Patient #1's wife. She stated that on the night they went to (Hospital #1) her eyes were messed up so her son was parking the van. She took her husband inside and told the woman in the front that her husband was having a stroke. "His eyes looked funny and he was dizzy. The woman told me she needed his drivers' license and insurance card. I told her he was dizzy and his blood pressure at home was 180/90 and can't someone see him. She checked in two more people behind us before she would get the nurse. The nurse came out and told me that there were seven or eight people ahead of us and he just needed to go sit down. I remember saying, 'Can you not just look at him? Oh my God you're not going to see him?' She wouldn't even look at him and take his vital signs. We left and took him to (Hospital #2). When we got there his blood pressure was 225/100. They said he had a blood clot in his brain, but it was too late to use the clot burster (buster). They also said this has happened before to others and they were not surprised." When asked how Patient #1 was doing now she stated, "He is getting Physical Therapy, Speech Therapy and a Home Health Aide is coming to the house to help." At this point she began to cry and we ended the conversation.



CONCLUSION:

The complaint regarding Patient #1 was substantiated and EMTALA violations were cited for the facility's failure to ensure Patient #1 received a Medical Screening Exam from a physician while in their facility.
1. A2400 Compliance with 489.24