HospitalInspections.org

Based on document review and staff interviews, the Acute Care Hospital's (ACH) administrative staff failed to ensure the emergency department's (ED) staff followed hospital policies, ensuring 1 of 20 patients (Patient #12) selected for review, received an appropriate medical examination (MSE). Failure of the hospital's ED staff to provide an appropriate medical screening examination within the hospital's capabilities, which included utilization of all pertinent evaluations and information obtained from the medical screening exam, resulted in Patient #12's discharge and subsequently being taken to another hospital's (Hospital A) ED approximately 5 1/2 hours later, that same day, for examination and treatment. The hospital's administrative staff identified an average of 2,120 patients per month who presented to the hospital's dedicated emergency department (DED) and requested emergency medical care.

Findings included:

1. Review of the policy Transfer and Emergency Examination - EMTALA," Reviewed/Revised 4/30/22, revealed in part, "...Any individual who comes to...emergency department requesting...examination or treatment...shall be provided with a medical screening examination by a qualified provider...nurse practitioner... the medical screening examination provided shall be within the capabilities of Trinity Medical Center's Emergency Department (including ancillary services routinely available to the emergency department..."

2. Review of the "Medical Staff Rules and Regulations" dated 12/26/2020, revealed in part, "...Emergency services and care will be provided to any person in danger of loss of life or serious injury or illness... Medical screening examinations...will be performed on all individuals who come to the Medical Center requesting examination or treatment to determine the presence of an emergency medical condition..."

3. Review of Patient #12's medical record revealed Patient #12, an 81-year-old who is wheel chair bound, presented to the ED via EMS on 6/16/22 at 11:23 AM. Patient #12 complained of chronic shoulder and back pain, requested assistance with nursing home placement due to inability to meet own needs, wheelchair bound, and homeless. ARNP A performed a physical exam, ordered laboratory tests to clear for nursing home placement, a physical therapy evaluation, and a case management consult. The Physical Therapy evaluation results were not reviewed, nursing home placement was not found, and Patient #12 was discharged at 5:02 PM to the streets with no transportation to another homeless shelter

4 During an interview on 8/2/2022 at 10:53 AM, ARNP A revealed Patient # 12 presented on 6/16/2022 with complaints of chronic shoulder and back pain and requested assistance with nursing home placement. ARNP A performed a physical exam, ordered laboratory tests to clear for nursing home placement, a physical therapy evaluation and a case management consult. ARNP A acknowledged the Physical Therapy evaluation results were not reviewed, nursing home placement was not found and Patient # 12 was discharged.

5. Review of Patient #12's medical record from Hospital A revealed Patient #12 presented to Hospital A's ED on 6/16/2022 at 11:23 PM by EMS after attempting to merge onto I-74 in his wheelchair. Patient #12 was provided a medical screening exam by ED Physician G, diagnosed with dehydration and altered mental status and admitted to Hospital A on observation status.

6. During an interview on 8/8/2022 at 10:26 AM, ED Physician G reported Patient #12 presented by ambulance to Hospital A's ED on 6/16/22 at 11:23 PM by ambulance. ED Physician G reported bystanders had found Patient #12 confused and attempting to merge onto the freeway. Patient #12 was admitted for altered mental status and dehydration. Patient #12 was admitted on observation status to Hospital A.

Please see A-2406 for additional information.

Based on document review and staff interviews, the acute care hospital's (ACH) emergency department (ED) staff failed to provide an appropriate medical screening examination for 1 of 20 patient's (Patient #12) that presented to the ED and requested care from 2/1/2022 through 7/31/2022. Failure to provide an appropriate medical screening exam occurred when ARNP A failed to utilize all information obtained from the medical screening examination and discharged Patient #12, a homeless 81-year-old wheelchair bound patient without any means of transportation, to a homeless shelter which was located miles from the ED, to the streets on a hot afternoon. This resulted in a second ED visit in another hospital's ED (Hospital A) that same day after Patient #12 was found confused and dehydrated in their wheel chair attempting to get on an interstate highway. The hospital's administrative staff identified an average of 2,120 patients per month who presented to the hospital's dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #12's medical record revealed Patient #12, an 81-yr. old, presented to the ACH's ED on 6/16/22 at 11:07 AM, via ambulance after being located in a parking lot at the local homeless shelter in his wheel chair. Patient # 12 complained of chronic shoulder and back pain, and request assistance with nursing home placement. Patient #12 reported they needed more help than the homeless shelter could provide. Patient #12 reported they are only able to walk a few feet before sitting down due to back pain. Patient #12 reported they bruise and bleed easily. ARNP A performed a physical examination, ordered lab tests, a case management consult for nursing home placement, and a physical therapy evaluation. ARNP A noted lab tests were reviewed and "unremarkable", Patient # 12 was cleared for nursing home placement.

At 11:17 AM, RN B documented pain assessment as "6" in unspecified shoulder, (0-10 pain scale with 0 being no pain to 10 being the worst pain imaginable). Patient #12 noted to have history of pain medication in chart but reported to RN B, they were no longer taking.

At 11:34 AM, Social Worker (SW) D, documented they talked with Patient # 12 over the phone to discuss "discharge planning" and reviewed current living arrangement, social support, level of functioning, and options for discharge planning needs.

At 12:05 PM, Physical Therapist (PT) C completed a physical therapy evaluation and documented in part, "...Barriers to return to Prior Living: Patient not safe to be alone secondary to decreased safety awareness. Patient unable to tolerated home mobility... Demonstrated decreased safety awareness and is at high risk for falls..." ARNP A failed to review and consider the PT's evaluation and recommendation.

At 2:25 PM, RN B documented, "...Person from the homeless shelter told registration person patient was no longer there and [Patient #12] could not return to the shelter."

At 4:35 PM, SW D documented, the patient had been denied placement at several nursing homes. SW D faxed a list of community resources and asked the ER nurse to write the VA number and Iowa Total Cares contact number on the paperwork so the patient would have all contact numbers.

At 4:44 PM, ARNP A documented in part," [Patient #12] is medically stable and cleared and such we will plan to discharge the patient from this facility. He has been given referrals to the state and VA for assistance in finding placement ..."

At 5:02 PM, RN B, reviewed information for discharge with Patient # 12 and was given the phone numbers SW D requested. RN B documented in part, "...Patient was told multiple times that he was to exit the ER as he was discharged. Patient was explained that the nursing home would not accept him...and the homeless shelter refused to take him back.... Patient was asked to pack up and vacate the ER...Patient was given a glass of coffee for the road and papers to be discharged."

At 5:07, Patient #12 was left the ACH ED per self via personal wheelchair with discharge paperwork.

The medical record lacked evidence that Patient #12's pain was further assessed or managed after RN B's initial assessment. The medical record further lacked evidence that Patient #12 had received an appropriate MSE to be safely discharged from the ACH ED.

2. During an interview on 8/2/2022 at 10:53 AM, ARNP A revealed Patient #12 was homeless, in a wheelchair, and wanted nursing home placement. ARNP A reported Patient #12 had been alert and oriented and that she had witnessed Patient #12 get off the ER bed and into their wheel chair, go to the phone and make a phone call. "I didn't have an admitting diagnosis, I didn't have any criteria to keep [Patient # 12]. ARNP A admitted they had not read the Physical Therapy evaluation note that identified the patient as unsafe to be alone and at high risk for falls, although the evaluation note had been electronically signed by ARNP A. ARNP A reported there were many homeless shelters in the area but was not aware of their locations. ARNP A verbalized she had not been aware that Patient #12 had been asked to leave the ER with no destination identified and without transportation to another homeless shelter and stated this was really "upsetting" to me. ARNP A commented ARNP A might have tried to keep [Patient #12] for the case manager to continue finding placement had I known all this.

3. During an interview on 8/2/2022 at 12:57 PM, RN B reported she remembered Patient #12 as an alert and oriented, elderly patient in a wheel chair that had been kicked out of a homeless shelter for behavior issues. RN B reported they had seen a lot of homeless people here in this hospital ER as well as another large ER that they work at. If they (patients) don't meet admission criteria they get discharged. RN A acknowledged RN B did not question ARNP A about Patient #12's discharge order, knowing Patient #12 had nowhere to go, no phone, and no transportation on a hot summer day. RN B verbalized, the way I look at it, I just follow what my provider tells me to do.

4. During an interview on 8/2/2022 at 12:10 PM, PT C reported they evaluated Patient #12 in the ER. Patient #12 told PT C that the shelter told Patient #12 that they exceeded the shelter's care limits and Patient #12 should find placement. Patient #12 informed PT C this conversation with shelter staff occurred the day prior and that Patient #12 had stayed out on the street the night before coming to the ER. PT C reported there were safety concerns identified and PT C shared evaluation results with RN B, then documented the results immediately so that ARNP A had access to the evaluation findings. PT C did not talk with ARNP A directly.

5. During an interview on 8/2/2022 at 1:48 PM, Social Worker (SW) D reported they completed the consultation and communicated with Patient #12 via telephone as SW D is physically located in another city. SW D reported they first communicated with Patient #12 on 6/16/2022 at 11:34 AM and last documentation was at 4:25 PM that same day. SW D reported the consult was for assistance with nursing home placement. SW D acknowledged by midafternoon on 6/16/2022, SW D knew Patient #12 had been kicked out of the shelter Patient #12 had been staying at and had nowhere to go. SW D was unable to find nursing home placement, the last denial was received at 4:25 PM. SW D left for the day at 5:00 PM. SW D provided the VA number, Iowa Total Cares Coordinator number, and a list of community resources for Patient #12 to call. SW D reported Patient #12 had been discharged by the time SW D returned the next day.

6. Review of Patient # 12's medical record from [Hospital A] revealed Patient #12 presented to [Hospital A] per EMS on 6/16/2022 at 11:23 PM, approximately 5 1/2 hours after discharge from ACH ED. Dr. G documented at 11:26 PM in part, "...patient presents with altered mental status...80 year old homeless...per EMS patient was found trying to take [their] wheelchair on I-74, ...disheveled, unkempt, poor hygiene...confused to hx of present illness...diagnosis altered mental status; dehydration...." Patient # 12 was physically examined, lab tests ordered, CT exam of head ordered to rule out a stroke. Patient # 12 was admitted to [Hospital A] on observation status and nursing home placement located 6/20/2022.

7. During an interview on 8/8/2022 at 10:26 AM, DR G recalled Patient #12 had been found in their wheelchair trying to merge onto the freeway. Patient #12 couldn't explain why they were trying to do that. That is what concerned Dr. G the most. Dr. G reported they worked Patient #12 up for a possible stroke. CT was normal, labs, everything OK, never found anything. Dr. G didn't discharge Patient #12 as something was wrong with Patient #12. Dr. G verbalized, we don't get a homeless person in a wheelchair at 80 years old very often. I was concerned about [Patient #12] and what caused [them] to do this so we admitted [Patient #12].