HospitalInspections.org

Based on observation and staff interview the facility failed to post signs specifying the rights of individuals, who present to the ED (Emergency Department) seeking health care services for emergency medical conditions or for women in labor. Findings include:

During tour of the Emergency Department (ED), at 11:03 AM on 1/19/11, there was no signage posted in the entry way, waiting room, examination or treatment room, or any other area of the department, specifying the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor. In addition there was no signage that indicated whether or not the hospital participated in the state Medicaid Program. This was confirmed, at the time of tour, by the ED Nurse Educator and the Director of Regulatory Readiness.

Based on staff interview and record review the hospital failed to assure that an appropriate MSE (Medical Screening Examination), to determine whether or not an EMC (Emergency Medical Condition) existed, was conducted for Patient #1 who presented to the ED (Emergency Department) complaining of hip and leg pain. Findings include:
Per record review, Patient #1, who had a past medical history including recent hospitalization and treatment for complex medical issues, presented to the ED on the afternoon of 6/18/10, via ambulance, with a chief complaint of left hip and leg pain that had started following a physical therapy session the day before. Although an MSE was conducted, at that time, by Provider #1, no clinical laboratory or other diagnostic studies were completed as part of that assessment and there was no evidence of ongoing monitoring of the patient's condition to assist in identifying whether or not an EMC existed. Following administration of IV (intravenous) pain medication and Valium (used to relieve muscle spasms), the patient was discharged back to the rehabilitation center, with a diagnosis of Sciatica (related to irritation of the sciatic nerve). Patient #1 returned to the ED via ambulance, 3 days later, on the morning of 6/21/10, with continuing left leg pain. The MSE at that time included clinical laboratory studies which identified a significant drop in blood levels requiring blood transfusions, as well as diagnostic imaging studies which revealed the presence of a retroperitoneal bleed (bleeding internally into the membrane that lines the abdominal cavity in the area of the lower back), subsequently requiring admission to the hospital for treatment.
Prior to the initial ED visit on 6/18/10, Patient #1 had spent 3 weeks in an acute care stay at the same hospital, having been discharged on 6/15/10, just 3 days prior to that ED visit. During that hospitalization the patient was treated for multiple medical conditions including; pneumonia, bilateral pulmonary emboli (blockage of arteries in the lungs) and DVT (Deep Vein Thrombosis-blood clot) of the left leg, for which the patient received anti-coagulation medication.
The assessment, during the 6/18/10 ED visit, documented by Provider #1 identified that the patient had been "discharged from the hospital to rehab 5 days ago after getting PCP pneumonia", had been having difficulty ambulating and had been having left hip pain since walking with PT (Physical Therapy) the day before the ED visit. S/he further stated that the patient had taken 7 Percocet without relief, had gone to the ED for further evaluation and "denied having bone cancer or any other reason to suspect a broken hip." Despite the patient's medical history, recent hospitalization and treatment for blood clots, which put the patient at increased risk for bleeding, there is no evidence that Provider #1 utilized routine clinical laboratory and diagnostic studies, in conjunction with the patient's presenting signs and symptoms, in their assessment and determination of whether an EMC existed at that time. The patient had received IV pain medication and Valium (used to relieve muscle spasms) for patient identified pain of 10 (using a numeric pain scale of 1-10, with 1 signifying minimal pain and 10 the worst pain) at 3:44 PM. Although a nursing assessment 37 minutes later revealed that the patient still identified his/her pain, at that time, at 9 out of 10, there was no further monitoring or assessment of pain prior to the patient's discharge 2 hours later. Despite this, Provider #1 had documented, under ED Course: "Pt feeling better will go to rehab with improved pain control".
During telephone interview, at 10:04 AM on 1/20/11, Provider #1 stated that, s/he vaguely recalled this case, and had recently reviewed the case with the ED Physician Clinical Leader on 1/19/11. When notes were read to him/her (by the surveyor at the time of interview) s/he stated that it sounded as though "my biggest concern was a fracture, but I had ruled that out". When further questioned, by the surveyor, about why laboratory or other diagnostic studies had not been used in the assessment of the patient's condition Provider #1 stated that "sciatica is more of a clinical diagnosis....(patient's) sounded more musculo-skeletal in nature"."..."I don't scan for Sciatica...I could have scanned ...or plain films....why I did not do them I do not know....it sounds like (s/he) was feeling better" S/he further stated s/he did not know why lab studies were not done. In addition, when questioned about how the determination was made to discharge the patient, when the last pain assessment, 2 hours prior to discharge, had revealed minimal pain relief, the provider stated that s/he had "clearly stated the patient was feeling better".
During interview, at 8:17 AM on 1/20/11, the ED Physician Clinical Leader stated that, although, "I do not think it was the right diagnosis" the evaluation provided by Provider #1 was appropriate and it was a "reasonable diagnosis as the patient presented"......."(Patient #1)..leg was in pain, consistent with Sciatica", and there was "no bone mets" (metastisis). When the surveyor posed the question of lack of further pain evaluation following nursing's last documented patient identified pain score of 9/10, the Clinical Leader stated that pain scores are subjective, and Provider #1 had documented, "Patient feeling better for pain control" prior to the patient's discharge.

Based on staff interview and record review the facility failed to assure stability of the medical condition prior to discharge for Patient #1, as evidenced by the facility's failure to complete an appropriate MSE to determine if an EMC existed, and the lack of ongoing monitoring to determine if the condition for which the patient sought treatment had been resolved. Findings include:
Per record review, Patient #1, who had a past medical history, including recent hospitalization and treatment for complex medical issues, presented to the ED on the afternoon of 6/18/10, via ambulance, with a chief complaint of left hip and leg pain that had started following a physical therapy session the day before. Although an MSE was conducted, at that time, by Provider #1, no clinical laboratory or other diagnostic studies were completed as part of that assessment to assist in identifying whether or not an EMC existed. In addition, there was no evidence of ongoing monitoring of the patient's condition, to determine if the condition was resolved prior to discharge. Following administration of IV (intravenous) pain medication and Valium, the patient was discharged back to the rehabilitation center, with a diagnosis of Sciatica (irritation of the sciatic nerve). Patient #1 returned to the ED via ambulance, 3 days later, on the morning of 6/21/10, with continuing left leg pain. The MSE at that time included clinical laboratory studies which identified a significant drop in blood levels requiring blood transfusions, as well as diagnostic imaging studies which revealed the presence of a retroperitoneal bleed (bleeding internally into the membrane that lines the abdominal cavity in the area of the lower back), subsequently requiring admission to the hospital for treatment.
Prior to the initial ED visit on 6/18/10, Patient #1 had spent 3 weeks in an acute care stay at the same hospital, having been discharged on 6/15/10, just 3 days prior to the ED visit. During that hospitalization the patient was treated for multiple medical conditions including; pneumonia, bilateral pulmonary emboli (blockage of arteries in the lungs) and DVT (Deep Vein Thrombosis-blood clot) of the left leg, for which the patient received anticoagulation medication. Despite the patient's medical history, recent hospitalization and treatment for blood clots, which put the patient at increased risk for bleeding, there is no evidence that Provider #1 utilized routine clinical laboratory and diagnostic studies, in conjunction with the patient's presenting signs and symptoms, in their assessment and determination of whether an EMC existed during the ED visit on 6/18/10.
The assessment, during the 6/18/10 ED visit, documented by Provider #1 identified that the patient had been "discharged from the hospital to rehab 5 days ago after getting PCP pneumonia", had been having difficulty ambulating and had been having left hip pain since walking with PT (Physical Therapy) the day before the ED visit. S/he further stated that the patient had taken 7 Percocet without relief, had gone to the ED for further evaluation and "denied having bone cancer or any other reason to suspect a broken hip."
The patient, who presented to the ED at 2:25 PM, had vital signs documented at 2:55 PM, and received IV Dilaudid (pain medication) 1 mg and Valium 2.5 mg for patient identified pain of 10 (using a numeric pain scale of 1-10) at 3:44 PM. A subsequent nursing assessment 37 minutes later, at 4:21 PM, revealed that the patient's pain level was still a 9 out of 10, and the patient's pulse was 78, respiratory rate of 18 and O2 sat of 100 % with the patient receiving 3 L of oxygen by nasal cannula at that time. The nurse's note, continued at 4:23 PM, stated that the patient was repositioned and still had pain in the groin and thigh areas at that time. There was no further monitoring or assessment of the patient's pain or physical condition prior to discharge 2 hours later at 6:28 PM. Despite this, Provider #1 had documented, under ED Course: "Pt feeling better will go to rehab with improved pain control".
During interview, at 1:09 PM on 1/20/11, Nurse #1, who had provided minimal care for Patient #1 on 6/18/10, stated, after reviewing the medical record, that s/he did not recall the patient or visit, and agreed that the record was lacking documentation of ongoing pain assessment.
During telephone interview, at 10:04 AM on 1/20/11, Provider #1 stated that, s/he vaguely recalled this case, and had recently reviewed the case with the ED Physician Clinical Leader on 1/19/11. When notes were read to him/her (by the surveyor at the time of interview) s/he stated that it sounded as though "my biggest concern was a fracture, but I had ruled that out". When further questioned, by the surveyor, about why laboratory or other diagnostic studies had not been used in the assessment of the patient's condition Provider #1 stated that "sciatica is more of a clinical diagnosis....(patient's) sounded more musculo-skeletal in nature"."..."I don't scan for Sciatica...I could have scanned ...or plain films....why I did not do them I do not know....it sounds like (s/he) was feeling better" S/he further stated s/he did not know why relevant lab studies were not done. In addition, when questioned about how the determination was made to discharge the patient, when the last pain assessment, 2 hours prior to discharge, had revealed minimal pain relief, the provider stated that the pain assessment had been done by nursing and when Provider #1 had assessed the patient 2 hours later, s/he had "clearly stated the patient was feeling better".
During interview, at 8:17 AM on 1/20/11, the ED Physician Clinical Leader stated that, although, "I do not think it was the right diagnosis" the evaluation of Patient #1 on 6/18/10, provided by Provider #1 was appropriate, it was a "reasonable diagnosis as the patient presented"......."(Patient #1)..leg was in pain, consistent with Sciatica", and there was "no bone mets" (metastisis). When the surveyor posed the question of lack of further pain evaluation following nursing's last documented patient identified pain score of 9/10, the Clinical Leader stated that "pain scores are subjective", and Provider #1 had documented, "Patient feeling better for pain control" prior to the patient's discharge.
Patient #1, who presented to the ED for evaluation and treatment of severe pain, self identified as 10/10, did not receive an appropriate MSE to determine whether or not an EMC existed. As a result of the lack of appropriate MSE in conjunction with the lack of ongoing monitoring of the patient's condition, there was no evidence that the condition had resolved, and the patient was stabilized, prior to the patient's discharge.