HospitalInspections.org

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Based on observation, interview, record review, and review of hospital policies and procedures and medical staff bylaws, the hospital failed to develop and implement policies and procedures for evaluation and treatment of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure patients receive a comprehensive medical screening examination by a qualified medical professional and stabilizing treatment prior to transfer or discharge risks poor health care outcomes, injury, and death.

Findings included:

1. The hospital failed to ensure that the patient's identity was verified and documented in the patient's medical record prior to discharging Patient #1 from the emergency department on 04/05/19.

2. The hospital failed to ensure that the medical screening examination included completion of a suicide risk assessment prior to discharging Patient #1 from the emergency department on 04/05/19

3. The hospital failed to ensure that the qualifications for physician assistants who performed medical screening examinations were specified in the medical staff bylaws.

Cross Reference: Tags A-2403, A-2406
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Based on interview and record review, the hospital failed to develop policies and procedures to ensure that the patient's identity is verified and documented in the patient's medical record, as demonstrated by Patient #1.

Failure to ensure that the patient's identity is verified and that the information in the patient's medical record is correct risks impaired care continuity during subsequent healthcare encounters and poor healthcare outcomes.

Findings included:

1. Review of the medical records of Patient #1 showed that the patient was treated in the hospital's emergency department (ED) on 04/05/19 for a drug overdose. The patient's ED records included a form titled "Report, Radio" that was completed by an ED staff member prior to the patient's arrival. The patient's name and birth date was incorrect on the form. The patient was confused and combative on arrival to the ED at 3:21 PM and unable to answer questions. The patient was treated and discharged from the ED at 10:21 PM. The ED records showed that the patient was "alert and oriented" at the time of discharge. The patient's name and birth date printed on his discharge instructions were incorrect.

2. On 05/22/19 at 11:10 AM, the investigator interviewed the hospital's Patient Access Manager (Staff #1) regarding the information found in Patient #1's medical records. The manager stated that Patient #1's name and birth date was corrected in his medical records on 04/06/19 after the patient's mother contacted the hospital regarding the errors on the patient's discharge instructions.

3. During an interview with the investigator on 05/22/19 at 12:10 PM, the hospital's quality consultant (Staff #2) stated the hospital did not have a policy and procedure for verifying patients' names and birth dates to ensure their medical records are accurate.
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Based on interview, record review, and review of hospital policies and procedures and medical staff bylaws, the hospital failed to ensure that 1) the medical screening examination included completion of a suicide risk assessment prior to discharging Patient #1; and 2) the qualifications for physician assistants who performed medical screening examinations were specified in the medical staff bylaws.

Failure to ensure patients receive a comprehensive medical screening examination by a qualified medical professional and stabilizing treatment prior to transfer or discharge risks poor health care outcomes, injury, and death.

Reference: 42 CFR 482.55(b)(2) - "The hospital must staff the emergency department with the appropriate numbers and types of professionals and other staff who possess the skills, education, certifications, specialized training and experience in emergency care to meet the written emergency procedures and needs anticipated by the facility."

Findings included:

Item #1 - SUICIDE RISK ASSESSMENTS

1. Review of the hospital's policy and procedure titled "Suicide Risk Assessment and Precautions," Policy #KGH003264 revised 08/2017, showed that all patients who presented at any Trios Health facility that provided inpatient, immediate, urgent, emergent care, or provider clinics would be screened for risks for suicide. Patients who presented "unresponsive or intubated" would be screened for suicide risk when they were alert.

2. Review of the medical records of Patient #1 on 5/22/19 at 1:30 PM showed that the patient was treated in the hospital's emergency department (ED) on 04/05/19 for a drug overdose. The patient was confused and combative on arrival to the ED at 3:21 PM and unable to answer questions. The patient's electronic medical record included a suicide risk screen completed at 4:00 PM that read "Unable to assess at this time". The patient was treated and discharged from the ED at 10:21 PM. The ED records showed that the patient was "alert and oriented" at the time of discharge. There was no evidence in the patient's record that he was screened for suicide risk prior to discharge.

3. During an interview with the investigator at the time of the record review, the hospital's quality consultant (Staff #2) confirmed that the patient had not been screened for suicide risk as directed by hospital policy and procedure.


Item #2 - QUALIFICATIONS OF PHYSICIANS ASSISTANTS

1. On 05/21/19 at 10:30 AM during an interview with the investigator, the ED director (Staff #3) and ED charge nurse (Staff #4) stated that physician assistants were routinely scheduled to evaluate and treat ED patients at the Southridge campus during a mid-day (11:00 AM to 9:00 PM) shift.

2. Review of the hospital's policy and procedure titled "Patient Transfers (Evaluation, Stabilization, and Transfer) EMTALA," Policy #KGH003029 revised January 2019, showed that patients who presented to the hospital's ED would receive a medical screening examination by qualified medical personnel. The policy defined "qualified medical personnel" as either a physician or a registered nurse trained in labor and delivery acting within their scope of practice and to the extent permitted by applicable law, job description, hospital policy and privileges granted by the hospital.

3. Review of the hospital's medical staff bylaws dated March 2019 showed that "qualified medical personnel" authorized to perform medical screening examinations in the ED included physician assistants. The bylaws did not identify the required qualifications of those physician assistants.
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