HospitalInspections.org

Based on a review of the facility's central log, medical records, policies and procedures, and staff interviews, it was determined that the facility failed to conduct an appropriate medical screening examination (MSE) for one patient P (#1) out of 20 sampled patients. Specifically, P#1 presented to the facility's ED accompanied by parents. The parents requested that the patient (P #1) be examined for a medical condition that had started earlier in the day. The facility failed to have a doctor examine the patient to determine whether a medical emergency existed.

Findings were:

Cross refer to A-2406, as it relates to the facility's failure to provide P#1 with an appropriate Medical Screening Examination (MSE).

Based on a review of the facility's central log, medical record, Medical Staff Bylaws, policy and procedures, and staff interviews, it was determined that the facility failed to provide one patient P (#1) out of 20 sampled patients with an appropriate Medical Screening Examination (MSE) within its capabilities. Specifically, on 12/8/23, P#1 was brought to the facility's (ED) emergency department by her parents for examination. During the triage assessment, P#1's mother announced that she intended to take the patient to a children's hospital. The facility failed to have a doctor examine the patient to determine whether a medical emergency existed. The parents transported the patient to another ED (Facility #2). P#1 went into cardiac arrest shortly after arrival to Facility #2 and expired thereafter.

Findings included:

A review of the Emergency Department (ED) central log revealed that P #1 presented to the ED and was registered on 12/8/23 at 3:48 a.m. with an assigned medical record number.

A review of the 'Medical Staff Rules and Regulations' last revised February 2022 revealed Article 2. Admissions, Assessments and Care Treatment and Services. 2.4 Availability and Alternate Coverage. (a) Physicians provided professional care for their patients in the Medical Center by being personally available or by making arrangements with an alternate member who had appropriate clinical privileges to care for their patients.
Under Article 10. Emergency Services. 10.2. Medical Screening Examinations. (a) Medical screening examinations (MSE), within the capability of the Medical Center, were performed on all individuals who came to the Medical Center requesting examination or treatment to determine the presence of an emergency medical condition. Qualified medical personnel who could perform medical screening examinations (MSE) within applicable Medical Center policies and procedures were defined as: (1) Emergency Department: members of the Medical Staff with clinical privileges in Emergency Medicine; other Active Staff members and appropriately credentialed advanced practice professionals (APP). (2) Labor and Delivery: members of the Medical Staff with OB/Gyn privileges; Certified Nurse Midwives with OB privileges and Registered Nurses who have achieved competency in Labor and Delivery and who have validated skills to provide fetal monitoring and labor assessment.

Review of policy title "ED Triage" revealed the purpose of this policy was to outline the triage process in the Emergency Department.
The policy delineated:
1) Triage was utilized to prioritize incoming patients and to identify those who could not wait to be seen.
a) The triage RN performed a brief chief complaint assessment, a complete set of vital signs, pertinent screenings, and assigned the patient a triage acuity level, which was a proxy measure of how long an individual patient could safely wait for a medical screening examination and treatment.
b) ESI (Emergency Severity Index) scoring was assigned to the patient after a rapid assessment of subjective and objective information.
c) The RN entered complaint-based, approved protocol orders.
2) The ED placed patients in rooms prior to a full history/physical exam until all beds/rooms were filled.
3) The bedside RN completed primary assessment upon the patient's arrival to the bed/room.

A review of the facility's "EMTALA/COBRA" policy, no policy number, no effective date, no revision date revealed it was the Policy of the Medical Center to provide a Medical Screening Examination by a Qualified Medical Person to any individual who came to the Medical Center's dedicated emergency department or the Campus of the Hospital and sought an examination or medical treatment to determine if the individual had an Emergency Medical Condition, whether or not eligible for insurance benefits and regardless of ability to pay; and if it was determined that the individual had an Emergency Medical Condition, to provide the individual with such further medical examination and treatment as required to stabilize the Emergency Medical Condition, within the capability of the Medical Center, or to arrange for transfer of the individual to another medical facility in accordance with the procedure set forth below.

Procedures:

The policy stated that the Medical Center was to provide a Medical Screening Examination for every person who came to the Medical Center's dedicated emergency department or the Campus of the Hospital and requested an examination or treatment for a medical condition or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual was considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needed examination or treatment for a medical condition. The policy defined Emergency Medical Condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in either:
1.Placing the health of the individual (or in regards of a pregnant patient, the health of the women or unborn child) in serious jeopardy; or 2. Or serious impairment to bodily functions; or 3. Serious dysfunction of any bodily organ or part.
Medical Screening Examination meant the Screening Process required to determine with reasonable clinical confidence whether an Emergency Medical Condition existed or did not.
Qualified Medical Person was defined as a licensed physician, advanced health professional as defined by Northeast Georgia Medical Center Medical Staff Bylaws acting pursuant to those Bylaws, state law, and within applicable scope of practice or a qualified registered obstetrical nurse acting within scope of practice and law.

During an interview with the Director of the Pediatric Unit/RN (AA) on 12/18/23 at 2:30 p.m. in the Pediatric Unit, Director AA said the pediatric unit operated 24/7 and was always equipped with nurses. Director AA said they received pediatric patients from the emergency room during late hours. Director AA said the ED physician saw pediatric patients in the emergency room and determined if the patients needed to be admitted. Director AA said the way the process worked was for the ED doctor to reach out to the Pediatrician on-call and discuss the case with the on-call pediatrician. Director AA said if the pediatrician on-call determined the facility had the capability to provide level of care the patient needed, then the on-call pediatrician was to accept and give the order to admit. Director AA explained once the child was admitted, then all communication about the patient, including treatment orders was between the unit nurse and the on-call pediatrician. Director AA explained that the facility did not offer high level of pediatric care such as respiratory, trauma and heart diseases among some other complex children's illnesses. Director AA said when they were unable to provide the level highly specialized of care, the facility transferred the patient to another local facility that they worked closely with. Unit Director AA said she was not aware of any incident where a child came and was not treated in recent times.

During an interview with the Manager of the Pediatric Unit/RN (BB) on 12/18/23 at 2:35 p.m. in the Pediatric Unit, Manager BB explained the way the process worked when it came to admitting pediatric patients. Manager BB said the unit received patients from private practice and from the ED at all times. Manager BB said they had Pediatrician on call at all times. Manager BB said when a patient went to the ED, the ED doctor saw the patient and after the patient was assessed, the ED doctor would determine if the child needed further treatment through admission. Manager BB said the ED doctor had the list of Pediatrician on-call and the ED doctor called the Pediatrician on-call to report the potential admission. Manager BB said the ED would call them upstairs until after the case had been discussed between the two doctors. Manager BB said once decision was made between the two doctors to admit the patient, the on-call pediatrician called the unit to place all orders. Manager BB said the facility did not see complex cases such as children with heart condition, and advanced trauma. Manager BB said they transferred all the complex cases to another facility that had more specialized doctors in children care. Manager BB said they never refused to admit a pediatric patient that was referred to the unit. Manager BB said she was not aware of any recent case where a pediatric patient did not get the care needed and was sent to another facility.

During an interview with ED Manager/RN DD on 12/18/23 at 4:42 p.m. in a private office in the administration suite, Manager DD explained that she was made aware of the complaint around P #1. Manager DD stated that the Director asked her to call the Nurse (RN FF) that was in triage the night P #1 was brought in the ED. Manager DD said she contacted RN FF and told her to call ED Executive Director CC. Manager DD said she did not know anything about what was said nor the nature of the conversation. Manager DD said she received report that a baby came to the ED and was sent to another children's hospital that they closely worked with. Manager DD said it was the ED policy for the nurses to assess all patients of all ages. Manager DD said that the next step was to get such patient in a room as soon as possible. Manager DD said the nurses had access to the on-call doctors and on the list, there was always a pediatrician (a doctor that treated children). Manager DD said the night P #1 came in it was busy as the facility's ED tended to be busy anyway, especially now with the flu season, but she added it was not crazy in the ED. Manager DD said after the nurse triaged a patient with high acuity (very sick patient), the nurse ought to try to convince the patient to stay and to call the ED doctor to talk to the patient if necessary. Manager DD said she was not sure of the details about the case, but it was just the facility's policy not to turn patients away.

During an interview with ED Registrar (EE) on 12/19/23 at 2:00 p.m. in a private office in the Administration suite, Registrar EE said she remembered night the parents brought P #1 to the ED. Registrar EE explained that she registered the baby (P #1) and during check in, the parent stated that the baby was not well and that the baby had a heart condition. Registrar EE said she informed triage nurse (RN FF) about the baby's heart condition. Registrar EE said she overheard conversation between the parent and RN FF and that the parent said she wanted to take the baby to another facility. Registrar EE said her job was to register all patients who came for treatment and the triage nurse was the first to assess the patients. Registrar EE said they tried to get patients in the back as fast as they could but that was always dependent on bed availability. Registrar EE said she was aware of the EMTALA law which required that the ED treated all patients in need of medical care.

During a phone interview with Triage Nurse RN FF on 12/19/23 at 2:32 p.m., RN FF said she remembered the parent who brought P #1 in the ED. RN FF said she was the triage nurse the night the parent came in the ED with the baby. RN FF said the parent reported to her during intake interview that she was concerned about the child breathing and brought her to the ED. RN FF said she took the baby's weight as part of her initial triage. RN FF said as she started triage, a patient that was unresponsive came in and she left the parent and the baby to briefly attend the unresponsive patient. RN FF said she then came back, and the baby's parent asked her about how long they were going to wait before a doctor could see the baby (P #1); RN FF said she replied that she did not know. RN FF stated that the baby's parent stated that she did not want to wait, and she made the decision to leave and to go another facility. The parent told her what facility she was going to. When asked if she asked the parent to sign anything as proof of refusal to get treatment, RN FF said she did not. RN FF did not say if she tried to convince the parent to stay either.

During an interview with ED Executive Director CC on 12/20/23 at 3:25 p.m. in a private office in the administrative suite, Executive Director CC stated that she had interviewed RN FF after they had received a call from the other facility about possible EMTALA violation. Executive Director CC stated that RN FF said P #1's parent asked her should she just go to the other facility after they discussed waiting time. Executive Director CC said she reviewed the ED video footage and put in place training with Director of Registration regarding patient cancelation on the system. Executive Director FF said the staff in registration should not have cancelled and allowed the RN to document her interaction with the baby's parent. Executive Director CC said that RN FF told the baby's parent that she had the option to go somewhere else if she wished, but they would treat the baby if she chose to stay.

A review of a medical record obtained from Facility #2 revealed Patient #1 (P #1) was an eleven-month-old female who presented unresponsive to the Emergency Department (ED) on 12/8/23 at 5:00 a.m. accompanied by her parents. P#1 had a history of congenital heart disorders and heart surgery. The parents reported that P#1 had difficulty feeding the night before and had had bloody stools. Facility #2 staff started resuscitation efforts on arrival. P#1 was placed on a ventilator and transferred to the cardiac intensive care unit. P#1 later expired.