HospitalInspections.org

Based on document review, medical record review and interview, the hospital did not comply with the requirements at 489.24(c). Specifically, the facility did not continue to monitor a patient's condition or complete testing in a timely manner to determine if an emergency medical condition (EMC) existed. Please reference findings at Tag 2406.

Based on medical record (MR) review, document review and interview in 1 of 23 MRs reviewed, the hospital failed to appropriately monitor and provide an ongoing medical screening exam (MSE) to a patient who presented to the emergency department (ED) with a head injury (Patient #1). This lack of ongoing MSE and reassessment could result in a poor patient outcome.

Findings include:

-- Review of Patient #1's MR revealed he was a 65-year-old male that presented to the emergency department (ED) on 8/10/18 at 7:01 am. Chief complaint was documented as alcohol intoxication. (Patient #1 was found lying on grass, neighbor called police department.) The patient was not answering questions or being cooperative. He was triaged at 7:11 am as a level 2 (on a scale of 1 - 5, level 1 - requires immediate life saving measures, level 2 - condition that has potential to threaten life or limb and requires rapid medical intervention, level 3-5 less severe.) Patients rectal temperature (T) - 91.3 Fahrenheit (F [normal rectal T 99.1-99.6 F]).

Physician documented that the patient had decreased mental status, found unresponsive, head injury, alert but confused, lethargic, unequal pupils, disoriented, laceration and contusion to face. Patient has mild mental retardation. At 7:23 am the physician ordered a STAT (emergent) computerized tomography (CT) of the head.

At approximately 7:30 am nursing documented Patient #1 was uncooperative and irritable. Patient in fetal position. Patient noted with right eye hematoma (collection of blood under the skin) and dried blood on hands and face. Neurological assessment indicated, he was agitated and appeared asleep. The Glasgow Coma Scale (GCS [a neurological scale which aims to give a reliable and objective way of recording the conscious state of a person for initial as well as subsequent assessment]) was 14 (eye response 4 - eyes open spontaneously, verbal response 4 - confused and motor response 6 - obeys commands. Normal GCS is 15).

There is no documented evidence the Patient #1's mental status was reassessed from 7:27 am until 1:00 pm.

Nursing documentation revealed that at 1:00 pm, patient noted to be having seizure-like activity and a bout of incontinence. Patient's pupils pinpoint and fixed. Rapid intubation was initiated at 1:26 pm.

At 1:00 physician documented, "Still unable to get CT scan, patient is uncooperative, intubated patient.

CT performed. Radiologist called, patient has intracerebral (brain) bleed. Neurosurgery was consulted.

At 3:00 pm Neurology consult documentation indicated, reviewed images, patient has acute intracranial bleed with high blood pressure, unstable. Possible worsening of bleeding need for acute life-saving craniotomy (brain surgery). Orders were obtained. Patient was transferred to a higher level of care.

CT was completed at 1:55 pm, 7 hours after Patient #1 presented to the ED with a head injury and unequal pupils.

-- Review of the hospital's policy and procedure (P&P) titled "EMTALA - Screening, Stabilization, Management of Transfers and Recordkeeping; Reporting Suspected EMTALA Violations," last revised 5/9/18, indicated a MSE is an ongoing process, not an isolated event. As screening and treatment progress, the record will reflect continued monitoring according to the individuals needs and continue until it is determined that the person does not have an EMC or the person is stabilized or appropriately transferred.

-- Review of the hospital's P&P titled "Emergency Department Triage Policy," last revised 7/31/18, indicated patients should be triaged according to the Emergency Severity Index (ESI) with a ESI level of 1 - 5. Patients noted as a level 2 (condition that has potential to threaten life or limb and requires rapid medical intervention) should have a focused reassessment and V/S documented at least every hour until stable.

There was no documented evidence that Patient #1 had V/S obtained between 7:27 am - 2:50 pm (only a rectal T documented at 10:24 am - 95.9 F).

-- During interview of Staff G on 1/30/19 at 10:15 am, he/she indicated patient's presenting with head trauma usually have a STAT CT of the head ordered. The patient would go to radiology immediately. Critical patients are monitored every 15 minutes (e.g., V/S, pulse oximetry) until stable.

-- During interview of Staff H (ED RN) on 1/30/19 at 10:20 am, he/she indicated patients triaged as a level 2 should have V/S documented every 15 minutes including neurological checks.

-- During interview of Staff M (ED RN) on 1/31/19 at 9:30 am, he/she indicated, patients placed in the acute rooms (Patient #1 was in an acute room) should have their V/S assessed every 15 minutes until stable and then hourly.

-- Review of the hospital's P&P titled "Bair Hugger/Bair PAWS Patient Warming System," last revised 11/17/15, indicated patients who are hypothermic (temperature less than 96.8) should be rewarmed with the Bair Hugger. The patient's temperature should be monitored every 15 minutes.

There was no documented evidence that Patient #1's temperature was taken every 15 minutes.

-- Review of the hospital's P&P titled "Nursing Priority Code Guidelines," last reviewed 3/19/19, indicated "Level I - highest priority : Stat/Emergent - Nursing staff should immediately initiate all Level I orders within approximately 15 minutes. Physicians writing these orders should verbally communicate the presence of these to nursing and indicate STAT orders were written.

-- During interview of Staff A, Lead Quality Professional, on 1/31/19 at 3:00 pm, he/she acknowledged the above findings.