HospitalInspections.org

Based on record review and interview, the hospital failed to:

I. enter an individual (Patient #24) who presented to the ED via EMS requesting medical attention for possible stroke into the central ED log.

II. enter the disposition into the ED log for eight entries for the period from 03/15/18 through 10/08/18.

This failed practice resulted in the hospital's inability to track all individuals presenting to the ED seeking emegency medical attention, ensure appropriate care was provided and disposition of the patient as defined by EMTALA regulations.

A review of hospital policy titled "Scope of Service/Plan of Care, dated 01/13/17" showed the hospital's ED log should contain the patient's name, date of arrival in the ED, time and mode of arrival, medical record number, age, sex, chief complaint, departure time, and disposition.

Review of the ED log for the date of the incident 06/03/18 showed no evidence Patient #24 was entered into the log.

Review of the ED log from March 2018 through October 08/2018 showed eight entries with no documentation of the patient's disposition:
* On 03/17/18 one of 10 ED log entries had no disposition identified.
* On 04/04/18 two of 18 ED log entries had no disposition identified.
* On 04/19/18 one of 20 ED log entries had no disposition identified.
* On 05/17/18 one of 11 ED log entries had no disposition identified.
* On 05/20/18 one of 10 ED log entries had no disposition identified.
* On 07/03/18 one of five ED log entries had no disposition identified.
* On 09/07/18 one of 18 ED log entries had no disposition identified.

On 09/28/18 at 11:01 am, an interview was conducted with Staff A, an ED staff nurse who was on duty in the ED on the day of the event. She reported the nurse technicians were responsible for entering the patients into the ED log. She stated she preferred to enter her own patients because there were times when patients were not entered into the log. She stated she would keep her patients on a list and check at the end of her shift and make sure they were on the log.

Based on record review and interview, the hospital failed to consistently provide appropriate medical screening examinations (MSE) that involved the use of ancillary studies and procedures from 01/29/18 to 10/07/18 as evidenced by:

I. One (Patient #24) of three ED patients who presented with signs and symptoms suggestive stroke who arrived via EMS was re-routed to another hospital from the hospital's ambulance bay secondary to no Activase (also known as the "clot buster") medication available. No evaluation performed by ED physician or diagnostic CT scan of head to determine stroke or presence of another emergency medical condition (EMC).

This failed practice had the likelihood for an emergency medical condition to go unrecognized, delayed treatment and risk to patient safety and adverse health outcomes.

II. Two (Patient #3 and #5, both less than 18 years of age) of nine ED patients who presented with suicidal ideations and/or suicide attempt did not receive a mental health evaluation via telemedicine services available by a contracted service agreement with the hospital to determine the safety of discharge to the parent's custody for follow-up or transfer to a mental health facility.

This failed practice had the likelihood for an acute suicidal or self harm event to go unrecognized and untreated, increase the risk to patient safety and others, and lead to adverse health outcomes.

III. One (Patient #6) of two patients who presented to the ED with complaints of a rattlesnake bite did not receive complete laboratory studies, observation and anti-venom according to current standards of practice.

This failed practice resulted in a venomous snake bite to go untreated in a timely manner according to standards of practice, increased risk to patient safety and adverse health outcomes.

IV. One (Patient #10) of two pediatric patients who presented to the hospital's emergency department with complaints of fever, abdominal pain, vomiting/nausea.

This failed practice resulted in a pediatric patient with an emergency medical condition, pyloric stenosis (a condition caused by abdominal muscles thickening which blocks food from reaching the small intestine, which causes weight loss, dehydration, constipation, jaundice) being undiagnosed and delay of surgery (surgery is the only treatment for pyloric stenosis). And had the potential for all pediatric patients who presented to the emergency department with similar presentations to be discharged without diagnosis.

Findings:

I. Stroke

A review of hospital policy titled "Emergency Medical Screening Examination and Stabilizing Treatment, dated 03/18/18" showed the hospital campus included physical areas and structures adjacent to the hospital within 250 yards such as the parking lot, sidewalk and driveways ...Capabilities included the level of care provided by staff through training and scope of practice, and availability of equipment, supplies, specialized services and routine ancillary services ... appropriate medical screening examination (MSE) will be offered in the ED for those who request services, on behalf of others, or the appearance of behaviors would suggest the need for examination or treatment of a medical condition ...Hospital does not have capability to provide immediate MSE for patients arriving via EMS, hospital should assess patient upon arrival to ensure patient prioritized and whether EMS can monitor patient's condition appropriately ...ancillary services routinely provided should be included in an MSE.

A review of hospital policy titled "Scope of Service/Plan of Care, dated 01/13/17" showed patients who presented to MHTC ED should receive an MSE that included all necessary labs, diagnostic testing and services within the capabilities of the hospital in order to reach a diagnosis.

A review of the hospital "Bylaws, Rules and Regulations of the Medical Staff, dated 4/28/15" showed no evidence the Governing Body or Board of Trustees designated or approved physicians who were "qualified medical personnel (QMP)" to conduct medical screening examinations in the ED.

A review of hospital document titled "Activase log 09/01/17 through 09/28/18" showed four patients had received Activase on the following dates: 09/07/17, 10/08/17, 05/15/18 and 05/25/18. The hospital was not able to provide evidence of a purchase order for Activase to show when the medication was purchased.

A review of an untitled hospital document showed the last purchase date for a package of two 100mg vials of Activase was on 09/07/17.

On 09/28/18 at 10:50 am, during a tour of the pharmacy, surveyors observed a box containing two 100mg vials in the pharmacy. Staff F was not able to identify when the Activase was purchased or determine how long the box Activase had been available at MHTC.

Review of document titled "Fire Department EMS Incident Report, dated 06/03/18" for patient showed EMS was dispatched at 2:23 pm to Patient #24's residence and arrived on scene seven minutes later at 2:30 pm. At 2:36 pm, EMS notified hospital of positive stroke scale. EMS departed scene with patient at 2:54 pm, and arriving at hospital at 3:07 pm. EMS staff were notified hospital did not have Activase available.

Review of hospital document titled "RM Log Incident with EMS, dated 06/03/18" showed EMS notified the hospital of a positive stroke scale to prepare for head CT. ED physician instructed nursing staff to notify EMS the hospital did not have Activase. EMS was notified at the same time they arrived in the ED ambulance bay. Incident was entered on 06/03/18 at 5:08 pm, by Staff M (ED RN). The incident was reviewed multiple times by Staff E (Manager of Quality/Risk Management) on 06/14/18, 06/25/18, 06/27/18 and no analysis, interventions or outcomes were documented. Staff N (peer review) noted on 06/28/18, Staff O (ED physician on duty on 06/03/18) reported had been made aware of the event and was concerned. It was noted the patient was "in fact in the ED ambulance bay before EMS was alerted there was no Activase in the hospital".

On 09/27/18 at 3:44 pm, Staff B he/she was notified by EMS crew on arrival at the hospital there was no Activase available. He/she stated the EMS crew was at the scene of the stroke patient within two to four minutes of the call. He/she stated the EMS crew were on scene approximately 23 minutes because the crew was having difficulty getting the patient out to the ambulance. He/she stated the hospital notified the EMS crew at the time they were pulling up on hospital property. He/she stated the patient remained in the ambulance and the physician did not evaluate the patient.

On 09/28/18 at 9:30 am, Staff C stated his/her role included taking radio calls from EMS. He/she reported there had been times when the hospital had not been able to perform tests because equipment was broken. He/she stated there had been a time when EMS arrived in the ambulance bay and they were told they needed to go someplace else because the hospital did not have something. Staff C reported he/she believed he/she was the one who notified EMS the hospital did not have Activase on the day of the event. Staff C stated he/she was not aware if the nurse or physician went out to the ambulance in the ambulance bay.

II. Suicide Assessment and Evaluation

A review of hospital policy titled "Emergency Medical Screening Examination and Stabilizing Treatment, dated 03/18/18" showed capabilities included the level of care provided by staff through training and scope of practice, and availability specialized and ancillary services available to the hospital ...A psychiatric emergency would be when a patient was a danger to him/herself or others ...patient who presented to the ED for a condition addressed through a pre-arranged community plan such as psychiatry an MSE would be performed and treatment initiated prior to transfer of patient pursuant to community plan.

A review of hospital policy titled "Patient Awaiting Psychiatric Evaluation, dated 12/28/16" showed the patient should evaluate the patient and determine the need for psychiatric evaluation.

Review of a hospital document titled "Telemedicine Mental Health Access Agreement, dated 01/14/14" showed a mental health facility would provide licensed mental health professionals to perform telemedicine mental health consultations for patients presenting to the hospital.

Review of document titled "Managing Suicidal Patients in the Emergency Department, dated 02/16" from the Annuals of Emergency Medicine showed a suicide risk assessment helps to determine appropriate treatment for suicide patients ...small percentage of patients with suicidal ideation or behaviors may be managed in the ED without a mental health evaluation and discharged home ...patients tend to be lowest risk with no suicide plan or intent, no prior attempts, mental illness, substance abuse, and/or agitation or irritability.

Review of document titled "Suicide Assessment Five-step Evaluation and Triage for Mental Health Professionals, dated 2009" from the Suicide Prevention Resource Center showed determination of suicide risk level included four factors: risk factors, protective factors, suicide inquiry and interventions. High risk for suicide included an acute precipitating event, potentially lethal suicide attempt or persistent ideation with intent or rehearsal. These patients should be admitted unless there was a significant change in suicide risk. Patients determined to be a moderate suicide risk usually have multiple risk factors, and present with suicidal ideation and plan, but generally no intent or behavior. Depending on the identified risk factors, patients with moderate suicide risk may need to be admitted.

Review of document titled "Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments" by the Suicide Prevention Resource Center showed after initial suicidal risk screening a more thorough secondary screening that provides disposition decisions for patients with suicidal ideations should be performed. The screen includes six questions that include thoughts of suicide, suicide intent, past suicide attempts, past mental health issues or issues that affect ability to do things in life, substance abuse issues, and behavioral issues. A mental health professional should be consulted in the ED if a patient answers "yes" to any of the questions for further evaluation, including a comprehensive suicide risk assessment.

Patient #3 was a 17 year old female who presented to the ED at 1:21 am, via EMS following ingestion of Fluoxetine (Prozac) and Tylenol approximately three hours prior to arrival. Review of Patient #3's medical record showed:
*Suicide assessment identified suicide ideation, suicide attempt, feelings of hopelessness and despair and a depressed mood.
*Initial physician assessment performed at 1:45 am, noted overdose was patient's second attempt. Patient was lethargic but arousable. Physician's plan was to repeat Acetaminophen level at nine hours post ingestion and at 6:00 am.
*Initial labs at 1:30 am, showed critical Acetaminophen level at 32 ug/mL (normal 13-30 ug/mL), ALT 57 (normal 8-34 IU/L). Acetaminophen level at 5:33 am, was 11 ug/mL.
*Medical Necessity for Air/Ground Transport was completed by physician stating a need for a higher level of care requiring a psychiatric physician specialist that was not available at the hospital.
*Transfer Request/Consent was completed and signed by physician and hospital staff that showed benefits of transfer to include psychiatric specialist availability to meet the needs of the patient and identifying the patient stable to transfer.
*At approximately 6:00 am, there was a change of shift in ED physicians.
*There was no re-assessment by the oncoming ED physician and no mental health consultation or evaluation obtained via telemedicine.
*At 6:36 am, ED physician discharged patient to home in care of foster parent with instructions "strongly recommend contact place where you had counseling earlier this year and talk with them about how you are feeling, what is happening in your life."
* ED physician's final diagnosis was anxiety disorder.

Patient #5 was a 14 year old female who presented to the ED via private vehicle with reports of ingesting "a handful of Tylenol" approximately 30 minutes prior to arrival. Review of Patient #5's medical record showed:
*Patient reported having family problems and not living with either parent.
*Diagnosed with depression and ordered medication.
*Patient reported "mom does not care enough to get medication for her". Noted "some messed up things happened to her last summer but would not elaborate".
*Physician noted patient was tearful and admitted to overdose by taking "2 handfuls of Tylenol".
*Labs were ordered including a CBC, CMP, UDS, urinalysis and Acetaminophen level. Initial Acetaminophen level was critical at 88 (low = 13, high = 30) and UDS was positive for amphetamines and methamphetamines.
*No psychiatric assessment performed by ED physician.
*No suicide assessment was performed by nursing staff at the time of triage or during the physical assessment.
*No documentation in the patient's medical record that DHS was notified of the patient's suicide attempt by overdose.
*There was no evidence the physician obtained a mental health evaluation via telemedicine to determine the presence of an acute psychiatric medical condition.
*Patient was diagnosed with Acetaminophen overdose, was given contact information for two psychiatric facilities to follow up with and discharged with her mother.

On 10/10/18 at 9:08 am, Staff J stated the staff asked the physician why the patient was being discharged home with her mother. Staff J stated the physician said "the patient was an adolescent and her mother could take her." Staff J stated the patient did not have a mental health evaluation at the hospital prior to discharge. Staff J stated he/she had not care for suicidal patients that had not had a mental health evaluation.

On 10/10/18 at 11:59 am, Staff G stated the hospital had issues in the ED regarding the quality of care provided to patients by ED physicians. Staff G stated patients who presented to the hospital with suicidal ideation or suicide attempts should receive a mental health evaluation. Staff G stated the hospital had a telemedicine agreement for mental health services.

III. Snake Bite

Review of hospital policy titled "Snake Bite, dated 03/18/18" showed treatment for known rattlesnake bites should include wound care, observation for four to six hours and discharge home if there was no development of clinical signs. The policy fails to clearly identify the treatment and disposition of the patient when there were development of clinical signs and symptoms such as swelling, erythema, ecchymosis, lab abnormalities and other non-life threatening symptoms. Policy failed to identify criteria of a "wet" snake bite and when to initiate orders for management of patients with wet snake bites.

Review of hospital document titled "Emergency Department Orders for Snake-Bite Patients (Wet Bite) Adult/Pediatric, undated" showed labs should be obtained including CBC with platelet count, PT/INR, PTT, Fibrinogen, CMP, and urinalysis. IV access should be obtained and Normal Saline or Lactated Ringer fluid bolus administered. Mark with a permanent marker from the distal edge of the fang to the leading edge of the swelling, and date and time it. Administer Crofab immediately.

Review of hospital document titled "Grievance Process Checklist and attachments, dated 04/12/18" showed a complaint was initiated by the quality/peer review personnel secondary to a concern regarding the care Patient #6 received in the ED and the standard of care was not met for the treatment of the rattlesnake bite.

Review of hospital document titled "Continuous Quality Improvement - Patient Complaints and Grievances, dated 04/12/18" showed the outcome of the quality review regarding Patient #6 was an "extremely unexpected" practice that "could have (or did) contribute to patient injury". Medical record was forwarded for medical record by ESS (ED medical staffing group) for peer review.

Review of untitled hospital document from Staff P, regarding the review of Patient #6's medical treatment in the ED. His/her review noted there was no significant change in the patient's condition during the approximately two hours she was in the ED. Staff P noted the patient was sent to Amarillo the next morning by her primary care physician for treatment with the anti-venom. His/her conclusion was two hours of observation with normal vital signs, normal labs and minimal edema met the "standard for reasonable care".

Review of document titled "Envenomations: Initial Management of Common U.S. Snakebites, dated 06/23/17" by the Academic Life of Emergency Medicine showed labs should include urinalysis, creatine kinase, fibrinogen, PT/INR, PTT, liver function tests, chemistry panel and complete cell count ...signs of envenomation include inflammation such as pain, heat, and redness. Systemic signs may include hypotension, vomiting, coagulopathy (elevated PT, decreased fibrinogen, thrombocytopenia), diarrhea or angioedema. Patients should be monitored for a minimum of 8 to 12 hours and repeat of labs prior to discharge even for those that show no immediate signs of envenomation.

One (Patient #6) of two ED patient medical records reviewed who presented to the ED with complaints of a rattlesnake bite was not provided an appropriate MSE that included complete laboratory testing and administration of anti-venom according to standards of practice.

Patient #6 was a 67 year old female who arrived in the ED at 7:31 pm, via EMS with complaints of a rattlesnake bite one hour prior to arrival. Review of Patient #6's medical record showed:
*Elevated vital signs: heart rate 117, respirations 22, and blood pressure 167/81
*Nursing assessment noted redness, bruising, tenderness and warmth of the foot, snakebite marked. Patient denied pain.
*ED physician assessment noted one fang mark on dorsum right foot with minimal swelling.
*At 7:53 pm, ice packs were provided and placed around the patient's foot due to swelling.
*Patient stated she did not want pain medication at 8:03 pm. There was no documentation of an assessment of the patient's pain to determine if the patient had pain.
*Labs were obtained including a CBC, CMP, PT/INR, and PTT. There were no abnormalities.
*Triple antibiotic ointment was applied to the bite and the patient was discharged to home at 9:20 pm, approximately 1 hour and 50 minutes after admission.

On 10/10/18 at 11:59 am, Staff G stated that he/she was aware that the hospital did not have anti-venom one time and a patient had to be sent to another hospital. Staff G reported the medical staff discussed in a meeting one time when the hospital did not have enough vials of the anti-venom to give a patient. Staff G stated it was a concern the hospital did not have anti-venom. Staff G stated he/she was not aware what happened but he/she thought "they were going to make sure they were not short anymore."

On 10/10/18 at 1:22 pm, Staff K stated he/she "was furious" about Patient #6's care in the ED because the hospital did have anti-venom and steroids but "they did not do anything for the patient". Staff K stated Staff P who reviewed Patient #6's medical record, "did the same thing with a 13 year child".

IV. Pediatrics

A review of hospital policy, "Scope of Service/Plan of Care: Emergency Department", revision date 01/13/17 showed the patient population served by the ED consisted of newborn, pediatric, adolescent, adult and geriatric patients requiring or seeking medical care. Support services included but were not limited to clinical laboratory studies and x-rays that were to be provided to the patient in a timely manner.

A document, "Emergency Staffing Solutions Case Review Form" 05/09/18, showed the form was to be utilized as part of the peer-review process as established by the hospital's medical staff bylaws. The conclusion of the review of Patient #10's medical care in the ED showed "there were several findings in the history and physical examination that should have prompted a more thorough evaluation in the emergency department. Treatment does not meet standard of care." The document also showed on 02/08/18, the patient was transferred from a primary care provider's clinic to another facility and underwent surgery for pyloric stenosis.

Patient #10 a 27 day old infant arrived in the ED on three different occasions with complaints of vomiting, constipation and jaundice. Review of the Patient #10's medical record showed:
* Patient was in the emergency department on three occasions from 01/29/18 to 02/08/18 with complaints of vomiting, constipation, jaundice (yellowing of the yes caused by elevated liver enzymes, which is an indication of malabsorption of nutrients).
* On 01/29/18 at 17 days old, infant was throwing up after feeding. The ED provider documented a normal physical exam, there were no orders for lab, imaging or medications. The patient's weight was documented in the nurse's notes as 3.81 kg.
* On 02/05/28 at 24 days old, infant was vomiting, had yellow tinted eyes, "jaundice tint to the skin" and blood in the urine. The ED provider documented "no mass, liver margin palpable", there were no orders for lab, imaging or medications. The ED provider did not address blood in the urine in the record. The patient's weight was documented in the nurse's notes as 3.45 kg.
* On 02/08/18 at 27 days old, infant was vomiting and had no bowel movement for five days. The ED provider documented "normal physical exam", there were no orders for lab or imaging. A glycerin suppository was administered. The provider documented the patient's weight at 3.45 kg, there was no documentation of weight in the nurse's notes.

On 10/10/18 at 1:30 pm, Staff L stated "we decided ESS should address these practices dealing with quality, we pulled records, we looked at census, we addressed concerns daily with ESS, there isn't documentation of the calls." Staff L stated for Patient #10 "the lack of care from the doctors was identified". Staff L stated the provider "had to go through training on pyloric stenosis", the facility was unable to provide documentation of training.

On 10/10/18 at 11:59 am, Staff G stated the hospital had issues in the ED regarding the quality of care provided to patients by ED physicians. Staff G stated he/she was aware the ED physicians had problems dealing with pediatric patients. Staff G stated another provider had notified him of Patient #10 and he/she had agreed the standard of care in the ED had not been met.