HospitalInspections.org

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Based on document review and staff interview during a Federal EMTALA (Emergency Medical Treatment and Labor Act) Survey the facility failed to provide a bariatric patient with a Medical Screening Examination (MSE). Additionally, the hospital failed to develop an Emergency Department (ED) Policy for the care of bariatric patients. This was evident in one (1) of thirty-two (32) patients reviewed (Patient #32).

Findings:

Review of the Ambulance Patient Care Report (PCR) dated 07/18/13 timed 6:31 AM states: "On arrival to Nursing Home the patient is found in bed, morbidly obese and required a bariatric stretcher. Patient was transported to the ED and County Ambulance called ahead to notify them of our arrival. Upon our arrival, Triage met us outside and refused the patient due to being obese and said they could not accommodate her. Transport diversion to next closest hospital. Patient transported without incidence."

Review of the facility's "Incident Report" dated 07/18/13 timed 6:45AM on 09/10/13 at 12:15PM documented: "Ambulance crew (EAS) pulled into Ambulance Bay asking if we could accommodate a 700 lb patient. Charge Nurse informed crew she needed to talk to Supervision to see if we had a stretcher to accommodate the patient. After several minutes the crew drove away."

Review of the Medical Record from the receiving (recipient) hospital revealed the patient was triaged in the Emergency Department on 07/18/13 at 7:09AM.

An interview was conducted on 09/10/13 at 11:40AM with the ED Triage RN/Charge Nurse who stated when the Med Com (Medical Communication) Phone rang she took the call. "The Dispatcher said they had an obese patient en route and could we 'handle' (accommodate) the weight limit? She asked how much does the patient weigh. EMS informed her they would call her back with the information but the call never came. Instead they showed up along with six (6) Police cars and about a dozen NCPD (Nassau County Police Department) Officers. I could see them on the camera so I went out and spoke with them and said I can get a stretcher but I am not sure if we can accommodate her so let me call my Supervisor first. I went inside to call the Supervisor and as I am on the phone I can see the camera and noticed that the EMS are closing the doors to the ambulance. So I sent a Tech outside to see what was going on but they had already closed up the door and left."

Review of the Emergency Room Policy and Procedure Manual dated 2010 on 09/10/13 at 2:30PM revealed that the facility has Policies for the care and transfer of patients with specific conditions including neurosurgical patients, psychiatric and drug impaired patients, obstetrical and gynecological patients, pediatric patients and trauma patients but does not include bariatric patients.

Review of the facility policy titled "Communication with Emergency Medical Services (EMS)" dated 09/2010 on 09/10/13 states: "The Emergency Department shall have a direct line (Med Communications) dedicated to Medical Control. Notification will be received from Medical Control of patient's condition and expected time of arrival by ambulance via the dedicated Medical Communication line. The Emergency Department will then make necessary preparations."

Review of the facility policy titled: "Treatment of Emergency Medical Conditions" dated 03/2012 on 09/10/13 states: "All individuals presenting to the Emergency Department must be given an appropriate Medical Screening Examination by a credentialed Physician, Physician's Assistant (PA) or Nurse Practitioner (NP)."

Review of the facility policy titled: "Emergency Department Overview" dated 09/2010 on 09/10/13 states: "No patient will be transferred prior to Medical Screening Examination and stabilization treatment."

Review of the facility Policy titled "Participation in the Nassau County EMS System" dated 09/2010 on 9/10/13, states: "PCR (Pre-Hospital Care Report) must be reviewed at time patient arrives at hospital by the EMS personnel with the ED staff. Receive patient report from Ambulance Technician both verbally and written."

The interview conducted on 09/10/13 at 11:40 AM with the ED Charge Nurse revealed that this "Participation in the Nassau County EMS System " policy was not implemented.

An interview conducted on 09/10/13 at 11:00 AM with the Night Nursing Supervisor stated that the ED Charge Nurse had called her on 07/18/13 to notify her of the arrival of an obese person and that she had instructed the Charge Nurse to get an exact weight. The ED Charge Nurse called her back a few minutes later to say that the EMS had left with the patient before she could find out the weight.

On 09/10/13 at 10:30AM an interview with the Director of the ED stated she was told "that the Med Com Phone rang and the Charge Nurse answered it. The Dispatcher asked the Nurse if they could handle/take a patient who was morbidly obese and the Nurse asked how much the patient weighed because the ED stretchers can only accommodate a patient up to 500 lbs. The Dispatcher was not sure and was going to call back with that information. However, there was no return phone call."

The Director of the ED further stated "The Charge Nurse then saw the ambulance arrive on the video camera and went out to assess the situation. The ambulances and the Police were refusing to offload the patient stating they were not taking the patient out of the ambulance unless the facility could provide care for her. The Police were stating that they were not going to move the patient twice due to her size which was approximately 800 lbs. With this the Nurse then went back into the Emergency Room and called the Night Nursing Supervisor to find out if they could accommodate the patient. While the Nurse was on the phone with the Supervisor, the ambulance and Police left with the patient.". "The patient was only here for about ten (10) minutes. The Physician on duty was with another patient and never saw this patient ".

The Medical Screening Examination was not done as per the "Emergency Department Overview" Policy dated 9/2010 .
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Based on record review and interview, the facility failed to obtain written consent from the patient and/or patient representative for transfer. This was evident in three (3) of four (4) Medical Records (MR) for patients requiring transfer to another facility (Patients #2, #3 and #14).

Findings:

Review of MR #2 on 09/09/13 documents a male admitted to the ED (Emergency Department) on 06/17/13 with the complaint of difficulty breathing. The "Inter Hospital Transfer Form" #135 documents that the patient required transfer to another facility for a higher level of care.

The record lacked the required facility "Patient Transfers (Consent/Refusal for Transfer)" Form #134.

Review of MR #14 on 09/10/13 documents a 12-year-old male admitted to the ED on 04/14/13 with the complaint of severe Migraine. The "Inter Hospital Transfer Form" #135 documents that the patient required transfer to another facility for a higher level of care.

The record lacked the required facility "Patient Transfers (Consent/Refusal for Transfer)" Form #134.

Review of MR #3 on 09/09/13 documents a female admitted to the ED on 05/06/13 with the complaint of chest pain and shortness of breath. The "Inter Hospital Transfer Form" #135 documents that the patient required transfer to another facility for a higher level of care.

The record lacks documentation of the patient's written consent on the "Patient Transfers (Consent/Refusal for Transfer)" Form #134.

Review of the "Treatment of Emergency Medical Conditions" Policy # T-20-1 revised 03/2012 on 9/10/13 documents "Patients who are medically stable will be transferred to another hospital willing to accept the patient. Written consent of the transfer is obtained from the patient. (See attached "Patient Transfers (Consent/Refusal for Transfer) Form SJH #134)".

During interview on 09/10/13 at 10:00AM the Director of Performance Improvement and Risk Management could not locate the documentation of written consent for transfer and stated "I think the original form sometimes goes to the facility receiving the patient by mistake".