HospitalInspections.org

1. Based on medical staff bylaw rules and regulations, facility policy, record reviews and interviews, the hospital (Hospital #1) failed to ensure all patients presenting to the Dedicated Emergency Department ("DED") seeking medical attention received appropriate monitoring while awaiting an appropriate Medical Screening Examination ("MSE") within the capability of the hospital's emergency department to determine whether or not an emergency medical condition exists for 1 of 20 (Patient #1) sampled patients presenting to the DED. Refer to findings in Tag A-2406.


2. Based on facility policy, record review and interviews, the hospital (Hospital #1) failed to inform all patients presenting to the Dedicated Emergency Department (DED) seeking medical attention of the risks of refusing a medical screening examination (MSE) for 5 of 20 (Patients #'s 1, 2, 4, 7, & 12) sampled patients presenting to the DED. Refer to findings in Tag A-2406.


The hospital was found not to be in compliance with CFR 489.20 and CFR 489.24, Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Based on medical staff bylaw rules and regulations, facility policy, record reviews and interviews, the hospital (Hospital #1) failed to ensure all patients presenting to the Dedicated Emergency Department ("DED") seeking medical attention received appropriate monitoring while awaiting an appropriate Medical Screening Examination ("MSE") within the capability of the hospital's emaergency department to determine whether or not an emergency medical condition exists for 1 of 20 (Patient #1) sampled patients presenting to the DED.

The findings included:

1. Review of Hospital #1's Bylaws rules and regulations revealed, "...All individuals presenting to the Hospital/Emergency Department who requests a non-scheduled examination and/or treatment shall receive a medical screening examination [MSE] from a doctor or qualified medical personnel...to determine if an emergency medical condition exists..."

2. Review of Hospital #1's "Admission Of Patient To The Emergency Department" policy revealed, "...To ensure timely treatment is rendered to every patient seen in the Emergency Department...All patients will be seen using the following guidelines for admission to the Emergency Department...The RN [Registered Nurse] will triage as soon as possible on arrival to determine severity of problem...All information and treatment rendered should be entered into area of our computerized ED [Emergency Department] records...All patients should be re-evaluated as often as necessary by an RN [Registered Nurse], LPN [Licensed Practical Nurse], or EMT-P [Emergency Medical Technician-Paramedic]..."

3. Review of Hospital #1's "Triage, Procedure for Emergency Severity Index (ESI)" policy revealed, "The purpose of triage is to assign acuity to patients who present to the Emergency Department (ED) and to identify those who will require the greatest number of resources..." The ESI algorithm outlines ESI assignment of numbers 1 - 5, with level 1 being a patient that requiring immediate life-saving interventions, level 2 acuity being high risk situation or confused/lethargic/disoriented or "severe pain/distress", level 3 acuity needing many resources. The ESI algorithm also documented to consider a level 2 acuity if the patient's oxygen saturation (Sat 02) is less than 92 percent (%).

4. Medical record review revealed Patient #1 was a 91 year old at female that presented to the DED on 4/9/19 at 5:51 PM with the chief complaint of "Laceration."

A triage and patient profile assessment was conducted by RN #1 from 6:32 PM - 6:46 PM and revealed the patient "...Fell the 3/16 [sic] [had fallen previously on 3/16/19], was seen at [name of Hospital #2] ER for laceration which they glued. Pt had CT [Computerized Tomography - An x-ray procedure that uses the help of a computer to produce a detailed picture of a cross section of the body] and Xrays which were negative. Pt [Patient] had hematoma that busted this morning when she bent over. Bleeding is controlled with dressing. No distress noted..."
The patient profile revealed Patient #1 was on "Warfarin [a blood thinner medication] 3 milligrams daily". After the triage assessment the patient was sent back to the waiting room.
Review of the DED log revealed Patient #1 remained in the waiting room for 3 hours and 22 minutes. There was no documentation the patient received a MSE or was re-evaluated after the triage assessment during the 3 hours and 22 minutes the patient remained in the waiting room.

At 9:05 PM RN #1 documented, "Spoke with family member several times concerning wait times, they are very upset. We are at full capacity. no bleeding at present pressure dressing intact and dry."

At 9:12 PM RN #1 documented, "Did inform family member they were up next for a bed."

At 9:19 PM RN #1 documented, "Family member questioned me about removing pressure dressing that was applied to head. I explained to family that we can not remove the dressing, that it would disturb clotting. It could start bleeding and we did not have a bed to put her in that happened. Bleeding was controlled with dressing. She stated that 'maybe I should remove the dressing so she could get back to a bed faster.' Family then went to the bathroom and manipulated dressing, came out screaming, that she was bleeding. Family has been very disrespectful to staff during wait." There was no documentation the nurse assessed or re-evaluated the patient for bleeding.


Review of the hospital operated emergency medical services (EMS) report dated 4/9/19 revealed EMS received a 911 call on 4/9/19 at 9:03 PM from Patient #1's family, EMS was dispatched at 9:04 PM and reached the Patient #1 at 9:05 PM.
The EMS report dated 4/19/19 at 9:15 PM revealed, "...EMS DISPATCHED NON-EMERGENCY TO [Name of Hospital #1] PARKING LOT FOR PT [Patient #1] BLEEDING FROM HEAD AND WANTING TO BE TAKEN TO [Name of another hospital]...UPON ARRIVAL, PT FOUND SITTING UPRIGHT IN FRONT SEAT OF TRUCK...THE HEMATOMA FROM THE FALL HAS NOW STRATED [STARTED] BLEEDING AND WONT [WON'T] STOP. PT FAMILY EXPRESSED DISCONTENT WITH CARE NOT RECEIVED IN [NAME OF HOSPITAL #1] ED. PT FAMILY TOLD EMS THEY HAD BEEN IN WAITING ROOM A FEW HOURS AND NO ONE HAD EVEN TRIED TO STOP PT BLEEDING. PT LEFT AMA WITHOUT BEING SEEN AND CALLED 911 FOR TRANSPORT TO ANOTHER FACILITY. NOTE: [NAME OF HOSPITAL #1] ED WAS EXTREMELY BUSY...HAD BEEN PLACED ON DIVERSION...PT ASSISTED FROM TRUCK ONTO STRETCHER...TOWELS REMOVED FROM PT. PRESSURE APPLIED WITH TRAUMA DRESSING...PT TRANSPORTED TO [HOSPITAL #3]..."
The EMS report revealed the ambulance left Hospital #1's parking lot at 9:22 PM transporting Patient #1 to Hospital #3 to receive a MSE, stabilizing treatment and care.

There was no documentation the nurse at Hospital #1 assessed or re-evaluated the patient for bleeding before the patient was transported to Hospital #3.

Review of Hospital #3's medical record for Patient #1 revealed on 4/9/19 the patient arrived to the DED via EMS. Review of Hospital #3's Nursing Progress Notes documented at 10:33 PM revealed, "...Patient has small hematoma...there is a small laceration that is actively bleeding, requiring multiple 4 x 4s and manual pressure with a pressure bandage to control..."

Review of Hospital #3's Physician's Clinical Note documented at 10:34 PM revealed, "...Oriented X [times] 4...Forehead: swelling and deep 1.0 cm [centimeter] laceration with bleeding...She had persistent bleeding that the family cannot control. They went to another emergency department in [name of the town where Hospital #1 is located] They stated that they waited for 3 hours and were not seen by anyone. They [family] called an ambulance from that facility [Hospital #1] and then was brought to this facility [Hospital #3]..." The physician documented the patient was taking Coumadin [same medication as Warfarin a blood thinning medication].

Review of Hospital #3's ED nursing notes revealed on 4/10/19 at 12:11 AM the patient was administered Tranexamic Acid (a medication which helps prevent prolonged bleeding) 500 milligrams intravenously. The notes revealed, "Wound repair...wound repaired with sutures (3 sutures). Estimated blood loss 200 ml [milliliters]..." The patient was discharged home "...Improved and stable..." on 4/10/19 at 1:42 AM.

5. In a telephone interview on 6/4/19 at 9:45 AM Confidential Interview (CI) #1 stated, "...took her [Patient #1] to the bathroom [at Hospital #1] and she started bleeding. Reception never offered to bring anything. [Named family member] knocked on the ED door and said 'We need help, she's bleeding.' No one came to help with the bleeding..."

In an interview on 6/4/19 at 10:45 AM in the conference room at Hospital #1, RN #1 was asked about Patient #1's ED visit on 4/9/19 and her progress notes regarding the family.
RN #1 stated upon triage Patient #1 had a dressing on her head and "I re-inforced it with Coban." RN #1 stated that she had checked on Patient #1 "three different times" while the patient was in the waiting room. There was no documentation of these checks by the RN.
RN #1 stated there were no beds available in in the ED, "we had EMS with patients backed up in the hallway...one daughter said ,'Maybe if she was bleeding, someone would see us faster.' I went back to triage and saw them go toward the bathroom...later I heard someone beating on the door hollering 'Help.' I didn't see the patient after that and don't know who called 911...".
RN #1 was asked if she actually witnessed the family going into the bathroom with Patient #1 and manipulating the patient's dressing and RN #1 stated, "No".
There was no documentation Patient #1 was re-evaluated and assessed for bleeding after the triage assessment and while the patient was waiting in the ED for 3 hours and 22 minutes.

In an interview on 6/5/19 at 9:15 AM in the conference room at Hospital #1, Unit Secretary (US) #1 stated on 4/9/19 the ED was full and EMS was backed up in the hallway. US #1 stated she saw Patient #1 when she came out of the bathroom and her head was bleeding. The US stated one of the patient's daughters was banging of the ED door saying that her mother was going to "bleed out". US #1 said that Registration Clerk (RC) #1 told her that a daughter called 911. There was no documentation the patient was re-evaluated or assessed after the daughter had reported the patient's head was bleeding and the daughter had requested help from the hospital ED staff.

In an interview on 6/5/19 at 1:35 PM in the conference room at Hospital #1, RC #1 stated Patient #1 came in with her 2 daughters and a son. RC #1 stated, "The patient came out of the bathroom and had blood running from her forehead to her chest area. I went into the ED and told [Name of RN #1], the secretary and 2 other nurses."
RC #1 was asked if a nurse or anyone came out to check the patient's bleeding and RC #1 stated, "No one came out to check her."
RC #1 stated the family started banging on the ED door and the an ED secretary went out to talk to her and that was when the family called 911.

In a telephone interview on 6/5/19 at 1:45 PM Emergency Medical Technician/Critical Care Paramedic (EMT/CCP) #1 stated he was dispatched to assist Patient #1. EMT/CCP #1 stated the patient "was sitting in a truck in the parking lot by the ED. The bandages or towels on her head were saturated with blood. Blood was running down all over...her shirt was covered in blood."

In a telephone interview on 6/5/19 at 3:30 with Advanced Emergency Medical Technician (AEMT) #1, the AEMT stated when they arrived at Hospital #1's ED, Patient #1 had a "bunch of wash rags wrapped with Coban" on her head. The AEMT stated the rags and Coban dressing were "soaked in blood and a lot of blood was on her [Patient #1]."

An interview was conducted on 6/6/19 from 3:14 PM - 5:15 PM in the board room at Hospital #1 with the ED Director, Chief Nursing Officer (CNO) and Chief Executive Officer (CEO) regarding Patient #1's ED visit on 4/9/19 and the CEO stated, "...They [Patient #1's family] by-passed 2 hospitals to get here [named 2 other hospitals] so they didn't think it was an emergency...We would have seen her but she was never in any distress and she was not emergency...I was told there was no blood [on Patient #1] from [Name of RN #1 and RC #1]...If they [family] were that concerned, why didn't they go to [named 2 other hospitals].

Based on facility policy, record review and interviews, the hospital (Hospital #1) failed to inform all patients presenting to the Dedicated Emergency Department (DED) seeking medical attention of the risks of refusing a medical screening examination (MSE) for 5 of 20 (Patients #'s 1, 2, 4, 7, & 12) sampled patients presenting to the DED.

The findings included:

1. Review of Hospital #1's policy titled, AMA, Leaving Against Medical Advice revealed, "...Patient decides to leave after being triaged but prior to the Emergency Medical Screening Exam (EMSE)...Make every attempt to have the patient remain for the EMSE...If patient insists on leaving AMA release form should be signed by the patient or significant other...The ER admission personnel will notify ED (Emergency Department) staff of patient's decision to leave ED and ED staff will have the form signed and witnessed..."

Review of Hospital #1's policy titled, Pain Management revealed the pain score range of 0 - 10, with "0" being no pain and 7-10 being "Severe" pain.

Review of Hospital #1's Refusal of Emergency Medical Screening Exam in the Emergency Department form revealed "This is to certify that, [name of patient] having been triaged by ED personnel at [Name of Hospital #1 and city in which the hospital is located] has decided to leave the facility prior to receiving an emergency medical screening exam by the ED physician. I acknowledge that I have been informed of the risk involved and hereby release all concerned physicians, hospital, and employees from effects from responsibility and any ill effects which may result from my action..."

2. Medical record review revealed Patient #1 was a 91 year old at female that presented to the DED on 4/9/19 at 5:51 PM with the chief complaint of "Laceration."

A triage and patient profile assessment was conducted by RN #1 from 6:32 PM - 6:46 PM and revealed the patient "...Fell the 3/16 [sic] [had fallen previously on 3/16/19], was seen at [name of Hospital #2] ER for laceration which they glued. Pt had CT [Computerized Tomography - An x-ray procedure that uses the help of a computer to produce a detailed picture of a cross section of the body] and Xrays which were negative. Pt [Patient] had hematoma that busted this morning when she bent over. Bleeding is controlled with dressing. No distress noted..."

After the triage assessment the patient was sent back to the waiting room.
Review of the DED log revealed Patient #1 remained in the waiting room for 3 hours and 22 minutes.

Review of the "Refusal of Emergency Medical Screening Exam in the Emergency Department" form dated 4/9/19 at 9:10 PM revealed Patient #1's name was listed on the form. The form revealed, "...This is to certify that [Name of Patient #1] having been triaged by ED personnel at [Name and city of Hospital #1] has decided to leave the facility prior to receiving an emergency medical screening exam by the ED physician. I acknowledge that I have been informed of the risk involved and hereby release all concerned physicians, hospital, and employees from effects from responsibility and any ill effects which may result from my action..." The form was signed by Patient #1's daughter and witnessed by RN #2. There was no documentation medical advice was given to the family or patient and no documentation of the risks and benefits were explained to the family and/or patient.

In an interview on 6/4/19 at 10:45 AM in the conference room at Hospital #1, RN #2 stated she was called to complete the patient assessment form for Patient #1 before the patient left in the ambulance to go to Hospital #3 and RN #2 stated, "...The patient was in the ambulance already. I had to flag them down...didn't see the patient. The daughter came back in the ED to sign the paperwork."
RN #2 was asked what comments were made during this encounter and RN #2 stated, "That she was taking her mother out against medical advice. There was no other comments..." There was no documentation the patient was re-evaluated and assessed or explained the risks and benefits of leaving against medical advice by the ED staff at Hospital #1.

3. Medical record review revealed Patient #2 was a 58 year old that presented to the DED on 4/1/19 at 1:46 PM with the chief complaint of Chest Pain.

A triage assessment was conducted at 1:49 PM by Registered Nurse (RN) #1 and revealed, "...sent from Health Department for further evaluation, due to SOB [shortness of breath], and chest pain...Lung sound are diminished upper R/L [right and left]. Pt (Patient) is anxious and crying..." The patient signed the General Conditions of Treatment /Authorization /Consents form at 2:08 PM after triage. The ED log revealed the waiting room time (wrt) was 58 minutes and the Patient left without being seen (LWBS).

Record review revealed Patient #2 signed the Refusal of Emergency Medical Screening Exam in the Emergency Department form on 4/1/19 at 2:43 PM. There was no documentation the patient received medical advice or of the risks of leaving AMA.


4. Medical record review revealed Patient #4 was a 47 year old that presented to the DED on 4/9/19 at 1:02 PM with the chief complaint of Chest Pain.

A triage assessment was conducted at 1:13 PM by RN #1 and revealed, "...chest tightness and left arm pain..." The patient signed the General Conditions of Treatment/Authorization/Consents form at 8:05 PM after triage and returned to the ED waiting room. The ED log revealed the patient LWBS.

Record review revealed Patient #4 signed the Refusal of Emergency Medical Screening Exam in the Emergency Department form at 1:56 PM. There was no documentation the patient received medical advice of the risks of leaving AMA.

Patient #4 was contacted via telephone on 6/6/19 at 2:03 PM by the surveyor to inquire about the ED visit, why the patient left, and if anyone explained the risks of leaving AMA and Patient #4 stated the ED staff performed an EKG (electrocardiogram - a recording of the electrical activity of the heart) to check her heart rate, checked her blood pressure and then put her back in the waiting room. The patient stated after she was put back in the waiting room no one checked on her again. The patient stated she did notify the person at the ED desk that she was tired of waiting and was leaving. The patient stated there was no response from the person at the desk so she left the hospital ED. The facility failed to ensure that their policy and procedure were followed as evidenced by failing to make every attempt to have patient #4 remain for the Emergency Medical Screening Examination on 4/9/2019.


5. Medical record review revealed Patient #7 was a 33 year old that presented to the DED on 5/15/19 at 1:02 PM with the chief complaint of Chest Pain.

A triage assessment was conducted at 1:17 PM by RN #4 and revealed the patient complained of , "...mid-sternal CP [chest pain]...diaphoresis, 'a little bit SOB [short of breath]...'a little bit' dizziness...has taken NTG [nitroglycerin - medication used to help the blood vessels become wider when a person experiences chest pain] 0.4 mg x 2 doses..." with an episode of nausea/vomiting. The patient was assigned a level 2 acuity. The ED log revealed the patient LWBS.

There was no documentation the patient received medical advice of risks of leaving AMA or signed the Refusal of Emergency Medical Screening Exam in the Emergency Department form.

Patient #7 was contacted via telephone on 6/6/19 at 10:36 AM by the surveyor to inquire about the ED visit, why the patient left, and if the ED staff explained the risks of leaving AMA and Patient #7 stated she was placed in the ED waiting room and had asked the ED registration clerk at least 4 times about the long wait period. Patient #7 stated the ED clerk would say, "You're next." Patient #4 stated she finally went to the registration clerk and she informed the registration clerk that she was leaving and the registration clerk said "Ok." There was no documentation the patient was explained the risks of leaving AMA. The facility failed to ensure that registration personnel notified ED staff of patient #7's decision to leave ED staff and have the form signed and witnessed as per the facility's policy.


6. Medical record review revealed Patient #12 was a 15 year old that presented to the DED on 5/26/19 at 4:06 PM with the chief complaint of an alleged assault.

A triage assessment was conducted at 4:24 PM by RN #3 and revealed the patient reported that 4 people had assaulted him at approximately 2:00 PM that day. RN #3 documented the patient had swelling and discoloration to the left eye, abrasions to the left forehead, a laceration under the left eye, swelling/discoloration to the right ear and multiple abrasions to the trunk of the body. The patient reported that he was "knocked out." The patient's parent signed the General Conditions of Treatment/Authorization/Consents form at 4:33 PM after triage.
The ED log revealed the patient was in the waiting room for 140 minutes (2 hours and 10 minutes) before the patient LBS.

There was no documentation the patient received medical advice of risks of leaving or signed the Refusal of Emergency Medical Screening Exam in the Emergency Department form.

Patient #12's parent was contacted via telephone on 6/6/19 at 9:27 AM by the surveyor to inquire about the ED visit, why the patient left, and if the hospital had informed them of the risks of leaving AMA and the patient's parent stated, "...I kept going up there [to the ED registration desk]...I couldn't keep him [Patient #12] awake. No one ever came out to check on him..."
The patient's parent stated they finally told the ED registration clerk that they were going to leave and go to Hospital #2 and the ED registration clerk responded to them, "If you want to leave, you can leave, that's your choice." The facility failed to ensure that their policy and procedure was followed as evidenced by failing to make every attempt to have patient #12 remain for the Emergency Medical Screening Examination. Additionally, the registration staff failed to notify ED staff of patient #12's parent decision to leave ED staff and have the form signed and witnessed.


7. An interview was conducted on 6/6/19 from 3:14 PM - 5:15 PM in the board room at Hospital #1, with the ED Director, Chief Nursing Officer (CNO) and Chief Executive Officer (CEO). The CNO stated the AMA forms have been revised to include patient risks. The final approval is expected the first of July.