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Based on medical record reviews, Emergency Department Log review Policy and procedure review and family and staff interviews it was determined the facility failed to ensure that an appropriate medical screening examination provided within the capability of the emergency department to determine whether or not an emergency medical condition existed for 1 (#1) of 22 sampled patients who was in the hospital's emergency department for 14 (fourteen) hours.

Findings include:

Emergency Department Log

A review of the Emergency Department (ED) activity log revealed that Patient #1 was registered into the facility ' s ED on 4/1/19 at 2:44 p.m. It was recorded that Patient #1 left Against Medical Advice (AMA) on 4/2/19 at 4:49 a.m.

Medical Record Review

A review of Patient #1 ' s medical record revealed that Patient #1 was an 86 year old who presented to the ED (Emergency Department) with a complaint of severe abdominal pain. A note written by an RN (Registered Nurse) revealed that Patient #1 was triaged (assessment to determine the priority in which patients will be seen based on presenting signs and symptoms) at a level 3 urgent walk-in patient on 4/1/2019 at 2:59 p.m. The patient's vital signs at triage 2:59 were listed as: Temperature: 36.6 (Normal temperature 37.5 to ); Heart Rate: 66; Blood Pressure: 153/61 -High (Blood Pressure Hospital Reference Range- Systolic 90-140; Diastolic: 60-90); Respirations: 20 and Oxygen saturation was 95%. Pain level 8 (Pain rating scale- 8 of 10-- Horrible pain).

The section of the "Emergency Documentation" note the section titled ED MSE (Medical Screening Exam) written by NP (Nurse Practitioner) #3 revealed that Patient #1 was seen by the NP #3 at 2:57 p.m. The History of Present illness: specified in part, "Lower abdominal pain for the past couple of weeks, denies nausea/vomiting, diarrhea; + for constipation but states she had a bowel movement today. Patient has presented to triage for a medical screening exam. At this time, patient warrants further treatment to evaluate for possible emergent condition. Labs and/or imaging have been ordered from triage area to expedite patient care in the department. I have not assumed care of this patient. Another provider will assume this patient's care and decide disposition. NP #3 discussed and reviewed the chart with another provider who also agreed with the assessment, treatment plan, and disposition of the patient. Lab results for Patient #1 resulted on 4/2/19 at 2:17 a.m. The lab results showed Patient #1's hematology (study of the blood) returned all within normal range. Patient #1's chemistry values were also within normal range. Patient #1's urinalysis (UA) (study of the urine) resulted on 4/1/19 at 4:21 p.m. revealed that a cloudy appearance of urine and trace leukocytes (white blood cells) in the urine. Patient #1's UA was negative for ketones, blood, and glucose in her urine. On 4/1/19 a diagnostic report revealed an abdominal x-ray with two (2) views were ordered. The diagnostic report resulted saying that stomach was partially distended with gas. Overall the bowel pattern was non obstructive. There was Phelbolithis (small blood clots in veins that harden overtime due to calcification), but no acute process was identified. The discharge report shows that Patient #1 left Against Medical Advice on 4/2/19. The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to ensure the medical record reflected continued monitoring of patient #1's needs prior to leaving the emergency department, since it was determined the warranted further treatment and evaluation for possible emergent condition. There was no evidence of this ongoing evaluation documented in the medical record prior to the patient leaving the ED, as the patient only received one set of Vital Signs at triage (pain level of 8), no further vital signs checks for the next 14 hours. The facility failed to ensure that an appropriate medical screening examination was provided for patient #1.

Interviews

An interview was conducted on 9/16/19 at 12:35 p.m. via the telephone with Patient #1's spouse who reported the allegations. Patient #1's spouse recalled arriving to the ED around 2:45 p.m. because Patient 1's primary care provider could not see her until Wednesday. The spouse stated they had some test and x-ray around 5 or 6 p.m. It was communicated that Patient #1 needed more blood test done, but when the spouse asked the admin available he was told they did not have someone in the ED currently to take the blood test. When the spouse asked to see the nurse, the spouse was told that she was busy at the moment. After 7 p.m. the nurse came and spoke with the spouse and stated there were no available beds currently in the ED. Patient #1 ' s spouse also recalled the nurse stating that had they come yesterday there would have been plenty of beds available. Patient #1's spouse stated that the blood labs were taken around 2:45 a.m. Other people were seen before Patient #1 during their twelve (12) hour waiting. Patient #1 ' s spouse stated they were charged but was never seen. The spouse called the hospital and filed a formal grievance. The spouse stated they feel no one follows up with patients on their needs and they feel no one is in charge of the ED. Patient #1 ' s spouse stated he was not aware of seeing a doctor or a nurse practitioner. Patient #1's spouse reported seeing a gentleman at 2:45 p.m. but was not aware of his title.

Interviews were conducted with the ED director (RN #10), ED nurse manager (RN #6), the ED Medical Director (MD #4), and the Director of Quality on 9/16/19 at 4:00 p.m. in the administrative conference room. During the interview when asked about the ED process MD #4 stated when patients present to the ED patients are registered and triaged. Patients that present between the hours of 10 a.m. - 10 p.m. a provider is in the triage area. The midlevel provider and the triage nurse perform an assessment in together. The provider then documents they have seen and assessed the patient and has also placed in orders and the appropriate diagnostic test. From that point patients will go either to an ED room in the back if a bed is available, or back to the waiting room. MD #4 stated they do not perform a screen out process (in that they do not state if a patient does not have an emergency condition at that moment and they cannot be seen). Patients who are brought to the main ED area are given full exam and medical diagnosis in this moment when test have been completed. When asked about delayed labs in the ED RN #10 stated the ED has now placed a designated phlebotomist in the ED during the hours of 10 a.m. -10 p.m.


An interview was conducted with NP #1 during the observation and tour of the ED on 9/17/19 at 11:00 a.m. revealed. During the observation portion it was observed that NP #1 was engaged with the patient and completing an assessment simultaneously with the triage nurse and imputing orders as well. When interviewed and asked about the process NP #1 stated while the triage nurse is taking a patient ' s vital signs the provider performs a focus assessment to the patients needs. The provider then put in orders based off the assessments. If a patient needs to be treated immediately the provider has the capability to do so in that moment and send them to the appropriate area of the ED. NP #1 stated that treatment is started before patients before patients go to the main ED area. NP #1 confirmed that during the hours of 10 a.m. and 10 p.m. the provider completing MSEs will write a note that they have seen the patient in the triage area and order are put in. The provider who states the screening process does not complete the process unless they discharge the patient from the triage area.

Policy and Procedure

A review of the facility policy labeled, " LL.026 EMTALA- Medical Screening and Treatment of Emergency Medical Conditions, Approved on 8/30/19, Effective 8/31/2019, revealed any individual who comes to the Hospital Property or Premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by a physician or other Qualified Medical Personnel to determine whether or not an Emergency Medical Condition exists. If an Emergency Medical Condition is found to exist, the Hospital will (without regard for the patient's insurance coverage or ability to pay) provide: (a) stabilizing treatment within the capabilities of the Hospital and its staff (including on-call physicians and diagnostic services), and/or (b) an appropriate transfer to another medical facility (if required for the patient's treatment or requested by the patient) ...3. Medical Screening Examination ...

Depending on the patient's presenting symptoms, the Medical Screening Examination may range from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures.

A Medical Screening Examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation documented in the medical record prior to discharge or transfer. Emergency department physicians and Qualified Medical Professionals may consult with the patient's primary care physician or other physician who is treating the patient for information and guidance so long as the Medical Screening Examination is not delayed while awaiting physician response.


B. Who May Perform Medical Screening Exam I
A Medical Screening Examination may be performed by an emergency department physician,
another physician, or a non-physician practitioner who is qualified to conduct such examination
("Qualified Medical Personnel" or "QMP") and approved by the Hospital's governing board.

· Medical Screening Examinations must be performed by an emergency department physician,
another physician or a non-physician practitioner who is qualified to conduct such examination.
· A qualified medical person may conduct the Medical Screening Examination provided the individual is:
i. determined qualified by Hospital medical staff bylaws, rules and regulations which are
approved by the Hospital's governing body, and
ii. functioning within the scope of his or her license and in compliance with State law and
applicable State nurse and medical practice acts.
· A Medical Screening Examination may be performed by an emergency department physician,
another physician, or a non-physician practitioner who is qualified to conduct such examination
("Qualified Medical Personnel") and approved by the Hospital's governing board:
· When non-physician personnel perform Medical Screening Examinations, the appropriate committees should approve specific screening protocols that outline the examination and/or diagnostic work-up required to determine if an Emergency Medical Condition exists.

These protocols will normally be complaint specific and will be limited to those presenting complaints that lend themselves to screening by such non-physician personnel ·

The competencies for any non-physician personnel performing Medical Screening Examinations
should be documented. There should also be an education plan for measuring and developing
core competencies in medical screening.
·
Hospitals must establish a process to ensure that an emergency department physician examines all patients whose conditions or symptoms require physician examination.
· Hospitals must establish processes to ensure that 1) an emergency department physician on duty is responsible for the general care of all patients presenting themselves to the emergency
department; and 2) the responsibility remains with the emergency department physician until the
patient's private physician or an on-call specialist assumes that responsibility, or the patient is

Based on medical record reviews, Policy and Procedure review and staff interviews it was determined the facility failed to offer the individual further medical examination and treatment and failed to inform the individual (or the a person acting on the individual ' s behalf) of the risks and benefits to the individual of the examination and/or treatment, but the individual (or person acting on the individual ' s behalf) did not consent to the examination and/or treatment. for 1 (Patient #1) of 22 sampled patient medical records reviewed. Additionally, the facility failed to ensure the medical record contained a description of the examination, treatment or both that was refused by the individual or on behalf of the individual.

Findings were:


Policy and Procedure

The facility ' s policy and procedure titled, " LL.026 EMTALA Medical Screening and Treatment of Emergency Medical Conditions, Approved 8/30/2018, Effective 8/31/2018 was reviewed. The policy specified in part, " ... D. Special Circumstances: Withdrawal of Request for Examination.
1. If a patient withdraws his or her request for examination or treatment, an appropriately trained individual from the emergency department staff should discuss the medical issues related to a voluntary withdrawal. In the discussion, the emergency department staff member should:

a. Offer the patient further medical examination and treatment as may be required to identify and
stabilize and/or Emergency Medical Condition;

b. Inform the patient of the benefits or the examination and/or treatment, and of the risks of withdrawal prior to receiving the examination and/or treatment; and

c. Use reasonable efforts to get the patient to sign a form indicating that the patient has refused the recommended examination and/or treatment. The form should contain a description of risks
discussed and of the examination and/or treatment that was refused.

2. If a patient leaves the Hospital without notifying Hospital personnel, this should be documented. The documentation must reflect that the patient had been at the Hospital and the time the patient was discovered to have left the premises. Triage notes and additional records must be retained.


Medical Record Review

A review of Patient #1 ' s medical record revealed that Patient #1 presented to the ED with a complaint of abdominal pain. A note written by an RN revealed that Patient #1 was triaged at a level 3 urgent walk-in patient at 2:59 p.m. Another note titled ED MSE (Medical Screening Exam) written by NP #3 revealed that Patient #1 presented to triage for a medical screening exam. The note stated that Patient #1 warrants further treatment for possible emergent condition. Labs and images were ordered from the triage area to expedite patient care in the department. NP #3 discussed and reviewed the chart with another provided who also agreed with the assessment, treatment plan, and disposition of the patient. Further review of the medical record revealed the discharge report shows that Patient #1 left Against Medical Advice (AMA) on 4/2/19. There is no record of an AMA form in the medical record. A coding note on 4/5/19 reinforced that Patient #1 discharged without Against Medical Advice, but the note reported that Patient #1 ' s procedure ad treatment was not carried out due to Patient #1 leaving prior to being seen by a health care provider. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure the medical record contained a description of the communication to the individual or the person acting on the individual ' s behalf or the risks and benefits and benefits of further examination or treatment for patient #1 on 4/2/2019 prior to patient leaving the ED.



Interviews

An interview was conducted on 9/16/2019 at 4:00 P.M., with RN #6 and RN #19. The surveyor asked the nurses how are the flow of patients tracked in the ED lobby and patients who leave. RN#6 and RN #10 both stated that patients are tracked on the ED's digital tracking board. If Patients leave they are called three (3) times and the times are entered into the tracking system. When asked about recalling the documentation both RN #6 and #10 stated that once a patient is removed from the tracking board so are the notes associated with the patient. When asked about the different levels of discharge RN #6, RN#10, and MD #4 confirmed the facility only has levels that patients are discharged, AMA, left without being treated (left prior to triage and MSE), and transfer to another facility.


An interview was conducted with a registration clerk during a tour of the ED on 9/17/19 at 10:15 a.m. When asked about her duties during registration the clerk stated when patients enter the ED she enters them into the system prior to them being seen by the triage nurse and the provider. When asked about what she does she do if a patient appears to be leaving the ED the clerk stated that she calls out the triage nurse or the charge nurse to come talk with the patient to have them stay and complete the process.


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