HospitalInspections.org

Based on hospital policy review, medical record review, physicians and staff interviews the hospital failed to comply with 42 CFR §489.20 and §489.24. The hospital's Dedicated Emergency Department (DED) failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, on the campus to which a patient presented via EMS (Emergency Medical Services) to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 9 sampled DED patients (#10) who presented to Campus B's DED for evaluation and treatment.

Findings include:

~ Cross refer to Medical Screening Examination - Tag A2406.

Based on review of policy and procedure, Emergency Medical Service (EMS) pre-hospital report, medical record, video recordings, and staff and physician interviews, the hospital failed to provide an appropriate Medical Screening Examination (MSE), within the capability of the Dedicated Emergency Department (DED), on the campus (Campus B) to which a patient presented via EMS to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 9 sampled patients (Patient #10) who presented to Campus B's DED for evaluation and treatment.

The findings included:

Review of the EMTALA policy, reviewed/revised date 03/31/2017, revealed "...Emergency services and care, including a Medical Screening Examination, will be provided to individual's who present to the Hospital's Emergency Department at either it's (A) Campus....or its (B) Campus....and request examination or treatment of a medical condition....A Medical Screening Examination will be performed in order to determine if an Emergency Medical Condition exists. ..."

Review of the "Pre-hospital Care Report Summary", dated 01/04/2021, revealed "... Narrative History Text: Dispatched.... for a behavioral call. Arrived to find a 31 yr (year) old female (Patient #10). LEO (Law Enforcement Officer) ....was out with the pt (patient) on the side of (road name). Pt was alert and oriented x4 (to person, place, time, situation). Our....notes showed pt was having suicidal ideations. Pt never admitted to me she wanted to harm herself. She told me she was assaulted by a man she met and he dropped her off on the side of the road. She stated she was from (a different city) and she met a man that assaulted her sexually. She stated he didn't hit her he just sexually assaulted her. Pt's secondary complaint was a headache. She explained her head has been hurting for 1 week. Pt did have a temperature to go with it. We were originally in route to (Campus B) hospital. I notified (Campus B) that we were in route to their hospital with a 31 yr old female who had a psychiatric hx (history) that stated she had been sexually assaulted. When we arrived at (Campus B) a Registered Nurse (RN) met us at the back of our ambulance and stated that they didn't have any sitters to be with the pt and directed us to go to (Campus A). We then went to (Campus A) routine traffic. During transport pt kept telling me she was going to die and please don't let her die. I had to keep reassuring her that she was going to be fine. I tried to get her to talk to me and ask her why she felt like she was going to die. I was able to reassure her that she was going to be fine and she calmed down. Upon our arrival at the hospital (Campus A) pt was directed to triage. I gave the Rn (sic) a report and pt was left in her care at triage. ..." Further review of the "Pre-hospital Care Report Summary" revealed documentation the ambulance left the scene with the patient for the hospital (the unit initially started to Campus B) at 1517.

Medical Record review, on 01/12/2021, revealed Patient #10 arrived to Campus A on 01/04/2021 at 1542. Review of "ED Triage...", performed 01/04/2021 at 1602, revealed "...Stated Complaint: States 'my mind is not right'. When asked about SI (suicidal ideations), pt states 'kind of and kind of not'. Would not elaborate more. ED (Emergency Department) Mode of Arrival: EMS ...Tracking Acuity: 2 - Emergent (on a scale of 1-5 with one being the most acute). ..." Review of the "ED Screening Assessment...", performed at 1602, revealed "...CSSRS (Columbia Suicide Severity Rating Scale) Short Version....CSSRS Screen Able to Assess: Yes 1. Have you wished you were dead or wished you could go to sleep and not wake up?: Past month, yes 2. Have you actually had any thoughts of killing yourself?: Past month, no 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life?: Lifetime, no. ..." Review of a RN note, at 1604, revealed "Dr. (Last name) assessing. Pt is now denying SI/HI (homicidal ideations)/hallucinations, etc. and states she was dropped off here and needs a ride back to (city name)." Review of "ED Physician Documentation" for Patient #10 revealed "...Time Seen ....16:03 History of Present Illness Patient is a 31-year-old....who was transported over from (City Name), as (Hospital 2) was on diversion, for psychiatric evaluation. She lives in (Home City Name) but decided to hook up with someone she met on Facebook and came up with him for what turned out to be a 1 night stand yesterday in (first City name). He left her by the roadside and she is looking for a way back to (Home City) and I would get back on her meds (as written). She gives a list of 5 or 6 different medications that she is prescribed but admits that she has only been taking the Vistaril that she is prescribed to take 4 times per day. She has reportedly been off her Zyprexa for several days and also has Celexa as one of her psychotropic meds. She admits to suicide attempt in her remote past but denies feeling suicidal at present. She states she wants to get back on her meds and 'get in a better place'. She says that she realizes she made a bad decision in hooking up with this individual and wants to get back to (Home City)... She has seen a physician in (Home City) approximately a month ago....from whom she gets her prescriptions. Review revealed "... Physical Exam ....T (temperature): 98.1....General: Well-developed, well-nourished. No acute distress Skin: Warm, dry, no cyanosis. There were a few transverse volar wrist scars from reported suicide attempt 5 to 10 years ago.... Psychiatric: Appropriate. Mildly depressed affect, but interactive and appropriate eye contact. Medical Decision Making Differential diagnosis: Depression, low self-esteem, ? Personality disorder.... Reexamination/Reevaluation Patient exhibits no SI or HI. She is lucid and has appropriate goals. We will verify her information with the pharmacy that she listed and if this is accurate we will work on possibly getting her a ride back to her home.... Review revealed the pharmacy information was verified, Patient #10 was provided transport and was discharged home. Review revealed "...The patient was given a single hydroxyzine 25 mg (milligram) p.o. (by mouth) here and a ride was arranged to take her back to her home place which was listed as (address - road and city). She is stable both medically and psychiatrically for discharge.... Follow up with primary care provider .... Call for Next Available Appt (appointment) ....Follow-up with your regular physician, Dr. (Name), and get into a therapeutic counseling relationship. Resume taking your medications that you already have prescribed and filled... ." At 1647, a nursing comment stated "...transport called for transport home." Review of " ...ED Discharge.... ", dated 01/04/2021 at 1655, revealed " .... D/C (discharge) - NO EMC Identified, STABLE at time of disposition decision... ." Further review of nursing comments revealed, at 1728, "DC (discharged) home with transport. ..." DED record review did not reveal documentation related to potential sexual assault as was mentioned in the EMS record.

Tour of Campus B and interview with the Nurse Manager on 01/12/2021 revealed it was a 9 bed DED. Search of location/ distance data revealed the two campuses were 9 miles, approximately 12 minutes apart.

Review of a document prepared and received from the facility on 01/13/2021 titled "Patients by Hour" revealed the ED census of Campus B on 01/04/2021 at 1400 was 8 patients, at 1500 13 patients, and at 1600 13 patients. Further review revealed at 1700 the overall census was down to 8 patients.

Video recording review on 01/14/2021 at 1300 and 1340 revealed 5 short views (parts) which together covered the entire visit to Campus B. Review of Part 1 or view 1, timed at 1522 revealed EMS arrived to Campus B and drove up and under the canopy of the DED entrance. Part 2, from 15:22:32 to 15:22:43, showed the vehicle parked in the ambulance bay. A female came from the facility ambulance entrance and approached the EMS vehicle passenger door, then turned and went towards the back of the ambulance. Approximately the same time, the EMS driver got out of the vehicle and proceeded to the back of the ambulance to open the door of the patient compartment. The female met the driver behind the ambulance and the two appeared to speak. Part 3 of the video, noted as from 15:23:03 - 15:23:17 showed the female walked away from the ambulance back towards the building and the driver got back into the vehicle. In Part 4, 15:23:18 to 15:23:40 the ambulance remained stationary in the bay. In the final portion, Part 5, from 15:23:50 to 15:24:05, the ambulance pulled away from the DED. Review of the video confirmed the EMS ambulance was on Campus B in the bay for approximately two minutes (1522 to 1524).

Telephone interview with RN #1, the Triage Nurse at Campus A, on 01/13/2021 at 1320, revealed EMS called over the radio to Campus A to say they were bringing in a patient with possible sexual assault. RN #1 stated she asked the patient in triage about sexual assault and the patient denied it. RN #1 stated she asked if they were " seeing her for sexual assault and she said no ". RN #1 stated the patient had a psych history and was not taking her medications. Further interview revealed the suicide risk screening flagged high risk if a patient answered all suicide risk questions "yes". Because Patient #10 did not do that, the patient did not flag as high risk and did not have a need for a sitter to be placed.

Telephone interview with Medical Doctor (MD) # 3, on 01/13/2021 at 1510, revealed the MD believed the other campus (Campus B) called Campus A and wanted the patient brought to Campus A. Interview revealed it sounded like a psych patient and Campus A had a bigger staff and more resources for managing these patients. Interview revealed the patient had "hooked up" with someone on Facebook and after 1 night left her in the woods and she was coming in for evaluation. Interview revealed the patient was stable. The hospital called and verified information with the pharmacy Patient #10 used at home and arranged transport back home. Interview revealed the patient did not say anything about sexual assault. Interview revealed Patient #10 was off her meds and said she made bad choices, not that she had been violated or harmed. MD #3 stated she had "remote scars" and asked if she had any thoughts of harming self. The physician stated the patient said no, it had nothing to do with that, she had just made bad choices. Interview revealed that once MD #3 knew the patient had medications available and a ride back home he was "pretty content". Interview revealed it was a thorough medical screening exam and the patient was stable for discharge. Further interview revealed MD # 3 "was glad" they did not see the patient at Campus B, it was smaller and could suffer more if staffing was short. MD #3 stated they were better equipped at Campus A. Interview revealed the hospital treated the two campuses as one. Further interview revealed they knew they were responsible for patients in the ambulance area outside the ED and tried to make the arrangements to send a patient to Campus A, if needed, ahead of time.

Telephone interview with MD #4, on 01/14/2021 at 1020, revealed MD #4 was on duty at Campus B on 01/04/2020. Interview revealed another hospital in the area was on diversion and the department was full at the time. Interview revealed he recalled hearing something about a patient on the radio but was not aware the patient actually arrived to Campus B. Further interview revealed the MD was not sure it was an issue anyway since they were the same hospital.

Telephone interview with RN #5, on 01/13/2021 at 1200, revealed the RN was working at Campus B on 01/04/2021. Interview revealed RN #5 got on dispatch to try to tell the EMS ambulance not to come to Campus B but to reroute to Campus A, but could not get EMS back on the phone. Interview revealed another nurse, RN #6, went outside. RN #5 stated the plan was for RN #6 to wait for EMS to arrive and reroute them from Campus B to Campus A. Interview revealed EMS had radioed they were coming. Interview revealed RN #6 had a conversation with the ED manager that they could reroute because Campus B was full (no ED rooms available), they had recently accepted three ambulances with medical patients and this was a psych patient who needed a sitter. RN #5 stated the nurse went out, told EMS to reroute to Campus A, and they did. RN #5 also stated the nurse called Campus A to let them know the patient was coming. Further interview revealed the nurses tried to reroute while the ambulance was in route and stated that was usually what happened. In this case, though, EMS did not answer so they met them when the ambulance arrived. Interview revealed the patient "would be safer and better cared for at (Campus A) based on resources." Interview revealed Campus B had only a 9 bed ED and when they did not have sitters they would sometimes reroute. If it had been a medical patient, the RN stated, they probably would have accepted the patient. RN #5 noted a medical patient could have been placed in the hallway. Also, with a psych patient, it would have taken staff completely away for an extended period due to the sitter need, the RN said.

Telephone interview, on 01/13/2021 at 1225, with RN #6, revealed she worked at Campus B on 01/04/2021. Interview revealed EMS called in that they were coming. RN #6 stated they reached out to their manager to see what they needed to do to take care of the patient and the manager said they could reroute. RN #6 stated the resources were greater at Campus A for sitters and safety for psych patients. Then they tried to contact EMS but EMS did not respond/call back, so RN #6 went and waited at the ambulance bay doorway. RN #6 started out to the ambulance and the driver got out of the driver's door and headed to the back of the ambulance. "We were moving at the same time I believe", RN #6 stated. She told the driver they had been asked to reroute the patient to (Campus A). Interview revealed RN #6 said it came from "my manager". Interview revealed it was not a decision RN #6 would make on her own. RN # 6 further stated rerouting did not happen that often, only when it was needed and that it was generally for psych patients. RN #6 stated the back ambulance doors were open when she talked with the driver and the patient was sitting up on the stretcher. RN #6 stated she did not have a conversation with the patient. Interview revealed this happened because of resources and sitter availability.

Telephone interview, on 01/13/2021 at 1335 with Nurse Manager (NM) #7 revealed the manager had responsibility for both campuses. Interview revealed they typically only rerouted patients prior to arrival to Campus B. On Monday 01/04/2021, Campus B already had rooms full and patients in the waiting room. When NM #7 received the call about rerouting to Campus A, the NM thought it was to reroute while still in transit. Interview revealed NM #7 did not realize the patient actually got on campus prior to being rerouted until "yesterday" (1/12/2021). Interview revealed there was no report or log of patients when they were rerouted. Interview revealed the safest thing for Patient #10 was to be at Campus A because of bed availability and staffing. Interview revealed there were extra resources at Campus A. Further interview revealed they are "1 department, 2 campuses connected by a long hallway called I40 (Interstate 40)".