HospitalInspections.org

Based on a review of medical records (MR), hospital policy and procedure, Hospital Rules and Regulations, and interviews with patients and staff, it was determined the hospital failed to ensure that individuals who comes to the emegency must provide an apprpriate medicalsreening examination within the capability of the hospital's emergency department, including ancillay services routinely avaiable to the emergency department to determine whether or not an emergency medical condition existed for 2 Patients, Patient Identifier (PI) PI #14 and Pt.#23) of 23 sampled ED patients:

Refer to findings in Tag A-2406.

Based on a review of medical records (MR), hospital policy and procedure, Hospital Rules and Regulations, and interviews with patients and staff, it was determined the hospital failed to ensure that individuals who comes to the emergency must provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed. for 2 (two) Patients, Patient Identifier (PI) PI #14 and Pt.#15) of 23 sampled ED patients:

This affected three of 23 MR reviewed including Patient Identifier (PI)- PI # 14, PI # 23, and had the potential to affect all individuals coming to this Emergency Department seeking care.

1. Conduct a Medical Screening Examination (MSE) to determine if an Emergency Medical Condition (EMC) existed for all persons presenting to the ED for care.

2. Reassess patients every 30 - 60 minutes as directed in the hospital policy.




Findings include:

Vaughan Regional Medical Center Rules and Regulations
Revised: 8/19/19

...6.1(a) Screening

1. Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition...

Hospital Policy: LL.026 EMTALA - Medical Screening and Treatment of Emergency Medical Conditions
Policy Number: 14495714
Approved: 11/16/2023

...Purpose: To ensure that individuals coming to an ... Emergency Department seeking assessment or treatment for a medical condition ... receive an appropriate Medical Screening Examination...


L. Medical Screening Examination is the process required to reach...whether or not an Emergency Medical Condition exists...

Hospital Policy: Assessment and Reassessment, 02-780-0017
Policy Number: 14964955
Revised: 11/2013

Policy: All patients presenting to the Emergency Department will be triaged and categorized according to the 5 tier triage system...

Hospital Policy: Triage, 02-780-0016
Policy Number: 14964811
Revised: 7/2011

...Procedure:

The Registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department into levels of priorities...

Priority 1...Immediate Care required...

Priority 2...Care required within 15 - 30 minutes...

Priority 3...Care is required within 60 minutes. Condition is acute but not severe. Initial assessment and reassessment documented every 30 - 60 minutes...

Priority 4...Care is required within 120 minutes. Initial assessment and reassessment documented every one hour...

Priority 5... Care is required within 120 minutes. Initial assessment and reassessment documented every two hours...


1.. PI # 14 presented to the ED on 1/17/24 at 12:13 AM with a complaint of difficulty breathing.

Review of the Emergency Patient Record, Triage Assessment, dated 1/17/24 at 12:45 AM revealed a blood pressure (BP) of 101/59, pulse 83, respirations 19, and oxygen saturation (O2 sat) of 99.

Further review of the Triage Assessment completed by EI # 12, Registered Nurse (RN), dated 1/17/24 at 12:45 AM revealed PI # 14 was assigned a triage classification priority of three (3) which, per hospital policy, required care within 60 minutes and reassessments documented every 30 to 60 minutes.

The surveyor was unable to contact EI # 12, for interview.

Review of the Emergency Patient Record, Departure Information, dated 1/17/24 revealed the staff documented PI # 14 did not answer when called at 8:39 AM, which was 8 hours and 26 minutes after the patient arrived at the ED.

There was no documentation the patient was reassessed every 30 to 60 minutes and no documentation a MSE was performed.

In an interview conducted on 3/7/24 at 11:05 AM, Employee Identifier (EI) # 1, Emergency Room Director, confirmed the hospital failed to ensure reassessments were performed and documented per hospital policy and failed to ensure a MSE was performed.

In an interview conducted on 3/7/24 at 1:55 PM, EI # 2, ED Medical Director, stated the reassessments of patients after triage had been an ongoing issue and the department had discussed the issue. EI # 2 stated the problem is with nursing staff shortage and it is a work in progress.

3. PI # 23 presented to the ED on 1/17/24 9:20 AM with a chief complaint of pregnancy and feeling like she wanted to pass out.

Review of the Emergency Patient Record, Triage Assessment, dated 1/17/24 at 9:25 AM revealed the staff documented a BP of 143/91, pulse 99, respirations 18, and O2 sat of 100.

There was no documentation of the gestational age of the fetus.

Further review of the Triage Assessment dated 1/17/24 at 9:25 AM revealed PI # 23 was assigned a triage classification of 3, which required care within 60 minutes and reassessments to be documented every 30 to 60 minutes.

Review of the Emergency Patient Record, Departure Information, dated 1/17/24 revealed the staff documented PI # 23 did not answer when called at 12:05 PM, which was 2 hours and 45 minutes after the patient arrived at the ED.

There was no documentation PI # 23 was reassessed every 30 to 60 minutes per hospital policy and no documentation a MSE was performed.

In an interview conducted on 3/7/24 at 4:00 PM, PI # 23 stated he/she was in the waiting area for a "couple of hours" before leaving and the nurse did not check on him/her while waiting for a room and was not evaluated by the ED doctor. PI # 23 stated he/she is currently 27 weeks pregnant.

In an interview conducted on 3/7/24 at 1:25 AM, EI # 1 confirmed the hospital failed to ensure patient reassessments were performed and documented every 30 to 60 minutes and failed to ensure a MSE was performed.