HospitalInspections.org

Based on policy review, complaint log review, ED log review, complaint investigation report review, medical record review, and staff interview, it was determined the facility failed to ensure a complete and accurate ED log. This resulted in the potential of 1 of 32 patients (Patient #32) being turned away from the ED and not being included on the ED log. It also resulted in 1 of 32 patient's (Patient #7) disposition being documented incorrectly. This had the potential to affect all patients presenting to the ED for emergency care. Findings include:

1. A facility policy titled, "Patient Triage / Left Without Being Seen," approved 12/20/21, stated, "All patient presenting to the ED or Hospital seeking medical attention without a scheduled appointment will be registered into the EMR [electronic medical record] and logged into the ED Central Log Book." This policy was not followed. An example includes:

Complaint logs for the ED were reviewed. A complaint regarding Patient #32 dated 1/03/23 from a local physician stated, "Phone call from [Physician name] concerning care of patient seen by [Physician B] in the ED. Stated that patient was experiencing significant pain. Patient's daughter told [Physician name] that [Physician B] met the patient at the door and stated there was nothing we could do for her and advised her to go to [different hospital]. Stated concern that patients are not being treated in the ED as noted by this occurrence. Recommended contacting patient's daughter for additional information."

The ED log was reviewed, and documented Patient #32 presented to the ED on 12/20/22 and 12/22/22. There was no record of Patient #32 presenting to the ED between 12/22/22 and 1/03/23.

The investigation report into the incident regarding Patient #32 was reviewed. The investigation stated Patient #32 was seen in the ED on 12/20/22 and 12/22/22 and stated, "I have no other documentation of this patient arriving at a later date and no documentation from [Physician B] that he saw the patient ... unsure of the date or time the patient arrived and [Physician B] had discussion with the patient ... chart sent to risk for follow up." The "Follow Up" portion of the investigation stated, "CEO aware of situation. No documentation present ... Primary physician called about his patient not being treated in the ED. Spoke with CEO ... CEO to address with ED physician." There was no additional information provided in the investigation. There was no documentation of a conversation with Physician B about the incident.

The CEO was interviewed on 5/24/23 beginning at 9:06 AM and the complaint about Patient #32 and the investigation regarding the incident was reviewed with him. When asked if there was any follow up with Physician B regarding the incident, he stated he did not know. He stated, "I don't recall addressing that with [Physician B] directly. I think [Physician A, the Medical Director of the facility] followed up," and, "whatever's in the occurrence report was what happened." When asked if it occurred to him that this could have been a potential EMTALA violation he stated, "yes."

Physician A was interviewed on 5/24/23 beginning at 10:05 AM and the complaint about Patient #32 and the investigation regarding the incident was reviewed with him. When asked if he was aware of the incident he said he did not recall it. When asked if anyone had spoken to him regarding the incident, he said the CEO spoke to him about it the morning of 5/24/23. When asked if this could have been a potential EMTALA violation he said, "yeah." He stated as Medical Director he wanted to be aware of incidents like this.

Physician B was interviewed on 5/24/23 beginning at 10:48 AM and the complaint about Patient #32 and the investigation regarding the incident was reviewed with him. After reviewing the incident, Physician B stated, "I've never ever met someone at the door and told them to go to [a different hospital]." When asked if anyone talked to him about the incident, he said he did not know.

The facility failed to ensure a potential EMTALA incident was fully investigated to ensure all patients presenting to the ED were not turned away and were included on the ED log. It was unclear why the investigation stopped when it was discovered Patient #32 was not in the ED log after 12/22/22. If Patient #32 was turned away from the ED, it was unclear if she would have been included on the ED log. It was unclear why the incident was not discussed with Physician B to determine what happened with Patient #32.

2. A facility policy titled, "Patient Triage / Left Without Being Seen," approved 12/20/21, stated, "If a patient chooses to leave after the triage assessment and before the medical screening exam by the physician, the stay will be classified as Left Without Being Seen."

Patient #7 was a 21 month old male who presented to the ED on 4/16/23 with chief complaint of cough and fever.

Patient #7's medical record included an addendum by Physician A which stated, "Medical screening exam performed by myself. 21-month-old male presents to the emergency department brought in by mother and father with chief complaint of cough and fever. They report the symptoms started recently. Parents report that they were instructed to come to this emergency department for initial work-up after having discussions with their oncology team ... They stated they want to make sure that patient was breathing adequately for transfer to [other hospital] which is their primary goal ... On exam patient is breathing comfortably in the emergency department lobby. He has no retractions ... Patient appears stable to continue onto their primary location of [other hospital]. Parents decline additional evaluation at this facility and will have the full work-up performed at [other hospital] when they get there."

Patient #7's record included an additional addendum by the Paramedic which stated, "Mother stated that pt had been making some grunting noises occationally [sic] when breathing after coughing ... Stated oncologist was concerning about grunting noises. Pt appeared to have ronchi cough, no obvious grunting noises or signs of respiratory distress ... I spoke with [Physician A] and he came to waiting room to assess pt. Pt's mother and father decided to go straight to [other hospital] after pt's respiratory effort was assessed by [Physician A] in waiting room. Medical Screening Exam Release Form was signed, with [Physician A] explaining that no bill would be generated by SMC [Shoshone Medical Center]."

Patient #7's medical record included a form titled, "Medical Screening Exam Release," which was signed by Patient #7's representative. The form stated, "I've been informed of my right to receive a medical screening exam to rule out an emergency medical condition regardless of my ability to pay but I have chosen to decline the medical screening exam, or further evaluation, treatment or transfer ... By signing below, I acknowledge that the hospital cannot rule out an emergency medical condition without a medical screening exam and my condition may worsen." It was unclear why the form was signed despite Physician A assessing Patient #7.

The ED log was reviewed and Patient #7's disposition was documented as left without being seen. It was unclear why Patient #7 would be documented as left without being seen after he was seen by Physician A and the Paramedic.

Physician A was interviewed on 5/24/23 beginning at 10:05 AM and Patient #7's record was reviewed with him. When asked what Patient #7's disposition was he stated it was a discharge. When asked why it was documented as left without being seen he stated it was because they had limited ways of documenting in the electronic medical record. When asked if it was possible to document a patient's disposition as discharged, he said it was.

The facility failed to ensure Patient #7's disposition was correctly documented in the ED log.

Based on policy review, record review, ED log review, guidelines review, and staff interview, it was determined hospital staff failed to ensure the MSE was sufficient to determine whether an EMC existed for 4 of 32 patients (Patients #2, #7, #21, and #16) whose records were reviewed. This put all patients presenting to the ED for emergency medical care at risk for a negative outcome. Findings include:

1. A facility policy titled "Triage," approved 7/12/22 stated, "the triage nurse should determine the following information during the triage assessment: ... vital signs which include ... respiration rate, oxygenation." This policy was not followed. An example includes:

Patient #7 was a 21 month old male who presented to the ED on 4/16/23 with chief complaint of cough and fever.

Patient #7's medical record included an addendum by Physician A which stated, "Medical screening exam performed by myself. 21-month-old male presents to the emergency department brought in by mother and father with chief complaint of cough and fever. They report the symptoms started recently. Parents report that they were instructed to come to this emergency department for initial work-up after having discussions with their oncology team ... They stated they want to make sure that patient was breathing adequately for transfer to [other hospital] which is their primary goal ... On exam patient is breathing comfortably in the emergency department lobby. He has no retractions ... Patient appears stable to continue onto their primary location of [other hospital]. Parents decline additional evaluation at this facility and will have the full work-up performed at [other hospital] when they get there."

Patient #7's record included an additional addendum by the Paramedic which stated, "Mother stated that pt had been making some grunting noises occationally [sic] when breathing after coughing ... Stated oncologist was concerning about grunting noises. Pt appeared to have ronchi cough, no obvious grunting noises or signs of respiratory distress ... I spoke with [Physician A] and he came to waiting room to assess pt. Pt's mother and father decided to go straight to [other hospital] after pt's respiratory effort was assessed by [Physician A] in waiting room. Medical Screening Exam Release Form was signed, with [Physician A] explaining that no bill would be generated by SMC [Shoshone Medical Center]."

Patient #7's medical record included a form titled, "Medical Screening Exam Release," which was signed by Patient #7's representative. The form stated, "I've been informed of my right to receive a medical screening exam to rule out an emergency medical condition regardless of my ability to pay but I have chosen to decline the medical screening exam, or further evaluation, treatment or transfer ... By signing below, I acknowledge that the hospital cannot rule out an emergency medical condition without a medical screening exam and my condition may worsen." It was unclear why the form was signed despite Physician A assessing Patient #7 in the lobby.

According to the ED log, Patient #7 arrived at 16:05. There was no triage time. The departure time was 16:12. Patient #7's total time spent in the ED from check-in to departure was 7 minutes.

There was no assessment of vital signs, including respiratory rate and oxygen level, for Patient #7. It was unclear how Physician A determined an EMC did not exist without vital signs.

Physician A was interviewed by phone on 5/24/23 beginning at 10:05 AM and Patient #7's record was reviewed with him. When asked why there were no vital signs he stated, "I don't have the answer." When asked if the respiratory assessment would include vital signs he stated, "yes often times that does." When asked about the "Medical Screening Exam Release" form included for Patient #7, Physician A stated the form was signed incorrectly.

The Paramedic who assessed Patient #7 was interviewed on 5/24/23 beginning at 11:15 AM and notes for Patient #7 were reviewed in her presence. When asked why the "Medical Screening Exam Release" form was signed for Patient #7, she stated Physician A said the form was needed.

It was unclear how Physician A determined an EMC did not exist without performing vital signs. Additionally, it was documented Physician A performed the MSE, however a form releasing the facility from providing an MSE was signed by Patient #7's representative.

2. According to Nationwide Children's Hospital, accessed 5/30/23, "During pregnancy, you might feel lightheaded or dizzy. There are a couple of reasons why this can happen. Your blood pressure is lower. Plus, your growing uterus can press on and block the large vein carrying blood to your heart. In either case, this reduces the blood supply in your brain. Low blood sugar and low iron can also be factors."

Patient #2 was a 26 year old pregnant female who presented to the ED on 5/16/23 with a chief complaint of dizziness. Her record stated, "26-year-old female presents to the emerged [sic] department by private vehicle with chief complaint of dizziness. Patient reports she was at work ... when she felt lightheaded and had difficulty with mentation. Patient reports these symptoms have resolved. She does report slight headache at this time. Patient is 5 months pregnant." The section titled, "PROGRESS AND PROCEDURES" was left blank. Patient #2 was discharged from the ED.

There was no diagnostic treatment for Patient #2. It was unclear how Physician A determined an EMC did not exist without diagnostic treatment.

According to the ED log, Patient #2 arrived at 13:31, was triaged at 14:07, and was discharged at 14:23. Her total time from triage to departure was 16 minutes.

Physician A who treated Patient #2 was interviewed by phone on 5/24/23 beginning at 10:05 AM and Patient #2's record was reviewed with him. When asked why there was no assessment of Patient #2's unborn baby, including fetal heart tones, he stated there wouldn't be any need for that since she had no bleeding, pain, or cramping. When asked why there was no lab draw or blood glucose assessment, he stated Patient #2 was eating and drinking, and if she was hypoglycemic, she would show symptoms. He stated there would have been nothing useful if labs were drawn on Patient #2.

It was unclear how Physician A determined an EMC did not exist for Patient #2 without diagnostic treatment.

3. Patient #21 was a 14 year old male who presented to the ED on 12/06/22 with a chief complaint of cough and wheezing.

Patient #21's medical record included a note from the Physician A which stated, "Course of care: ( Patient's [sic] had cough for the last 2 to 3 days. No fever, chills, vomiting, diarrhea. Patient appears well. Lungs are clear to auscultation bilaterally on exam. Patient likely has a benign process. Patient's had multiple sick contacts at school. Mother notes that other children at school had had about [sic] RSV [respiratory syncytial virus]. All questions answered mother prior to discharge. She agrees with discharge plan.). [sic]" There was no treatment or diagnostics for Patient #21 to treat or determine the cause of his cough, and Patient #21 was discharged.

According to the ED log, Patient #21 arrived at 21:12, was triaged at 21:14, and was discharged at 21:32. His total time from triage to departure was 18 minutes.

Physician A was interviewed by phone on 5/24/23 beginning at 10:05 AM and Patient #21's record was reviewed with him. When asked why he would not test Patient #21 for RSV due to having an RSV exposure, he stated the test result would not change anything for the patient.

It was unclear how Physician A determined an EMC did not exist for Patient #21 without diagnostic treatment.

4. Patient #16 was a 16 year old female who presented to the ED on 4/14/23 with a chief complaint of chest pain.

Patient #16's medical record included a note from Physician A which stated, "16-year-old female presents to the emerged [sic] department by private vehicle brought in by father with chief complaint of chest pain. Patient reports she has had ongoing chest pain for the last 2 days ... Physical exam patient appears well. No acute distress resting comfortably in bed sitting upright. She is breathing normally and speaking in full sentences. No retractions. She had generalized tenderness to her chest wall with palpation ... Patient likely has a benign process for her chest discomfort." There was no treatment or diagnostics for Patient #16 to treat or determine the cause of her chest pain, and Patient #16 was discharged.

According to the ED log, Patient #16 arrived at 18:49, was triaged at 18:55, and was discharged at 19:15. Her total time from triage to departure was 20 minutes.

Physician A was interviewed by phone on 5/24/23 beginning at 10:05 AM and Patient #16's record was reviewed with him. When asked why no diagnostics were done for Patient #16 he stated it was not needed. He stated it would be different if it was an older male presenting with chest pain.

It was unclear how Physician A determined an EMC did not exist for Patient #16 without diagnostic treatment.