HospitalInspections.org

Based on record review and interview, the facility failed to provide a Medical Screening Examination of a minor at the request of the responsible party within the capability of the hospital emergency department in 1 of 21 sampled patients (Patient #1).

Findings:

Review of the facility's current policy and procedure on EMTALA, documents as follows: "It is the policy of Sweeny Community Hospital that all patients coming to Sweeny Community Hospital requesting emergency services receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Active Labor Act (EMTALA) 42 U.S.C, Section 1395 and all regulations and interpretive guidelines promulgated there under."
MEDICAL SCREENING EXAMINATION: "All patients who present to SCH for emergency medical treatment shall receive an appropriate MSE. Neither the MSE nor necessary stabilizing treatment shall be delayed in order to inquire about the individual's method of payment, insurance status, or in order to obtain prior authorization. Note: Anyone may make the request for an evaluation or treatment. Specifically, A minor (child) can request an examination or treatment for EMC. Hospital personnel should not delay the MSE by waiting for parental consent. If after screening the minor, it is determined that no EMC is present the staff can wait for parental consent before proceeding with further examination and treatment."

Review on 07/11/2013 of the patient's clinical record (demographic data) revealed that on 06/23/2013 at 23:55 Patient #1 presented to the facility's emergency department with chief complaint of pain in her vaginal area. Documentation in the emergency room nurses' notes indicated the following entry: "0030, 16 year old female presents to ER with c/o pain in her vagina, asked her about her parents - stated she lived with her brother. She went in and brought in a young man that had no identification on him. Told her we did not know him and that this was not an emergency and to either bring her parent or follow up with her doctor. Asked her for her mother's phone number but she said she "didn't know it by heart". Review of the patient's demographic data revealed the following notation 06/24/2013, 0030 "Not seen home".

Review of the patient's emergency department clinical record revealed a Patient Authorization Record and Consent for Service which was signed and witnessed on 06/23/2013. Signature unknown. Review of the patient's emergency room clinical record revealed no indication that the patient was triaged or medically screened by a medical practitioner from the facility.
There was no evidence that the patient was assessed by the facility's emergency room staff. Review of the patient's clinical record (emergency department log) revealed an entry that the patient had visited the facility's emergency department on 06/23/2013.

Further review of the patient's clinical record (emergency department record) revealed no evidence that the patient was triaged and that a baseline of the patient's vital signs (temperature, pulse respiration and blood pressure) was obtained. There was no indication in the record that the patient's pain level was evaluated by the facility's staff. The patient presented with complaint of vaginal pain.

Return Visit to Facility:
Review of the patient's clinical record dated 06/24/2013 revealed documentation on a triage form dated 06/24/2013, which indicated that the patient returned to the emergency room on 06/24/2013 at 10.59 a.m. with chief complaint of pain in her vaginal area. The Nursing Triage Assessment documented that the patient was experiencing pain at 9 out of 10, on a scale of 0/10. The patient was administered Narco 10 mgs ? orally in the emergency room.
A urinalysis was done which showed the presence of epithelial bacteria 1+, and 3 + leukocyte. A medical screen was done by the attending physician on duty. The clinical impression included diagnosis of Vaginitis and Herpes Genitalis. A prescription was written by the physician for antibiotic of Flagyl 500 mgs twice daily, Monistat cream, Valtrex 1 gram orally twice daily, Narco 5 mg every 6 hours when necessary for pain and follow up visit with the gynecologist in 2-3 days.

The clinical record (Exit Care/Discharge Summary) revealed the patient was discharged from the facility on 06/24/2013 at 12.00 p.m. to her residence.

INTERVIEWS:

Compliance Officer:
During an interview on 07/11/2013 at 9:36 a.m. with facility's Compliance Officer, she stated that in general she gets a report on all patients who visit the facility's emergency department, who left without being seen, left against medical advice and all patients medically screened, to determine the appropriateness of the medical screen. She said on 06/24/2013 she reviewed the record of Patient #1 and at that time she made a determination that the patient was not triaged or medically screened on her visit to the facility's emergency department. She then self-reported the findings to the State Agency. She said after making the determination that the patient was not triaged or medically screened, she instructed the registered nurse involved in the patient's care to telephone the patient and request that the patient return to the hospital. She said the patient returned to the facility the following morning after the incident and was medically screened and treated by a physician.

Clinical Director of Emergency Room:
During an interview on 07/11/2013 at 1:10 p.m. with the facility's Emergency Department Clinical Director revealed she became aware that the patient was present in the emergency room on 06/23/2013. She said the registered nurse who was assigned to the patient called her at home via the telephone and informed her that there was a minor present in the emergency room with presenting symptom of vaginal pain. The Registered Nurse informed her that there was no parent present but there was a young man who the patient claimed was her brother and that she lived with him. The nurse told her that the young man did not have any form of identification and that she had no way of proving that it was the patient's brother. The Clinical Director said she instructed the Registered Nurse assigned to the patient to go ahead and triage the patient, put her in a room and have the physician do a medical screen on the patient.

She said the following day when she arrived at the facility she reviewed Patient #1's clinical record and at that time she became aware that the patient was not triaged or provided with a medical screen. The Clinical Director said she placed a call to the patient at home and requested her to come back to the facility.

The Clinical Director said she had a meeting with the Registered Nurse who was assigned to the patient. She was told by the nurse that she did not triage the patient because there was no parental consent.

The Clinical Director said she has not had a formal in-service with the emergency room staff but that she met with staff in groups and discussed the scenario.

Registered Nurse (A):
During an interview on 07/12/13 at 8:17 a.m. with Registered Nurse (A) who was the registered nurse assigned to Patient #1 on 06/23/2013 when she presented to the facility's emergency department, revealed the following: Registered Nurse (A) said on the night of Patient #1's visit to the facility's emergency department she was one of the nurses on duty. She said the registration clerk notified her that she had registered a 16 year old minor but there was no parent available for consent. Registered Nurse (A) said she did not know what to do but she brought the patient into the triage area and at that time told her that she needed a parent to treat her. She said Patient #1 told her that she lived with her brother. The patient then left the room and returned with two young men, one of whom she identified as her brother. The young man did not have any form of identification. She then asked her for her mother's telephone number, since she needed her mother's permission to treat her. The patient told her she did not know her mother's telephone number. Registered Nurse (A) said she asked the patient if she was bleeding or pregnant and the patient told her no. Registered Nurse (A) stated "I just thought without a parent's consent we could not treat her."

During the interview the Surveyor asked Registered Nurse (A) if she had been in-serviced on the EMTALA rules and the requirements for medical screening. Registered Nurse (A) said she was in-serviced by the facility on the EMTALA rules but she could not recall when she received the in-service. She stated "Anybody that comes to the emergency department has to be medically screened."

Registered Nurse (A) said she called her Nursing Director at home and the Nursing Director instructed her to triage the patient. She said she spoke to the patient but she did not triage the patient, did not obtain vital signs (temperature, pulse, respiration, and blood pressure) on the patient. She said she did not assess the patient's pain level and on a scale of 0-10 she was not aware of the patient's pain level during her visit to the emergency department..

The Surveyor asked Registered Nurse (A) if a medical screen was performed on the patient. She said there was no medical screen done on the patient. She said the physician on duty was present in the emergency department but she cannot recall if the physician was aware that the patient was present in the emergency department.

ER Medical Doctor:
On 07/12/2013 at 10.10 a.m. during interview with the facility's Medical Doctor revealed he was on duty on 06/23/2013 when Patient #1 presented to the emergency department. He said he did not actually make contact with the patient, but heard and was informed by the nurse that there was a 16 year old minor present with pelvic pain. He said the facility staff told him that facility staff were trying to make contact with one of her parents to obtain consent for treatment.

He said while having a conversation with the registration clerk he caught a glimpse of the patient leaving the facility. He said he thought the patient left because of sheer frustration of not being able to contact her parent. The Medical Doctor said he was never asked by facility staff to conduct a medical screen on the patient. He said generally all patients are taken to the triage area and once the patient is triaged, then he is requested to perform a medical screen on the patient.