HospitalInspections.org

Based on interview and record review the facility failed to ensure a medical screening examination (MSE) was completed for one patient (Patient 10) that was seen in the Emergency Department (ED). This failure has the potential to impact and delay the care of patients needing emergent care.

Findings:

On March 7, 2023, at 9:00 a.m., an unannounced visit was conducted at the facility for an EMTALA survey.

On March 7, 2023, at 1:35 p.m., the Director of Quality (DOQ) provided the facility's ED patient log. This log indicated Patient 10 arrived at the Emergency Department on February 20, 2023, at 9:40 p.m., and left without being seen (LWBS) on February 21, 2023, at 12:50 a.m.

On March 7, 2023, at 2:05 p.m., Patient 10's medical record was reviewed with the Assistant Chief Nursing Officer (ACNO). Patient 10's Information Sheet indicated Patient 10 arrived at the Emergency Department on February 20, 2023, at 9:46 p.m., for complaints of bizarre paranoid behavior.

Patient 10's "Daily Focus Assessment Report," dated February 20, 2023, indicated Patient 10 complained of left sided chest pain and rated it a four out of ten.

Patient 10's "Triage Report," dated February 20, 2023, at 9:58 p.m. indicated Patient 10's acuity level was at a three (which meant urgent). The document indicated, "...Brought in by grandmother for complaint of left sided chest pain and bizarre behavior and confusion for one week..."

Patient 10's "Progress Notes Report," dated February 21, 2023, at 2:25 a.m., indicated Patient 10 walked out of the ED around 12:50 a.m. on February 21, 2023.

There was no documented evidence an MSE was conducted on Patient 10.

A concurrent interview was conducted with the ACNO who stated there was no documentation an MSE was conducted on Patient 10. The ACNO stated there was no documentation of physician notes nor physician orders in Patient 10's medical record. The ACNO stated an MSE should have been conducted and documented and there should have been documentation of the physician's notes and orders on Patient 10's record.

On March 8, 2023, at 8:45 a.m., the ACNO was interviewed and stated she was still trying to get a copy of the MSE from the ED's contracted physician group's office. The ACNO stated she has not received a copy of the MSE.

On March 8, 2023, at 2:28 p.m., the Director of Quality (DOQ) provided a copy of Patient 10's "History of Present Illness," signed by Physician 1 and dated March 8, 2023, at 9:43 a.m. The document was observed to have a watermark which read "DRAFT."

The facility's policy and procedure titled, "ESI (Emergency Severity Index) - General Guidelines," dated July 2019, was reviewed. The policy indicated, "...ESI Level Three (Urgent): The patient presents with a condition that could progress to a serious problem requiring emergency intervention..."

The facility's policy and procedure titled, "Triage and Registration of Patients Entering the Emergency Department," dated June 2022, was reviewed. The policy indicated, "...All persons seeking care in the Emergency Department who are not immediately evaluated by a medical provider will be triaged...The Triage Nurse will conduct an appropriate assessment of the patients' condition, sufficient to assign the patient to a triage category...Patients that are assigned a Level 3 (Urgent) will have a rapid medical exam by a health care provider and depending on resources needed, will be placed either in Rapid Medical Examination (RME) or in a bed in the Emergency Department as soon as possible..."

The facility's policy and procedure titled, "Rapid Medical Examination (RME) Work Flow Process Guideline," dated April 2019, was reviewed. The policy indicated, "...Purpose: To improve Emergency Department (ED) patient flow by reducing patient/provider contact time on arrival to the emergency department, utilizing RME to decrease the number of patients that leave without being triaged (LWBT) or seen (LWBS), and reducing ED wait times and average patient length of stays..."