HospitalInspections.org

Based on Hospital EMTALA (Emergency Medical Treatment and Active Labor Act) inservice, Medical Staff By-Laws, policy review, medical record review, video footage review and interview, the hospital failed to ensure no delay in examination or treatment by not performing pain assessments and not administering pain medication as ordered for pain for 1 of 2 (Patient #22) sampled patients who presented to the Emergency Department (ED) with a complaint of abdominal or pelvic pain and were less than 20 weeks gestation.

Refer to A-2408

Based on Hospital EMTALA (Emergency Medical Treatment and Active Labor Act) inservice, Medical Staff By-Laws, policy review, medical record review, video footage review and interview, the hospital failed to ensure no delay in examination or treatment by not performing pain assessments and not administering pain medication as ordered for pain for 1 of 2 (Patient #22) sampled patients who presented to the Emergency Department (ED) with a complaint of abdominal or pelvic pain and less than 20 weeks gestation.

The findings included:

1. Review of the facility's "EMTALA ESSENTIALS: For All Staff at [Corporation #1]-Affiliated Hospitals" powerpoint presentation used for annual medical staff training revealed, "...Emergency Medical Treatment and Labor Act... A Federal Law requiring Medicare participating hospitals to provide a Medical Screening Exam (MSE) and stabilizing treatment(s) for anyone that presents to the hospital's dedicated emergency department requesting care..."

Review of the hospital's "Medical Staff Rules & [and] Bylaws" revealed, "...Emergent patients are defined as patients who meet the following Emergency Medical Treatment and Active Labor Act (EMTALA) criteria for having an "emergency medical condition"...A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain...) such that the absence of immediate medical attention could reasonably be expected to result in: 1) Serious jeopardy to the health of the individual (or, with respect to a pregnant woman, to the health of the woman or her unborn child)...Patients who present to the Emergency Room (ER) and are assessed as emergent patients will be evaluated and treated immediately by Emergency Department (ED) physicians..."

Review of the hospital's "EVALUATION AND TREATMENT OF PREGNANT PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT" policy revealed, "...PROCEDURE/SPECIAL INSTRUCTIONS...Pregnant women presenting to the ED who are less than 20 weeks gestation remain in the ED for treatment including incomplete abortion (when applicable)..."

Review of the hospital's "Standard Times of Administration" policy revealed, "...Medications will be administered to patients according to the administration times and guidelines set forth in this policy...STANDARD ADMINISTRATIONS TIMES AND DESCRIPTIONS...STAT... Description... Immediately... Times... Medication will be sent within 15 minutes of pharmacy receipt of order..."

Review of the hospital's "ADMINISTRATION OF MEDICATIONS: GENERAL GUIDELINES AND PATIENT IDENTIFICATION" policy revealed, "...Medication is administered using the "Five Rights" approach... c) Right time..."

Review of the hospital's "PAIN MANAGEMENT PROGRAM" policy revealed, "...Healthcare professionals will be educated about pain management, demonstrate at least basic pain assessment skills, and provide pain interventions in a prompt, caring fashion...Patients will be assessed for presence, absence, and history of pain...Pain intensity and pain, as reported by the patient, will be assessed and documented...Patients should be reassessed routinely for pain within one hour of intervention..."

2. Medical record review revealed Patient #22 presented to the ED on 2/23/17 at 6:36 AM and was triaged at 7:08 AM with chief complaint of 15 weeks pregnant, cramping and bleeding for 2 days, worse since last night, bleeding has progressed to bright red, patient is G1P0 (gravidity and parity is number of times a female is or has been pregnant [gravity] and carried the pregnancies to viable gestational age [parity]). She was assigned an ESI (Emergency Severity Index) score of 3 (non-high risk but requiring many resources). There was no documentation of the patient's pain level. The MSE (Medical Screening Exam) was initiated at 7:11 AM by MD (Medical Doctor) #2 who documented, "This is a 42-year-old female with a past medical history significant for the fact that she is G1P0 ...who presents to the emergency room with 2 day history of pelvic pain and vaginal bleeding. The patient states that started 48 hours ago, she developed some very mild bilateral pelvic cramping and light vaginal spotting. She states her pelvic cramping increased last night, as well as the vaginal bleeding. She states it is moderate ...She's been seen 3 times by her obstetrician and as far she know, there are no complications..." Review of the ED physician's physical examination revealed, "...Scant amount of vaginal blood in the vaginal vault. The OS [orifice of the uterus] is closed..." Review of the pelvic ultrasound performed at 8:16 AM revealed, "...Impression: 1. Intrauterine pregnancy is identified without fetal heart tones or fetal motion consistent with fetal demise. Recommend clinical follow-up. 2. Uterine masses are consistent with fibroids." At 9:50 AM, the ED physician documented, "...went back and spent 10 minutes with the patient. I explained that her ultrasound mostly showed fetal demise. I explained she would need a shot of Rogan. She needs to see her doctor either this afternoon or tomorrow...She was given strict return precautions for increased bleeding, increased pain, or any other new or unusual symptoms..." A discharge order was placed at 9:54 AM.

3. Medical record review revealed Patient #22 presented to the ED on 2/24/17 with a chief complaint of pelvic pain. Patient #22 arrived in the ED at 8:21 AM and was triaged at 8:32 AM by Nurse #2. Nurse #2 did not document a pain assessment. Qualified Medical Personnel (QMP) #1 documented, "...Seen initially from triage and then in room...This patient...is 15 weeks pregnant...presents [to] the emergency department with pelvic pain...She was seen here [ED] yesterday and had an ultrasound that showed an intrauterine pregnancy with fetal demise...she was told she was having a miscarriage and was told to come back if she had any increase in pain...She tells me she has not slept all night and she has had severe pelvic pain and cramping..." The Registered Nurse Assessment performed by Nurse #1 on 2/24/17 at 11:13 AM revealed Patient #22 reported pain in the bilateral lower abdominal and pelvic region and rated her pain as a 10 (worst possible pain) on a 1-10 scale (first and only documented pain assessment during ED visit) and affect/behavior was crying and restless.

A physician's order dated 2/24/17 documented morphine 4 mg (milligram) was ordered IV (intravenous) push STAT (instantly/immediately) at 10:22 AM. The morphine was administered at 11:30 AM, 68 minutes after it was ordered STAT. A second dose of morphine 4 mg IV push was ordered by QMP #1 at 11:31 AM and administered by Nurse #1 at 11:37 AM. There was no documentation for the reason the second dose of morphine 4 mg IV push was ordered 1 minute after the first dose was administered. Nurse #1 documented Patient #22 continued to have pain at 12:00 PM but did not document an assessment of the pain. Patient #22 left the ED and was transported to the operating room (OR) on 2/24/17 at 12:07 PM for a Dilation and Curettage.

4. Review of video footage (no audio) from the ED waiting room revealed Patient #22 entered the ED on 2/24/17 at 8:16 AM (time of video footage) and walked to a chair across from the front desk. Patient #22's ambulation was slow and guarded. Patient #22 was accompanied by a male. At approximately 8:30 AM, Nurse #2 assisted Patient #22 to a wheelchair and escorted her down the hall toward the triage room and back to the waiting room at 8:36 AM. The male pushed Patient #22 in the wheelchair down the hall toward the ED at 9:39 AM and then back to the waiting room at 9:45 AM. The male pushed Patient #22 in the wheelchair down the hall toward the ED at 10:14 AM, and there was no further video footage of Patient #22 in the waiting room. Throughout the video footage, Patient #22's movements were slow and guarded. Patient #22 was often slightly slumped over in the wheelchair, and the male who accompanied her patted her hand or arm and rubbed her back at times.

5. During an interview in the ED on 3/13/17 at 4:20 PM, QMP #1 stated she had briefly seen the patient in triage for abdominal and pelvic pain and brought her back to one of the fast track rooms for lab work. QMP #1 stated the patient looked like she was in pain. She stated the patient was sent back to the waiting room because there were no rooms available in the ED at that time. QMP #1 confirmed she ordered morphine 4 mg IV push for pain but was unaware of when the medication was administered. QMP #1 stated she could not remember the circumstances around ordering the second dose of morphine on 2/24/17 at 11:31 AM for Patient #22.

During an interview in the conference room on 3/13/17 at 12:18 PM, the Chief Quality Officer stated the medical staff at the hospital was inserviced about EMTALA using the tool, "EMTALA ESSENTIALS: For All Staff at [Corporation #1]-Affiliated Hospitals," when physicians began working at the hospital and annually. The last annual inservice with this presentation for the medical staff was on 7/27/16.

During an interview in the conference room on 3/14/17 at 12:55 PM, the Interim Director of Emergency Services provided a written copy of "Priority Patients for Reassessment" guidelines which she used for ED patients. The document revealed patients with severe pain (number rating 8 or higher) should be reassessed. The Interim Director of Emergency Services stated staff should assess each patient's pain at triage, after any pain intervention and at time of discharge.

During an interview in the conference room on 3/14/17 at 1:23 PM, the Interim Director of Emergency Services stated all medications in the ED were ordered STAT. The Interim Director of Emergency Services was unable to provide a time frame for the administration of STAT medications.

During an interview in the conference room on 3/15/17 at 11:26 AM, Nurse #1 confirmed Patient #22 rated her pain as a 10 on a 1-10 scale on 2/24/17 at 11:13 AM. Nurse #1 confirmed QMP #1 ordered morphine 4 mg IV push STAT on 2/24/17 at 10:22 AM, and he administered the medication on 2/24/17 at 11:30 AM.

The hospital's failure to perform pain assessments and administer pain medication as ordered resulted in a delay in the treatment of Patient #22's pain.