HospitalInspections.org

Based on interview, record review, document review and policy review the Hospital failed to ensure a central log was maintained for each patient that comes to the emergency department (ED). The hospital also failed to ensure an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department (ED) was provided to each patient presenting to the ED to determine whether or not an emergency medical condition (EMC) existed for one of 20 (Patient 1) patient records reviewed from 07/07/20 through 02/21/21.

The cumulative effects of the hospital ED's failure to log and track patients and failure to conduct an appropriate MSE has the potential for all patients to be discharged or leave the ED with an unidentified EMC which may lead to deterioration of the person's condition including death.

Findings Include:

Review of the Hospital's document titled, "Medical Staff Rules and Regulations Manual," dated 02/20/20, showed patient's presenting to the ED for treatment, shall be treated by a member of the ED staff ...a medical screening exam shall be performed by a qualified medical individual on all patients who present for emergency care or are in labor. The exam will include a history, physical examination, and ancillary studies and procedures to determine that an emergency condition does or does not exist or that the patient is stable or can be transferred appropriately. A log of patients who present and who are transferred shall be maintained by the hospital.

Review of the Hospital's policy titled, "EMTALA - Definitions and General Requirements," dated 02/01/16, showed in part, the hospital ...must provide to any individual ...an appropriate medical screening exam ...to determine whether or not an emergency medical condition exists. ...an acute care or specialty hospital with an emergency department provides an appropriate medical screening examination and any necessary stabilizing treatment to any individual ...who comes to the Emergency Department and requests such examination, as required by EMTALA and all Federal regulations and interpretive guidelines...to determine whether or not an emergency medical condition (EMC) exists ...the Chief Executive Officer of the Hospital, the executive officer responsible for the emergency department, and the Emergency Department director are responsible for implementing the EMTALA policies ...each facility must develop and implement state-compliant facility-specific policies regarding the screening and treatment of patients with emergency conditions. These governing policies must support compliance with federal and state regulations. ... Leaving Dedicated Emergency Department (DED) after Triage but before an MSE. If an individual present to the DED and requests services for a medical condition, is triaged and then indicates a desire to leave prior to the MSE ("LPMSE"), the facility should use its best efforts to: ...c. offer the individual further medical examination and treatment as may be required to identify and stabilize an EMC; d. log the individual in the Central Log; e. discuss with the individual the risks and benefits involved in leaving prior to the medical screening and document same; f. ask the patient to sign the Waiver of Right to Medical Screening Examination form; ...

Review of the Hospital's policy titled, "EMTALA-Central Log," dated 02/2019, showed in part, the hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance ...whether he or she left before a medical screening examination could be performed ...whether he or she refused treatment ...or whether he or she was refused treatment.

Review of the Hospital's policy titled, "EMTALA - Medical Screening Examination and Stabilization," dated 05/2017, showed in part, the hospital must perform an MSE to determine if an EMC exists. It is not appropriate to merely "log in" or triage an individual with a medical condition and not provide an MSE.


Review of the Hospital's undated document titled, "Facility Summary of Self-Reported EMTALA Incident," showed EMS rolled the patient ...into the ED ...patient does not put a mask on at the screening station ...the Advanced Practice Registered Nurse (APRN) stated that she would not see the patient if she did not wear a mask ...the triage RN stated that the patient could not wear a mask because she had a medical exemption and could not breathe with a mask on ...the APRN was able to do a quick examination of the patient's ankle to determine that the patient had pulses and her ankle was pink ...the patient stated that she would not put on a mask because she had asthma and chronic obstructive pulmonary disease (COPD- a chronic respiratory disease) ...the APRN stated that she never said she would not care for the patient but that the patient said she did not want to be seen if she had to wear a mask...there is no documentation of an MSE ...there is no documentation of refusal of treatment or leaving prior to medical screening examination (LPMSE) ...a lack of adherence to hospital policy related to initial and repeat vital signs and assessment of ED patient ...withholding examination and treatment based on patients refusal to wear a mask ...situation not elevated per chain of command to resolve.

Review of a document title, "Prehospital Care Report," dated 02/21/21, showed, Patient 1 was taken to the hospital by ambulance with complaint of right foot pain. Upon arrival at 12:14 PM, she was taken into the ED and full report was given to an RN at bedside.

Review of the Hospital's document titled, "Central Log," dated 02/02/21 to 02/28/21, showed Patient 1 failed to be entered on the log upon arrival to the hospital on 02/21/21 at 12:16 PM.

Review of documents provided for Patient 1 showed a face sheet dated 02/21/21 at 12:16 PM and a coding summary document that showed, "left before seen by health care provider."

During an interview/phone call on 03/24/21 at 9:00 AM, Staff G, ED RN, stated that Patient 1 refused to be COVID-19 screened, that she brought the patient a mask, the patient's verbal and body language were strong, security, the police department (PD), the advanced practice registered nurse (APRN) all came in to help her get the patient to put on a mask on and the patient's anger escalated. Staff G stated that she saw another patient come to check in, so she walked away and sometime within that time frame she saw security taking the patient outside. Staff G stated that she did not spend much time convincing the patient to be seen, offer the patient paperwork for leaving against medical advice (AMA) or leaving prior to medical screening examination (LPMSE.)

During an interview on 03/24/21 at 10:20 AM, Staff L, Security Supervisor stated that the patient was argumentative and refused to wear a mask. Staff L was instructed by the triage nurse Staff G, Registered Nurse (RN) "to get the patient out of here, if she will not wear a mask, get her out". Staff L stated that he explained to the patient if you do not put a mask on we will need to ask you to leave and the patient stated that she wanted to be seen, but she could not wear a mask.

The evidence showed the hospital denied the patient a medical screening examination because she was not wearing a mask. There was no evidence that staff intervened on behalf of the patient, or attempted to move her to a safe place in the ED while waiting for an examination. There was no evidence that the hospital offered Patient 1 further medical examination and treatment as may be required to identify and stabilize an EMC or discussed the medical risks associated with leaving prior to the medical screening.

Based on interview, document review and policy review the Hospital failed to maintain a central log for each individual who comes to the emergency department seeking for one of 20 patients (Patient 1.) The hospital's failure to maintain a central log has the potential to create loss of information related to the treatment and disposition of patients.

Findings Include:

Review of a document title, "Prehospital Care Report with EKG," dated 02/21/21, showed, Patient 1 was taken to the hospital by ambulance with complaint of right foot pain. Upon arrival at 12:14 PM, she was taken into the ED and full report was given to an RN at bedside.

Review of documents provided for Patient 1 showed a face sheet dated 02/21/21 at 12:16 PM and a coding summary document that showed, "left before seen by health care provider."

There was no documented evidence that an appropriate MSE was completed and no documentation of the events that occurred while Patient 1 was in the ED or while sitting outside in a wheelchair.

Review of video footage on 03/23/21 at 12:59 PM, with Staff Y, Ethics/Compliance/Privacy and Contract Manager showed at 12:15 PM the ambulance arrived at the ED, and the patient was wheeled in by EMS on a gurney not wearing a mask at 12:16 PM. The patient was in a triage room from 12:16 PM to 12:24 PM (eight minutes), At 12:24 PM, she was wheeled outside and sat in a wheelchair, facing the street, in front of windows that could be seen by the screener/triage desk until 4:44 PM (4 hours and 20 minutes.) At 2:43 PM, the triage RN comes out (2 hours and 19 minutes later) to check on the patient and she walks back into the ED at 2:44 PM (one minute later.) At 4:44 PM, the patient is seen walking back into the ED caring a blanket then back out without the blanket. She then gets into the back seat of a truck and it pulls away at 4:45 PM. The hospital staff failed to obtain patient information to enter into the central log throughout the patient's four hour and 20-minute stay.

During an interview on 03/24/21 at 10:55, Staff BB, Paramedic/ Emergency Medical Service (EMS), stated that they tried to give the nurse report, but she was more worried about the patient not wearing a mask and she did not seemed worried about getting report. The nurse failed to get patient information to enter into the central log from EMS.

During an interview on 03/24/21 at 10:20 AM, Staff L, Security Supervisor stated that he was instructed by the triage nurse Staff G, Registered Nurse (RN), "to get the patient out of here, if she will not wear a mask, get her out". Staff L stated that he explained to the patient again, if you do not put a mask on we will need to ask you to leave, the patient stated that she wanted to be seen, but could not wear a mask.

During a telephone interview on 03/24/21 at 9:00 AM, Staff G, ED, RN, stated that EMS brought Patient 1 past the check in to the triage room. Staff G remembers EMS came up to her to give report and she told them she would get it from the patient. Staff G stated that she thought she could get the patient's information once the patient had calmed down, but when she went outside, one or two times, to check on her, the Patient 1 refused to give her any information.

Review of the Hospital's document titled, "Central Log," dated 02/02/21 to 02/28/21 showed Patient 1 failed to be entered on the log upon arrival to the hospital on 02/21/21 at 12:16 PM.

Based on interview, document review and policy review the Hospital failed to ensure an appropriate medical screening examination (MSE) was completed to determine whether or not an emergency medical condition (EMC) exists for one of 20 patients (Patient 1.) The hospital's failure to ensure a MSE was completed has the potential for patients to be discharged or leave the emergency department with an unidentified EMC which causes delays in necessary stabilizing treatment and may lead to deterioration of the person's condition including death.


Findings Include:


Review of the Hospital's undated document titled, "Facility Summary of Self-Reported EMTALA Incident," showed EMS rolls patient ...into Emergency Department (ED) ...patient does not put a mask on at the screening station ...the APRN stated that she would not see the patient if she did not wear a mask ...the triage RN stated that the patient could not wear a mask because she had a medical exemption and could not breathe with a mask on ...the APRN was able to do a quick examination of the patient's ankle to determine that the patient had pulses and her ankle was pink ...the patient stated that she would not put on a mask because she had asthma and chronic obstructive pulmonary disease (COPD- a chronic respiratory disease) ...the APRN stated that she never said she would not care for the patient but that the patient said she did not want to be seen if she had to wear a mask...there is no documentation of an MSE ...there is no documentation of refusal of treatment or leaving prior to medical screening examination (LPMSE) ...a lack of adherence to hospital policy related to initial and repeat vital signs and assessment of ED patient ...withholding examination and treatment based on patients refusal to wear a mask ...situation not elevated per chain of command to resolve.

Review of a document title, "Prehospital Care Report" dated 02/21/21, showed, Patient 1 was taken to the hospital by ambulance with complaint of right foot pain. Upon arrival at 12:14 PM, she was taken into the ED and full report was given to an RN at bedside.

Review of the Hospital's document titled, "Central Log," dated 02/02/21 to 02/28/21 showed Patient 1 failed to be entered on the log upon arrival to the hospital on 02/21/21 at 12:16 PM.

Review of documents provided for Patient 1 showed a face sheet dated 02/21/21 at 12:16 PM and a coding summary document that showed left before seen by health care provider.

There was no documented evidence in Patient 1's medical record to show that an appropriate MSE was completed or that that staff explained the benefits versus risk of leaving prior to an MSE. There was no documented evidence in the medical record of the events that occurred while Patient 1 was in the ED or while sitting outside in a wheelchair.

Review of video footage on 03/23/21 at 12:59 PM, with Staff Y, Ethics/Compliance/Privacy and Contract Manager showed at 12:15 PM the ambulance arrived at the ED, and the patient was wheeled in by EMS on a gurney not wearing a mask at 12:16 PM. The patient was in a triage room from 12:16 PM to 12:24 PM (eight minutes), At 12:24 PM, she was wheeled outside and sat in a wheelchair, facing the street, in front of windows that could be seen by the ED screener/triage desk, until 4:44 PM (4 hours and 20 minutes.) At 2:43 PM, the triage RN comes out (2 hours and 19 minutes later) to check on the patient and she walks back into the ED at 2:44 PM (one minute later.) At 4:44 PM, the patient is seen walking back into the ED caring a blanket then back out without the blanket. She then gets into the back seat of a truck and it pulls away at 4:45 PM.

During an interview on 03/24/21 at 10:55, Staff BB, Paramedic/ Emergency Medical Service (EMS), stated that they tried to give the nurse report, but she was more worried about the patient not wearing a mask and she did not seemed worried about getting report.

During an interview/phone call on 03/24/21 at 9:00 AM, Staff G, ED RN, stated that the patient came to the ED via EMS, the patient refused to be COVID-19 screened, and Staff G had EMS bring the patient directly into the triage room. Staff G stated that she brought the patient a mask, the patient's verbal and body language were strong, security, the police department (PD), the advanced practice registered nurse (APRN) all came in to help her get the patient to put on a mask on and the patients anger escalated. Staff G stated that she saw another patient come to check in, so she walked away and sometime within that time frame she saw security taking the patient outside. Staff G stated that sometimes the APRN's will perform a medical screening examination (MSE) and dismiss the patient. Staff G remembers asking the patient if she wanted to be seen and the patient told her she did not. Staff G stated that she did not spend much time convincing the patient to be seen, offer the patient paperwork for leaving against medical advice (AMA) or leaving prior to medical screening examination (LPMSE.) Staff G stated that she collaborated with Staff Q, APRN who told her she was not going to fight the patient over foot pain.

Staff G failed to discuss the risks and benefits involved in leaving prior to the medical screening and document same and failed to asked Patient 1 to sign the Waiver of Right to Medical Screening Examination form

During an interview on 03/24/21 at 10:20 AM, Staff L, Security Supervisor stated that the patient was argumentative and refused to wear a mask. Staff L was instructed by the triage nurse Staff G, "to get the patient out of here, if she will not wear a mask, get her out". Staff L stated that he explained to the patient if you do not put a mask on we will need to ask you to leave and the patient stated that she wanted to be seen, she could not wear a mask, and the triage nurse instructed us to get the patient out, so they followed her directions.

During an interview on 03/24/21 at 11:38 AM, Staff M, Security Supervisor stated that the patient refused to wear a mask and Staff G, ED, RN told them they needed get the patient out of here.

During an interview on 03/23/21 at 11:47 AM, Staff GG, Hospital Security stated that if a patient refuses to wear a mask and the nursing staff cannot convince them to wear a mask, security would be called. He stated that all patients presenting to the ED for care must wear a mask and if they refuse they would walk the patient outside.

During an interview on 03/24/21 at 2:39 PM, Staff O, PD, stated that he remembers hearing the nurse telling security the lady needs to go, and she would call to have someone pick the patient up. Staff O clarified there was not a legal issue concerning this patient and he did not have to trespass her off the grounds.

During an interview/phone call on 03/24/21 at 4:15 PM, Staff Q, APRN stated that when the hospital staff asked the patient to wear a mask she became belligerent and loud. Staff Q remembers the patient reported she had ankle pain for 2 weeks, and Staff Q decided it was not a life-threatening emergency. Staff Q told the patient it's the hospital policy wear a mask, the patient stated that she did not want to be treated, she asked to be put in a wheel chair, taken outside and she would call someone to pick her up. Staff Q stated that she did not document anything since the patient was not registered. Staff Q was asked if she ever went outside to check on the patient and perform an MSE, and she stated that she could see the patient was fine, and never went outside to see her since she refused to be patient and wear a mask.

During an interview on 03/24/21 at 4:54 PM, Staff D, ED Nursing Director stated that if a patient refuses to wear a mask we are to escalate the situation through the chain of command, and if the charge nurse needs help the ED manager, house supervisor or administrator on call are available. Staff D clarified if a patient refuses to wear a mask the patient can be placed in a room, staff can wear an N95 mask and still treat the patient. Staff D stated that all patient's need to receive an MSE if they come to the ED.

The hospital failed to perform an appropriate MSE to determine whether or not an EMC existed for Patient 1 and left her sitting in a wheelchair, outside with a blanket, in 50 degree weather, in front of windows where she could be seen by the screener/triage desk for four hours and twenty minutes on 02/21/21.