HospitalInspections.org

Based on policy review, medical record reviews, and staff interviews, the hospital failed to comply with 42 CFR §489.20(l) and §489.24.

The findings included:

The hospital failed to ensure an appropriate medical screening examination was provided within the capability of the hospital's Dedicated Emergency Department (DED) by failing to document discussion of the risks of refusing the medical screening to 3 of 24 patients who presented to the DED requesting care. (Patients #3, 5, 25)

~cross refer to §489.24(a) & §489.24(c), Appropriate Medical Screening Exam - Tag A2406

Based on policy review, medical record reviews security incident report and staff interviews, the hospital failed to document discussion of the risks of refusing a medical screening examination for 3 of 24 Dedicated Emergency Department (DED) patients. (Patients #3, 5, 25)

The findings included:

Review of the "EMERGENCY DEPARTMENT PROCEDURE IN RECEIVING AND TREATING ILL OR INJURED INDIVIDUALS" policy, revised October 2019, revealed "...The purpose of this policy is to establish guidelines for compliance with the Emergency Medical Treatment and Labor Act ....and it's implementing regulations in regards to screening and stabilization of patients .... Refusal to Consent to Examination or Treatment. If an individual refuses to consent to examination or treatment, staff should document the offer of such examination and treatment and inform the individual of the risks and benefits of the examination and treatment. The medical record must contain a description of the examination and/or treatment that was refused by or on behalf of the individual. The Hospital must take all reasonable steps to secure the individual's written informed refusal, which should indicate that the person has been informed of the risks and benefits of the examination and/or treatment. ..."

1. Dedicated Emergency Department (DED) record review, on 09/13/2022, revealed Patient #3, a four (4) year-old, arrived to the DED with a parent on 07/10/2022 at 1018 for "wrist pain". The consent to treat was signed by the parent at 1020. At 1028, "Nursing Annotations" documentation noted "...Pt's (parent) speaking with admin. (administration) nursing supervisor and decided to leave." An "ED Note-Nursing" at 1039 revealed "(parent) took pt out of triage and refused to let ER staff triage pt ..." The "ED Clinical Summary", service date/time 07/10/2022 at 1054, noted "...Discharge Disposition: Left without being seen. ..." Review of "Encounter Information" revealed the Discharge Time was 1025 (7 minutes after arrival). DED record review did not reveal any documentation to indicate the risks of leaving were explained.

Review of a "Security Incident Report" dated 07/10/2022 at 1015 revealed "...At approximately 1015 hours on July 10, 2022 (first and last name) came to the Emergency Room ....requested that...daughter be seen for an injured wrist. After checking in at the screening desk, I asked ....to put a surgical mask on.... refused.... informed the Nurse Supervisor, (name of Security Supervisor), and myself that if....harassed in the future....would call Mr. (name) and hospital administration and file a complaint. The Nurse Supervisor again asked.... (last name) to put on a mask. (Parent) said, 'No'. (Parent) was asked to leave by the nurse supervisor. ..."

Interview with the Nurse Supervisor (Supervisor #1) on 09/13/2022 at 1600 revealed the Supervisor recalled Patient #3. Interview revealed Supervisor #1 was called and told a patient (parent of Patient #3) had been asked to put on a mask and refused and that the parent was making a video recording with a mobile phone and would not quit filming in the ED. Interview revealed Supervisor #1 introduced herself by first name and asked the parent to put on a mask. Interview revealed the parent became "defensive" and said the Security Guard had said the word "f---" in front of the child. Supervisor #1 indicated she told the parent she was not there when that happened and apologized to the parent. The Supervisor stated they (the staff) were going to weigh the patient in case medication was needed and had one arm out of Patient #3's coat before the parent started to leave the ED. Interview revealed her parent was trying to pull her back from the scales. Supervisor #1 stated "I did not ask (the parent) to leave. ..." Interview revealed the supervisor asked the parent to quit videoing inside the hospital and to wear a hospital mask, which could be taken off once inside an ED room. Interview further revealed Supervisor #1 told Patient #3's parent "It is your right to walk out of the hospital but you understand you have not been seen so you are at your own risk if you leave." Interview revealed Supervisor #1 did not document this in the medical record.

Interview on 09/14/2022 at 0855 with Registered Nurse (RN) #2, who wrote the ED note about Patient #3 leaving, revealed RN #2 was training to triage when Patient #3 arrived to the DED. Interview revealed RN #2 did not hear the conversation between the Nurse Supervisor and Patient #3's parent. RN #2 stated that Patient #3 left the ED, the RN asked the Nurse Supervisor what she should do and was told to take the patient out of the system as "left without being seen"and document what happened. Interview revealed RN #2 wrote "decided to leave" because she saw them leave and did not hear anything.

Interview on 09/14/2022 at 1318 with RN #3 revealed she was the Charge Nurse in the ED when Patient #3 arrived. Interview revealed RN #3 heard loud talking in Triage and since RN #2 was new to Triage, she went out to Triage to see if everything was OK. Interview revealed the Nurse Supervisor was there. Interview revealed RN #3 "figured it was a mask issue" because issues with masks "escalate quickly." Interview revealed Patient #3's parent was already determined to leave. Interview revealed RN #3 tried to ask if they could check the child (Patient #3) but stated "I didn't have (the parent's) attention." RN #3 stated Patient #3's parent said they were leaving and they left.

Interview with Security Officer #5 on 09/14/2022 at 1400 revealed there were two officers in the ED at the time of the incident on 07/10/2022. Interview revealed Patient #3's parent went to the ED registration desk and was asked to put on a mask. The parent, per interview, started filming and stated the Security Director said the parent did not have to wear a mask. Interview revealed Officer #5 told the parent a mask was needed and that the parent could not video record in the ED due to private patient information. Interview revealed the Nurse Supervisor and Security Director were called. Interview revealed that Patient # 3's parent kept filming and narrating the recording. Security Officer #5 stated the parent said into the phone as it was taping "(Name) fire this man." Interview revealed Security Officer #5 told Patient #3's parent to "stop harassing me and get out of my face". Interview revealed the parent advanced towards Officer #5 and backed him up against a wall. Security Officer #5 stated they (other staff) were walking behind the parent. Interview revealed the Nurse Supervisor stated if the child (Patient #3) needed to be seen she could be seen at the same time the parent was filming and stating they were being kicked out. Security Officer #5 stated "I did not curse at (the parent)" and further stated he did not hear anyone else curse or use derogatory language. Security Officer #5 stated he did not hear anyone tell the parent to leave.

Interview on 09/14/2022 at 1502 with CNA #6, the individual at the registration desk, revealed the CNA did not recall anything about Patient #3 or her parent.

2. DED record review, on 09/13/2022, revealed Patient #5, a seven (7) year old, was brought to the DED on 05/22/2022 at 1352 with a chief complaint of fever. Review of a Pediatric ED Triage Note, at 1352, revealed " ...Patient came in due to increase in cough, fever and headache. Pt (patient) last dose of Tylenol 1330 today. Motrin last night ....Temperature Oral : 39.1 DegC [Degrees Celsius] (converted to 102.4 DegF [degrees Fahrenheit] (HI).... Peripheral Pulse Rate : 140 bpm [beats per minute] (HI) .... SpO2 [pulse oximetry] 99%. ... " Record review revealed an acuity of 4, less urgent, was assigned. Record review revealed Patient #5 was documented as leaving without being seen by a provider at 1419 (27 minutes after arrival). Record review did not reveal a respiratory rate obtained during triage and did not reveal whether the patient was observed leaving with her parent. Further record review did not reveal any discussion of the risks of leaving without being seen.

Interview on 09/14/2022 at 1440 with RN #7, the nurse who triaged Patient #5, revealed most of the time patients leaving before receiving treatment would come up say they were leaving. In that case, the RN stated, staff tried to find out why, apologize, tell them the risks of leaving and get them to stay. Interview revealed she tried to document this but it "could get overwhelming with the waves of patients we have".

3. DED record review, on 09/13/2022, revealed Patient #25, an eleven [11] year old female, was brought to the DED on 09/11/2022 at 2114. Review of the Triage Note, at 2114, revealed "...pt reports sore throat that started today. Hx [history] of strep. Review revealed vital signs were taken at 2207 and were Temperature 98.4, Pulse 101 bpm, Respiratory Rate 18, Blood Pressure 114/76 and SpO2 98% on room air. DED record review revealed patient #5 was having acute throat pain but did not reveal a pain scale. Review revealed Patient #25 was assigned an acuity of "4 - less urgent." A Beta-Strep Culture was ordered at 2217 and collected at 2236 with a result of the Rapid Beta Strep screen negative. Review revealed a ED Pediatric Assessment was done on 09/12/2022 at 0138 by a RN. Review revealed "...Mouth and Throat Symptoms: Swollen Tonsils. ..." At 0206 vital signs were Pulse 97, Respirations 20, Blood Pressure 118/70, and SpO2 99%. Further record review revealed Patient #25 left the DED on 09/12/2022 at 0222 (4 hours, 5 minutes after arrival). Record review did not reveal if Patient #25 was observed leaving and did not reveal whether the risks of leaving were discussed with the parent.

Telephone interview with the nurse who triaged Patient #25, on 09/15/2022 at 1525, revealed RN #8 remembered the patient. Interview revealed when the patient came in there was quite a wait in the lobby. Interview revealed Patient #25's parent came up to the reception desk and RN #8 assured her they were doing the best they could, that all the providers were tied up and they needed to clean a room in the back. Interview revealed they did get Patient #25 into a room but all the providers were busy. Interview revealed the parent peaked her head out and stated they were going to the pediatrician the next day and they left without being seen by a provider. The RN stated they were there over 4 hours. Interview revealed the parent knew the strep was negative before she left. RN #8 stated she tried to make a note when possible, but when they are "swamped it doesn't get done."