HospitalInspections.org

Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires that hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by:

The hospital failed to ensure an appropriate medical screening examination was provided for 1 (#3) of 23 sampled ED records. This was evidenced by failure of the Emergency Department Practitioner to assess the patient's use (amount, frequency and duration) of narcotic medications and assess the patient's need for medical supervision of narcotic withdrawal (see findings in A-2406).

Based on record review and interview, the hospital failed to ensure an appropriate medical screening examination was provided for 1 (#3) of 23 sampled ED records. This was evidenced by failure of the Emergency Department Practitioner to assess the patient's use (amount, frequency and duration) of narcotic medications and assess the patient's need for medical supervision of narcotic withdrawal. Findings:

Review of the hospital policy titled Medical Screening Exam, provided by S4ED Manager as current, revealed in part the following:
A Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. The determination of whether an emergency medical condition (EMC) exists is made by the examining physician and/or QMP (Qualified Medical Person)....
Medical Screening Exams should include at a minimum the following:
History
Physical exam of affected systems and potentially affected systems
Exam of known chronic conditions
Notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary
Vital signs upon discharge or transfer
Complete documentation of the medical screening exam.
A medical screening examination is not an isolated event. It is an ongoing process. The record must reflect continued monitoring according to the patient's needs until he/she is stabilized, admitted or appropriately transferred.

Patient #3
Review of the ED record for Patient #3 revealed the patient was a 34 year old male who presented to the ED on 10/19/15 at 3:35 p.m. Review of the Emergency Department Triage Form dated 10/19/15 at 3:45 p.m. revealed the chief complaint was as follows: Patient to ER with withdrawal from Morphine and Norco --History Cervical Spine Disc Disease and states someone broke into home and stole meds, off meds X 3 days. Vital Signs: Temperature: 98.1, Pulse: 100, Respirations: 20, Blood Pressure: 130/80, Pain: 5, O2 Saturation: 98 %. Arrived from home, ambulatory. Triage Class: III - Urgent. Directly to ED Room. Triage Nurse Signature: S10RN.

Review of the Fast Track Nursing Assessment, Interventions, & Nurses Notes dated 10/19/15, documented by S5RN and S6RN revealed the following:
4:45 p.m. - To ER Fast Track for exam.. No obvious distress noted.
5:50 p.m. - 22 Gauge Jelco to right hand with one attempt after alcohol prep. Good blood return and flushes easily.
6:30 p.m. - Patient states that he is unable to urinate.
7:00 p.m. - 2nd liter fluids added to existing IV site. Ativan given for shaking and anxiety.
8:40 p.m. - IV discontinued with tip intact.
8:50 p.m. - Discharge instructions given to patient and attendant. Verbalized understanding. Discharged to home via private auto with attendant.

Review of the Medications section of the form revealed the following:
5:50 p.m. - 1 liter NS bolus IV. Completed 16:55 p.m.
5:50 p.m. - Zofran 8 mg. IVP. 8:20 p.m. nausea, pain pre - 5, pain post - 1.
7:00 p.m. - NS 1 Liter bolus IVP. 8:10 p.m. completed.
7:00 p.m. - Ativan 1 mg. IVP. 7:30 p.m. partial relief.
8:10 p.m. - Lomotil 1 mg. PO.
8:10 p.m. - Ativan 1 mg. IVP. 8:40 p.m. calm.
10/19/15 at 8:50 p.m. Condition Stable.
Review of the nurses' documentation revealed no documented evidence that the patient's vital signs were checked after medication administration or at discharge. There was no documented evidence that the patient's pain (Rated 5 at triage) was re-assessed during the ER visit. There was no documented evidence of how the patient left the ED.

Review of the Emergency Physician Record dated 10/19/15 and documented by S7APRN revealed the following:
A T-System form for "Miscellaneous Complaint/General Adult" was used for this patient.
10/19/15 - Time seen: 5:15 p.m. Historian: patient.
Review of the section titled HPI (History of Present Illness) revealed the following:
Chief complaint: Withdrawals from narcotics, diarrhea, abdominal pain, nausea, restlessness. Onset: 3 days ago.
Timing: Still present.
Severity (blank).
Modifying factors: (blank)
Context: States someone stole his Morphine and Norco out his house on Saturday. Sees pain management for chronic neck pain. Quality (blank). Location: (blank).
Similar symptoms previously: (blank)
Recently seen/treated by doctor/hospitalized.... (blank).
ROS (Review of Systems): abdominal pain, nausea, diarrhea, weakness and anxiety. Problems urinating was not checked or circled.
Past History: Herniated Disc in neck. No surgeries or procedures. There was no documented evidence of an assessment of the patient's mental health history.
"Med list reviewed" was circled.
Social History: Smoker 1 ppd, no drugs or alcohol. Occupation and living situation was left blank.
Physical Exam: alert, anxious was checked, and "no acute distress" was not checked.
Abdomen/GU: tenderness mild, diffuse. Normal bowel sounds, no distention.
Skin: cyanosis, pallor. Warm, dry, intact.
Neuro/Psych: Oriented X 4, Cranial Nerve's normal, motor normal, sensation normal, mood/affect normal.
EKG: reviewed at 5:55 p.m., rate 106, normal ST (Sinus Tachycardia).
Labs & X-rays: White Blood Cell: 15.3, Hemoglobin: 18.4, Hematocrit: 55.5 (report identified as critical high), Chloride: 108, Glucose: 116. Urinalysis normal. Abdominal x-ray - no obstruction or free air.
Progress: (Time left blank) Feeling better. Will D/C (discharge) home with meds. VSS (Vital Signs Stable).
Prescriptions given: Zofran, Ativan. Counseled patient for follow up.
Clinical impression: Narcotic withdrawals; Gastroenteritis.
Disposition decision time: 8:45 p.m.
Condition: improved, stable.

Review of the discharge instruction given to Patient #3 revealed the following: You were seen in the ED with a diagnosis of Narcotic Withdrawals; Gastroenteritis. Follow up care with your Family Physician is recommended on the next working day. Additional instructions: Follow up with your Primary Care Provider in 24-48 hours. Return to the Emergency Department if symptoms change or worsen. Clear liquids for 24 hours....

There was no documented evidence that the patient's use of narcotic medications was assessed for the frequency and duration of use. There was no documented evidence that the patient was assessed for the need for medical supervision of the withdrawal from narcotic medications.

In an interview on 11/04/15 at 2:45 p.m. S10RN confirmed he was one of the ED Charge nurses and confirmed he triaged Patient #3 on 10/19/15. After reviewing the patient's ED record, S10RN stated the patient was here for medication refills. He stated the patient was stable and was not actively withdrawing, but wanted to get his medications. S10RN stated the patient was here more for medication refill. S10RN stated, "If he had been actively withdrawing I would have sent him to the back." S10RN stated if the physician documents anxiety as a diagnosis, the nurses are required to do a suicide risk assessment. After reviewing the NP's documentation of the patient's symptoms, he stated the patient did not tell him he had abdominal pain, nausea, or diarrhea. S10RN confirmed the nurse should have rechecked the patient's vital signs after administering medications and at least documented vital signs upon discharge. He confirmed the only vital signs documented were the ones he did at triage.

In an interview on 11/04/15 at 4:15 p.m S5RN stated she remembered Patient #3. She stated he was not one of their usual patients. She stated, "He was a regular guy trying to fight his withdrawals." She stated the patient just needed his medication, something to help until he could get to his doctor. She stated she did not think he needed a suicide risk assessment, and stated that S4ED Manager just told her she should have done one. S5RN stated she did not see the patient as substance abuse, and did not see him as suicidal or at risk. She stated the patient appeared more sick to her and stated he could not urinate when he first arrived. She stated the patient looked like he felt bad and he did seem worried about his prescriptions. S5RN confirmed she did not close out the record or document the vital signs and stated she did not remember why she did not document the vital signs at discharge. She stated S6RN usually writes the vital signs on piece of paper for her to complete in electronic record. S5RN stated she was aware the patient had committed suicide the day after being discharged from the ED and stated nothing about this patient indicated he was suicidal. She stated nothing he said indicated he was depressed. She stated he had diarrhea for 2 days and was dehydrated. S5RN stated she "focused on the physical instead of the mental with the patient." She stated she knew the patient had an appointment with his doctor and they were trying to "Band-Aid" him until he could see his physician.

In a telephone interview on 11/04/15 at 4:45 p.m., S7APRN stated she remembered Patient #3. She stated he came in with viral symptoms. She stated in triage he said he had been on narcotics and was weaning himself off. She stated the patient complained of stomach pain and nausea. She stated the patient was with his girlfriend or fiance. S7APRN stated he did not have an emergent condition. She stated he was feeling much better after medications and fluids. She stated anytime there is a diagnosis of anxiety the nurse has to do the suicide risk assessment. The girlfriend with him said she was going to be taking care of him. She stated she did not see a suicide risk assessment, but thinks it is on the computer. S7APRN stated she did ask the patient if he had a history of depression and he told her he was not depressed. She confirmed she did not document that in the patient's record. S7APRN stated the patient also told her he did not have anxiety but was feeling that way due to the medications. She stated nothing stood out about the patient, he was feeling good when we discharged him. S7APRN stated the patient said he was going to call his doctor in the morning. She stated she did give the patient prescriptions for Ativan and Zofran.

In an interview on 11/05/15 at 7:20 a.m., S9Physician stated in the Fast Track, the mid-level practitioners do not consult with the physician, unless there is an issue or they have a question, and then they come back to the ED and talk to us. S9Physician stated he was told he had to sign all fast track charts and his signature indicated a review of the record. He stated he mainly reviews the medical decision making column. He stated the review of the record was a, "Quick look over." He confirmed he had reviewed the ED record for Patient #3 and stated he had no concerns with the record. He stated he never saw this patient and stated he only reviewed the record hours after the patient was discharged.

In an interview on 11/05/15 at 8:50 a.m., S6RN stated she remembered Patient #3 and stated he came in complaining of physical symptoms. She stated the patient was restless and shaking from being sick. S6RN stated she gave medications for nausea, vomiting, and diarrhea. S6RN stated the patient had gone several times to the bathroom with diarrhea. She stated the woman with him was very appreciative. She stated this was an acute event since his medications were stolen and it was his third day with no medication. S6RN stated she did not remember him saying anything about pain. She stated the patient was restless and anxious, and only complained of physical symptoms. She stated the patient never said anything related to suicide or depression. S6RN confirmed she did the discharge of the patient. She stated she took vital signs and wrote them on a piece of paper and gave S5RN. She stated the patient was better at discharge and did not have diarrhea. She stated the patient's vital signs were normal, but confirmed there were no vital signs documented in the record since triage. Nothing she can remember would have indicated he needed a suicide risk assessment. S6RN stated she doesn't look at the physician's documentation. When asked if she communicated with S7APRN, she stated she thought she talked to her about the diarrhea and thought she told her he was restless. S6RN stated the patient said he thought he was going through withdrawals because he did not have medications.

In an interview on 11/05/15 at 10:03 a.m., S8MD, Emergency Department Medical Director reviewed the ED record for Patient #3 and confirmed there was no documentation of any mental health issue in the patient's record. She stated the NP did more of a work up than they usually do. She stated drug withdrawals are a complicated picture. She stated they see a lot of patients with complaints of withdrawals and suicide risk is not routinely assessed. She stated in hind sight they could do better at assessing these patients regarding depression and suicidal ideations.

In a telephone interview on 11/05/15 at 10:40 a.m., the fiance of Patient #3 confirmed she was present with Patient #3 during the ER visit on 10/19/15. When asked if she had concerns about the patient's care, she stated they treated him well. She stated the patient had mental issues in the past and the staff should have asked about that when they gave the Ativan. She stated she had to drive him home because he was loopy. She stated he told her he was seeing double and felt like he was drunk. She stated the staff told them his only option was to ride it out. She stated he had an appointment with his pain management physician in about 2 weeks. She stated he had decided he wanted to get off the pain meds and was going to talk to her about that. She stated she felt like the ER doped him up and sent him home to ride it out and felt they could have done more. When asked if he had pain during this time, she stated he did but the other symptoms he was having were bothering him more. She stated the patient said he could ride out the pain.

In an interview on 11/05/15 at 12:25 p.m. S4ED Manager stated he found out on 10/28/15 that the mother of Patient #3 had questions about this patient's ER visit. He confirmed he had reviewed the record and confirmed there were no discharge vital signs documented. He also confirmed there was no ending disposition documented. He stated when he saw that the patient had anxiety he looked to see if a suicide risk assessment was documented, but there wasn't. He stated he had spoken to S7APRN and she told him the patient said he was not depressed, but it was not documented.

In a telephone interview on 11/05/15 at 3:35 p.m S7APRN was asked if she had assessed the amount, frequency and duration of the narcotic medication the patient had been taking. S7APRN stated she reviewed the, "Med Rec" (Medication Reconciliation) form. When asked if she assessed the patient for the need for medical supervision of withdrawals from narcotics, she stated, "That wasn't even a thought because he was feeling better and said he was going to see his pain management doctor the next day." When asked if she had assessed the patient to be in withdrawals, S7APRN stated she would not say that he was in withdrawals, he had gastroenteritis. After reading the clinical impression to her from the patient's record of "Narcotic withdrawals; gastroenteritis." she stated, "Oh." S7APRN was asked if admission or transfer of the patient was considered for monitoring of symptoms, she stated no, and said the patient was feeling good and wanted to go home. When asked if she reviewed the patient's vital signs before discharge, she stated she did. When informed there were no vital signs documented on the record except at triage, she stated the nurse took them but maybe did not document the vital signs. S7APRN confirmed she was not aware the patient had committed suicide within 24 hours of his ER visit and stated she saw nothing in the patient to indicate he was in that state.