HospitalInspections.org

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Based on medical record (MR) review, document review, and interview, the hospital failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA).

This failure potentially placed all patients arriving to the Emergency Department (ED) at increased risk for adverse outcomes.

Findings:

The hospital failed to provide Medical Screening Examination (MSE) to determine whether an Emergency Medical Condition exists, for one (1) of twenty-five (25) patients presenting to the ED (Patient #1).

(See Tag A-2406)
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Based on medical record review, document review, and interview in one (1) of 25 medical records reviewed, the facility failed to ensure that a patient who presented to the Emergency Department (ED) for evaluation received a Medical Screening Examination (Patient #1).

Findings include:

Review of the medical record of Patient #1 revealed this 38-year-old female presented to the ED at 2:16 AM by Basic Life Support (BLS) ambulance from home. Nursing Triage Note indicated she was triaged in at 2:47 AM with chief complaint of insect bite to left gluteal area two days ago and left gluteal pain. Vital signs were Temperature 98.4-degree Fahrenheit, Heart Rate 75 beats per minute, Blood Pressure 107/78, Respirations 18. She was assigned an Emergency Severity Index (ESI) 4 non-urgent.
At 3:10 AM, Staff H, ED Attending documented that the patient was yelling, cursing, and not listening when advised that she would be discharged if disruptive behavior continued. "Patient to be discharged."
At 3:11 AM, ED provider documented discharge diagnosis of disruptive behavior and discharge status to home.

At 3:19 AM ED Attending addendum note documented: "Patient advised to return to the emergency room when she is calm and corporative."

At 3:20 AM, Attending addendum note documented: "A medical screening exam was performed and no immediate threats to life or limb were identified."

At 3:35 AM, Attending addendum note documented: "A full evaluation could not be performed because the patient was disruptive, uncooperative, and threatening."

At 3:36 AM, Attending addendum note documented: "The patient was administratively discharged."

At 3:51 AM, Attending addendum note documented: "Patient also threatened multiple staff members."

There was no documentation in the medical record of a Medical Screening Examination.

Review of facility policy titled EMTALA (Screening, Stabilization, and Management of Emergency Transfers) last reviewed September 2021 page 1 states..."
III. PROCEDURES:
1)SCREENING AND STABILIZATION REQUIREMENTS
A. Medical Screening Examination
All individuals who come to the location noted above for examination or treatment of a medical condition, and all individuals requesting examination or treatment of an Emergency Medical Condition presenting elsewhere on the hospital property, shall receive an appropriate Medical Screening Examination ...
1. Scope of Examination

A Medical Screening Examination is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an Emergency Medical Condition exists. The scope of the examination must be tailored to the presenting complaint and the medical history of the patient. The process may range from a simple examination (such as a brief history and physical) to a complex examination that may include the laboratory tests, MRI or diagnostic imaging, lumbar punctures, other diagnostic tests and procedures and the use of on-call physician specialist. A medical record documenting the history and physical examination, and any special reports such as consultations, clinical laboratory, x-ray, etc. will be created to document the screening exam. "

In addition, facility policy titled "The Rules and Regulations of the St. Barnabas Hospital Medical Staff " (last reviewed on 12/09/2021) states in section 10- Emergency Medical Treatment: 10.1 "Any patient who presents to the emergency department will be provided with a timely and appropriate medical screening examination within the capability of the hospital emergency department to determine whether an emergency medical condition exists."

On 09/22/2023 at 11:23 AM, during interview with Staff F, Security Officer he stated that on 08/14/2023 Patient #1 was escorted out by stretcher to the triage area where she eventually got off the stretcher and left the Emergency Department.

During interview on 09/22/2023 at 11:36 AM, Staff G, Sergeant, Security Supervisor stated that he was called to the ED on 08/14/2023 and was informed that Patient #1 had accused Staff I, the Medical Assistant of hitting her with a curtain, and the patient was threatening ED staff members, including nurses and the doctors. Staff G stated Patient #1 became very aggressive, spat at the Staff I, Medical Assistant. He spoke with Staff H, Attending ED Physician who informed him the patient was discharged. He recalled the patient was taken by stretcher to the triage area. He remained with Patient #1 for approximately 30 minutes during which time the patient made calls and then got up and left the ED.

On 09/22/2023 at 11:57 AM during interview, Staff H, Attending ED Physician reported: "I was speaking with another patient several beds across from her (Patient #1) when I heard yelling; something about a curtain touching the patient. I walked over to speak to her, asked her to calm down.... I told her I would have to ask her to leave if she didn't. She continued yelling and making threats to staff. Security told me they could escort her out if she was discharged so I put in the discharge papers .... She was then wheeled out." Staff H was asked if Patient #1 received a medical screening examination. He responded: "I reviewed the triage note and checked the vital signs, and examined her as best as I could, given the circumstances ... She did not appear to be intoxicated, having disorders of thoughts or delirious. She was being disruptive and threatening to staff ..." Staff H was asked if a psychiatric consult was placed to assess the patient's mental condition. Staff H stated: "I did not request a psych consult because there were no signs of psychiatric disorder." When asked if he requested for another provider to examine the patient. He replied: "I did not specifically request another provider to speak with her. Her anger was not directed at me. Her anger was directed at the person who pulled the curtain ... " I did not look at the site of the insect bite/boil because she was being loud and threatening. I think I can say with certainty that a life threatening situation did not exist. My justification for discharge was she was disruptive and violent, and a medical emergency did not exist..."

These findings were shared with Staff K, Senior Vice President (VP) and Chief Medical Officer Staff, Staff M, Director, Risk Management, and Staff X, VP of Quality and Risk Management on 09/25/2023 at approximately 4:15 PM.