HospitalInspections.org

Based on document review and interview the facility failed to provide medical screenings to 8 of 9 patients (patient #1, #17, #18, #19, #20, #21, #22, #33). The Medical Screening Exam and the Nurse Triage were being documented as the same. The facility Registered Nurses (RNs) were functioning outside their scope of practice by exercising independent medical judgment, medical diagnosis and/or prescription of therapeutic and/or corrective measures. The RNs prescribed over the counter medications, therapeutic diet, released a patient to return to school after reporting flu like symptoms. The RNs failed to act on patient's behalf and turned patient away from the Emergency Room (ER and/or ED) with pain of 10 on a scale of 1-10, 10 being the worst.


A review of patient #1's medical record revealed:

ICD10 coding summary M54.5 Low back pain

A review of the document titled "Musculoskeletal Symptoms (Adult) - Nurse Initial Assessment Note" Collected on: 02/02/17 at 08:24am revealed:
"History of present Illness:
.... Narrative of presenting problem, patient complains of back pain 10/10, chronic back pain, .... Timing Continuous, upper back, Current pain 10, Pain at worst 10.
Assessment:
Musculoskeletal: Back pain; Distal pulses normal, No injury or deformity; had back surgery approx. 7 years ago, chronic back pain, no new injuries
Neurologic: Denies any symptoms.

A review of the document titled "Soarian Chart report - Visit", Visit Information revealed "Patient Complaint: Back Pain, Treating Complaint: Backache"

The document titled "Musculoskeletal Symptoms (Adult) - Nurse Initial Assessment Note" provided no evidence of an assessment of the patient's chief complaint with a focused physical assessment appropriate to the organ system related to chief complaint, general appearance of the patient, location and degree of pain based on both subjective and objective data, and/or the ability to walk/limits on ambulation or movement of affected extremity as required. The patient's pain rating 10 of 10 was not treated.

A review of patient #1's medical record revealed staff #27 did not function with in the registered nurses scope of practice. Staff #27 did not act on the patient's behalf and address the patient's reported pain 10 of 10. The nurse participated in the act of medical diagnosing the patient with chronic pain. The staff did not perform and document an assessment of the patient's chief complaint with a focused physical assessment appropriate to the organ system related to chief complaint.

The established policy "Medical Screening Exam and Referrals in the Emergency Department" (ED) was not followed when staff #27 saw patient #1 with upper back pain.


A review of patient #17's medical record revealed:

A review of the document titled "General Medicine (Adult) - Nurse Initial Assessment Note" revealed a 16 year old male was seen by staff # 28. The patient was accompanied by himself. There was no evidence the minor patient's family and/or guardian was notified of the patient being in the emergency room. There was no evidence the minor patient was emancipated.
"History of present Illness:
Chief complaint, patient stated complaint body aches, Narrative of presenting problems patient states he had the flu 2-3 days ago, he now has body aches and fever, Onset 3 days ago, Timing Continuous.
Assessment:
Chills, fever, body aches.
Respiratory; clear to auscultation bilateral, Normal rate and effort."

A review of the document titled "Disposition - Nursing Disposition Note" revealed the patient was referred to the RHC and the minor patient declined the appointment. There was no evidence the minor patient's family and/or guardian was notified of the patient being in the emergency room. There was no evidence the minor patient was emancipated.

A review of patient #17's medical record revealed staff #28 did not function with in the registered nurses scope of practice. Staff #28 did not act on the patient's behalf and notify the minor patient's family and/or guardian. The staff did not perform and document an assessment of the patient's chief complaint with a focused physical assessment appropriate to the organ system related to chief complaint. Staff #28 participated in the act of medical diagnosing when the patient was not referred to ER doctor for further testing for the flu.


A review of patient #18's medical record revealed:

A review of the document titled "Gastrointestinal Symptom (Pediatric) - Nurse Initial Assessment Note" revealed:
"History of present Illness:
Chief complaint, patient stated complaint flu like symptoms, Narrative of presenting problems patient states body aches, vomiting and diarrhea today. Sent home from school. Onset 11 hours ago. Timing intermittent, occurred at home, body aches, Current pain 8; Quality aching, exacerbated by nothing, relieved by nothing, associated symptoms chills."

The document titled "Treatment Plan Resulting from Medical Screening Exam" was not filled out for patient #18.

A review of the document titled "Note Text Only - Nurse Text Only" revealed "Instructed patient and parents on sips of clear fluids, and taking ice chips, popsicles, jello, and then progressing to a BRAT diet once vomiting is resolved. Also instructed on proper hand washing techniques and to take OTC (Over the Counter) Tylenol or Motrin for fever as needed."

A review of patient #18's medical record revealed staff #29 did not function with in the registered nurses scope of practice. Staff #29 participated in the act of medical diagnosing when the patient was not referred to ER doctor for further testing for the flu. Staff #29 practiced medicine when the patient was prescribed a special diet and prescribed over the counter Tylenol or Motrin for fever as needed.


A review of patient #19's medical record revealed:

A review of the document titled Quick Triage (Adult) - Nurse Triage Note revealed 53 year old male presented with a skin rash to left leg that does not seem to be getting any better.

A review of patient #19's ED record revealed the patient did not receive a Nurse Initial Assessment.

A review of the document titled Medical Screening Examination Disposition revealed the patient did not receive a referral for follow up care.

A review of the document titled Treatment Plan Resulting from Medical Screening Exam was left blank and not filled out.


A review of patient #20's medical record revealed a 12 year old female patient, Historian Self, Accompanied by Self, Arrived from Home, Arrival Mode Walk In, Treatment prior to Arrival None. There was no evidence the minor patient's family and/or guardian was notified of the patient being in the emergency room. There was no evidence the minor patient was emancipated.

"History of present Illness:
Chief complaint, patient stated complaint foot pain, Narrative of present problem patient complained of hurting foot 3 weeks ago and reports it is still hurting, No bruising, swelling, or crepitus noted. Onset 3 weeks ago, Timing Continuous, Occurred at home, Quality aching, Mild, Exacerbated by nothing, Associated Symptom None."

A review of the document titled "Medical Screening Examination Disposition" revealed the patient did not receive a referral for follow-up care.

A review of the document titled "Treatment Plan Resulting from Medical Screening Exam" was left blank and not filled out.

No evidence of:
Assessment of the patient's chief complaint with a focused physical assessment appropriate to the organ system related to chief complaint.
General appearance of the patient.
Location and degree of pain based on both subjective and objective data.
Ability to walk/limits on ambulation or movement of affected extremity.

A review of the document titled "Work/School Excuse Slip" revealed "2/7/2017 Patient #20 was seen through our Outpatient Department today. May return to school/work 2/13/2017."

A review of patient #20's medical record revealed staff #30 did not function within the registered nurses scope of practice. The staff did not perform and document an assessment of the patient's chief complaint with a focused physical assessment appropriate to the organ system related to chief complaint. Staff #30 participated in the act of medical diagnosing when the patient was not referred to ER doctor for further testing. Staff #30 was practicing medicine and did not have the prescriptive authority to release the patient to return to school.


A review of patient #21's medical record revealed the patient was a 35 year old female arrived from home with no treatment prior to arrival to the facility. Chief Complaint Congestion. Patient stated she has been congested and coughing for 4 days.

A review of the document titled Medical Screening Examination Disposition revealed the patient did not receive a referral for follow up care.

A review of the document titled Treatment Plan Resulting from Medical Screening Exam was left blank and not filled out.

A review of the document titled Medical Screening Exam and Referrals in the Emergency Department (ED) revealed ...Based on whether the patient meets any exclusion criteria and the results of this MSE, the patient may either be directed to the Rural Health Clinic, their primary physician or the ED for further medical examination and treatment.


A review of patient #22's medical record revealed:
Review of document titled EAR Nose Throat Symptom (Adult) - Nurse Initial Assessment Note revealed:
History of Present Illness:
Chief Complaint Patient Stated Complaint Flu like Symptoms, Narrative of Presenting Problem Patient stated she started feeling sick last night. She stated her nose is stopped up and feels like she has a fever. Onset 1 day ago, Head, Current Pain 6; quality aching, Moderate ...

A review of the document titled Treatment Plan Resulting from Medical Screening Exam was left blank and not filled out.

A review of patient #22's medical record revealed staff #31 did not function with in the registered nurses scope of practice. The staff did not perform and document an assessment of the patient's chief complaint with a focused physical assessment appropriate to the organ system related to chief complaint. Staff #31 participated in the act of medical diagnosing when the patient was not referred to ER doctor for further testing. Staff #31 did not act on the patient's behalf by making the patient's appointment for follow up testing for diagnosis of the flu. Staff may have delayed the treatment of the flu with antiviral medications.


Review of the document titled Medical Screening Exam and Referrals in the Emergency Department (ED) revealed Flu like Symptoms are not on the list of Non-emergent Complaints:
Policy and Procedure Medical Screening Exam (MSE) and Referrals in the Emergency Department (ED)
The nature of the MSE will depend on the patient's presenting symptoms, and may involve a brief history and physical examination.
I. The MSE consists of:
a. Assessment of the patient's chief complaint with a focused physical assessment appropriate to the organ system related to chief complaint
b. Vital signs
c. General appearance of the patient
d. Mental status
e. Location and degree of pain based on both subjective and objective data
f. Skin-visual inspection and tactile assessment when indicated
g. Ability to walk/limits on ambulation or movement of affected extremity
h. Exclusionary criteria questions
V. Non-emergent Complaints:
The descriptions below outline, but are not limited to, common chief complaints that may be deemed non-emergent and may be appropriate for referral to the Rural Health Clinic or patient's PCP:
Minor muscle aches and pains
Seasonal allergy symptoms
Mild URI/cold symptoms
Cough
Sore throat
Earache
Prescription refills in the absence of acute symptoms or need for control of chronic condition
which, if left untreated, may result in an emergent condition
Tooth fractures
Dental pain
Lumbar pain
Joint pain
Skin lesion/Rash
Insect bite or sting
Scabies/lice
Physical exams for work/school
STD testing
Penile discharge
Vaginal discharge
Minor lumps/bumps/bruises/cuts
Lab testing requested by patient (i.e., blood typing, HIV testing, cholesterol testing, pregnancy test etc.)
Non-urgent conditions categorized as ESI Level 4 and 5 Triage acuity in the absence of acute symptom recent change in symptoms or deterioration in conditions.


A review of patient #33's medical record revealed the patient was a 69 year old female patient that was seen in the ER by staff #32 with a chief complaint of back pain. Pain described as burning quality, sharp, stabbing and severe. Patient's current pain was 7 out of 10. The patient was discharged and not admitted to the ER as required by policy.

A review of patient #33's medical record revealed staff #32 did not function with in the registered nurses scope of practice. The staff did not perform and document an assessment of the patient's chief complaint with a focused physical assessment appropriate to the organ system related to chief complaint. Staff #32 participated in the act of medical diagnosing when the patient was not referred to ER doctor for further testing. Staff #32 did not act on the patient's behalf by pursuing treatment for the patient's pain.

A review of the document titled Medical Screening Exam and Referrals in the Emergency Department (ED) revealed VI. Exclusionary Criteria Questions: 4. Is the patient sixty-five or older? If any of the answers are "yes" admit the patient to the ER.


A review of the document titled Medical Screening Exam (Nursing Department) - Nurse Triage Note revealed the Medical Screening Exam being provided by the Nursing staff (QMP) is the same as a Nurse Triage.

A review of the Texas Board of Nursing Q&A revealed:
Is a medical screening exam the same as triage?
No, a medical screening exam is not the same as triage. The differentiation is discussed in depth under the Interpretive Guidelines for Enforcement for 42CFR §489.24 on the EMTALA web page. This guideline to surveyors states in part that "[i] Individuals coming to the emergency department must be provided a medical screening examination beyond initial triaging. Triage is not equivalent to a medical screening examination. Triage merely determines the order in which patients will be seen, not the presence or absence of an emergency medical condition."

A review of the document titled Medical Screening Exam and Referrals in the Emergency Department (ED) revealed: ...Based on whether the patient meets any exclusion criteria and the results of this MSE, the patient may either be directed to the Rural Health Clinic, their primary physician or the ED for further medical examination and treatment.

Review of the document titled "Medical Screening Exam and Referrals in the Emergency Department" (ED) revealed:
"I. The MSE consists of:
a. Assessment of the patient's chief complaint with a focused physical assessment appropriate to the organ system related to chief complaint
General appearance of the patient
Location and degree of pain based on both subjective and objective data."

A review of the Texas Board of Nursing Q&A revealed:
How do the NPA and Rules apply to RNs performing medical screening exams under EMTALA?
The definition of "professional nursing" in Texas Occupation Code §301.002 (2) of the Nursing Practice Act (NPA) states that the practice of professional nursing "does not include acts of medical diagnosis or prescription of therapeutic or corrective measures." This means an act must not require the RN to exercise independent medical judgment or medical diagnosis, as this is the practice of medicine, not nursing....
Rule 217.11, Standards of Nursing Practice, contains the minimum standards of acceptable nursing practice. Some of the standards in Rule 217.11 that would apply to EMTALA medical screening exams performed by an RN include, but are not limited to, the requirements that an RN must:
" (1)(A) know and conform to the NPA, rules, as well as federal, state, or local laws affecting the nurse's current area of practice;
" (1)(B) maintain a safe environment for clients and others;
" (1)(D) accurately and completely report and document: (i)-(vi);
" (1)(M) institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications;
" (1)(P) collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care;
" (1)(T) accept only those nursing assignments that take into consideration patient safety and that are commensurate with one's own educational preparation, experience, knowledge and physical and emotional ability.
" (3)(A)(i) performing comprehensive nursing assessments regarding the health status of the client.
Regardless of practice setting, the nurse's duty to keep patients safe cannot be superseded by physician orders, facility policies, or administrative directives see Position Statement 15.14 Duty of a Nurse in Any Practice Setting.

Based on document review the facility failed to provide Medical Screening Examinations (MSE) in a non-discriminatory manner. 18 of 18 (patient #1, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33) patients were asked if they have VA benefits. If the answer is "yes" admit the patient to the Emergency Department (ED).

A review of the document titled Medical Screening Exam (Nursing Department) - Nurse Triage Note, Exclusionary Questions; revealed: Do you have VA benefits?

A review of the document titled Medical Screening Exam Policy (MSE) and Referrals in the Emergency Department (ER) revealed:
Policy Statement: ...The MSE must be the same MSE that would be performed on any individual coming to the Emergency Department, regardless of the individual's ability to pay. No information regarding the patient's payer status, HMO/PPO membership, or insurance shall be asked prior to the completion of the MSE.

An interview with staff #7 revealed all patients with VA benefits are admitted to the ED and their MSE are provided by a physician. These patients can't be screened by a Qualified Medical Person (QMP).