HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The hospital failed to ensure a medical screening examination was provided for an individual who was brought to the emergency department by paramedics to determine if an emergency medical condition existed. (A- 2406)

Based on document review, observation, and interview, it was determined that for 1 of 1 Emergency Department, the Hospital failed to post signage related to the rights of the individual with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA-Emergency Medical Treatment and Labor Act), and whether the Hospital participates in the Medicaid program.

Findings include:

1. The Hospital's policy titled, "Emergency Room Triage Medical Screening and Registration" (revised October 2003), was reviewed and required, "Purpose: ... To comply with the Federal Emergency Medical Treatment and Active Labor Act (EMTALA)..."

2. On 8/26/2024 at 12:15 PM, an observational tour of the Emergency Department (ED) was conducted. There was no EMTALA signage posted at entrance where patients would present, waiting area, or throughout the Emergency Department.

3. An interview was conducted with the Senior Vice President of Patient Care (E#8) on 8/26/2024, at approximately 12:30 PM. E#8 stated that the signage may have been removed when they painted the walls, but E #8 could not provide a date or timeframe of when repainting may have occurred. E#8 stated that they should have signs posted in the ED regarding the patients' rights regarding EMTALA.

4. On 8/28/2024 at 9:35 AM, another observational tour of the ED was conducted. EMTALA signage had been posted at the main entrance, waiting area, and treatment area of the ED.

Based on document review and interview, it was determined that for 2 of 20 patients' (Pt. #1 and Pt. #20) clinical records reviewed who presented to the ED (emergency department), the hospital failed to ensure the central log included each individual who came to the emergency department seeking assistance and the appropriate disposition for each patient.

Findings include:

1. On 8/26/2024, the hospital's policy titled, "Emergency Room Triage Medical Screening And Registration" (10/2003) was reviewed and required, "I... To comply with the Federal Emergency Medical Treatment and Active Labor Act... III. Procedures: A. Emergency cases will be directed immediately to the treatment room where triage, and registration will also take place. Upon entry, patient/family members... CFD (Local Fire Department) personnel will proceed to registration... The registrar will document this information on the ED sign in log..."

2. On 8/26/2024, the clinical record for Pt. #1 was reviewed. On 5/07/2024, Pt. #1 was brought to Hospital A's ER (emergency room) due to suicidal ideation. Pt. #1 has past medical history that included hypertension, seizure disorder, and bipolar disorder (type of mental illness). From the ER, Pt. #1 was admitted to the 4th floor behavioral health unit with diagnoses of suicidal ideation and bipolar disorder. On 5/14/2024, Pt. #1 was discharged accompanied by the paramedics via ambulance.

3. On 8/26/2024, the paramedic run sheet for Pt #1's discharge via ambulance was reviewed. On 5/14/2024 at 5:08 PM, the paramedic run sheet indicated, " ... dispatched to a non-emergency hospital discharge out of (Hospital A) going to (Name of Nursing Home) ... The crew (paramedics) ... made it to 4th floor ... After (Pt. #1) was dressed, the crew moved (Pt. #1) into the ambulance ... After returning to the ambulance ... (Pt. #1) started (complaining) of pain in the left leg around (tibia and fibula/lower leg bones) ... When the crew started to unload (Pt. #1) to bring (Pt #1) into the ER ... (Pt. #1) started to have contractions and (show) signs of partial seizures ... the crew decided (that Pt. #1) was not stable for transport. After the crew notified (Hospital A's desk attendant, the attendant) called the (ER) nurse..."

4. On 8/26/2024, the timeline of Pt. #1's incident, completed by E #7 (Director, Behavioral Health Unit) was reviewed and indicated, "On 5/14/2024, (Pt. #1) was discharged (from Hospital A). (Pt. #1) left ... with (Name of Ambulance) at 5:05 PM ... to (Name of Nursing Home) ... (Pt. #1) was loaded into (the) ambulance ... started complaining of leg pain. EMT (emergency medical technician) assessed (Pt. #1) and could not determine a reason for the leg pain, so the decision was made to bring (Pt. #1) to (Hospital A's ED) to be examined. As (Pt. #1) was being unloaded from the ambulance, (Pt. #1) began having seizure-like activity. EMTs went to (Hospital A's) observation desk, where the nurse (E #3/ED RN) at the desk called ... (E #4/ED Charge Nurse)..."

5. The clinical record of Pt. #20 was reviewed on 08/27/2024. Pt. #20 presented to the ED on 05/11/2024 with a chief complaint of substance misuse/intoxication. Pt. #20 had a medical screening exam and was treated. Pt #20 was discharged to home.

6. On 8/26/2024, the hospital's ED logs from February 2024 - July 2024 were reviewed:.
- The log from 5/11/2024 lacked the correct disposition for Pt. #20, it was documented as "unknown."
- The log from 5/14/2024 did not include Pt #1 who was brought to the ED by paramedics due to concern about seizures.

7. On 8/27/2024 at approximately 3:00 PM, an interview was conducted with E #1 (Senior Vice President of Quality). E #1 stated that all patients coming into the ED should be registered on the log. E #1 stated that an appropriate disposition should have been written on the ED log for Pt. #20.

Based on document review and interview, it was determined that for 1 of 20 patients' (Pt. #1) clinical records reviewed for individuals seeking care in the emergency department (ED), the hospital failed to provide a medical screening examination, to determine if Pt. #1 had an emergency medical condition.

Findings include:

1. On 8/26/2024, the Hospital's Rules and Regulations of the Medical Staff (2020) was reviewed and indicated, " ... Department of Family Medicine ... II. Scope of Services. The Department of Emergency Medicine provides emergency care to patients of all ages. Comprehensive general emergency medicine is provided by physicians with clinical privileges in the Department of Emergency Medicine. Individuals presenting to (Name of Hospital) Emergency Department will be provided with comprehensive triage to assess acuity followed by an appropriate medical screening examination within the capability of the department... The medical screening examination will be performed by a member of the medical staff qualified to work in the Emergency Department ..."

2. On 8/26/2024, the clinical record for Pt. #1 was reviewed. On 5/07/2024, Pt. #1 was brought to Hospital A's ER (emergency room) due to suicidal ideation. Pt. #1 has past medical history that included hypertension, seizure disorder, and bipolar disorder (type of mental illness). From the ER, Pt. #1 was admitted to the 4th floor behavioral health unit with diagnoses of suicidal ideation and bipolar disorder. The clinical record included:

- On 5/14/2024, the attending psychiatrist's note indicated, " ... (Pt. #1 is) doing relatively well ... discharge back to ... nursing home today ..." The attending psychiatrist placed an order to discharge Pt. #1 to the nursing home. Pt. #1 was discharged accompanied by the paramedics via ambulance at 5:08. Pt #1's clinical record did not include documentation of Pt #1 returning to the 4th floor or the ED after discharge.

3. On 8/26/2024, the paramedic run sheet, dated 5/14/2024 at 5:08 PM, was reviewed and included, " ... dispatched to a non-emergency hospital discharge out of (Hospital A) going to (Name of Nursing Home) ... The crew (paramedics) ... made it to 4th floor ... After (Pt. #1) was dressed, the crew moved (Pt. #1) into the ambulance ... After returning to the ambulance ... (Pt. #1) started (complaining) of pain in the left leg around (tibia and fibula/lower leg bones) ... When the crew started to unload (Pt. #1) to bring (Pt #1) into the ER ... (Pt. #1) started to have contractions and (show) signs of partial seizures ... the crew decided (that Pt. #1) was not stable for transport. After the crew notified (Hospital A's desk attendant, the attendant) called the (ER) nurse. After the phone call, the crew was told to bring (Pt. #1 back to the 4th floor. After the crew brought Pt. #1) to the 4th floor, the crew was told that (Pt. #1) could not be admitted on the floor due to (Pt. #1) having a medical problem, so the nursing staff (called) the ER and after 30 minutes, all the crew heard was that they (hospital staff) were wondering if it was a real seizure. So, after waiting for around 30-45 minutes and hearing no word from (the hospital) staff, the crew was worried for (Pt. #1's well-being) ... the crew notified (ambulance's dispatch for medical direction of the situation) ..." Subsequently, Pt. #1 was taken to Hospital B's ER by the paramedics.

4. On 08/26/2024, the incident report dated 5/14/2024 at 5:50 PM, completed by E #7's (Director, Behavioral Health Unit) was reviewed and included, "On 5/14/2024, (Pt. #1) was discharged (from Hospital A). (Pt. #1) left ... with (Name of Ambulance) at 5:05 PM ... to (Name of Nursing Home) ... (Pt. #1) was loaded into (the) ambulance ... started complaining of leg pain. EMT (emergency medical technician) assessed (Pt. #1) and could not determine a reason for the leg pain, so the decision was made to bring (Pt. #1) to (Hospital A's ED) to be examined. As (Pt. #1) was being unloaded from the ambulance, (Pt. #1) began having seizure-like activity. EMTs went to (Hospital A's) observation desk, where the nurse (E #3/ED RN-Registered Nurse) at the desk called ... (E #4/ED Charge Nurse). After (E #3's) phone call, the EMTs were instructed to take (Pt. #1) back to 4 South. Once the EMT and (Pt. #1) arrived (on) the 4th floor, (E #5 and E #6/4th floor RNs) told the crew (paramedics) that (Pt. #1) was discharged and needed to be seen in (the ED) for medical reasons. The 4th floor nurses, house supervisor (E #2), and ER continued to discuss and debate ... 30-45 minutes elapsed. The (Name of Ambulance) crew decided to call their Medical Direction Supervisor regarding the situation due to a concern of (Pt. #1's) well-being and delay in care ... (Pt. #1) arrived (at Hospital B's ED) ... at 6:48 PM ..."

5. On 8/26/2024, the clinical record for Pt. #1 at Hospital B was reviewed. On 5/14/2024 at 6:42 PM, Pt. #1 arrived at Hospital B's ED. The clinical record included:

- On 5/14/2024, the ED provider's note indicated, " ... (Pt. #1 with past medical history of) depression ... seizure disorder ... presents with shaking ... History provided by BLS (basic life support/ambulance) crew and (Pt. #1). (Pt. #1) is a difficult historian. (Pt. #1) was reportedly being transferred via ambulance from an inpatient psychiatric facility to the nursing home ... when (Pt. #1) had an episode of shaking. EMS crew described the activity more like an absence seizure (no convulsion) ... Assessment and Plan ... Will get basic labs (laboratory test) and lactic acid to evaluate ... whether (Pt. #1) had ... a true seizure ... concern for syncope... Higher concern for psychogenic non-epileptic seizures (seizure due to psychological distress) ..."

- On 5/15/2024, the ED physician's notes indicated, "(Pt. #1) with ... questionable seizure disorder ... presents with upper extremity shaking and chest pain ... On arrival (at) the ED, noted to be tachycardic (heart rates to the 110s/normal 60-100). Blood pressure was 147/107 (normal range is 90-120/60-80). Pt. #1's oxygen level was normal) ... on room air. Initial (laboratory tests) were notable for lactic acid (acid caused by cell breakdown/stress) of 5.9 (normal level is less than 2), which subsequently down trended to 2.9 after 3 (liters) of fluid resuscitation ... Neurology was consulted in the ED due to concerns about the upper extremity tremors. The tremor was noted to be distractible and suppressible. Neurology recommended no further neurologic inpatient workup. (Pt. #1) was then admitted to the medicine service for alternative tremor workup and tachycardia ... Assessment and Plan ... Upper Extremity Shaking ... likely represents dystonia/catatonia (neurological movement disorder) ... EEG during shaking showed no epileptiform activity (spike waves associated with epilepsy) ... Plan: 4-6 hours EEG ... Stop ... serotogenic agents (antidepressant medication); psychiatry consult for evaluation of possible dystonia/catatonia ... Lactic acidosis (high lactic acid level) (is) likely (due to) hypovolemia (low body fluid volume)... Plan: Fluid resuscitation. Sinus Tachycardia (Fast Heart Rate) ... will fluid resuscitate ..."

- On 5/16/2024, the attending physician note indicated, " ... I ... examined (Pt. #1) on 5/16/2024 ... The risk associated with (Pt. #1's) management today was high... concern for seizure yesterday with IVF (intravenous fluid) resuscitation also, but now more dystonia..." Pt. #1 stayed at Hospital B for two days, and required assessment, monitoring, diagnostic testing, including psychiatric and medical consultation.

6. On 8/26/2024 at approximately 2:06 PM, an interview was conducted with E #7 (Director, Behavioral Health Unit). E #7 stated, "(On 5/14/2024, E #5/4th Floor RN) called and told me that (Pt. #1) was discharged accompanied by paramedics to the nursing home. The paramedics brought (Pt. #1) to the ED due to a change in medical condition. The paramedics were instructed to take (Pt. #1) back to the 4th floor."

7. On 8/27/2024 at approximately 9:19 AM, a telephone interview was conducted with E #2 (Nursing Supervisor). E #2 stated, "I received a phone call from (E #6/4th Floor RN). (E #4) told me that (Pt. #1) was picked up by the paramedics. While in the ambulance, (Pt. #1) had a seizure. The paramedics took (Pt. #1) to the ED and reported to (E #3/ED RN) that (Pt. #1) had a seizure... (E #4) did not notify the ED doctor about the incident."

8. On 8/27/2024, at approximately 9:49 AM, a telephone interview was conducted with E #3 (ED RN). E #3 stated, "I was at the desk then. The paramedics brought the patient to the ED because the patient had a seizure. I called (E #4/ED Charge Nurse), who told me to tell the paramedics to take the patient back to the 4th floor."

9. On 08/27/2024, at approximately 10:00 AM, a telephone interview was conducted with E #4 (ED Charge Nurse). E #4 said, "That day, I was at the back of the ER. (E #3) called me and said paramedics were transporting a patient. The paramedics thought that the patient was going to have a seizure and did not feel comfortable transferring the patient. (E #3) told me the patient was not having a seizure." E #4 stated that E #3 did not tell the full story. So, E #4 instructed E #3 to tell the paramedics to take the patient back to the 4th floor."

10. On 8/27/2024 at approximately 11:59 AM, an interview was conducted with E #8 (Senior Vice President of Patient Care). E #8 stated that Pt. #1 should have been seen in the ED and provided a medical screening examination.

11. On 8/27/2024 at approximately 12:28 PM, an interview was conducted with MD #1 (ED Attending Physician). MD #1 stated that any patient entering the ED should receive a full assessment and medical screening examination by a physician to determine if a patient has an emergency medical condition. MD #1 stated that the ED assessment and medical screening exam should be documented in the clinical record.