HospitalInspections.org

Based on review of the hospital's Emergency Department (ED) medical records, policy review, and staff interviews, it was determined the hospital failed to comply with the provider's agreement as defined in §489.20 and §489.24. Findings include:

1. The hospital failed to provide a medical screening examination that was, within reasonable clinical confidence, and sufficient to determine whether or not an Emergency Medical Condition (EMC) existed for two of three sampled ED patients (11 and 12) who after presenting to the ED were referred to the clinic attached to the hospital. Refer to A2406, findings A1, A2, and A3.

Based on medical record review, medical staff bylaw review, policy review, and interview, the provider failed to ensure a medical screening evaluation had been performed for two of three sampled patients (11 and 21) who presented to the emergency department (ED) with ear pain. Findings include:

1. Review of patient 11's ED medical record revealed:
*She presented to the ED on 11/4/17 at 9:35 a.m.
*She was discharged from the ED on 11/4/17 at 9:50 a.m.
*Her chief complaint was ear pain, unable to hear out of ears bilaterally, and buzzing in ears at times.
*The patient's condition at admission was listed as fair.
*Her ED priority was listed as urgent.
*The physician was notified at 9:38 a.m.
*Nursing triage assessment at 9:39 a.m. included taking the patient's vital signs, isolation precautions assessment, travel history, tuberculosis screening, infection control for resistant organisms, immunizations, fall risk, substance use, admission abuse assessment, home medication review, and allergy confirmation.
*No documented physical evaluation of the patient's ear.
*Nurse's note documented at 10:24 a.m. stated spoke with doctor about patient's condition. Doctor stated the patient was stable and could be seen at the clinic. Walked the patient, her mother, and her little brother to the clinic.
*No documentation regarding the discussion with the physician for determination of a nonemergent situation was found in the medical record.
*Departure assessment documented at 11:27 a.m. stated discharged and taken to the clinic area.
*The patient's condition at discharge was listed as fair.

2. Review of patient 21's ED medical record revealed:
*He presented to the ED and was triaged on 3/23/17 at 12:15 p.m. with the chief complaint of ear pain.
*An ED basic assessment was performed at 12:15 p.m. which included orientation parameters, respiratory parameters, heart sounds, integumentary parameters, skin parameters, and no edema noted.
*The patient's vital signs were taken at admission.
*No pain assessment had been performed.
*No physical evaluation of the patient's ear was documented.
*The physician was notified at 12:25 p.m.
*Nurse's note at the time of the physician notification stated "Assessed patient and spoke with provider (provider's name) and agreed patient condition non emergent, and sent patient up to clinic to be seen."
*No documentation regarding the discussion with the physician for determination of a nonemergent situation was found in the medical record.

3. Review of the provider's 6/19/17 Medical Staff bylaws revealed:
*"A screening exam [examination] will be provided by qualified medical personnel to determine the presence of an emergency medical condition. The charge nurse or RN [registered nurse] designated by the charge nurse, is responsible for assessment of the patient initially and contacting the physician/nurse practitioner/physician assistant who is on call."
*The medical record should have contained:
-Pertinent history of the injury or illness including details relative to first aid or emergency care given prior to their arrival at the hospital.
-Description of significant clinical, laboratory, and x-ray findings as applicable.

Review of the provider's 1/15/18 Emergency Department policy and procedure revealed:
*The nurse would initiate the medical screening.
*A nurse would contact the provider on call with the results of the initial medical screening exam.
*If the provider in consultation with the person performing the medical screening exam determined an emergency medical condition existed, they would direct further cares, evaluation, testing, and would arrive at the facility within thirty minutes.
*If the provider in consultation with the person performing the medical screening exam determined an emergency medical condition did not exist, further care would be directed by the on call provider.

Interview on 3/13/18 at 1:50 p.m. with medical director D regarding patients 11 and 21 revealed:
*More information than the patient's vital signs would have been discussed when a decision had been made.
*He would have asked if there was trauma, fall, bleeding, and if there was any fluid discharge.
*He was not sure what was usually documented in the patient's chart concerning a patient's evaluation.
*He was not sure about the above cases, but he would have asked if there was any trauma or any fluid discharge.
*The decision would have been made in conjunction with the nurse.
*He agreed more documentation would have been needed to reveal the comprehensive discussion that had occurred between the nurse and the physician.

Interview on 3/13/18 at 3:09 p.m. with director of patient services A regarding patients 11 and 21 revealed:
*The nurse and physician would have discussed other information from the patient's assessment, but it was not documented.
*She did not always look into the patient's ear, because sometime the physician wanted to look into the patient's ear themselves.
*"Not in the scope of practice for a nurse to diagnose a ear."
*"From a documentation standpoint, doesn't look like a thorough medical screening evaluation was performed."