HospitalInspections.org

Based on medical record review, document review and interview, in two (2) of 32 medical records reviewed, it was determined the facility failed to ensure that all patients that presented to the Emergency Department received an appropriate medical screening examination. (Patients #s 1 and 2).

These failures may have placed patients at risk for harm.

Findings include:

The facility's policy titled "Emergency Medical Treatment and Transfer, including Labor (EMTALA)," which was last revised 9/2017 states, "all patients that present to a dedicated Emergency Department (ED or LDRP Triage) or presents within 250 yards of the hospital property requesting examination or treatment will be offered a medical screening examination (MSE)."

Review of the medical record for Patient #1 identified the following: This is a 24-year-old who was taken to the ED by ambulance on 12/14/19 at 12:46 AM. The triage assessment at 1:18 AM noted the patient was speaking fast, his thoughts were incoherent, and he was jumping from one subject to another. The patient's vital signs were normal except for his B/P which was 142/104 (Normal range 90-130/ 50-90). The patient complained of upper back pain that he rated at 2/10 (10 being the most severe pain imaginable). The triage note indicated the patient was trespassing at Vassar College Campus and the police were called to the scene. The patient was sent to the ED via EMS when he complained of back pain. The patient had a prior history of mental health disorders and Marijuana abuse. Staff D, Charge Nurse on duty, documented at 2:00 AM that the "patient was threatening staff and yelling in the waiting room. Code Gray was called. The patient was escorted out of the ED department by city PD."

There was no documented evidence that the patient received a medical screening examination by a qualified medical staff prior to being escorted out of the ED.

During an interview on 1/23/2020 at 3:00 PM, Staff D stated that the patient asked the registrar for Percocet and that she saw the patient on his phone in the waiting area and he was threatening to shoot these "mother f ....". Staff D, the charge nurse, stated that she did not see a weapon, but she thought he may have been threatening to shoot someone in the waiting area. She also stated that security and the triage nurse were trying to deescalate the patient. She confirmed that the patient did not receive a medical screening examination.


Review of medical record for Patient #2 identified the following: The triage notes on 7/14/19 at 8:51 PM indicated that a "Code Gray was called in the parking lot." This 51-year-old patient had a previous medical history that included but was not limited to Diabetes Mellitus type 2, Chronic high blood sugar, Chronic Kidney Disease Stage III, Hypertension, Alcohol Abuse and homelessness. The patient's vital signs were within normal limits.

On 7/14/19 at 8:51 PM, a case manager noted that the patient presented to the facility "after arriving via taxi cab, and reportingly walked out of the cab independently, and then put himself on the ground. SW attempted with RN and attending MD to speak with patient, however patient presented verbally aggressive and agitated and appropriate conversation could not occur. Patient is currently receiving time to decompress to have a hopeful appropriate interaction/assessment of patient. SW reviewed the patient's case management contact with the ED social worker documented on 7/10, which indicated that the patient was not receptive to assistance offered."

At 8:46 PM, a nurse documented that the patient was screaming and yelling "I'm not going there, I want Staff C." The staff attempted to explain provider available in ED, patient yelling and refusing to go to HW (hallway) stretcher. Code Gray was initiated. Patient upset and cursing in hallway. Requesting to speak to a Director. Patient refusing to be seen by the assigned provider at this time. Saying just 'kick me out or let me see Staff B or C (ED medical doctors). Patient advised of providers in emergency room at this time. Patient refusing to see providers assigned at this time. Patient escorted to waiting room in wheelchair."

Review of the form titled "Security Incident Report" dated 7/14/19 indicate the charge nurse and security officers attempted to verbally deescalate the patient because he was yelling and irate. The report further notes the police were notified at approximately 8:53 PM and at approximately 8:55 PM they arrived and escorted the patient off the premises.

There was no documented evidence in the medical record that the patient received a medical screening evaluation by a physician prior to his departure from the ED.

During an interview with Staff A, Charge Nurse on 1/27/2020 at 10:50 AM, she stated that during his encounter with the patient, he smelled of alcohol. Staff A confirmed that the patient did not receive an MSE prior to his departure from the ED on 7/14/19.

Based on medical record review, document review and interview, in one (1) of eight (8) medical records reviewed, it was determined the facility failed to provide stabilizing treatment and implement an appropriate transfer to a receiving facility for psychiatric evaluation (Patient # 3).

These failures may have placed the patient at risk for harm.

Findings include:


The facility's policy titled "Emergency Medical Treatment and Transfer, including Labor (EMTALA)," which was last revised 9/2017 states, for patients that are been transferred to another hospital "all efforts at stabilization and treatment should occur that are within the capabilities and capacity at VBMC at that time."

Review of medical record for Patient #3 identified the following: This is a 56-year-old who was triaged in the Emergency Department (ED) on 11/29/19 at 6:26 PM with a complaint of constipation and not sleeping well. The nurse noted the patient was anxious, very disruptive, acting out, verbally aggressive and crying. The patient stated she felt dehydrated. The patient had a previous medical history that included Anxiety, Depression and Hypertension. The patient's vital signs were Blood Pressure 174/131, heart rate 113, and pain score was 9/10 (10 being the most severe pain imaginable).

The ED physician documented at 7:05 PM that the patient was verbally abusive with the staff, she refuses to present the story and she did not report any other symptom. The physician's assessment indicated the patient appeared aggressive and verbally abusive. She was alert, in no acute distress, her mood was hostile, and her behavior was uncooperative and belligerent.

Review of Security Incident Reports revealed that on 11/29/19 at approximately 5:57 PM a Security Coordinator and a Security Officer responded to an activated Code Gray in the triage area. Upon their arrival Patient #3 was screaming and cursing at two (2) ED technicians and another security officer. The Lead ED technician attempted verbal de-escalation techniques. At approximately 6:05 PM the patient calmed herself down and the Code Gray was cleared. At 6:19 PM, a Code Gray was called, the patient was screaming and cursing at staff. The patient calmed down and was walked into the triage area to be assessed.

At 7:05 PM 2 (two) security officers observed the patient knocking on the ED doors and becoming extremely verbally irate. The patient stated that she needed a "sedative now and that she would not take no for answer." The staff attempted verbal de-escalation techniques but the patient immediately started to show combative body language. The patient spat at the staff and broke the left frame temple of a security officer's glasses. A manual hold was implemented and while attempting to place the patient on a stretcher she kicked a Mobile Life Medic. The police arrived after they were contacted, took the patient into custody and the police officer requested that the patient be transported to a nearby hospital for psychiatric care. The security officers escorted the patient to Mobile Life Transportation vehicle at approximately 7:20 PM.

There was no documented evidence in the medical record that the patient received treatment for her elevated blood pressure, abnormal heart rate and severe pain. There was no documented evidence of an appropriate transfer; the receiving facility was not contacted and there was no evidence that the facility accepted the patient. The facility did not send all medical records related to the patient's condition to the receiving hospital.

During an interview with Staff E, the Medical Director of the ED on 1/27/2020 at 10:00 AM, she was asked if it was acceptable to discharge or transfer a patient to another hospital with a B/P of 174/131 and heart rate of 113 beats per minute, she stated it may be acceptable, but it depends on the patient's condition. Staff E also stated that the transfer was not appropriate because the receiving facility was not informed of the patient's impending transfer and a copy of the patient's medical record was not sent to the recipient facility.