HospitalInspections.org

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Based on observation, interview, and record review, the hospital failed to develop and implement policies and procedures for evaluation and treatment of patients presenting for emergency care via ambulance in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure patients are prioritized to receive a medical screening exam (MSE) by a qualified medical professional risks delay in care, further injury, and death.

Findings included:

The hospital failed to triage and prioritize patients for medical screening exams (MSEs) upon arrival for 2 of 32 patients reviewed (Patients #26, #27).

Cross Reference: A 2406
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Based on observation, interview, and document review, the hospital failed to assume care of patients arriving by ambulance and provide a medical screening exam (MSE) in 2 of 32 patients reviewed (Patients #26, #27).

Failure to provide a MSE to patients presenting to the emergency department (ED) risks poor health outcomes, injury, or death.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment & Labor Act (EMTALA)," policy number 13340714, last approved 03/21/23, showed that the triage, MSE, or necessary stabilizing treatment are not to be delayed. The record must reflect continued monitoring according to the patient's needs and must continue until they are stabilized or appropriately transferred or discharged.

Review of the hospital's policy titled, "Triage - Emergency Center," policy 8478585, last revised 09/08/20, showed that upon presenting to the ED, patients shall be evaluated to determine the appropriate priority in which they will be seen for an emergency medical exam (MSE). A patient may be triaged either as a walk-in at triage or at the bedside.

2. The investigator reviewed medical records and prehospital patient care records (PCRs) for patients who received care in the ED. The documentation showed the following:

a. Emergency medical service (EMS) documentation showed that Patient #26 arrived at the hospital via ambulance on 01/21/24 at 4:34 PM. The hospital documentation showed that hospital staff acknowledged Patient #26's ED arrival at 4:38 PM. Patient #26 complained of a recent fall and subsequent head injury. By 5:37 PM, 59 minutes after the initial request for emergency services, the patient remained in the hospital breezeway and continued to wait to be triaged and prioritized for an MSE. The patient told ambulance staff that her pain was increasing, and she was also having pain on the right side of her chest. The patient requested to be taken to a hospital that could provide care.

The ambulance staff checked-in with the charge nurse again to verify that they couldn't assume care for Patient #26. Upon confirmation, the ambulance staff transported the patient to another hospital in the area to receive care. The hospital and ambulance documentation both indicated that the patient was at the hospital but that the hospital did not assume care, triage to prioritize the MSE, or provide monitoring for changes in condition.

On 01/30/24 at 12:30 PM, the investigator interviewed the Quality Manager (Staff #9). Staff #9 confirmed that the medical record showed that Patient #26 arrived for emergency care and waited for 59 minutes in the hospital's breezeway without hospital-provided monitoring, triage, or MSE.

On 01/23/24 at 6:50 PM, the investigator interviewed the Fire Lieutenant (Staff #21) responsible for Patient #26's prehospital care. Staff #21 confirmed the patient's ED arrival time, the patient's change in condition, and the ambulance crew rerouting to another hospital. Staff #21 also stated that hospital staff were notified of the patient's change in condition and her request to go to another hospital if they could not care for her. Staff #21 stated that the patient continued to wait in the breezeway without hospital care until she was transported to another hospital.

b. EMS documentation showed that Patient #27 arrived at the hospital via ambulance on 01/24/24 at 1:04 PM. The hospital documentation showed that hospital staff acknowledged Patient #27's ED arrival at 1:06 PM. Patient #27 arrived at the ED via ambulance with the primary complaint of a witnessed seizure (disrupted brain activity that leads to involuntary movements or loss of consciousness) and fall.

The ambulance documentation showed that the ambulance staff held the patient in the breezeway until 1:41 PM, 35 minutes. The ambulance documentation also showed that the patient's condition improved while she awaited care and the ambulance staff handed over care to the charge nurse and the hospital assumed care at that time. Hospital documentation of a triage, monitoring, or MSE could not be found. The patient's disposition was updated to left without being seen and before triage at 9:43 PM by an ED nurse, 8 hours and 37 minutes after the patient arrived.

On 01/30/24 at 3:05 PM, the investigator interviewed the ED Manager (Staff #15) and also reviewed the medical record of Patient #27 with Staff #15. Staff #15 stated that the ambulance record didn't align with their processes. The charge nurse would not have assumed care. The investigator asked how we could verify if this patient was brought to the waiting area since her condition improved. Staff #15 stated that patients who were brought to the waiting area and then leave against medical advice or without being seen were documented as such in the medical record. Staff #15 confirmed that the medical record did not indicate the disposition of the patient or if a triage or MSE occurred.

3. On 01/22/24 at 4:00 PM, the investigator interviewed the registrar (Staff #14). Staff #14 confirmed that the ED's registration process was to document the patients' arrival time when the patient presented for care at the ambulance bay or the waiting room entrance. Staff #14 also stated that the time a nurse documents that they are assuming care does not necessarily reflect the time the patient arrived for care.

4. On 01/22/24 at 12:00 PM, the investigator interviewed the ED Assistant Manager (Staff #11). Staff #11 stated that the hospital process was to receive reports from the ambulance staff. Based on that report, some patients were to wait in the breezeway or ambulance until a bed became available. The investigator asked how the patients were prioritized to receive an MSE. Staff #11 stated that patients in the breezeway or ambulance were not considered hospital patients and remained the responsibility of the ambulance staff.

5. On 01/30/24 at 3:05 PM, the investigator interviewed the manager of the ED (Staff #15). Staff #15 stated that patients remained the responsibility of EMS until hospital staff were available to assume care and begin the triage process.
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