HospitalInspections.org

Based upon review of 20 medical records of patients seeking treatment at the facility emergency department (ED), interviews with emergency department staff, review of the facility's emergency department policies and procedures, and review of one patient/visitor incident report, the facility failed to implement their written policies and procedures to meet the Federal Emergency Medical Treatment and Active Labor Act (EMTALA) requirements by failing to conduct a medical screening examination for 1 of 20 sampled patients presenting for treatment at the hospital emergency department (sample patient #1).

The findings are:

Review of the hospital's policies and procedures (P&P) for the emergency department (ED) showed their most recent approval was 9/20/17 by the CEO (Chief Executive Officer), CNO (Chief Nursing Office) , the ED Nurse Manager, and the Chair of the Board.

The EMTALA (Emergency Medical Treatment and Active Labor Act) Guidelines for Emergency Department Services, Reference #4005, effective 2/1/2016 and approved by the Calhoun Liberty Hospital Association, Inc. was included as part of the P&P review.

The policy defined an emergency medical condition as "A medical condition with sufficient severity (including severe pain, psychiatric disturbances, symptoms of substance abuse, pregnancy/active labor) such that the absence of immediate medical attention could place the individuals health at risk". The policy defined a medical screening exam as "The process required to reach, with reasonable confidence, the point at which it can be determined whether the individual has an emergency medical condition or not".
The policy further stated: "All patients presenting to the emergency department and seeking care, or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay. All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic. Medical Screening exams (MSEs) should include at a minimum the following: emergency department log entry including disposition of the patient, patient's triage record, vital signs, history, physical exam of the affected symptoms and potentially affected systems, and complete documentation of the medical screening exam".

A record review was conducted for sampled patient #1. The patient record consisted of 2 documents:
1. "Emergency Room - Outpatient Record", a one page registration sheet, which contained demographic information including address, date of birth, name, an assigned patient number, date of service (DOS), age, and time of arrival. The emergency room - outpatient record also has a section to record the chief complaint of the patient, and contained the words "Neck IV Leaking Blood".
2. Authorization for Emergency Treatment form used by the hospital. The patient's name, date of birth, medical record number, account record number, and admission date appeared on the top right corner of the form; however, the form was not dated or signed by the patient, responsible party, or other witness.
The record review revealed that sampled patient #1 presented to the facility ED at 7:45 PM on 9/14/2017 and left the ED at 7:54 PM the same day (a total of a 9 minute visit).
On 9/29/17, at approximately 11:35 AM, an interview was conducted with the ED nurse manager. The nurse manager confirmed the entire medical record for patient #1 consisted of only a face sheet and an unsigned consent form. There were no nursing or physician notes; however, there was an incident report, which was obtained and reviewed.

A review of the "Patient/Visitor Incident Report" dated 9/14/17 at 8:20 PM revealed the following:
Date of occurrence was noted as 9/14/17 at 7:50 PM, and concerned an emergency room visit by sampled patient #1. The diagnosis for patient #1 was documented as "bleeding dialysis port". Text entered into the "nature and site of injury" section of the report stated "Patient had surgery today to put in a dialysis port. Patient noticed that the port had blood all around it, dripping from under the bandage. Explained to patient that the doctor couldn't touch the new device, and it would be in the patient's best interest to go back to the surgeon that put it in, per the nurse practitioner. Explained that he could be seen, but ultimately would have to be seen by the placing surgeon for proper treatment. Daughter called back 15 minutes later saying we refused treatment." The signature of the person completing the report was documented as a licensed practical nurse who worked in the emergency department. The report was received by the facility risk manager on 9/15/17 at 7:30 AM. Investigative facts per the facility risk manager (RM) notes stated: "Attempted to contact patient - no answer - message left - notified emergency department manager and physician. All staff being brought in for EMTALA re-education. Spoke with the involved Advanced Registered Nurse Practitioner and verbally reviewed EMTALA law and proper procedure. Involved LPN called and will be coming in to meet with ED nursing manager. The RM notes went on to describe actions taken as: "Called Agency for Healthcare Administration (AHCA) to self report the EMTALA violation, and message left. Spoke with patient's daughter about incident - feedback given and will follow up with staff. At 12:30 called AHCA again and left message on voicemail. At 9:45 AM the Chief Nursing Officer (CNO) was informed. At 10:30 AM the Chief Executive Office (CEO) made aware." This portion of the report was signed by the facility risk manager on 9/15/17.


A telephone interview was conducted with sample staff "H" (LPN who was present with patient #1 in the registration area) on 9/29/17 at approximately 12:10 PM. She stated that the ARNP (staff sample "A") did not interact with the patient, and only saw patient #1 from afar in the waiting room. The ARNP stated "it would be in their best interest to return to the surgeon who placed the port because he would not be able to treat it". She informed the patient and family (wife and daughter) of what the ARNP said. The daughter was aggravated and said "so in other words, he doesn't know what he's doing". The patient had no comment. The patient had no other obvious symptoms. They then left the facility, stating they were going to go back to Panama City. LPN "H" stated they all received EMTALA training after that incident, and actually had EMTALA training not too long before the incident, also.

A telephone interview was conducted with sample staff "A" (the ARNP identified in the facility incident report) on 9/29/17 at approximately 7:50 PM. Staff "A" gave the following statement from what he recalled regarding the incident: "The triage nurse approached me (unknown time) and explained there was a patient there who had a newly placed, temporary dialysis catheter in his neck and it was collecting a lot of blood under the dressing. I told the nurse (in passing) to let the patient know I could not treat him with medications." He stated he was very busy treating another patient, and did not take the time to think the situation through. He stated he never spoke to the patient, and never examined him. He stated that his intent was for the triage nurse to merely inform the patient not to have expectations of resolving his problem in the emergency room, and it was not meant to be taken as an instruction to go elsewhere for treatment. In response to questions, he stated that he received EMTALA training annually, and had worked at the hospital for about 3 years. He also stated that he received EMTALA training the very next day after the incident. He stated that if he had taken the time to think the situation through thoroughly, he would have chosen his words more carefully, which would have resulted in the patient receiving the required medical screening examination.

Based upon review of 20 medical records of patients seeking treatment at the facility emergency department (ED), interviews with emergency department staff, review of the facility's emergency department policies and procedures, and review of one patient/visitor incident report, the facility failed to conduct a medical screening examination for 1 of 20 sampled patients presenting for treatment at the hospital emergency department (sample patient #1).

The findings are:
A record review was conducted for sampled patient #1. The patient record consisted of 2 documents:
1. "Emergency Room - Outpatient Record", a one page registration sheet, which contained demographic information including address, date of birth, name, an assigned patient number, date of service (DOS), age, and time of arrival. The emergency room - outpatient record also has a section to record the chief complaint of the patient, and contained the words "Neck IV Leaking Blood".
2. Authorization for Emergency Treatment form used by the hospital. The patient's name, date of birth, medical record number, account record number, and admission date appeared on the top right corner of the form; however, the form was not dated or signed by the patient, responsible party, or other witness.
The record review revealed that sampled patient #1 presented to the facility ED at 7:45 PM on 9/14/2017 and left the ED at 7:54 PM the same day (a total of a 9 minute visit).
On 9/29/17, at approximately 11:35 AM, an interview was conducted with the ED nurse manager. The nurse manager confirmed the entire medical record for patient #1 consisted of only a face sheet and an unsigned consent form. There were no nursing or physician notes; however, there was an incident report, which was obtained and reviewed.

A review of the "Patient/Visitor Incident Report" dated 9/14/17 at 8:20 PM revealed the following:
Date of occurrence was noted as 9/14/17 at 7:50 PM, and concerned an emergency room visit by sampled patient #1. The diagnosis for patient #1 was documented as "bleeding dialysis port". Text entered into the "nature and site of injury" section of the report stated "Patient had surgery today to put in a dialysis port. Patient noticed that the port had blood all around it, dripping from under the bandage. Explained to patient that the doctor couldn't touch the new device, and it would be in the patient's best interest to go back to the surgeon that put it in, per the nurse practitioner. Explained that he could be seen, but ultimately would have to be seen by the placing surgeon for proper treatment. Daughter called back 15 minutes later saying we refused treatment." The signature of the person completing the report was documented as a licensed practical nurse who worked in the emergency department. The report was received by the facility risk manager on 9/15/17 at 7:30 AM. Investigative facts per the facility risk manager (RM) notes stated: "Attempted to contact patient - no answer - message left - notified emergency department manager and physician. All staff being brought in for EMTALA re-education. Spoke with the involved Advanced Registered Nurse Practitioner and verbally reviewed EMTALA law and proper procedure. Involved LPN called and will be coming in to meet with ED nursing manager. The RM notes went on to describe actions taken as: "Called Agency for Healthcare Administration (AHCA) to self report the EMTALA violation, and message left. Spoke with patient's daughter about incident - feedback given and will follow up with staff. At 12:30 called AHCA again and left message on voicemail. At 9:45 AM the Chief Nursing Officer (CNO) was informed. At 10:30 AM the Chief Executive Office (CEO) made aware." This portion of the report was signed by the facility risk manager on 9/15/17.


A telephone interview was conducted with sample staff "" (LPN who was present with patient #1 in the registration area) on 9/29/17 at approximately 12:10 PM. She stated that the ARNP (staff sample "A") did not interact with the patient, and only saw patient #1 from afar in the waiting room. The ARNP stated "it would be in their best interest to return to the surgeon who placed the port because he would not be able to treat it". She informed the patient and family (wife and daughter) of what the ARNP said. The daughter was aggravated and said "so in other words, he doesn't know what he's doing". The patient had no comment. The patient had no other obvious symptoms. They then left the facility, stating they were going to go back to Panama City. LPN "H" stated they all received EMTALA training after that incident, and actually had EMTALA training not too long before the incident, also.

A telephone interview was conducted with sample staff "A" (the ARNP identified in the facility incident report) on 9/29/17 at approximately 7:50 PM. Staff "A" gave the following statement from what he recalled regarding the incident: "The triage nurse approached me (unknown time) and explained there was a patient there who had a newly placed, temporary dialysis catheter in his neck and it was collecting a lot of blood under the dressing. I told the nurse (in passing) to let the patient know I could not treat him with medications." He stated he was very busy treating another patient, and did not take the time to think the situation through. He stated he never spoke to the patient, and never examined him. He stated that his intent was for the triage nurse to merely inform the patient not to have expectations of resolving his problem in the emergency room, and it was not meant to be taken as an instruction to go elsewhere for treatment. In response to questions, he stated that he received EMTALA training annually, and had worked at the hospital for about 3 years. He also stated that he received EMTALA training the very next day after the incident. He stated that if he had taken the time to think the situation through thoroughly, he would have chosen his words more carefully, which would have resulted in the patient receiving the required medical screening examination.

Review of the hospital's policies and procedures (P&P) for the emergency department (ED) showed their most recent approval was 9/20/17 by the CEO (Chief Executive Officer), CNO (Chief Nursing Office) , the ED Nurse Manager, and the Chair of the Board.
The EMTALA (Emergency Medical Treatment and Active Labor Act) Guidelines for Emergency Department Services, Reference #4005, effective 2/1/2016 and approved by the Calhoun Liberty Hospital Association, Inc. was included as part of the P&P review.
The policy defined an emergency medical condition as "A medical condition with sufficient severity (including severe pain, psychiatric disturbances, symptoms of substance abuse, pregnancy/active labor) such that the absence of immediate medical attention could place the individuals health at risk". The policy defined a medical screening exam as "The process required to reach, with reasonable confidence, the point at which it can be determined whether the individual has an emergency medical condition or not".
The policy further stated: "All patients presenting to the emergency department and seeking care, or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay. All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic. Medical Screening exams (MSEs) should include at a minimum the following: emergency department log entry including disposition of the patient, patient's triage record, vital signs, history, physical exam of the affected symptoms and potentially affected systems, and complete documentation of the medical screening exam".