HospitalInspections.org

Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42 CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare-participating hospitals in emergency cases as evidenced by:

A2406: Medical Screening Examination: The hospital failed to provide a Medical Screening Examination (MSE) to Patient #7 who presented to the Emergency Department (ED) with chest pain. The patient left without treatment after waiting approximately 15 hours without being evaluated by a [physician]. The patient went to a different acute care hospital directly after leaving Banner University Medical Center Tucson for care and treatment.

Based on reviews of clinical records, policies and procedures, hospital documents, logs and records, and staff interviews, it was determined the hospital failed to provide a Medical Screening Examination (MSE) to Patient #7 who presented to the Emergency Department (ED) with chest pain. The patient left without treatment after waiting approximately 15 hours without being evaluated by a physician. The patient went to a different acute care hospital directly after leaving Banner University Medical Center Tucson.
Findings include:

The hospital's policy and procedure titled, "EMTALA-Medical Screening Examination and Stabilization Treatment," (Policy Number 1330, Version 13, Effective 11/04/2020) included: "An appropriate MSE will be offered to individuals on the Campus of Banner Hospitals with a Dedicated Emergency Department who request emergency medical services, on whose behalf such services are requested, or, in the absence of such a request, whose appearance or behavior would cause a prudent layperson observer to believe that such individuals need an emergency examination or treatment...An MSE will be conducted to determine whether the Patient has an EMC (emergency medical condition)...The MSE is an ongoing process requiring continuous monitoring based upon the Patient's needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred."

The hospital's "Emergency Department Standards of Care" (Policy Number 629, Version 10, Effective 01/26/2022) revealed triage assessments completed by Registered Nurses (RN's) were to include the assignment of an Emergency Severity Index (ESI) score from 1 to 5 with an ESI 1 score requiring immediate life-saving interventions and ESI 5 requiring no resources needed. An ESI 2 score was defined as: "High-risk situation or confused/lethargic/disoriented or severe pain distress." Reassessments, "Occurs according to the patient's clinical presentation or any significant clinical event with the minimum requirements as follows...ESI 2 = Documented reassessments every 1 hour until hemodynamically stable, then minimally every 4 hours or per admitting unit standard of care."

Patient #7 presented to the ED at 3:46 p.m. on 6/9/2022. The patient was triaged by an [RN] at 3:50 p.m. who documented the patient's [Pulmonary and Infectious Disease doctors] sent the patient for "workup" related to chest and lung pain for one month. The patient was assigned an ESI of 3. The ED [hysician's] note at 3:56 p.m. included: "The patient presents for evaluation for PE (pulmonary embolism) from [her] specialists. [He] {sic} a history of lung problems...Patient is awake, alert. Speaking clearly and cogently. No respiratory difficulty...There are currently no available rooms in the emergency department. As there are no rooms currently available, the patient will wait for a room in the lobby. Patient is currently safe to wait for an available room. The patient's additional diagnostic work up is currently pending." The ED [physician] ordered lab work and a CT of the chest for "PE" (Pulmonary Embolism) at 3:55 p.m. The lab work was drawn and sent to the Lab at 9:57 p.m. The CT scan was not performed. A [nurses] note on 6/10/2022 at 7:19 a.m. included: "Patient upset that [she] was waiting for so many hours without CT scan performed. This [RN] spoke with CT assistant (name) who stated that [she] has seafood allergy listed and needs to be monitored 30 minutes after scan for reactions. Patient still in triage without staff for appropriate monitoring. Spoke with patient and confirmed no seafood allergy. Patient states 'I have had many CT scans with no contrast reactions'. This [RN] removed seafood allergy in Cerner and informed (name) that patient does not have reaction. Patient ultimately decided to leave and signed form due to CT scanning trauma read and still have to wait until patient done in scanner..." A Refusal of Examination form was signed by the patient on 6/10/2022 at 7:11 a.m. The patient reported during an interview that [she] was told that her insurance might not pay if [she] did not sign the form, however, this could not be verified during the investigation.

Patient #7 left after waiting over 15 hours without a Medical Screening Examination.

Patient #7 presented to Hospital #3's ED on 6/10/2020. A review of the medical records obtained from Hospital #3 revealed the patient arrived at 11:59 a.m. and received an MSE at 12:24 p.m. Documentation in the MSE included: "...Patient symptoms did not seem cardiac in nature appear to be muscular possible PE or pleurisy. Chest x-ray was done it was negative CBC chemistry troponin were negative EKG showed a sinus rhythm no acute changes. Did a CT chest x-ray showed subacute bilateral rib fractures 2 on the left and 4 on the right which I thought to be the cause of patient's pain. There is also some pulm multiple point nodules with cavitation questionable atypical infection...I talked to (name) our pulmonologist on-call. He looked at the CT felt there was no acute infection but did send off a cocci serology and have her follow-up with a pulmonologist. From a pain standpoint I felt we can discharge patient home on pain medication...[She] understood this and felt comfortable with this disposition, CT also showed a left renal mass of 18 mm educated patient to follow-up rule out malignant versus benign lesion..."

The hospital provided the following information specific to Emergency Department volumes for the period from May 2022 through October 2022:

May 2022:
# of patients who presented: 6,155
# of patients who left without treatment (MSE): 758
# of patients who left AMA (against medical advice): 111

June 2022:
# of patients who presented: 5,178
# of patients who left without treatment: 526
# of patients who left AMA: 75

July 2022:
# of patients whopresented: 5,539
# of patients who left without treatment: 1,189
# of patients who left AMA: 63

August 2022:
# of patients who presented: 6,001
# of patients who left without treatment: 847
# of patients who left AMA: 100

September 2022:
# of patients who presented: 6,698
# of patients who left without treatment: 895
# of patients who left AMA: 34

October 2022:
# of patients who presented: 5,904
# of patients who left without treatment: 1,045
# of patients who left AMA: 38

November 1 to November 14, 2022:
# of patients who presented: 2,924
# of patients who left without treatment: 497

Hospital leadership acknowledged during interviews that they were aware of the numbers of patients who were leaving without Medical Screening Examinations and continued to develop action plans to address the issues.