HospitalInspections.org

Based on record review, observation and interviews, the facility failed to ensure there are complete MSEs, transfer forms are complete with signatures, Pt specific risks and benefits for transfer, and EMTALA signs are missing, in 9 of 20 MRs reviewed (1, 2, 4, 5, 7, 9, 14, 15 and 17) and 1 of 1 areas observed (ED).

Findings include:

The facility failed to ensure EMTALA signs are prominently placed in treatment rooms, waiting areas and entrances to the hospital, in 1 of 1 area observed (ED). See Tag C2402.

The facility failed to ensure a complete MSE is conducted for each Pt presenting to the ED, in 4 of 20 MRs reviewed (1, 2, 14 and 15); and the MD failed to arrive after notification within 20 minutes of patient arrival per facility policy, in 1 of 20 MRs reviewed (5 ). See Tag C2406

The facility failed to ensure transfer forms are complete for Pt specific risks and benefits of transferring to another facility, in 4 of 4 transfer MRs out of a total 20 MRs reviewed (4, 7, 9 and 17). See Tag C2409.

The cumulative affect of these deficiencies potentially affect all ED Pts treated at the facility, there were no Pts seen in the ED during survey.

Based on observation and interview, the facility failed to ensure EMTALA signs are prominently placed in treatment rooms, waiting areas and entrances to the hospital, in 1 of 1 area observed (ED).

Findings include:

Per observation on 1/6/15 at 11:30 AM with RN B, there are no EMTALA signs in the ED treatment room, treatment bay, or the entrances to the hospital. One sign on a door in the waiting area is not visible if the door is closed. These findings were confirmed with Sup B on 1/6/15 at 11:30 AM adding Pts arriving for emergency treatment enter by either the ED door or front door of the hospital, and there are no signs at the entrances. RN was unaware of the need for the signs in the treatment areas.

Based on record review and interview, the facility failed to ensure a complete MSE is conducted for each Pt presenting to the ED, in 4 of 20 MRs reviewed (1, 2, 14 and 15); the MD failed to arrive after notification within 20 minutes of patient arrival per facility policy, in 1 of 20 MRs reviewed (5).

Findings include:

Per interview with RN B on 1/6/15 at 12:36 PM, RNs "sometimes just call MD with assessment and get orders for treatment and discharge."

Per review on 1/6/15 at 2:00 PM, of facility policy titled Emergency Department Medical Screening dated 4/28/11, it states under Medical Screening Exam states "the RN completing the assessment will assess document blood pressure, heart rate, respiratory rate, temperature, present illness or injury, severity of symptoms, past medical history, present medications, allergies."

Per review on 1/6/15 at 2:00 PM, of facility policy titled On Call Personnel, last reviewed 4/11/14, it states "All on call personnel will respond to their call within 20 minutes."

Example of incomplete screen:

Pt #1's MR review on 1/6/15 at 12:20 PM revealed on 10/18/14 at 4:15 AM, Pt #1 arrived in the ED for a medical clearance, escorted by the county sheriff, claiming Pt #1 had taken some drugs and was "tearing up the house". The MSE conducted by MD D on 10/18/14 at 4:35 AM states "The police are concerned that (Pt #1) was on some kind of drug. She was not acting normally....is on multiple different drugs...Cognitively impaired (Pt #1) in no real acute distress...did not seem to listen to reason...did improve somewhat through (Pt #1's) ER visit with improved interactions and speaking...refused EKG..." The Plan in the note states: "The patient definitely improved over the hour...is stable and has no signs of progressive delirium from (Pt #1's) drugs. It looks like (Pt #1) is actually coming out of ...drug stoop(sic) or whatever it was. We will go ahead a discharge to jail." There is no documentation the MD considered of lab work being done.

Per RN notes at 4:45 AM the RN notes "MD not attempting urine drug screen or labs at this time because of the patient's uncooperation". At 5:15 AM the RN states "Patient calmed down, letting nurse get a full set of vitals without disagreement. MD cleared patient to go home becasue (Pt #1) is improving. Discharged via ambulation accompanied by ...county officer." There is no documentation of attempted labs while Pt is calm.

The MR has no orders for lab work and no lab work, or refusal of lab work, documented in the MR to determine any toxic levels of drugs.

Per interview with CO F on 1/6/14 at 1:37 PM, Pt #1 did not recall the ED visit, and became concerned after receiving a bill for the visit and no tests were done, and was told by hospital staff (Pt #1) was too combative to do anything. C/O F stated the event was related to a metabolic toxic reaction (delirium and acute confusional state).

Per interview with RN C on 1/6/14 at 3:20 PM, RN C recalled Pt #1 was combative, and yelled to not touch, but once out of cuffs, (Pt #1) seemed fine. RN C said there were pills brought in, but had not entered them into the MR. RN C confirmed they did not do lab work, but was not sure why.

Per interview with MD D on 1/6/14 at 4:10 PM, Pt #1 would not let MD D "do much of an exam". MD D stated the pills were loose in baggies and tried to identifying them on a website called "Pill Finder", but did not record what the pills were in the MR, and could not recall any pills identified. MD D said Pt#1 was delirious on arrival but improved, and said lab work was not done because Pt #1 would not let us touch her. Pt #1 was improving while we were watching her. MD D confirmed there is no documentation in the MR as to why lab work was not done.

Pt #2's MR review on 1/6/15 at 12:30 PM revealed Pt #2 arrived in the ED on 9/6/14 at 10:20 PM, with a complaint of shortness of breath and throat swelling. The RN notes timed 11:20 PM state "Pt said (Pt #2's) symptoms started at around 2115 (9:15 PM)...took 20 (mg) of Prednisone with little relief. At 10:25 PM the RN note state "Vitals assessed, heart and lungs auscultated, Pt is calm and cooperative. Pt does not show SxS (signs and symptoms) of distress". At 10:33 PM the RN called the MD and received orders for .3 (mg) Epi (epinephrine) (sub Q)(just under the skin), 50 mg Benedryl, and 40 mg prednisone, with orders to watch 45 minutes. The note at 11:10 PM states "Pt states...is feeling better...says that it is easier to swallow and...is breathing better as well." The RN physical assessment includes Level of Consciousness: awake and alert are checked; Orientation: time person and place are checked; Psychological: calm and cooperative are checked; Respiratory: unlabored with clear breath sounds; Abdomen: soft and non-tender are checked; Skin Condition: pale and dry are checked. There is no documentation the RN looked in Pt #2 mouth to determine if and to what extent there is swelling. The Past Medical History states "Pt has an extensive heath Hx (history) with cancer and allergies, there is no list of allergies in the assessment. There is no present list of medications. The MD did not come in to see this Pt. This is confirmed in interview with RN B on 1/6/15 at 12:30 PM, adding the RN should have looked in the Pts mouth. RN B stated "sometimes we just call MD with assessment and get orders for treatment and discharge."

Pt #14's MR review on 1/6/15 at 12:48 PM revealed Pt #14 arrived in the ED on 11/3/14 at 1:00 AM with a complaint of back pain. RN notes timed 1:00 AM state "Patient to ER complaining of back pain inbetween (sic) (Pt #14's) shoulder blades. Patient was in the ER on Saturday (11/1) with the same complaint...took Flexeril Sunday (11/2) at 1800 (6:00 PM)...States it hurts to lay down, cough, or breath deep." The Nursing Assessment has Past Hx as "Chronic back pain, back surgery", pain is rated as 7 out of 10 and constant, no lung sounds are documented, no cardiovascular assessment is documented. At 1:10 AM the RN notes states "EKG done showing normal sinus rhythm with frequent PACs (premature arterial contractions)." At 1:20 AM the RN noted the MD was called "orders for Toradol 60 mg and to go to chiropractor in the morning. If pain not relieved by chiropractor, make appointment with primary doctor." Pt was discharged at 1:35 AM, with no reassessment of pain after Toradol. Pt was not seen by the MD. This was confirmed in interview with RN E on 1/6/15 at 12:48 PM.

Pt #15's MR reviewed on 1/6/15 at 1:00 PM revealed Pt #15 arrived in the ED on 11/1/14 at 12:10 AM with a complaint of a toothache. The Nursing assessment at 12:10 AM states Pt #15 rates pain an 8 out of 10. At 12:15 AM the MD was notified and documented "orders for Toradol 60 mg IM and discharge with orders to make appointment with Dentist on Monday." There is no documentation the RN looked in Pt #15's mouth for any swelling or signs of infection. Pt #15 was discharge at 12:30 AM, there is no reassessment of Pt #15's pain. This is confirmed in interview with RN E on 1/6/15 at 1:00 PM.

Examples of MD not arriving in specified timeframe:

Pt #5's MR review on 1/6/15 at 2:00 PM revealed Pt #5 arrived in the ED on 11/26/14 at 6:50 PM with a complaint of chest pain and shortness of breath. The RN note timed 6:50 PM states "Chest pain started around 1700 (5:00 PM). Pt has a history of anxiety, took a xanax (anti anxiety medication) at this time. At the time of arrival to ER, patient states the pain is less now." At 7:15 PM the RN documented the MD was called, received lab orders and "will call when results are back." At 7:45 PM it is noted the lab results came back, and the MD arrived, 30 minutes after notification, rather than 20 minutes per policy. Notes at 8:00 PM indicate the Pt may have GERD (gastric acids to reflux into the esophagus). An antacid was offered, refused by Pt, and Pt #5 was discharged at 8:30 PM. This was confirmed in interview with RN B on 1/6/215 at 2:00 PM, with no comment why the MD did not arrive sooner.

Based on record review and interview the facility failed to ensure transfer forms are complete for Pt specific risks and benefits of transferring to another facility, in 4 of 4 transfer MRs out of a total 20 MRs reviewed (4, 7, 9 and 17).

Findings include:

Per interview with DON A on 1/6/15 at 5:00 PM there is no P&P for completing Certification of Transfer forms.

Per interview with MD D on 1/6/15 at 4:10 PM, "the nurses fill out the risks and benefits on the transfer form."

Per interview with RN B on 1/6/15 at 3:00 PM, the RNs will fill out the risks and benefits on the transfer form, adding if they are not present when it is discussed between the MD and Pt, the RN will just "fill it out".

Pt #4's MR review on 1/6/15 at 1:00 PM revealed Pt #4 arrived in the ED on 11/24/14 at 10:05 AM following a crush injury and required transfer to a facility to repair a compression fracture in the back. The Certification of Transfer form, dated 11/24/14, has no risks listed specific to Pt #4's condition. This is confirmed in interview with RN B on 1/6/15 at 1:00 PM, agreeing the risks should be completed.

Pt #17's MR review on 1/6/15 at 1:10 PM revealed Pt #17 arrived in the ED on 10/14/14 at 1:00 PM with a complaint of shortness of breath, requiring transfer for suspected pulmonary embolism (clot in lungs). The Certification of Transfer form, dated 10/12/14, has no benefits or risks specific to Pt #17 condition. This is confirmed in interview on 1/6/15 at 1:10 PM with RN E, agreeing the transfer form should be complete.

Pt #7's MR review on 1/6/15 at 2:30 PM revealed Pt #7 arrived in the ED on 12/17/14 at 8:20 AM following a CVA (stroke), requesting transfer to another hospital to see a neurologist. The Certification of Transfer form, dated 12/17/14, has no benefits of transfer listed and lists "Death" and "Deterioration en route" checked with no risk specific to Pt #7's condition. This is confirmed in interview with RN B on 1/6/15 at 2:30 PM, agreeing the benefits and specific risks should be completed.

Pt #9's MR review on 1/6/15 at 3:41 PM revealed Pt #9 arrived in the ED on 9/14/14, no time listed, was seen by the MD at 9:20 AM following a seizure and unwitnessed fall. The Certification of Transfer form, dated 9/14/14, has no benefits or risks specific to Pt #7 condition. There is no signature on the transfer form by the MD. This is confirmed in interview on 1/6/15 at 3:41 PM with RN E, agreeing the transfer form should be complete.