HospitalInspections.org

Based on policy review, Emergency Department (ED) Logs, ED Medical Record reviews and interviews, the facility failed to provide a Medical Screening Examination within its capability and capacity, to determine if an Emergency Medical Condition existed for one patient (#20) out of 20 sampled ED records reviewed from May 2018 through October 2018, that presented to the ED seeking care. The patient presented with complaints of jaw pain, swelling in the left upper jaw region and wheezing. The patient was directed by registration staff to go across the street to the clinic for treatment.

Based on interview, record review, Emergency Department (ED) log review and policy review, the hospital failed to provide a Medical Screening Examination (MSE) within its capability and capacity, to determine if an Emergency Medical Condition (EMC) existed for one patient (#20) of 20 patients who presented to the hospital ED seeking care, out of a sample selected from May 2018 to October 2018.

Findings included:

1. Review of the facility policy titled, "EMTALA POLICY" dated 10/2018, showed:
- Each individual who comes to the Emergency Department (ED) receives an appropriate MSE.
- All required personnel have consistent information and understand the requirements and expectations regarding the criteria of a complete and thorough MSE.
- "Comes to the Emergency Department" refers to all individuals who request examination or treatment for a medical condition.
- A MSE is the process of assessment by Qualified Medical Professional (QMP) and may include an examination, diagnostic interventions and treatment to determine an Emergency Medical Condition (EMC).

Review of the facility, "Quality Improvement Report," dated 09/21/18, showed Patient #20 presented to the facility on 09/21/18, time unknown, complaining of trouble swallowing, facial swelling, shortness of breath and tooth pain. She stated that she went to the ED registration desk and was told by staff to go the clinic to be seen. She reported that she had not been triaged prior to being sent to the clinic. The patient was evaluated by the clinic nursing staff and a Nurse Practitioner and sent back to the ED. On presentation the second time, she was in obvious distress and was experiencing cyanosis (a bluish discoloration which indicates poor circulation or impaired oxygenation) around her mouth.

Review of the ED log showed no first presentation by Patient #20. The log showed the second presentation on 09/21/18 at 10:25 AM.

Review of Patient #1's ED record dated 09/21/18 at 10:25 AM showed:
- She complained of jaw pain, swelling and wheezing.
- Her oxygen saturation (the amount of oxygen in the blood) was 85 percent (normal is greater than 92 percent) on finger, and 95 percent on forehead.
- A chest x-ray showed she had bilateral (left and right) patchy lung infiltrates (part of the lung looks normal, and part looks infected).
- A diagnosis of asthma exacerbation (a sudden worsening of symptoms of shortness of breath, wheezing, etc).
- A diagnosis of dental abscess (a buildup of pus inside the teeth or gums).
- A diagnosis of bilateral pneumonia (an infection of the air sacs of both lungs).
- She was administered a breathing treatment, a pain medication and an antibiotic was prescribed.
- She was to follow up with an oral/dental surgeon and her Primary Care Physician.

An interview could not be obtained with Staff O, Registration Clerk.

An interview could not be obtained with Staff U, Registration Supervisor.

An interview could not be obtained with Staff T, ED Medical Director.

During an interview on 11/05/18 at 1:00 PM, Staff P, Registration Lead, stated that if a patient presented to the ED and the complaint was minor, he would send them to the clinic across the street. He stated he received EMTALA training on his hiring about five months ago.

Review of the facility's new employee EMTALA training showed that any and all patients who presented to the ED or the hospital grounds must be seen in the ED. It further stated, "Do not tell them to go anywhere else."

During an interview on 11/05/18 at 1:15 PM, Staff G, Quality Risk Manager, stated that she was not aware of any EMTALA education provided to staff by the Registration Manager, and she could not find any documentation of education to staff. She stated that she provided an EMTALA handout to seven registration staff on 10/18/18.

During an interview on 11/07/18 at 10:15 AM, Staff J, Chief Executive Officer (CEO), stated that he was aware of this incident a couple of days after it happened, but did not know if EMTALA re-education had been provided to staff.