HospitalInspections.org

Based on review of hospital Rules and Regulations, EMTALA (Emergency Medical Treatment and Labor Act) policy, medical records and interviews, it was determined Thomas Hospital failed to:

1. Provide an appropriate medical screening examination.

2. Provide an appropriate transfer that included a countersignature by the physician within the established timeframe.

3. Send to the receiving facility, all medical records related to the emergency condition which the patient has presented.

Cross Refer to A 2406 and A 2409 for findings.

Based on review of the hospital rules and regulations and medical record (MR) review it was determined the hospital failed to provide an appropriate medical screening examination (MSE).

This deficient practice affected one of one patient that required a consultation including Patient Identifier (PI) # 8, and had the potential to affect all patients who require consultations served by the hospital Emergency Department (ED).

Findings include:

Thomas Hospital Rules and Regulation
Date Review: 10/22/24

Article 1, General Rules and Regulations

1.A.3 Admissions

...(d) Medical Screening Exams

(1) Medical screening examinations, within the capability of the hospital, will be performed on all individuals who come to the hospital requesting examination or treatment to determine the presence of an emergency medical condition...Qualified medical personnel... are defined as:

... members of the Medical Staff with clinical privileges in Emergency medicine,
Other Staff members...


Article 2, Medical Records Content and Access

...2.A.2 Reports

(a) The following reports or examinations performed on a patient...shall be incorporated into their medical records.

1. Consultations: Each consultant who may have occasion to examine a patient shall write his findings and recommendations on the progress notes... Consultations shall show evidence of a review of the patient's record by the consultation, pertinent findings on the examination of the patient, the consultant opinion and recommendations. This record shall be part of the medical record.

Article 3, Conduct of Care

3.A.1 Consultations

(a) Any physician with clinical privileges in this Hospital can be called for consultation within his/her area of expertise....

(b) The attending physician is primarily responsible for requesting consultation when indicated and for calling in a qualified consultant.

1. Patient Identifier (PI) # 8 presented to the hospital ED on 8/19/24 at 4:28 PM with progressive auditory and visual hallucinations, paranoia, and delusions.

Review of the ED provider note dated 8/19/24 at 4:28 PM revealed documentation the patient had poor concentration, delayed verbal responses, was anxious, displayed signs of paranoia and delusions, including beliefs that people were putting date-rape drugs directly into his/her bloodstream. The patient was brought in for evaluation of increasingly abnormal behavior including auditory and visual hallucinations over the course of the previous several months. The patient denied illicit drug use or alcohol use. The patient had no signs of trauma.

Review of the Computed Tomography (CT) dated 8/19/24 at 7:41 PM revealed no evidence of acute intracranial finding. If clinically indicated, consider further evaluation with an MRI examination. There was no documentation of an MRI to assess the pituitary gland.

Review of the nursing flowsheet dated 8/19/24 at 8:35 PM revealed PI # 8's neurological status as alert, awake, confused, unable to follow commands, short term memory loss, and delayed speech.

Review of the case manager progress note dated 8/20/24 at 5:25 PM revealed PI # 8's spouse verbalized the patient had not received treatment for the Pituitary Adenoma but Magnetic Resonance Imaging (MRI) was conducted to ensure there were no changes in the tumor within the past one and half years.

Review of the MR revealed no documentation a Neurosurgical and/or Endocrinology consult was provided.

An appropriate MSE was not provided due to no documentation an MRI was performed and a Neurosurgical and/or Endocrinology consultation was provided for the patient with a known or suspected pituitary tumor experiencing progressive alteration in mentation.

Based on review of Policy and Procedure, General Rules and Regulations, medical record (MR) reviews and interview, it was determined Thomas Hospital failed to:

1. Provide an appropriate transfer that included signed certification by the physician that the medical benefits of treatment at another facility outweighed the risks of being transferred.

2. Send to the receiving facility, all medical records related to the emergency condition which the patient has presented.

This deficient practice affected patient identifier (PI) # 6 and PI # 8, two of five transfer MR's reviewed, and had the potential to affect all patients transferring from this hospital.

Findings include:

Hospital Policy: Transfer of Patients: EMTALA
(Emergency Medical Treatment and Labor Act)
Approval Date: 9/29/2022

Policy:

3. The physician at Thomas Hospital has determined that the patient is medically stable for transfer or has certified that the benefits of transfer outweigh the risks.

Procedure:

4. The physician will complete and sign the Physician's Summary of Risks and Benefits form...prior to transfer.

8. A copy of all available medical records, test results, and a copy of the completed transfer form should be sent with the patient on transfer. Copies of records not available at the time of transfer shall be sent to the receiving facility as soon as practical....

General Rules and Regulations
Article 1
Date: None Provided

1.A.2. Advanced Practice Professionals...
(b) Advanced Practice professionals may discharge a patient if the discharge/transfer criteria are met.

(e) Regardless of the note type, notes by an Advanced Practice Practitioner must be countersigned within 24 hours.

1. PI # 6 presented to the emergency department (ED) on 9/4/24 at 12:01 PM with a chief complaint of suicidal.

Review of the MR revealed the Patient Transfer Form contained a signed certification from the PA-C (Physician Assistant - Certified), that the medical benefit from transfer outweigh the risks of transfer, but no countersignature by the physician within the hospital's established timeframe of 24 hours.

Further review of the MR revealed no documentation the medical record was sent to the receiving facility on transfer.

An interview conducted on 12/5/24 at 1:30 PM with EI (Employee Identifier) # 8, Director of Critical Care Services, confirmed the physician did not countersign the certification and there was no documentation the medical record was sent to the receiving facility on transfer.

2. PI # 8 presented to the ED on 8/19/24 at 4:28 PM with a chief complaint of psychiatric evaluation and adrenal adenoma.

Review of the MR revealed the Patient Transfer Form contained a signed certification from the PA-C that the medical benefit from transfer outweigh the risks of transfer, but no countersignature by the physician within the hospital's established timeframe of 24 hours.

Further review of the MR revealed no documentation the medical record was sent to the receiving facility on transfer.

An interview conducted on 12/5/24 at 1:30 PM with EI # 8, confirmed the physician did not countersign the certification and there was no documentation the medical record was sent to the receiving facility on transfer.