HospitalInspections.org

Based on review of facility documents, review of medical records, and staff interview, the facility failed to maintain a central log on each individual who came to the emergency department seeking assistance for 1 of 20 patients (patient #1) reviewed.

Findings included:

The "Bylaws of the Medical Staff" and the "Medical Staff Rules and Regulations," approved May 20, 2019, revealed rules related to physician responsibility to respond.
Article II Categories of the Medical Staff stated in part, "Section 1: The Active Medical Staff: ...Members of the active medical staff are required to take emergency room call and treat patients who present themselves to the hospital ..."

Facility Emergency Room policy entitled "General Care," included the following:
" ...1.1.2 Interventions
General Patient Care
...*The Emergency Department team will ensure EMTALA guidelines are followed.
1.2 Patient Care Guidelines - Triage of the ED patient - General Care
1.2.1 Purpose
*All patients shall be triaged upon entrance into the Emergency Department to determine the care treatment and services needed
...* upon arrival into the Emergency Department triage/waiting area, the patient shall be checked in by the Admitting Department Clerk ..."

Review of the medical record for patient [pt] #1 revealed an untimed physician note dated 11/15/20 that stated in part, "Pt came here by family. Drove up in truck outside. [Family] asking me, 'What do I do?' I discussed [pt #1] case, as I saw [pt #1] last night ... I called [staff #12, another physician at Facility A] who knows pt very well. [Staff #12] felt that it is not safe here considering how much active COVID we have. I gave pt options:
1) Come here and be seen & evaluated or
2) they could drive directly to [Facility B, approximately 80 miles away] & be seen as is larger institution.
Pt [family] wanted to not be seen here and [they] preferred to go right to [Facility B]. I agree with [family] decision, but told [them] we could call and transfer [patient] as this may facilitate the total process. Pt family was aware it is risky to transfer but accepted risk."

In an interview with staff #1, when asked about patient #1, staff #1 stated, "I told them I'd be happy to see them. They just wanted to drive on. They asked me to call [staff #12] because they have so much respect for [staff #12]. [Staff #12] thought [pt #1] should be seen. I told them 'Come on in, I'll see you.' Maybe some of them wanted to stay and some of them wanted to go. There were a lot of people from what I remember. I went and talked to them in the truck. I'm an experienced physician, it takes 5/10 mins to get someone transferred. I thought that was the best."

Review of witness statements from four staff members (three who were working on 11/15/20) revealed staff #18 met patient #1 and their family outside and reported they wanted to be seen. All witness statements confirmed staff #1 had a conversation with patient #1 and family, called staff #12, had another conversation with patient #1; then patient #1 drove away. No other staff member witnessed the conversation between staff #1 and patient #1 on 11/15/20.

A Review of the Emergency Department registration log revealed 16 patients were seen on 11/15/20; Patient #1 did not appear on the log for this day. Patient #1 presented on 11/15/20 with family and left without being treated; there was no documentation on the log the patient even presented requesting treatment.

In an interview with the Quality Director on the afternoon of 12/1/20, when asked what is expected of staff if someone presented to the ED but decided to not be seen, the Quality Director stated, "Register them and document they went AMA [against medical advice]." When asked how that process worked if a patient refused to sign the AMA form, they stated, "There should, ideally, be two nurses that sign and witness, but sometimes it can be another staff like the clerk ..."

There was no AMA or Consent to/Refusal of Treatment and Transfer form in patient #1's medical record.

The above was verified in an interview with staff #9 and 10 on the afternoon of 12/1/20.

Based on a review of facility documents, review of medical records, and staff interviews, the facility failed to ensure each patient presenting at the hospital emergency department received an appropriate and complete medical screening examination according to hospital policy and current standards of care for 2 of 20 emergency department patients [Patients #1 and 12].

Findings included:

Facility policy entitled "Vital Signs," included the following:
"Procedure: Vital signs are taken on admission to the ED and repeated ... A full set of vital signs are taken within 10 minutes of discharge, transfer, or admission to the hospital. Any deviation from normal vital sign ranges are reported to the provider immediately. Documentation should include the notification and any orders given and carried out.
...Pulse [or Heart Rate, HR] ...Normal adult range: 60 - 80 BPM
...Respirations [or Respiration Rate, RR] ... Adult normal range: 12 - 20 breaths/min
...Oxygen Saturation [O2; measure of the amount of oxygen in a person's blood]: ...supplemental oxygen will be administered when O2 saturation is below 92%, or at the discretion of the provider."

The "Bylaws of the Medical Staff of Yoakum County Hospital," and the "Medical Staff Rules and Regulations," approved May 20, 2019, revealed rules related to physician responsibility to respond.
Article II Categories of the Medical Staff stated in part, "Section 1: The Active Medical Staff: ...Members of the active medical staff are required to take emergency room call and treat patients who present themselves to the hospital ..."

Article VIII Medical Staff Rules and Regulations stated in part,
"17. Emergency Room: The emergency room nurse will encourage the patient to see the Mid Level Practitioner or Physician on call ... In the event of a bona fide emergency, it is understood that if any active staff member is on the premises or available by telephone, he will check the emergency room patient to ascertain if immediate orders need to be given the nurse."

Facility Emergency Room policy entitled "General Care," included the following:
" ...1.1.2 Interventions
General Patient Care
*A focused triage assessment should be completed within 15 minutes of ED arrival (whenever possible), Triage documentation consists of initial vital signs, pain scale, chief complaint, mechanism of injury, GCS [Glascow Coma Scale, a clinical tool to measure level of consciousness. The maximum score is 15, indicating someone is fully awake; minimum score is 3, indicating brain-dead state] and (RTS [revised trauma score] if needed), mode of arrival, height and weight.
*An initial head-to-toe assessment will be performed on all patients to identify abnormalities and/or injuries and documented by an RN.
...*All patients will be reassessed after each intervention and medication administration and the response to treatment will be documented.
...*The Emergency Department team will ensure EMTALA guidelines are followed.

...1.2 Patient Care Guidelines - Triage of the ED patient - General Care
1.2.1 Purpose
*All patients shall be triaged upon entrance into the Emergency Department to determine the care treatment and services needed
...* upon arrival into the Emergency Department triage/waiting area, the patient shall be checked in by the Admitting Department Clerk ..."


Review of the medical record for patient #1 revealed he was a 73-year-old male with a history of bladder cancer. He presented to Facility A's emergency department on 11/14/20 at 10:21 pm for lethargy, vomiting and diarrhea. His triage Vital Signs were Blood Pressure 160/80, 99.8°F, HR 110, RR 38 and O2 of 91% on nasal cannula (no indication how many liters per minute). He was triaged as an acuity level of 3 on the Emergency Severity Index [a triaging system to determine the needs of a patient; level 1 is most urgent to level 5 which is least urgent] and was taken to a room.

Laboratory studies, including a complete blood count, comprehensive metabolic panel and lipase serum, were ordered and drawn. On 11/14/20 at 10:49 pm, Ondansetron 4 mg IV [milligrams intravenously] push was given for nausea and 1000 mL Sodium Chloride 0.9% [Normal Saline] IV fluids given for hydration. His vitals were taken again on 11/14/20 at 10:59 pm which included a decrease in pulse at 103, decrease in BP at 117/70 and O2 94% on 6 Liters per nasal cannula.

On 11/14/20 at 11:45 pm, nurse's discharge assessment and instructions stated in part, "Neurological: Awake/Alert
Respirations: No Distress Noted
CVS: Regular Rate
Skin Warm & Dry
Condition: Improved/Stable"

Discharge Vital Signs on 11/15/20 at 12:01 am indicated BP 105/51 [a greater decrease]; HR 93; RR 38 [continued to remain elevated]; O2 95% nasal cannula [without any indication on how much oxygen the patient was on].

The physician emergency record with no date or time, stated in part, "Chief complaint: N/V [nausea/vomiting] - 'little bit' onset/duration: yesterday am - emesis 4x, 3x today. Severity: moderate; context: Had CTX [chemotherapy] for bladder CA [cancer] yesterday. No [illegible]. Emesis started 2 hrs after CTX. Did not eat today ..."
A past history and physical exam was completed which stated in part, "General Appearance: No acute distress; alert ... EENT [ears, eyes, nose and throat]: ...no signs of dehydration; Dry mucus membranes ..."
Labs were drawn and reviewed by the physician who indicated all were normal except:
"WBC 25.20 [white blood cell, high levels can indicate infection or an underlying condition, such as leukemia; normal range 4.11-11.10; pt #1's level was critically high];
Creat 2.20 [creatinine, a measure of kidney function. Normal levels 0.55-1.30];
Hx [history] cr 1.83 on 7/23/20."
The physician's clinical impression stated,
"1) Leukocytosis - hx high WBC;
2) AKI [Acute Kidney Injury];
3) Dehydration"
This record indicated the disposition was "home" and was signed but undated and untimed by the physician. No progress of the patient or condition on discharge was documented.

There was no documentation of the patient's response after medications were administered. There was no indication of the amount of oxygen the patient presented with, if this amount was titrated, or what amount the patient was discharged on. There was no documentation the out-of-range pulse and respiratory rates were within normal limits, improved, or reported to the physician prior to discharge.

An untimed physician progress note dated 11/15 stated in part, "Pt came here by family. Drove up in truck outside. Wife asking me, 'What do I do?' I discussed his case, as I saw him last night. I told them he probably has CLL [Chronic Lymphocytic Leukemia possibly, illegible, unable to ask staff #1 to clarify]. They wanted me to d/w [staff #12, another doctor at Facility A]. I called [staff #12] who knows pt very well. He felt that it is not safe here considering how much active COVID we have. I gave pt options:
1) Come here and be seen & evaluated or
2) they could drive directly to [Facility B, approximately 80 miles away] & be seen as is larger institution.
Pt wife wanted to not be seen here and she preferred to go right to [Facility B]. I agree with her decision, but told her we could call and transfer him as this may facilitate the total process. Pt family was aware it is risky to transfer but accepted risk."

Patient #1 returned to the emergency department approximately 12-16 hours after his first ED visit with his family for a decline in condition. The patient was not seen at Facility A on 11/15/20, so it could not be determined if the patient had an emergency medical condition or was stable for transfer. Facility A did not contact Facility B for a transfer. The patient's family attempted to drive to Facility B, but the patient's condition continued to worsen while en route.

Review of the helicopter ambulance report revealed they were dispatched on 11/15/20 at 4:41 pm and arrived at the patient at 5:08 pm with initial VS of BP 105/57, HR 124, RR 32, O2 90% on 15 LPM. Initial GCS was 11 and dropped to 3 at 5:11 pm. A 12-lead ECC was obtained, medications were given and the patient was intubated.

Patient #1 arrived at facility B emergency department at approximately 6:07 pm on 11/15/20 where he was admitted for acute respiratory failure, urinary tract infection, acute renal failure, and severe sepsis. He was treated in the Intensive Care Unit for several days before being able to be discharged home.

In an interview, staff #12 stated, "I was at home and this pt is one of mine so [staff #1] called me. The impression I got was he was seen the day before, got fluid, discharged home, called and said they were coming back. He also just received chemotherapy. [Staff #1] said, 'Don't you think he'll be better going up to [facility B] to see a specialist?' I wasn't there, I said, 'I want to defer to your judgement.' He was probably right, we have a hospital full of COVID and he had already had COVID, so I agreed with him. I didn't know he was in the parking lot. I thought he was calling from home ... I didn't know his status. He lives in [a city about 30 miles away] and he's driving by the ER in [that city] and driving all the way over here. If you're capable, if you're able to do that, I would encourage you to see a specialist. I kind of agreed with [staff #1] there really, but if someone comes, I would see him, of course. If someone comes to the doorway and say, 'I want to go [to another hospital],' we can only recommend they be seen ... If we recommend they should see a specialist and they agree with it, if someone has been seen and triaged by a staff member and they're not stable, we should stabilize and transfer, but if someone is stable, then it's reasonable to think they should go see their specialist."

The above was verified in an interview with staff #9 and 10 on the morning of 12/2/20.

Review of the medical record for patient #12 revealed they presented to the ED on 11/15/20 for dizziness/vertigo but was never triaged and discharged AMA [Against Medical Advice] after 68 minutes. The nurse noted in part, "Pt left because she was tired of waiting patient priority and more serious pts needed to be put emergently before her ..."

When asked what time the patient actually left, staff #10 reported they could not be sure of the exact time. When asked how it could be determined that patient #12's priority was lower than another without being triaged, staff #10 confirmed the patient should have been triaged before the documented discharge time of 68 minutes. Staff #10 went on to say, "Looks like she wasn't triaged. It's highly possible that someone did [the triage], just didn't document that. If it's not documented, it's not done ... The RN may have actually triaged her, but it didn't get filled out."

When discussed the provided policy titled "General Care" detailed a "primary" and "secondary survey" of emergency patients but did not detail what a Medical Screening Exam was and who could perform it, staff #10 stated, "Right now, it's not delineated who can do it and what an MSE is. We had a discussion with our lawyers [involving who can perform MSEs], but we didn't put it in a policy."

When asked about staff training regarding EMTALA, staff #10 reported it was a yearly instructor-led training but recently transferred to on-line. Training files were requested throughout the survey. The only training provided was related to updated CMS guidance during the pandemic, which was shared with leadership and medical staff on 3/16/20. No evidence was provided that non-leadership hospital staff received EMTALA training.

The above was verified in an interview with staff #10 on the afternoon of 12/10/20.

Based on review of facility documents, review of medical records, and staff interview, the facility failed to ensure 1 of 20 patients presenting to the ED was stable and appropriate for transfer. This failure resulted in an emergency transfer via helicopter to Facility B and admission for several days.

Findings included:

Facility form titled "Consent to/Refusal of Treatment and Transfer" stated in part, "The Emergency Room Physician and / or my attending physician has evaluated me and explained my medical condition. I have been informed of my right to receive, within the capabilities of this hospitals [sic] staff and facilities, all appropriate medical screening examinations, necessary stabilizing treatment and an appropriate transfer to another medical facility. The physician has recommended that I be transferred to ___ Hospital under the care of Dr. ___. The physician has explained the potential benefits and the potential risks associated with such transfer and the probable risks of not being transferred, and I fully understand them."

Review of the medical record for patient [pt] #1 revealed an untimed physician note dated 11/15/20 that stated in part, "Pt came here by family. Drove up in truck outside. [Family] asking me, 'What do I do?' I discussed [pt #1] case, as I saw [pt #1] last night ... I called [staff #12, another physician at Facility A] who knows pt very well. [Staff #12] felt that it is not safe here considering how much active COVID we have. I gave pt options:
1) Come here and be seen & evaluated or
2) they could drive directly to [Facility B, approximately 80 miles away] & be seen as is larger institution.
Pt [family] wanted to not be seen here and [they] preferred to go right to [Facility B]. I agree with [family] decision, but told [them] we could call and transfer [patient] as this may facilitate the total process. Pt family was aware it is risky to transfer but accepted risk."

In an interview with staff #1, when asked about patient #1, staff #1 stated, "I told them I'd be happy to see them. They just wanted to drive on. They asked me to call [staff #12] because they have so much respect for [staff #12]. [Staff #12] thought [pt #1] should be seen. I told them 'Come on in, I'll see you.' Maybe some of them wanted to stay and some of them wanted to go. There were a lot of people from what I remember. I went and talked to them in the truck. I'm an experienced physician, it takes 5/10 mins to get someone transferred. I thought that was the best."

Review of witness statements from four staff members (three who were working on 11/15/20) revealed staff #18 met patient #1 and their family outside and reported they wanted to be seen. All witness statements confirmed staff #1 had a conversation with patient #1 and family, called staff #12, had another conversation with patient #1; then patient #1 drove away. No other staff member witnessed the conversation between staff #1 and patient #1 on 11/15/20.

Patient #1 returned to the emergency department approximately 12-16 hours after his first ED visit with his family for a decline in condition. The patient was not seen at Facility A on 11/15/20, so it could not be determined if the patient had an emergency medical condition or was stable for transfer. Facility A did not contact Facility B for a transfer. The patient's family attempted to drive to Facility B, but the patient's condition continued to worsen while en route.

In an interview with the Quality Director on the afternoon of 12/1/20, when asked what is expected of staff if someone presented to the ED but decided to not be seen, the Quality Director stated, "Register them and document they went AMA [against medical advice]." When asked how that process worked if a patient refused to sign the AMA form, they stated, "There should, ideally, be two nurses that sign and witness, but sometimes it can be another staff like the clerk ..."

There was no AMA or Consent to/Refusal of Treatment and Transfer form in patient #1's medical record.

The above was verified in an interview with staff #10 on the afternoon of 12/10/20.