HospitalInspections.org

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Based on interview and document review, the hospital failed to ensure that all patients seeking treatment in the emergency department (ED) received a medical screening exam (MSE) (Item #1) and that all staff adopt and implement policies and procedures when a patient withdraws a request for examination or treatment in the ED (Item #2).

Failure to ensure that all patients seeking treatment in the ED receive an appropriate medical screening exam, and failure to ensure that all ED staff follow policies and procedures when a patient withdraws a request for treatment or exam places patients at risk for serious injury, serious harm, or death from an untreated emergency medical condition.

Findings included:

1. The hospital failed to provide an appropriate medical screening exam for 1 of 25 patients (Patient #1201) seeking treatment in the ED.

Cross-reference: A2406

2. The hospital failed to ensure that staff adopt and implement policies and procedures when a patient withdraws a request for examination or treatment in the emergency department (ED) for 2 of 25 records reviewed (Patients #1201 and #1202).

Cross-reference: A2407
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Based on interview, document review, and review of hospital policies and procedures, the hospital failed to provide an appropriate medical screening exam (MSE) for 1 of 25 patients (Patient #1201) seeking treatment in the emergency department (ED).

Failure to provide appropriate medical screening examinations by qualified medical professionals with stabilizing medical treatment prior to ED discharge or transfer risks poor health outcomes, injury, and death.

Findings included:

1. Review of the hospital's policy titled "EMTALA - Medical Screening and Treatment of Emergency Medical Conditions," policy number 10814051, approved 12/02/21, showed the following:

a. A medical screening examination (MSE) is required to reach the point at which it can be determined whether or not an emergency medical condition exists.

b. The MSE must be performed by qualified medical personnel, as set forth in the medical staff bylaws.

c. The medical records must reflect continued monitoring based on the medical needs of the patient until the patient is either stabilized or appropriately transferred.

d. If a patient withdraws his or her consent for examination or treatment, an appropriately trained emergency department (ED) staff member should:

i. Offer the patient further medical examination and treatment as may be necessary to identify and stabilize an emergency medical condition

ii. Inform the patient of the benefits of the exam and/or treatment, and of the risks of not receiving the exam/treatment

iii. Use of reasonable efforts to obtain the patient's signature showing that a refusal to receive an examination/treatment. The form should contain a description of the risks discussed and the exam and/or treatment that was refused.

2. On 03/23/22 at 1:00 PM, the investigator interviewed an ED physician (Staff #1206). The interview showed that all hospital ED providers were expected to complete EMTALA education on a yearly basis.

3. On 03/22/22 at 1:30 PM, the investigator reviewed patient records and interviewed the Quality Manager (Staff #1201). The record review and interview showed the following:

a. Patient #1201 had a history of a small bowel obstruction. On 02/14/22 at 3:41 AM, Patient #1201 went to the ED complaining of abdominal pain lasting one week. During the triage process, Patient #1201 began swearing at the nurse and complaining about the care received during a prior visit.

b. Upon introducing himself to the patient, the provider (Staff #1207) attempted to establish some "ground rules," including not disrespecting or swearing at the hospital staff. Patient #1201 verbalized disagreement with the ground rules, continued to swear, and was told by Staff #1207 that if the behavior continued, she would have to leave.

c. Patient #1201 threatened to report Staff #1207 to the state and demanded that the provider call an ambulance to take her to a different hospital. Staff #1207 told Patient #1201, "she could call the ambulance herself."

d. Staff #1207 informed Patient #1201 that he would evaluate her as long as she did not swear at him or the staff. Patient #1201 continued to use foul language, and Staff #1207 ended the exam and escorted her to the front.

e. Staff #1201 confirmed the investigator's findings that Patient #1201 did not receive a MSE prior to ED discharge, and the medical record contained no documentation that the patient refused a MSE.

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Based on document review and interview, the hospital failed to ensure that staff adopt and implement policies and procedures when a patient withdraws a request for examination or treatment in the emergency department (ED) for 2 of 25 records reviewed (Patients #1201 and #1202).

Failure to ensure that staff adopt and implement policies and procedures when a patient withdraws request for examination or treatment places patients at risk from harm from an untreated emergency medical condition.

Findings included:

1. Review of the hospital's policy titled, "EMTALA - Medical Screening and Treatment of Emergency Conditions," policy number 10814051, approved 12/21, showed the following:

a. If a patient withdraws consent for examination or treatment, an appropriately trained member of the ED staff should:

i. Offer the patient further medical examination and/or treatment as needed to identify and/or stabilize an emergency medical condition

ii. Inform the patient of the benefits of the exam or treatment and the risks of withdrawal prior to receiving the exam or treatment

iii. Use reasonable efforts to obtain the patient's signature on a form indicating the refusal examination or treatment. The form should include a description of risks discussed and the examination or treatment that was refused.

2. Review of the hospital's policy titled, "Standards of Nursing Care in the ED," policy number 8267144, approved 03/21, showed the following:

a. A patient who voices a desire to leave before completing treatment should be counseled as to the risks of leaving without completion of medical care.

b. Whenever possible, the provider should counsel the patient on the risks of leaving without completing medical treatment.

c. If the patient intends to leave before completing medical treatment, the "Consent, Leaving Against Advice" (AMA) should be completed, and the patient will be asked to sign the form. The nurse signs the form as a witness. If the patient refuses to sign the form, a second staff member should sign the form.

d. The nurse caring for the patient documents the patient's request, completion of the AMA form, and the risks discussed with the patient in the medical record.


Patient #1201

3. Medical record review showed that on 02/14/22 at 3:41 AM, Patient #1201 went to the ED complaining of right upper abdominal pain for one week, with increasing pain and nausea, vomiting, and diarrhea on the night of the visit. Document review showed that:

a. During the triage process, Patient #1201 began to complain about a previous visit to the hospital and tell the nurse she was a terrible nurse and should be ashamed of herself for the care provided during the last visit.

b. When the ED doctor (Staff #1207) entered the room, he attempted to establish some "ground rules" for how Patient #1201 would behave, including not swearing at or disrespecting staff. The patient informed Staff #1207 that staff insulted her first, and she had every right to do what she wanted.

c. Staff #1207 informed Patient #1201 that if the behavior continued, she would need to leave. Patient #1201 demanded that Staff #1207 call her an ambulance to take her to another hospital, but Staff #1207 refused and told her to "call one herself."

d. Staff #1207 documented that he told Patient #1201 once more that he would evaluate her on the condition that she not swear at him or the staff, but the patient only responded with vulgarities and walked out.

e. The investigator found no documentation that Staff #1207 discussed the risks of leaving without completing medical care with Patient #1201 or documentation that Patient #1201 signed, or refused to sign, a "Consent, Leaving Against Advice" form.


Patient #1202

4. Medical record review showed that on 12/16/21 at 10:50 PM, Patient #1202 was brought into the ED by the police for erratic behavior and a crisis evaluation. The medical record showed the following:

a. Patient #1202 had a history of bipolar disorder, and on 12/16/21, was experiencing a manic episode. The patient had been drinking alcohol earlier that evening, was behaving erratically, and was acting paranoid and psychotic.

b. The medical screening exam showed that the patient denied suicidal or homcidal thoughts, but she had random nonsensical movements and conversations that made it difficult to determine if she was having a psychotic episode. The patient denied pregnancy or other medical problems. Significant lab findings included a blood alcohol level of 244.1 mg/dL and a positive urine pregnancy test.

c. At 12:50 AM, Patient #1202 became agitated and aggressive with staff, and the provider made the decision to medicate the patient for safety.

d. At 3:30 AM, the provider noted that the patient was sleeping and medically cleared for crisis evaluation. At 3:52 AM, documentation showed that the patient's medical record was faxed to crisis. The investigator found no documentation that a crisis response team evaluation occurred.

e. At 8:00 AM, nursing note documentation showed that Patient #1202 was awake and verbalized a desire to leave. Documentation showed that the patient was "encouraged to stay" and walked out without assistance.

f. The investigator found no documentation that the nurse notified the provider of the patient's desire to leave, no documentation that any qualified hospital staff attempted to counsel the patient on the risks of leaving before completing treatment or the benefits of receiving treatment, and no documentation of an AMA form in Patient #1202's medical record.

5. On 03/23/22 at 9:00 AM, the Quality Manager (Staff #1201) confirmed the investigator's findings of the missing documents for Patients #1201 and #1202.