HospitalInspections.org

Based on observation, document review, and staff interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.20 and 42 CFR 489.24.

Findings include:

1. The hospital failed to post signage specifying the rights of individuals with respect to the Emergency Medical Treatment and Labor Act (EMTALA). See deficiency at A-2402.

2. The hospital failed to perform a Medical Screening Exam (MSE) for a patient. See deficiency at A-2406

Based on observations, hospital document review, and staff interviews it was determined that the Hospital failed to post signage in the Emergency Department ambulance entry, triage area, and treatment areas specifying the rights of individuals with respect to the Emergency Medical Treatment and Labor Act (EMTALA). Findings include:

Hospital policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA) stated, "...Hospital/center must post one or more signs conspicuously or in a place or places that all individuals entering the Dedicated Emergency department/center, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments/centers (that is, at the entrances, admitting areas, waiting rooms, and treatment areas" will likely notice them...The signage must provide, at a minimum...specific rights of patients with emergency condition and women in labor..."

On a tour of the Main Emergency Department (Main ED) on 7/17/23 between 10:06 and 10:49 AM, no signs specifying the rights of individuals with respect to the Emergency Medical Treatment and Labor Act (EMTALA) were observed in the triage area, patient treatment areas, or ambulance entry way.

During an interview on 7/17/23 at 10:44 AM. Employee #4 confirmed there were no signs specifying the rights of individuals with respect to the Emergency Medical Treatment and Labor Act (EMTALA) posted in the triage area, patient treatment areas, or ambulance entry way. The only such sign in the Main ED was located next to the registration desk and visible in the waiting room.

On a tour of the OB Emergency Department (OB ED) on 7/17/23 between 10:49 and 11:28 AM, no signs specifying the rights of individuals with respect to the Emergency Medical Treatment and Labor Act (EMTALA) were observed in the patient treatment area.

During an interview on 7/17/23 at 11:27 AM, Employee #5 confirmed there were no signs specifying the rights of individuals with respect to the Emergency Medical Treatment and Labor Act (EMTALA) posted in the patient treatment areas. The only such sign in the OB ED was located next to the registration desk and visible in the waiting room.

On 7/19/23 Employee #2 provided pictures verifying the OB ED posted a sign specifying the rights of individuals with respect to the Emergency Medical Treatment and Labor Act (EMTALA) in the OB ED treatment area.

Based on medical record reviews, hospital policy and document reviews, and staff interviews, it was determined that for 1 of 20 patients (Patient #14), the Hospital failed perform the same Medical Screening Exam (MSE) for patients who came to the Emergency Department with similar chief complaints and signs and symptoms. Findings include:

Hospital policy titled "Emergency Medical Treatment & Labor Act (EMTALA)" stated, "...Dedicated Emergency department/center refers to the Bayhealth Medical Center Emergency Departments at Bayhealth Medical Center, Kent Campus...The medical screening examination...medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either stabilized or appropriately transferred...Qualified Medical Personnel refers to those who can perform medical screening examinations...Emergency department/center Physician members of the medical staff with clinical privileges to practice in the Emergency department/center...Allied Health Staff with clinical privileges to practice in the emergency department/center...When an individual comes by..him or herself or with another person to the emergency department/center...and a request is made...for treatment...the hospital /center must provide for an appropriate Medical Screening Examination within the capability of the hospital's...emergency department/centers, including ancillary services routinely available to the emergency department/centers...Qualified Medical Personnel must provide every individual who presents to the Emergency department/center and requests...treatment a Medical Screening Examination..."

Hospital policy titled "Patient's Rights and Responsibilities" stated, "...Bayhealth will...Be sensitive to cultural...differences...needs...Exhibit...poster...Bayhealth is dedicated to providing quality medical care...While you are a patient, we respect your rights including the following...To a reasonable response to the request for appropriate and medically indicated care and services regardless of race ...national origin, or sources of payment for care..."

A. Patient #14

I. Review of Medical Record for 7/14/23 (Friday) date of service revealed:

a. "Patient Care Timeline" for ED visit on 7/14/23 documents:
- 7:19 AM patient arrived in ED with arrival complaint of dialysis.
- 7:29 AM chief complaint updated to "Needs Dialysis (Patient arrived to ED with no complaints other than she needs dialysis M/W/F and received her last two treatments at [an acute care hospital]..."
- 7:29 AM weight documented as 71.4 kg (kilogram) which is a 1.9 kg weight gain since 7/1/23 ED visit.
- 7:30 AM vital signs recorded, blood pressure 198/109 and pulse 108.
- 7:33 AM chief complaint updated to "Need Dialysis (Patient arrived to ED with no complaints other than she needs dialysis. Patient received dialysis M/W/F and received her last two treatments at [an acute care hospital]. Patient does not have an established facility to go for her dialysis)..."
- 9:48 AM lab results documents hemoglobin level of 10.9 and hematocrit level of 34.2.
- 10:20 AM lab results documents Potassium level of 5.5, BUN level of 42, creatinine level of 9.8.
- "Patient Care Rounding" completed at 12:44 PM, 3:13 PM, and 5:45 PM.
- 5:01 PM vital signs recorded; blood pressure 158/90 and pulse 90.
- Disposition documented as LWBS (left without being seen) at 7:51 PM after 3 room calls at 6:35 PM, 7:04 PM, and 7:43 PM indicating patient left, 11 hours and 16 minutes, or 676 minutes, after arrival.

b. "Progress Note" entered by Employee #15, Social Worker, dated 7/14/23 at 2:50 PM revealed patient came to hospital requesting dialysis, recently immigrated to the US and had approval for Delaware Medicaid. Last dialysis treatment was on 7/12/23.

c. There is no evidence of any physician, physician assistant, or nursing progress notes for patient's 7/14/23 ED visit.

d. There is no evidence that a medical screening exam was completed during the patient's 7/14/23 ED visit.

II. Staff interviews revealed:

a. During an interview of 7/18/23 between 2:20 and 2:26 PM, Employee #13 stated that the Dialysis Unit at Bayhealth Medical Center, Kent Campus, will always provide emergent dialysis treatments as needed per physician order. Employee #13's understanding is Patient #14 presented to the ED to be set up for routine dialysis. Routine dialysis cannot be scheduled but emergent dialysis will be provided as determined by a physician. Employee #13 stated she did read the written "After Visit Summary" instruction provided to Patient #14 during her 7/1/23 ED discharge and was concerned that the wording was not accurate. Employee #13 stated he/she spoke with the Director of Care Management and scheduled a meeting to discuss developing talking points for patients requesting long term (routine) dialysis.

b. During an interview on 7/19/23 between 9:40 and 10:10 AM, Employee #15, Social Worker, stated that she had been contacted by a local outpatient dialysis center sometime after Patient #14's 7/1/23 ED visit. The dialysis center was letting Employee #15 know they received a referral for Patient #14 but could not provide outpatient dialysis. The Employee #17, Social Worker, contacted Employee #15 on 7/14/23 to let him/her know Patient #14 was in the ED. Employee #15 met with patient and his/her brother in the ED waiting room to discuss referral to a dialysis center.

c. During an interview on 7/19/23 between 9:40 and 10:10 AM, Employee #13, Nurse Manager, stated that Patient #14 has been accepted to at an outpatient dialysis center because of the work and coordination provided by Employee #15 with the family and dialysis center. Patient #14's first dialysis treatment at the local dialysis center will be Thursday, 7/20/23. Employee #13 stated that the Dialysis Unit at Bayhealth Medical Center, Kent Campus, does not have a policy on when to provide dialysis treatments to patients in the ED. The decision to dialyze ED patients is based on physician orders. Dialysis Unit at Bayhealth Medical Center, Kent Campus will always do emergent dialysis if ordered by a physician; dialysis staff are on call 24 hours 7 days a week.

d. During an interview by phone on 7/25/26 between 8:30 and 8:35 AM, Employee #16, Physician Assistant (PA), stated he/she worked 7:00 AM to 5:00 PM on Friday, 7/14/23. Employee #16 remembers the day was very busy with a large number of patients in the ED waiting room, he/she did not remember number of patients. When he/she started the shift, the "swing" nurse (nurse working to move patients from waiting room to an ED room) asked Employee #16 to order labs for Patient #14. Patient's renal status needed to be assessed for possible "emergent" dialysis and if patient needed to be placed on a monitor. Employee #16 stated he/she "did not see patient" or review lab results. Employee #16 stated the lab results are reviewed by triage which is staffed by 1 Registered Nurse (RN) and 1 PA. Employee #16 stated he/she remembers that other than the Triage PA, she was the only PA working that day, 7/14/23.

On 7/19/23 at 1:30, Employee #2 confirmed there is no evidence of physician progress notes, or a medical screening exam, documented in the medical records for Patient #14's 7/14/23 Bayhealth Medical Center's Kent Campus ED visit.


B. Patient #10, ED patient presenting to ED in similar manner as Patient #14 - No findings with Patient #10

I. Review of medical records for date of service 7/12/23 (Wednesday) revealed:

a. Patient arrived in the ED on 7/12/23 at 8:35 AM. At 9:00 AM, Patient was seen by provider (Employee 18, MD).
b. Patient's chief complaint - On vacation, needs dialysis. Patient was supposed to be dialyzed at an outpatient clinic, but the clinic is supposed to be closed.
c. Patient denies shortness of breath, chest pain. Labs without significant abnormalities - no hyperkalemia or electrolyte derangement.
d. Patient #10 was dialyzed and discharged to home.

During an interview on 7/19/23 at 2:30 PM, Employee #1 acknowledged Patient #14 was not dialyzed on 7/14/23, that Patient #10 was dialyzed 7/12/23, and stated that the difference between Patient #14 and Patient #10 was that Patient #10 was a current patient at a dialysis center.


II. Bayhealth Medical Center's Kent Campus ED and HD reports

Review of Bayhealth Medical Center's Kent HD "Register" revealed:
- Wednesday 7/12/23 - 9 patients were dialyzed which included 1 ED patient, 1 outpatient, and 7 inpatients.
- Thursday 7/13/23 - 10 patients were dialyzed which included 3 outpatients and 7 inpatients.
- Friday 7/14/23 - 8 patients were dialyzed which included 1 ED patient (started 4:40 PM and ended at 7:45 PM), 2 outpatients, and 5 inpatients.

Review of "ED Patient Statuses Per Hour" report for Bayhealth Medical Center Kent ED revealed:
- Wednesday 7/12/23 - 92 patient arrivals between 7:00 AM to 7:00 PM
- Thursday 7/13/23 - 85 patient arrivals between 7:00 AM to 7:00 PM
- Friday 7/14/23 - 104 patient arrivals between 7:00 AM to 7:00 PM
- Friday 7/14/23 - Running census documents census of 30 patients at 7:00 AM peaking up to approximately 78 patients at 12:00 PM and remaining steady to 6:00 PM with a census of approximately 74 patients. This is a similar finding for Wednesday 7/12/23 and Thursday 7/13/23.

Review of "ED Daily Snapshot" report for Bayhealth Medical Center Kent ED revealed:
- July 12, 2023
a. Median time from arrival to provider of 110.9 minutes
b. Median time of length of stay of 376.0 minutes
- July 13, 2023
a. Median time from arrival to provider of 30.38 minutes
b. Median time of length of stay of 364.0 minutes
- July 14, 2023
a. Median time from arrival to provider of 59.05 minutes
b. Median time of length of stay of 433.0 minutes

Review of "ED Arrivals by Day of Week" per month report Bayhealth Medical Center Kent ED revealed:
- July 2023
a. Wednesdays in July 2023 had an average number of arrivals of 140.0
b. Fridays in July 2023 had an average of arrivals of 137.0
- June 2023
a. Wednesdays in June 2023 had an average number of arrivals of 150.5
b. Fridays in June 2023 had an average of arrivals of 124.2