HospitalInspections.org

From 10/21/13 to 10/23/13, an unannounced on-site EMTALA (Emergency Medical Treatment and Labor Act) complaint investigation survey authorized by the Centers for Medicare and Medicaid Services (CMS) was conducted at Big Horn County Memorial Hospital. One deficiency was cited as a result of this investigation. The facility is not in compliance with CFR ?489.24.

Based on staff interview, clinical record review, and review of medical staff bylaws and meeting minutes, the facility failed to provide an appropriate medical screening exam to 9 (#s 4, 8, 9, 11, 12 ,13, 15, 19, and 21) of 22 sampled patients who presented to the emergency department. Findings include:

1. Patient #4, a 7 month, 29 day old male, presented to the ED with his mother on 10/16/13 at 11:04 a.m., with a stated complaint of, "fever and cough. Decreased appetite. Coughing until he vomits x1." He was triaged at 11:28 a.m., as a level 5 meaning non-urgent. His initial vital signs were taken at 11:19 a.m., which included: a temperature of 99? F, heart rate of 161, respirations 40, and 94% on room air. A blood pressure was not recorded. His height and weight were 25 inches and 21 pounds.

A nursing assessment was performed in the ED at 11:25 a.m. The on-call provider for the ED was notified at 11:30 a.m. A nurses note in the medical record revealed, "1130 [11:30 a.m.]-Patient report called to the clinic, spoke with [name of physician]. Patient is non emergent and referred the clinic. 1140 [11:40 a.m.]-Patient escorted to the clinic accompanied by CNA." There was no evidence of documentation in the ED record that patient #4 was seen by a medical provider while in the ED.

2. Patient #8, a 71 year old male, presented to the ED on 10/10/13 at 9:20 a.m., with a stated complaint of, "Patient woke up this am and had short 10 minute or less period of confusion and lightheadedness, it scared him and he wanted to be checked. He now denies confusion or lightheadedness, reports feeling like his normal self at this time." Patient #8 was triaged at 9:30 a.m., as a level 5 meaning non-urgent. The on-call provider for the ED was notified at 9:50 a.m. At 9:50 a.m., patient #8 was discharged from the ED to the clinic, which is across the street from the hospital, with a CNA, according to the ED patient log.

Patient #8's past medical history included: gout,unspecified, and mild cognitive impairment, so stated. His home medications included: lisinopril 10 mg daily, Plavix 75 mg daily, aspirin 81 mg daily, and Lopressor 50 mg twice daily. There was no evidence of documentation in the ED record that patient #8 was seen by a medical provider while in the ED. He did receive a CT of his head without contrast at 11:17 a.m.

3. Patient #9, a 12 month, 19 day old male, presented to the ED with his mother on 10/7/13 at 2:33 p.m., with a chief complaint of diarrhea, nausea, and/or vomiting. He was triaged at 2:49 p.m., as a level 5 meaning non-urgent. His vital signs included: a temperature of 98.9? F, heart rate of 149, respirations 26 and 98% on room air. A blood pressure was not recorded. His height and weight were 25 inches and 22 pounds.

A nursing assessment was performed in the ED at 3:03 p.m. The record revealed, "Nausea/vomiting comments: Mother reports pt has vomited 4-5 times this AM. ... Date of most recent bowel movement: loose and watery X 6 today last BM 1430 [2:30 p.m.]" The on-call provider for the ED was notified at 2:40 p.m. At 2:50 p.m., patient #9 was discharged from the ED to the clinic. There was no evidence of documentation in the ED record that patient #9 was neither seen by a medical provider while in the ED nor was there documentation that a staff member accompanied patient #9 to the clinic.

4. Patient #11, a 23 year old female, presented to the ED on 10/2/13 at 2:48 p.m., with a chief complaint of abdominal pain. She was triaged at 3:00 p.m., as a level 4 meaning semi-urgent. The nurses note in the ED record revealed, "1500 [3:00 p.m.]-- presents with lower abd pain that radiates around to back has had off and on for 1 year 1515 [3:15 p.m.]-- provider notified 1520 [3:20 p.m.]-- escorted to [name of town] clinic ambulatory" There was no evidence of documentation in the ED record that patient #11 was seen by a medical provider while in the ED.

5. Patient #12, a 72 year old male, presented to the ED on 9/26/13 at 9:18 a.m., with a chief complaint of extremity pain. His stated complaint from the record was, "right knee started to hurt and by this am it was very swollen and painful." His initial set of vital signs were taken at 9:35 a.m., and the on-call provider was notified at 9:40 a.m. The documentation in the medical record indicated that patient #12 was triaged as a level 4 meaning semi-urgent.

Patient #12's past medical history included: diabetes type 2, history of kidney stones, gastroesophageal reflux, dizziness/vertigo, other acute pain, knee pain, and effusion of lower leg joint. His home medications included: allopurinol 100 mg daily, aspirin 81 mg daily, Glucophage 500 mg twice daily with meals, and a multivitamin once daily. Patient #12 rated his pain during the triage assessment at a 9 out of 10. At 10:30 a.m., patient #12 was discharged from the ED and taken to the clinic per wheelchair with a CNA, according to the ED patient log. There was no evidence of documentation that a nursing assessment was completed in patient #12's medical record. There was also no evidence of documentation that patient #12 was seen by a medical provider while in the ED.

6. Patient #13, a 49 year old female, presented to the ED on 9/24/13 at 10:00 a.m. Patient #13 was triaged at 9:45 a.m., as a level 5 meaning non-urgent. No vital signs were documented in the ED visit. The on-call provider was notified at 9:45 a.m.

The nurses notes in the medical record revealed, "0945 [9:45 a.m.] - Pt ambulated to nurses desk and states that she feels sick and needs to be seen in the ER. Pt was seen ambulating in hallways of hospital and was observed working prior to c/o feeling ill. Pt breathing and ambulating without difficulty. A & O, answers questions appropriately. States she has been sick for last couple of days. [Physician name], the on call doctor, was sitting at the nurses desk. When asked what was wrong, pt states she feels faint and is sick. Pt requested to be seen in the ER and states she is going to check in and go lie down somewhere. Pt walked to waiting rm. [Physician name] stated that he was going back to perform the surgery now and to send the pt to the clinic. [Nurse's name] stated that she would go talk to the pt. Pt was sitting at the check in desk with her head on the desk. [Nurses name] instructed pt that the provider on call was getting ready to go into surgery and would not be available for 45min [sic] to an hour and that she should go to the clinic to be seen as per instructed by [physician name]. Pt stated that she was too sick to go to the clinic and would go somewhere else. Pt got up and walked down the away [sic]. .... 1015 [10:15 a.m.] - [CNA's name] to front waiting room and unable to find pt. [CNA's name] checked both waiting rooms and then went to pt's office to see if she was there. [ADON name] stated that pt had left. [CNA's name] notified [nurse's name]. 1021 [10:21 a.m.] - Called pt on cell phone. Informed pt that we were looking for her to see her in ER. Pt states "They are taking care of me." Asked pt if she was at clinic or if she still wanted to be seen in the ER. Pt hung up phone without answering. 1045 [10:45 a.m.] - Notified on call provider of situation." Patient #13 was discharged from the ED on 9/24/13 at 10:21 a.m., with the disposition of: "Left against medical advice or discontinued care."

7. Patient #15, a 43 year old male, presented to the ED on 9/23/13 at 9:54 a.m., with a chief complaint of nausea and/or vomiting. He was triaged at 10:08 a.m., as a level 5 meaning non-urgent with a stated complaint of, "Patient states he had a burrito at a truck stop in [name of city] and while he was driving he picked-off [sic] a skin -tag [sic] by his (L) eye, was bleeding so he got a sanitizer wipe and cleaned it , thinks he may have gotten some in his eye, because since than [sic] he has been nauseated, dizzy, can't keep anything down." A nurses note written at 10:08 a.m. revealed, "Patient presented stating he has been nauseous, dizzy, and unable to keep anything down since last night approx. 7pm [sic]. Also, stated that he had pulled a skin-tag from his (L) cheek and used a sanitizer wipe and may have gotten some in his eye, because this all started after he used the sanitizer." The on-call provider was notified at 10:25 a.m. A nurses note written at 11:18 a.m. revealed, "Called the [name of town] Clinic and spoke with [on-call physician name] who said to send him over to the clinic for further evaluation and care. Patient escorted over to the clinic per [CNA's name]." There was no evidence of documentation in the ED record that patient #15 was seen by a medical provider while in the ED.

8. Patient #19, a 35 year old female, presented to the ED on 5/14/13 at 2154 [9:54 p.m.]. The nurses notes in the ED record written on 5/23/13 at 4:44 a.m. revealed, "Late entry for 05/14/2013 @ 21:54 [sic]: Pt admitted with c/o "allergic reaction." Pt was registered and moved to waiting area. 2200 [10:00 p.m.]: Pt was triaged; VS: 98.7 [temperature]/84 [pulse]/15 [respirations], 146/92 [blood pressure], 95% ORA. In response to questioning, pt verbalized a PMH of anxiety DO characterized by "panic attacks." Pt was asked, "Are you feeling anxious right now?" to which she replied yes. Pt denied SOB or difficulty breathing but did state that she had taken "4 Benadryl, in case It [sic] was an allergic reaction. I asked what she was having an allergic reaction to and she stated that she was working in her garden and thought she might have broken out into hives from one of the fertilizers she used. No hives were present on exam. Pt had difficulty standing still and states she is feeling nervous. 2230 [10:30 p.m.]: Pt was at the nurses station and spoke with [physician name]. 2250 [10:50 p.m.]: A woman who stated that she is this pt's mother, came into the nurse's station demanding that someone needs to see her daughter now. She became very loud and combative. I asked her to have a seat in the waiting room and someone would be with them momentarily but she continued to argue very loudly demanding someone get up now. I informed her that if she didn't move out of the nurse's station that I would call the Sheriff's Department. At that time she and the pt left without waiting to be seen by the ERP. Patient #19 was discharged from the ED on 5/14/13 at 2255 [10:55 p.m.], with the disposition of: "Left against medical advice or discontinued care." There was no evidence of documentation in the ED record that patient #19 was seen by a medical provider while in the ED.

9. Patient #21, a 22 year old female, presented to the ED on 4/7/13 at 2149 [9:49 p.m.]. Patient #21's medical record lacked a triage assessment and a nursing screen. The ED record under, "Patient Complaint" revealed, "Pt left /p being informed that she could receive/obtain "plan B" over the counter pharmacy." Under "Chief Complaint" the record revealed, "No [circle with a line through it] nursing screen completed. pt ok with information and left ambulatory." Under "History" the record revealed, "Pt informed by R.N. [nurse's name] of OTC Plan B option." At the bottom of the page the record revealed, "left w/o being seen at 2220 [10:20 p.m.]." The record was signed off by a physician's assistant.

10. Staff member E, a staff emergency department RN, was interviewed on 10/22/13 at 2:30 p.m. When asked to explain the triage/admission process to the ED, staff member E stated, "Check if the patient is in respiratory distress, do vital signs, then the patient registers. If the patient is stable, they go to the waiting area. The nurse then calls the on-call provider and they come in and do the medical screening exam." When asked who can perform medical screening exams in the ER, staff member E stated, "The provider."

Staff member D, a medical provider for the facility, was interviewed on 10/22/13 at 3:30 p.m. When asked who performs medical screening exams in the ER, staff member D stated, "The nurses, they take a history from the patient, do vital signs, and a focused physical exam."

11. The medical staff bylaws were reviewed on 10/22/13 at 8:30 a.m. The bylaws did not indicate which individuals were determined to be qualified, and what their qualifications were, to perform a medical screening exam on a patient. The medical staff bylaws were last revised on 4/13/04.

The medical staff meeting minutes were reviewed. On 8/14/12 the minutes included the following, "[Hospital administrator's name] says that he has some concerns about EMTALA. He and [DON's name] do not feel that we are doing things correctly according to EMTALA regarding the medical screening exam before a patient is sent to the clinic. He mentions he will be seeking a legal opinion on this. [Physician name] said that she will read the EMTALA rules as well. The only option besides have [sic] the providers come over from the clinic and assess every patient in person is to have an Allied Health provider on 24/7. The EMTALA issue will be researched and gone over again at the next meeting."

On 9/25/12 the minutes included the following, "[Hospital administrator's name] reported on the EMTALA issue that was discussed at last month's meeting. He said he got in touch with a lawyer who gave him some information on what needed to be done. The lawyer said we need to have a procedure for the screening exam laid out and specify who is qualified to perform the screen. This information would need to be incorporated into the Medical Staff Bylaws. For now the Medical Staff feels that the RNs are qualified to perform the screening exam. [Physician name] will write up the needed language to be put into the bylaws."