HospitalInspections.org

Based on review of facility video recordings, facility policies and procedures, medical record (MR) reviews from Hill Hospital of Sumter County (Hospital A, sending hospital) and Hospital B (receiving hospital), Patient Registration Logs, Emergency Department (ED) Log, and interviews, it was determined the facility failed to ensure an appropriate medical screening examination and appropriate transfer was provided within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for Patient Identifier (PI) # 1.

This deficient practice affected one of two MR reviewed of patients who left without being seen (LWBS), including PI # 1, and had the potential to affect all patients presenting to this hospital ED for treatment.

Refer to tags: A2406 and A2409

PI # 1 arrived by private car to Hospital A ED on 2/5/23, was registered by the admissions clerk at 1:56 PM, then taken to the ED waiting room by a Certified Nursing Assistant. At 2:18 PM the ED physician entered the ED waiting room. At 2:23 PM the ED physician exited the waiting room with PI # 1 and two family members and wheeled PI # 1 out of the ED entrance door. At 2:27 PM the ED physician re-entered the ED entrance with the wheelchair only. There was no video recordings available for the outside of the ED.

Review of the MR from Hospital A revealed no documentation of a medical screening examination, no documentation stabilizing treatment was provided, and no documentation of transfer arrangements.

Review of the MR from Hospital B, receiving hospital, revealed PI # 1 arrived to the ED on 2/5/23 face down in the backseat of a private car, unresponsive with shallow breathing.

Per Google Maps, Hospital B is 70 miles from Hospital A.

Further review of Hospital B MR revealed PI # 1 was triaged at 4:43 PM and was assessed by the ED physician at 5:17 PM. The initial blood pressure was 20/0 by doppler palpation and pulse was 87. PI # 1 required mechanical respirations.

PI # 1 was stabilized in the ED at Hospital B and admitted to the Intensive Care Unit.

PI # 1 expired on 2/6/23 at 1:09 AM.

Based on review of video recordings, facility policies and procedures, Medical Record (MR) reviews from Hill Hospital of Sumter County (Hospital A, sending hospital), Patient Registration Logs, Emergency Department (ED) Log, and interviews it was determined the facility failed to ensure an appropriate medical screening examination was performed on one of twenty one MRs reviewed.

This deficient practice did affect Patient Identifier (PI) # 1 and had the potential to affect all patients presenting to this ED.

Findings include:

Facility Policy: EMTALA (Emergency Medical Treatment and Labor Act) Guidelines for Emergency Department Services.

Policy number: 2302

Revised: 2/7/22

...Policy:

...2. If a person comes to the Hospital and a request is made for their emergency care, or if the person is unable to communicate, a reasonable person would believe the person is in need of emergency care, then qualified medical personnel will, within the Hospital's capability and capacity, conduct and document an appropriate medical screening examination...to identify an emergency medical condition.

Procedures:

...B. Medical Screening Exam (MSE)

...The MSE ... must reflect continued monitoring based on the patient's need, until transfer, admission, or discharge...

The MSE Exam includes:

Log entry with disposition
Triage record
Ongoing recording of vital signs
Oral history
Physical exam
Use of all necessary available testing...
Adequate documentation of all the above...

1. Review of the Patient Registration Log dated 2/5/23 revealed PI # 1 was signed in at 1:56 PM with a chief complaint of not alert and not communicating.

Review of the ED Log dated 2/5/23 revealed PI # 1 arrived at 1:56 PM. There was no documentation for reason for visit or service rendered. The patient disposition was documented as LWBS (left without being seen) at 2:40 PM.

Review of the MR dated 2/5/23 revealed documentation of registration and demographic information only. There was no documentation of a MSE examination.

On 2/13/23 at 2:00 PM, a review of the video recordings from the ED entrance at the registration area conducted with Employee Identifier (EI) # 14, Administrative Assistant, revealed PI # 1 entered the ED on 2/5/23 at 1:53 PM escorted by EI # 5, Certified Nursing Assistant, and two family members. At 1:59 PM, EI # 5 wheeled PI # 1 into the waiting room across the hall then EI # 5 exited the waiting room at 2:02 PM.

Further review of the video recordings revealed EI # 6, Medical Doctor (MD) entered the ED waiting room at 2:18 PM. At 2:23 PM EI # 6 exited the waiting room accompanied by two family members pushing PI # 1 in a wheelchair and the four exited the ED door. At 2:27 PM, EI # 6 re-entered the ED with the wheelchair only.

No video recordings were available from outside of the ED entrance.

In an interview conducted on 2/15/23 at 8:45 AM, EI # 6, MD, stated "...I talked to them (the family of PI # 1) in the waiting room...I told them they had choices. I said if it was me, I would try to get somewhere as soon as possible." EI # 6 was asked if a MSE was performed for PI # 1, EI # 6 responded, "no, not on that visit".

In an interview conducted on 2/16/23 at 11:12 AM, EI # 1, Administrator, confirmed the hospital staff failed to perform a MSE for PI # 1 who presented to the ED requesting emergent care. EI # 1 further confirmed Hospital A had the capacity and capability to treat PI # 1.

Medical records obtained from Hospital B, receiving hospital, which is seventy miles away, revealed PI # 1 arrived at approximately 4:57 PM which was eighty minutes after leaving Hospital A ED. PI # 1 was examined, stabilized, and admitted to the Intensive Care Unit at Hospital B.

PI # 1 expired on 2/6/23 at 1:09 AM.

Based on review of video recordings, facility policy and procedures, Medical Record (MR), Patient Registration Logs, Emergency Department (ED) Log, Hospital B (receiving hospital) MR, and interviews it was determined the facility failed to ensure an appropriate transfer was provided for one of five transfer records reviewed.

This deficient practice did affect Patient Identifier (PI) # 1 and had the potential to affect all patients presenting to this ED.

Findings include:

Facility Policy: EMTALA (Emergency Medical Treatment and Labor Act) Guidelines for Emergency Department Services.

Policy number: 2302

Revised: 2/7/22

...Procedure:

a. Appropriate Transfer: The movement of a patient outside the hospital's facilities at the direction of any person employed by or affiliated or associated, directly or indirectly, with the hospital...

Transferring hospital provides medical treatment within its capacity that minimizes the risk to the individual...

The receiving facility has ... available space and qualified personnel...Has agreed to accept the transfer...The transfer must be made by qualified personnel and must employ appropriate transportation equipment, as required, and include the use of necessary and medically appropriate life-support measures during the transfer.

Transferring hospital completes all documentation, including sending copies of medical record.

b. Unstable Patient Transfer: Hospital must document the likelihood of deterioration of the patient's condition if not transferred including

Benefits and risks of the transfer.

Certification of need documented and signed by the attending physician treating the patient.

Have patient...sign they have been provided this information.

Document patient condition at time of transfer.

Mode of transport and equipment/personnel needed.

Accepting hospital and physician...

Copies of Medical Records.

Facility Policy: Transfer of a Patient to Another Facility

Policy number: 2302

Revised: 12/22

...Policy:

1. All patients will be evaluated by the Emergency Department physician regardless of condition, race, religious preference, or ability to pay.

2. If the physician determines, through the hospital policy, that the patient should be transferred to another facility for further care, EMTALA standards must be followed...

1. Review of the Hospital A Patient Registration Log dated 2/5/23 revealed PI #1 was signed in at 1:56 PM with a chief complaint of not alert and not communicating.

Review of the ED Log dated 2/5/23 revealed PI # 1 arrived at 1:56 PM. There was no documentation for reason for visit or service rendered. The patient disposition was documented as LWBS (left without being seen) at 2:40 PM.

Review of the MR dated 2/5/23 revealed documentation of registration and demographic information only. There was no documentation a transfer of the patient was arranged and documented.

On 2/13/23 at 2:00 PM, a review of the video recordings from the ED entrance at the registration area conducted with EI # 14, Administrative Assistant, revealed PI # 1 entered the ED on 2/5/23 at 1:53 PM escorted by EI # 5, Certified Nursing Assistant, and two family members. At 1:59 PM, EI # 5 wheeled PI # 1 into the waiting room across the hall then EI # 5 exited the waiting room at 2:02 PM.

Further review of the video recordings revealed EI # 6, Medical Doctor (MD) entered the ED waiting room at 2:18 PM. At 2:23 PM EI # 6 exited the waiting room accompanied by two family members pushing PI # 1 in a wheelchair and the four exited the ED door. At 2:27 PM, EI # 6 re-entered the ED with the wheelchair only.

No video recordings were available from outside of the ED entrance.

In an interview conducted on 2/15/23 at 8:45 AM, EI # 6, MD, Hospital A ED, stated "...I talked to them (the family of PI # 1) in the waiting room...I told them they had choices. I said if it was me, I would try to get somewhere as soon as possible."

EI # 6 was then asked if the transfer was arranged to Hospital B including contacting the facility for accepting physician, attempts to transfer by ambulance, completion of a transfer form with patient and MD signature, and sending copies of medical records. EI # 6 responded, "No, because I did not know where they were going. I was thinking (he/she) was probably going to Meridian because it is closer..."

Review of Google Maps revealed Hospital B was seventy miles from Hospital A and the Meridian Hospital was 27 miles from Hospital B.

In an interview conducted on 2/16/23 at 11:12 AM, EI # 1, Administrator, confirmed the hospital staff failed to arrange an appropriate transfer to Hospital B for PI # 1 who presented to the ED requesting emergent care. EI # 1 further confirmed Hospital A had the capacity and capability to treat PI # 1.

Review of the Hospital B, receiving hospital, MR dated 2/5/23 revealed the ED physician documented PI # 1 presented to Hospital B by private car and "according to the sister, the physician at the hospital in York (placed) the patient in the backseat of the car facedown and told them to drive to Tuscaloosa as (he/she) was too sick for them to care for. Upon arrival here patient appeared to be in extremis (at the point of death). Had to be removed from the backseat ... (He/she) had faintly palpable central pulses and agonal respirations... The caregiver confirms that they were sitting in the waiting room awaiting evaluation when they were approached by the physician at (Hospital A) who told them that he "cannot take care of (him/her) here"... Per their report, the physician did not evaluate or examine the patient."

Further review of the Hospital B MR revealed the initial vital signs documented at 4:57 PM were blood pressure 20/0 by doppler palpation and pulse of 87. PI # 1 was treated and stabilized in the ED and the decision was made to admit to the Intensive Care Unit (ICU) with diagnoses including Shock Liver, Acute Respiratory Failure with Hypoxia, Lactic Acidosis, Septic Shock, Anuria, Acute Respiratory Failure, DIC (Disseminated Intravascular Coagulation), Anemia, and Acute Renal Failure.

PI # 1 expired on 2/6/23 at 1:09 AM.

In an interview conducted on 2/13/23 at 3:18 PM with Employee Identifier (EI) # 10, Hospital B ED physician, stated "...They paged out they needed lift assistance in the ED. The nurses ... brought (him/her) down to the trauma hall. When I saw (PI # 1), (he/she) look was pale, clammy, and looked extremis. We could not get a blood pressure on (him/her), so we tried to get it with a doppler. It was in the 20's systolic which is not high enough to support life...the glucose was 20 which is the lowest we can measure...I went out and talked to the family after we got her stable...The family stated (Hospital A) basically did nothing...The family said they were sitting in the waiting room. The ED physician came in and told them (he/she) was too sick to treat at (Hospital A).

EI # 10 was then asked if he/she had been notified the patient was coming or receive a report on the patient. EI # 10 responded, "no, the first I heard of (him/her) being here is when they called for lift assistance".

In an interview conducted on 2/15/23 at 11:30 AM, EI # 11, Hospital B Registered Nurse (RN), stated "I went out to the car, there were two (family members) beside the car. The patient was laying face down on the backseat. (He/she) was unresponsive, shallow breathing...I talked to the family a little while they were getting (PI # 1) out. (He/she) said they (Hospital A) told her that (his/her) cousin was anemic and they could not take care of (him/her) there. (He/she) said the doctor put (PI # 1) in the car. (He/she) said (his/her) condition was just like that when they left (Hospital A)...The cousin was very concerned, (he/she) said normally they are taken by ambulance...When I talked to the cousin, (he/she) did not say if (he/she) preferred to come by car or ambulance, but said (he/she) thought (PI # 1) should have come by ambulance."