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Based on interview, record review, policy review and video recording review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient #30 from University of Missouri Healthcare Emergency Department (ED) of 31 records reviewed from 10/20/2022 through 03/20/2023. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 7,918.

Findings included:

Review of the hospital's policy titled, "EMTALA-Emergency Medical Treatment and Active Labor Act - Compliance," dated 10/17/22, showed that any individual that presents to the ED or any location on the hospital campus, and requests a medical examination or treatment, should receive a MSE within the department's capability, including ancillary services, to determine if an EMC exists. An EMC would be any medical condition manifested by acute symptoms of sufficient severity such as severe pain, psychiatric disturbance and/or symptoms of substance abuse which could impair bodily function or result in the dysfunction of any body organ or part. The hospital must provide an appropriate MSE.

Review of the hospital's policy titled, "Medical Staff - Rules and Regulations of the Medical Staff," dated 12/12/19, showed that for emergency room visits, the history and physical examination should include: chief complaint, history of present illness, relevant medical and surgical history, relevant past social and family history, medications and allergies, review of systems, physical examination, test results, assessment or impression, and plan of care.

Review of the hospital's policy titled, "Emergency Department-Triage-Protocol," dated 11/15/2022, showed that upon patient presentation to ED, triage (process of determining the priority of a patient's treatment based on the severity of their condition) must be initiated. The ED should use the five level triage level to classify the acuity levels of patients. The emergency severity index triage (ESI-an algorithm to prioritize how long a patient can safely wait to be seen.) The parameters for assigning an acuity level include: vital signs, chief complaint, and medical history. The Danger Zone Vital Signs (body temperature, blood pressure [BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80], heart rate, and respiratory rate [RR, the number of breaths per minute, normal range for adults at rest is 12 to 20]) showed that if someone had a Heart Rate of 100 or greater, Respiration Rate of 20 or above, or Oxygen Saturations (measure of how much oxygen is in blood) 92% and below the patient would be at least an ESI level 2. Re-assessment guidelines are based on the acuity level of the patient. ESI level 1 would receive continuous monitoring and assessment, Level 2 would receive monitoring every 15-30 minutes until stable, then at minimum an hour. Level 3 would receive monitoring every 30-60 minutes, and level 4 and 5 would receive monitoring every 60-90 minutes.

Patient #30 was a 56-year-old female who presented to the ED by Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) on 02/14/23 at 4:11 PM, with complaints of a headache that she rated an eight out of 10 for pain. Her BP was 189/90 and she had recently suffered a stroke (medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue form getting oxygen and nutrients). She was triaged and given an acuity rating of three. She was not reassessed while she was in the waiting room. The patient reported to the triage nurse that she wished to go home and staff called her family to pick the patient up. Family expressed to staff that they had no intention of picking up the patient before she was seen by a provider. After speaking with the family staff removed her intravenous (IV, in the vein) line and removed her name from the ED tracking board. The patient remained in the waiting room until 8:39 PM, when she fell and hit her head on a chair and then the floor. She was taken to a trauma room. It is unknown how long she was in the trauma room before the physician saw her and evaluated her. The patient's blood pressure was too high for machines to obtain. Nursing staff did not communicate the patients fall in the waiting room to the Physician. The physician was only aware of the fall after the CT scan showed an intracranial bleed and she reviewed video recording of the patient in the waiting room. The patient passed away on 02/15/23 at 10:17 AM, from an intracranial (within the skull) bleed.

Please refer to 2406.

Based on interview and record review, the hospital failed to maintain an accurate central log for patients who presented to the Emergency Department (ED) for care. The hospital failed to enter one patient (#31) on the log and to accurately document the disposition of four patients (#5, #6, #7, and #12) of 31 ED records reviewed from 10/20/22 through 03/20/23. The hospital's average monthly ED census over the past 6 months was 7,918.

Findings included:

Although requested, the hospital did not have a policy that addressed the ED log.

Review of the hospital's policy titled, "Patient Rights & Responsibilities - Patient Right to Refuse Care, Treatment, and Services Against Medical Advice (AMA)," dated 12/19/2017, showed that if a competent adult patient expresses a desire to refuse care and/or leave AMA, the following should be done:
- Request that the patient discuss the AMA decision with the physician; the physician will discuss the possible consequences to the patient of the AMA decision and identifying the risks and benefits of leaving AMA versus following medical advice.
- Prior to leaving the facility, the patient would be provided discharge instructions for care including signs and symptoms that could indicate deterioration in the patient's condition.
- The patient would be asked to sign the completed "Patient Right to Refuse Care, Treatment, and Services" form that was signed and dated by the physician or nurse, or indicating on the form that the patient refused to sign.
- The conversation with the patient regarding the decision to refuse care and/or leave AMA should be documented in the electronic medical record (EMR) along with the time of the patient's departure.

Review of the ED log dated 01/06/23, failed to show that Patient #31 had presented to the ED via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.).

Review of EMS document titled, "Patient Care Report," dated 01/06/23 at 6:45 PM, showed Patient #31 had been transported from her home to the hospital's ED for nausea and vomiting for one week. The arrival time at the hospital was documented as 7:03 PM.

Review of the ED log dated 10/31/22, showed Patient #5 presented to the ED on 10/31/22 at 1:29 PM, for complaints of malaise (body weakness or discomfort), fatigue (weakness or tiredness), and weakness, his disposition was listed as left AMA on 10/31/22 at 2:09 PM.

Review of the EMS document titled, "Patient Care Report," dated 10/31/22 at 12:56 PM, showed Patient #5 had been transported to the ED for overdose/poisoning/ingestion. He was experiencing withdrawal symptoms related to fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use) abuse. The arrival time was documented as 1:20 PM.

Review of Patient #5's ED record showed he was 31-year-old male that presented to the ED on 10/31/22 at 1:29 PM, via EMS, with the complaint listed as malaise, fatigue, and weakness. The patient was entered on the log, but was never triaged (process of determining the priority of a patient's treatment based on the severity of their condition). He left without being seen (LWBS), prior to triage. AMA paperwork was not in the medical record.

Review of the ED log dated 11/01/22, showed Patient #6 presented to the ED on 11/01/22 at 9:22 AM, with a complaint of post-operative complications. Her disposition was listed as left AMA, on 11/01/22 at 11:55 AM.

Review of Patient #6's ED record showed she was a 37-year-old female that presented to the ED on 11/01/22 at 9:22 AM, with the complaint listed as dehydration (a condition caused by excessive loss of water from the body), left sided abdominal pain, and constipation. She was three weeks post-operative from gastric bypass surgery. Documentation showed that she was awaiting a computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) scan and had asked the nurse to remove her intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream). The nurse attempted to explain the necessity for the IV and asked that Patient #6 speak with the provider before removing it. When the provider entered the room, Patient #6 was gone. She had eloped (when a patient makes an intentional, unauthorized departure from a medical facility) from the ED in the middle of her evaluation. AMA paperwork was not in the medical record.

Review of the ED log dated 11/01/22, showed Patient #7 presented to the ED on 11/01/22 at 10:30 AM, via EMS for a possible stroke (a medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients). Her disposition was listed as left AMA on 11/01/22 at 2:37 PM.

Review of Patient #7's ED record showed she was a 58-year-old female that presented to the ED on 11/01/22 at 10:36 AM, via EMS, with left sided headache that began the previous evening, left sided arm/leg numbness and weakness, along with left sided facial drooping. She completed her evaluation, including a neurology (relating to or affecting the nervous system) consult. Documentation showed her agreement to begin a new medication and to follow up with her primary care provider. AMA paperwork was not in the medical record.

Review of the ED log dated 12/13/22, showed Patient #12 presented to the ED on 12/13/22 at 3:27 PM, with seizure (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness) listed as the chief complaint. His disposition was listed as left AMA at 3:33 PM.

Review of Patient #12's ED record showed he was a 43-year-old male that presented to the ED by EMS on 12/22/23 at 3:27 PM, with the complaint listed as seizure. Physician documentation showed that Patient #12 was resistant to provide any information. When he attempted to assist the patient to remove his boots the patient became angry and made physical threats before eloping from the ED. AMA paperwork was not in the medical record.

During an interview on 03/21/23 at 3:35 PM, Staff S, Supervisor Patient Admissions, stated that every patient that presented to the ED should be placed on the ED log. The log should include accurate information such as their name, date of birth, chief complaint, and ultimately their disposition.

During an interview on 03/20/23 at 3:35 PM, Staff K, ED RN, stated that everyone was placed on the ED log when they signed in for treatment. If a patient expressed that they would like to leave prior to being treated, they would be encouraged to wait and to discuss the risks and benefits of staying. If the patient insisted on leaving, staff would have the patient sign an AMA form, which would include the date and time they departed. The ED log should be complete and accurate.

The overall failure of the hospital to accurately enter patient information, including an accurate date, time and disposition, made it difficult to identify whether or not patients received a MSE, stabilizing treatment, were discharged appropriately, eloped or left AMA. This failure has the potential to effect all patients that presented to the hospital ED.


41474

Based on interview, record review and policy review, the hospital failed to provide an appropriate medical screening examination (MSE) to determine the presence of an emergency medical condition (EMC) for one patient (#30) out of 30 Emergency Department (ED) records reviewed. The hospital's ED average monthly census over the past six months was 7,918.

Findings included:

Review of the hospital's policy titled, "EMTALA-Emergency Medical Treatment and Active Labor Act - Compliance," dated 10/17/22, showed that any individual that presents to the ED or any location on the hospital campus, and requests a medical examination or treatment, should receive a MSE within the department's capability, including ancillary services, to determine if an EMC exists. An EMC would be any medical condition manifested by acute symptoms of sufficient severity such as severe pain, psychiatric disturbance and/or symptoms of substance abuse which could impair bodily function or result in the dysfunction of any body organ or part. The hospital must provide an appropriate MSE.

Review of the hospital's policy titled, "Medical Staff - Rules and Regulations of the Medical Staff," dated 12/12/19, showed that for emergency room visits, the history and physical examination should include: chief complaint, history of present illness, relevant medical and surgical history, relevant past social and family history, medications and allergies, review of systems, physical examination, test results, assessment or impression, and plan of care.

Review of the hospital's policy titled, "Emergency Department-Triage-Protocol," dated 11/15/2022, showed that upon patient presentation to ED, triage (process of determining the priority of a patient's treatment based on the severity of their condition) must be initiated. The ED should use the five level triage level to classify the acuity levels acuity (the severity of a patient's illness and the level of service needed) of patients. The emergency severity index triage (ESI-an algorithm to prioritize how long a patient can safely wait to be seen.) The parameters for assigning an acuity level include: vital signs, chief complaint, and medical history. The Danger Zone Vital Signs (body temperature, blood pressure [BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80], heart rate, and respiratory rate [RR, the number of breaths per minute, normal range for adults at rest is 12 to 20]) showed that if someone had a Heart Rate of 100 or greater, RR of 20 or above, or Oxygen Saturations (measure of how much oxygen is in blood) 92% and below the patient would be at least an ESI level 2. Re-assessment guidelines are based on the acuity level of the patient. ESI level 1 would receive continuous monitoring and assessment, Level 2 would receive monitoring every 15-30 minutes until stable, then at minimum an hour. Level 3 would receive monitoring every 30-60 minutes, and level 4 and 5 would receive monitoring every 60-90 minutes.

Review of the Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) report dated, 02/14/23 at 3:15 PM, showed dispatch was contacted by Patient #30 with a complaint of pain/headache. Her past medical history included a stroke (medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue form getting oxygen and nutrients) and high blood pressure. Patient #30's family reported to them that the patient had a stroke about one month prior and had residual dysphagia (condition that affects your ability to produce and understand spoken language), but had no new stroke symptoms. She had slurred speech, a BP of 174/86 and her RR was 28. Repeat assessments en-route to the hospital showed that her BP remained elevated. Paramedics placed an intravenous (IV, in the vein) catheter in her left arm. A report was given to Staff AA, Registered Nurse (RN) upon arrival to the ED, and care was transferred to her at 3:54 PM.

Review of the ED log dated 02/14/23, showed Patient #30 presented to the ED on 02/14/23 at 3:53 PM, with a headache, and her acuity was a one. Disposition was admit to inpatient on 02/15/23 at 2:45 AM.

Review of Patient #30's ED record showed she was a 56-year-old female who presented to the ED by EMS with a headache, and rated her pain at an eight out of 10. Past medical history included high BP and a recent stroke. The patient had started a new medication for her blood pressure, but it was not helping. A triage assessment documented by Staff AA, RN, at 4:11 PM, showed a blood pressure of 189/90, a RR of 20 and an oxygen saturation of 97%. Her tracking acuity rating was a three. Nursing documentation showed Patient #30 wanted to leave without seeing a physician, and asked the nurse to call her family. The nurse called the patients family and they told her that they would pick her up when they finished what they were working on. The nurse informed the patient that her family would be there shortly. The patient requested that her IV be taken out by pointing at it. The nurse asked if she wanted the IV out and the patient said yes. The patient was up walking around the ED triage area and outside while waiting for her ride. The nurse heard a loud noise at the triage doors inside the ED, Patient #30 fell and hit her head on a chair in the vestibule, then fell onto her back and hit her head on the ground. She began shaking and her eyes rolled back in her head. Patient #30 was unconscious and was moved into an ED room. Physician documentation on 02/14/23 at 8:51 PM, showed Patient #30 was responsive and attempted to communicate, but within minutes she stopped responding, started to have agonal respirations (gasping, labored breathing) and had to be intubated (process where a healthcare provider inserts a tube through a person's mouth or nose down into the windpipe when a person is not breathing on their own). Her pupils were unequal and she had a right facial droop. Vital signs documented at 8:00 PM and 8:30 PM, showed a BP of 145/107, a RR of 37 and her oxygen saturation was 92%. Medications were ordered at 9:00 PM, and no blood work was ordered or obtained until 9:03 PM. A computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail that a regular x-ray) showed a subarachnoid hemorrhage (SAH, a medical emergency where there is bleeding in the space between the brain and the tissue covering the brain) and a subdural hematoma (SDH, a pool of blood between the brain and it's outermost covering). Patient #30 was admitted to an inpatient room for comfort care (a patient care plan that is focused on symptom control, pain relief, and quality of life at the end of life) on 02/15/23 at 12:48 AM. The discharge summary showed that Patient #30 passed away on 02/15/23 at 10:17 AM, with the cause of death being intracranial (within the skull) bleed.

Review of hospital video recordings titled, "UH ER Waiting room," dated 02/14/23, showed:
- 8:39:54 PM, Patient #30 was in a room adjacent to the nursing station. She grabbed the door frame and then fell to the ground.
- 8:40:44 PM, Nursing staff entered the room and assisted Patient #30 to sit up, then stood her up.
- 8:41:18 PM, Nursing staff wheeled Patient #30 from the room adjacent to the nursing station and out of the waiting room.
- 8:41:54 PM, Patient #30 and nursing staff entered the trauma room in the ED.

During an interview on 03/27/23 at 10:00 AM, Staff AA, RN, stated that EMS brought Patient #30 into the ED. Family members had reported to EMS that the patient had become unresponsive and had seizure (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness) activity, but was back to her baseline by the time EMS arrived. Patient #30's only complaint was that she had a headache. Her vital signs were stable and she was walking and talking. She started an IV and got blood work started for the patient. Assigning an acuity rating to patients was very important because it determined how fast the patient was seen by a physician. A BP of 189/90 should be reassessed. Patient #30 decided after a few hours that she wanted to leave and asked if she could call her family to pick her up from the ED. She tried to talk the patient into staying and being evaluated, but the patient wanted to leave. She let Patient #30 use the phone to call her family. She gave a verbal report to the oncoming triage nurse around 7:00 PM, and told her that Patient #30 wanted to leave and had called her family. Reassessments would have been documented in the medical record if there were any. The ED was very busy that day, there were no open rooms and the waiting room was full.

During an interview on 03/27/23 at 9:00 AM, Staff Y, RN, stated that Patient #30 told her she wanted to leave and wanted her IV taken out. Staff Y called the family, who told her they had no intentions on picking her up from the ED before a physician assessed her. She then took out the Patient's IV and removed her name from the ED board, because the patient just wanted to leave. An unknown amount of time later, she heard a loud noise and saw Patient #30 on the floor shaking like she was stunned and had her eyes only half opened. She called for a nurse and a gurney, but decided to take her back to a room in a wheelchair because it was faster. She did not remember who she gave a report to when she took the Patient back to the trauma room. An acuity of one would be used for patients that were not walking and talking so the acuity was likely changed on the ED log after the patient collapsed. Patients in the waiting room should be reassessed every three hours, and patients with a higher acuity should be reassessed every hour and a half. Assigning an acuity for patients was very important because it directed staff on how often they needed to be reassessed and affected how quickly they were taken back to a room. She did not know what time she removed Patient #30's IV, her name from the ED tracking board, or when she called the patient's family.

During an interview on 04/03/23 at 9:45 AM, Staff CC, Physician, stated she did not see Patient #30 prior to her being brought into the trauma room. She was told that Patient #30 had a headache, but there was no mention of her fall. She saw Patient #30 on a stretcher, alone, in the trauma room so she went in to check on her. Patient #30 was trying to interact with her, but the patient couldn't communicate verbally. She left the trauma room to check the patient's chart and found her to have "odd" rhythm strips from her electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions). She got nursing staff and returned to the patient's room. She was only away from the patient for a minute or two and when she returned to her room the patient was already less responsive, could not follow any commands and rapidly progressed to agonal breathing. She consulted with the neurology (the branch of neuro, relating to or affecting the nervous system) team and called a code stroke. Staff were unable to obtain an accurate BP, and the patient was intubated. An arterial line (thin, flexible tube placed into an artery) was placed and her BP was found to be higher than their machines could read. She sent the patient for a CT scan. While the patient was in CT she reviewed her chart and found the patient had a recent admission for a stroke. The CT scan showed an intracranial bleed, so she went to review the security video and saw that Patient #30 had fallen in the waiting room. That was the first she knew about her fall. Staff did not inform her or nursing staff on that pod that Patient #30 had been brought back to a trauma room, and she did not know how long the patient was alone in the room before she went in to see her. If a patient was taken off the tracking board in the triage area then they would not be taken back to be evaluated by a physician.

During an interview on 03/30/23 at 6:00 PM, Staff BB, RN, stated that she did not see or assess Patient #30 prior to her collapse in the ED waiting room. The patient was taken into a trauma room and she was the scribe personal assistant who enters documentation into an electronic health record). Since she did not know exactly what time everything in the waiting room occurred, but did know it was sometime between 8:00 PM and 9:00 PM, she documented within that hour and the vital signs were electronically placed at 8:00 PM and 8:30 PM. She had no contact with that patient when she was in the waiting room, so the vital signs documented were obtained after the patient fell in the waiting room and was taken to the trauma room. If no other vital signs were documented in the medical record, then it was likely that they were not rechecked while the patient was in the waiting room.

During an interview on 03/30/23 at 1:25 PM, Staff EE, ED Director of Nursing, and Staff FF, Supervisor/Nurse Educator for the ED, stated reassessments in the waiting room were supposed to be performed hourly for Patient's with an acuity of three. Sometimes if they were very busy those assessments might not be documented. Staff were always assessing patients in the waiting room. Nursing staff had to prioritize the waiting room patients and reassessments based on their acuity. Depending on what else was going on at the time and the amount of patients could delay a reassessment. Staff EE stated that it would be reasonable to reassess a patient's pain level, but was not in the policy that it had to be reassessed along with the vital signs.

During an interview on 03/30/23 at 1:00 PM, Staff C, Service Line Director for the ED, stated that there had been a lot of recent education with the ED staff regarding patient triage and assigning the correct acuity.

During an interview on 03/27/23 at 10:36 PM, Staff Z, Physician, stated that the triage area of the ED had been a weakness and struggled with staffing issues, bed space and personnel issues.