HospitalInspections.org

Based on observations in the emergency deptartment, staff interview, and policy review, the hospital failed to post Emergency Medical Treatment and Labor Act (EMTALA) information in the ambulance enterance area of the Emergency Department (ED). The finding included:

Observations during a tour of the ED on 7/13/23 at 10:20 AM identified that in the ambulance bay entryway, no EMTALA (Emergency Medical Treatment and Labor Act) signage was posted.

Interview on 7/13/23 at 10:20 AM with the ED RN Nurse Manager stated that signs are to be posted at the entryways.

Review of the hospital policy for EMTALA identified that the hospital will post conspicuously in the ED (i.e., waiting, treatment and registration areas, hospital entrances, admitting and waiting room areas), signs that specify the rights of individuals presenting with an Emergency Medical Condition (EMC).

Based on clinical record review, review of hospital policies and documentation, and interviews, for 2 of 20 patients reviewed for stabilizing care in the Emergency Department (ED), (Patients #600 and 611), the hospital failed to ensure that documentation reflected that the Emergency Medical Condition (EMC) was resolved when there was no documented reassessment prior to discharge, failed to ensure that a request for a medical consultation related to the EMC was provided or that a reason why the consult was denied was documented, and failed to take steps necessary to ensure the safety and wellbeing of a patient with suicidal ideations who left without being seen. The findings include:

a. Patient #600 was admitted to the Emergency Department (ED) on 7/3/23 with a chief complaint of vaginal bleeding, stated that she had vaginal bleeding that was much greater than normal, was passing clots the size of oranges, and assigned an ESI acuity level of 3 (requiring more than 1 resource).

Patient #600 was seen and treated by Physician Assistant (PA) #600 and MD #600. MD #600 documented that the patient was being seen for dysfunctional uterine bleeding, a vaginal inspection identified scant bleeding, a transvaginal ultrasound was negative, the patient received medications to control the reported bleeding, and was discharged to follow-up with her OB/GYN and return if symptoms worsened. The clinical record failed to identify the patient's level of bleeding prior to discharge at 2:16 PM

Review of nursing documentation identified that Patient #600 was admitted to the ED on 7/3/23 at 7:23 AM, complained of vaginal bleeding, and passing clots the size of an orange. At 9:38 AM the nurse documented a vaginal bleeding assessment that included a nondistended flat abdomen, all four quadrants were nontender and soft, and there was bloody vaginal drainage. Although vital signs were obtained several times until discharge at 2:16 PM, the clinical record failed to identify that nursing staff performed a reassessment of Patient #600's bleeding.

Interview with RN #600 on 7/13/23 at 9:45 AM identified that she conducted a vaginal bleeding assessment on Patient #600 at 9:38 AM and identified bloody vaginal discharge, the patient was initially tachycardic (pulse 113, then 91, 90, 92, then 74 at time of discharge) and all other assessments were within normal limits. RN # 600 identified that Patient #600 did not report having any clots while in the ED and RN #600 could not recall if she asked the patient about her bleeding status.

Interviews with Nurse Manager #50 on 7/12/23 at 10:15 AM and RN #600 on 7/12/23 at 9:45 AM identified that on review of Patient #600's clinical record, there were no documented nursing reassessments of the patient's report of bleeding. The hospital charts (documents) by exception and if there was a change in condition, change in staff, or change of shift, there would be a reassessment.

Patient #600 presented to another acute care hospital on 7/4/23 at 9:22 AM, The patient was identified with profuse vaginal bleeding, medications to stop the bleeding had not been effective, and with a hemoglobin of 7.4. The patient was offered surgical management of ablation/uterine embolization verses hysterectomy, elected to have a hysterectomy, and received 2 pints of blood product presurgical intervention.

Interview with PA #600 on 7/11/23 at 2:00 PM identified that Patient #600 complained of heavy bleeding and crampy back pain, blood work was obtained to assess the patient's hemoglobin level which was identified as 10.7 (normal 11.7-15.7) and tested for blood type and cross for standby should a transfusion be necessary. The patient was hydrated with IV fluids and medicated with Zofran, IV tranexamic acid, and Provera for the patient's report of bleeding. A transvaginal ultrasound was obtained which identified an ovarian cyst and no other issues. Patient #600 had requested an OB/GYN consult but PA #600 identified that he didn't have someone available, he discussed it with MD #600, and it was determined that a consult was not warranted as the patient was stable and did not have a life-threatening issue. PA #600 stated he and Patient #600 had many conversations about a discharge plan and noted that the patient had good resources to follow up with after discharge.

Interview with MD #600 on 7/12/23 at 8:15 AM and review of the clinical record identified that MD #600 performed a history and physical and documented that due to IV hydration, the repeat hemoglobin value was expected to be lower due to dilution. The repeat hemoglobin was 8.7, and MD #600 and PA #600 both identified that if the patient's hemoglobin level fell below 7, they would have ordered a transfusion. MD #600 identified that she performed a visual exam of Patient #600's vaginal area and identified a scant amount of blood. MD #600 identified that neither she nor the nurse saw any increased bleeding. As for the request for a consult, the patient was stable and identified that a consult would not be completed based on a complaint of heavy bleeding, but that a consultant would see the patient if MD #600 felt it was necessary.

Interview with the Regulatory Manager on 7/13/23 at 1:15 PM identified that in review of Patient #600's clinical record, the patient's request to the PA for an OB/GYN consult and PA #600's denial was not documented and should have been.

Review of the medical staff rules and regulations (2021) identified that a consult will be required if the patient requests one, or if the physician disagrees, the physician shall explain his/her concerns.

Review of the medical record documentation requirements policy (4/4/2023) identified that the emergency medical record must contain, in part, the patient's condition at the conclusion of treatment.


b. Patient # 611 had diagnoses of depression and a previous suicide attempt and presented to the ED on 10/10/22 for a complaint of suicidal ideation. Review of the suicide/homicide risk assessment (C-SSRS) dated 10/10/22 at 11:43 PM noted the patient was at high risk for self-harm. Nurse's notes dated 10/11/22 at 12:13 AM noted Patient #611 "took off" while the triage was being done, and security went after the patient, but the patient was not found. Review of the disposition of Patient #611 on 10/11/22 at 12:16 AM noted Patient #611 eloped from the ED, patient was last seen in triage, patient did not notify staff before leaving, and an IV was not present prior to elopement. The clinical record lacked documentation that the patient, patient's family, or law enforcement were contacted for a wellness and safety check.

Interview with the ED Nurse Manager on 7/14/23 at 11:30 AM stated that if the security team was unable to locate the patient, the police department is to be contacted for a wellness check and it is to be documented in the clinical record.

The hospital did not have an elopement policy. Review of hospital elopement education identified education dated 4/17/23 (after the incident) and noted that if a patient is evaluated in the ED for concerns for safety to self/others and they elope, staff is to contact the local police department, notify them that the patient is a risk to self or others, and request that the patient be brought back onsite.


14216