HospitalInspections.org

Based on review of Medical Records (MR), facility policy and definitions, Medical Staff Rules and Regulations, and interviews with staff, it was determined the facility failed to:

1. Provide a Medical Screening Exam (MSE) for a patient presenting to the Emergency Department (ED).

2. Provide stabilizing treatment for all patients presenting to the ED.

These deficient findings did affect one of two MR's reviewed with a disposition of left without being seen (LWBS), including Patient Identifier (PI) # 1, and had the potential to affect all patients served by the facility ED.

Findings Include:

Refer to findings in tag A 2406.

Based on review of Medical Records (MR), facility policy review, Medical Staff Rules and Regulations review, on-call physician's schedules review, and interviews with staff, it was determined the facility failed to provide an appropriate medical screening exam (MSE) within the capability of the hospital's emergency department, including ancillary services routinely available to the Emergency Department (ED) to determine whether or not an emergency medical condition (EMC) exists.

This deficient practice affected one of two MR's reviewed with a disposition of left without being seen (LWBS) including Patient Identifier (PI) # 1, and had the potential to affect all patients served by the facility ED.

Findings include:

Health System Policy: EMTALA (Emergency Medical Treatment and Labor Act) - General Requirements and Definitions

Reference Number: None
Effective Date: 8/29/22

II. Policy:

It is the policy of The Health Care Authority of the City of Huntsville, for all Huntsville Hospital Health System (HHHS) acute-care or specialty hospitals to comply with the Medicare Conditions of Participation ...otherwise known as ...EMTALA or 42 CFR 489.24.

III. Overview of EMTALA:

All persons presenting for emergency care at HHHS Hospitals will be considered to have "come to the hospital" if a request is made by the individual or on the individual's behalf for emergency medical care. Each individual shall receive a MSE and stabilizing treatment within the capacity and capabilities of the hospital...

A. EMTALA General Requirements:

...2. The MSE will be performed by a Physician, Advanced Practice Provider, Physician Assistant, or trained Labor and Delivery Registered Nurse as defined and/or described by each hospital's medical staff by laws or other governing body document.

...4. The hospital provides care in response to the patient's request and need, provided the patient's request and need are consistent with the hospital's capability and capacity.

...10. Maintain a list of physicians who are on-call to provide further examination and/or treatment necessary to stabilize an individual with an EMC...

Definitions:

The following terms and definitions are used throughout the HHHS policies and procedures to demonstrate consistency and compliance with all state and federal regulations related to EMTALA.

...2. Capabilities of a medical facility or hospital provider mean the physical space, equipment, supplies and services...available at the hospital. The capabilities of the hospital's staff mean the level of care that the hospital's personnel can provide within the training and scope of their professional licenses, including coverage available through the hospital's on-call roster.

3. Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment...Capacity encompasses such things as numbers and availability of qualified staff, beds, equipment...

...16. On-Call List refers to the list that the hospital is required to maintain that defines those Physicians who are on the hospital's medical staff or who have privileges at the hospital,...and are available to provide treatment necessary after the initial examination to stabilize individuals with EMC's.

Policy: Medical Staff Rules and Regulations
Policy Number: None
Effective Date: 8/12/22, approved by Advisory Board

...Section V.

1. A MSE will be provided for all individuals presenting to the hospital for emergency care. The purpose of the examination is to determine whether or not a medical emergency exists...The MSE will be performed by a physician or an approved midlevel provider...

The August 2022 ED Unattached Surgery Call Schedule was reviewed. The On-Call schedule revealed a surgeon (Capability) was on-call 8/4/22 from 5 PM to 7 AM 8/5/22, when PI # 1 presented to the emergency department.

1. Review of the Marshall Medical Centers North (Hospital A) ED MR revealed PI # 1 presented to the facility ED via private vehicle, accompanied by family, on 8/5/22 at 12:31 AM with a chief complaint of a broken and leaking central (venous) line. PI # 1 received Triage Assessment by Employee Identifier (EI) # 3, Registered Nurse (RN) at 12:53 AM.

Review of EI # 2's (ED RN) Physical Assessment and Nursing Progress Notes dated 8/5/22 1:00 AM revealed, "After consult with EI # 4 (Hospital A ED physician), it was relayed to pt (patient) mother that the services required for repair/replacement of indwelling central line is not available at this facility at this time." " EI # 4 recommends following up with (surgeon who placed the current central line) immediately in AM."

Review of the MR Disposition/Discharge dated 8/5/22 1:33 AM revealed EI # 2 documented, "The patient left the ED without being seen by a physician."..."He/she notified staff prior to leaving the department and stated is leaving (services unavailable)." "Notified the ED physician and charge nurse of patient departure." EI # 2 also documented the patient left ambulatory, via private vehicle, and signed a LWBS form prior to leaving.

Review of the signed facility form, "LWBS Or Against Medical Advice" revealed LWBS was circled, and signed by PI # 1's family member on 8/5/22 at 1:13 AM. The documented patient stated reason for leaving was, "Services Unavailable."

In an interview conducted with EI # 1, Chief Nursing Officer, on 9/29/22 at 3:23 PM, EI # 1 confirmed PI # 1 did not receive a MSE.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that on 8/5/22 PI # 1 received an appropriate medical screening examination to determine if an emergency medical condition existed. The patient's identified emergency medical condition was the patient's broken and leaking central line. The facility had the capability (surgeon on call) to replace the broken and leaking central line.