HospitalInspections.org

Based on review of the facility's Medical Staff By-Laws, review of facility policies, review of medical records, and interviews the facility failed to provide a Medical Screening Examination (MSE) and failed to provide Stabilizing Treatment for one (#3) patient of 33 patients reviewed. These failures resulted in Patient #3 leaving Hospital A's Emergency Department (ED) after waiting 8 hours 22 minutes without an MSE or any stabilizing treatment being provided and driving 40 miles to Hospital B where she was admitted with diagnosis of Dog Bite and Cellulitis (infection) of Right Hand.

The findings included:

Refer to A-2406 and A-2407.

Based on review of the facility's Medical Staff By-Laws, review of facility policies, review of medical records, and interviews the facility failed to provide a Medical Screening Examination (MSE) for one (#3) patient of 33 patients reviewed. This failure resulted in Patient #3 leaving Hospital A's Emergency Department (ED) after waiting 8 hours 22 minutes without an MSE being provided and driving 40 miles to Hospital B where she was provided an MSE and admitted with diagnosis of Dog Bite and Cellulitis (infection) of Right Hand.

The findings included:

Review of the facility's Medical Staff Rules and Regulations dated 6/23/2008 revealed, "...All Medical Staff members must comply with Emergency Medical Treatment and Active Labor Act (EMTALA) regulations and must comply with all applicable state laws..."

Review of the facility's policy titled "Emergency Medical Treatment and Active Labor Act" dated December 2015, revealed, "...A Medical Screening Examination (MSE) will be performed for any individuals that...presents on hospital property and requests examination or requires treatment for what may be an emergency medical condition...Medical Screening Examinations will be conducted by a Qualified Medical Professional (QMP) who is determined qualified by the governing body of the hospital..."

Medical record review revealed Patient #3 presented to the ED at Hospital A on 11/13/21 at 5:08 PM. Continued review revealed the patient was triaged by Registered Nurse (RN) #1 on 11/13/21 at 5:19 PM. Continued review of RN #1's assessment note revealed, "...dog bite to right hand...Pt [patient] was seen here yesterday and given tetanus along with an antibiotic. Pt feels like it is getting worse..."

Review of a Patient Note dated 11/13/21 at 8:10 PM revealed, "...SUPERVISOR...RN HAS SPOKE WITH PATIENT ABOUT COMPLAINTS..."

Review of a Patient Note written by the ED Director dated 11/13/21 at 11:39 PM revealed, "...Went to lobby to speak to pt. pt inquired as to when she was going to be seen, she states that she has been waiting 6 hours. I explained that we would see her as quickly as possible but there were many patients that have been waiting longer..."

Review of the medical record revealed no documentation of Patient #3 being provided an MSE by a Qualified Medical Personnel (QMP).

Review of Patient #3's Medical Records from Hospital B revealed the patient arrived at the ED there on 11/14/21 at 2:30 AM (approximately one hour after leaving Hospital A) for complaint of dog bite to right hand. Continued review of a nurses note dated 11/14/21 at 2:41 AM revealed, "...No deficits noted...skin is pink and warm...swelling is present right hand..."

Review of a Physician's Note dated 11/14/21 at 4:34 AM revealed, "...R [right] HAND DORSAL [top] ERYTHEMA [redness], EDEMA [swelling], TENDERNESS, PUNCTURE MARKS...FINGER TIPS PINK, WARM...AROM [active range of motion] AND PROM [passive ranger of motion] OF THE FINGERS PAINFUL..."

Continued review revealed on 11/14/21 at 6:53 AM Patient #3 was admitted to Hospital B as an Observation Patient, with diagnosis of Cellulitis Right Hand.

Review of an Orthopedic Consult note dated 11/15/21 at 1:33 PM revealed, "...Noted TTP (tender to touch) mostly overlying dorsal aspect of right distal hand...Noted decrease in erythema and edema to affected area...Able to fully flexion all digits...

Continued review revealed the patient was discharged home from Hospital B in stable condition on 11/15/21 at 3:08 PM.

Interview with Patient #3 on 11/18/21 at 9:00 AM, by phone revealed the patient did confirm that she presented to the ED at Hospital A on 11/12/21 and again on 11/13/21 for complaint of dog bite. The patient stated she had to wait 9 hours on 11/13/21 at Hospital A and was never examined by a physician or other provider. The patient stated she left the ED at Hospital A and immediately drove herself to Hospital B. The patient stated she was seen immediately at Hospital B and was admitted to the hospital. The patient stated she remained at Hospital B overnight and was given 5 doses of intravenous (IV) antibiotics. The patient stated she was currently on oral antibiotics and has an appointment to see an orthopedist.

Interview with RN #1 on 11/17/21 at 11:00 AM, by phone confirmed RN #1 was the nurse on duty at Hospital A's ED on 11/13/21. RN #1 stated she remembered Patient #3's 11/13/21 ED visit and stated she had triaged the patient on the 11/13/21 ED visit. RN #1 stated the ED was very busy on 11/13/21 and all non-acute patients were having long waits for MSE. RN #1 stated the ED Director and the nursing supervisor both went to talk to Patient #3 due to the patient having multiple complaints and demanded to speak to a supervisor. RN #1 confirmed Patient #3 left the hospital on 11/14/21 without an MSE being performed.

Interview with the ED Director on 11/17/21 at 9:30 AM, in the Administration Conference Room revealed the ED Director remembered Patient #3's visit to the ED on 11/13/21. The ED Director stated she spoke with the patient several times during her wait in the ED and encouraged her to remain in the ED to be screened. The ED Director stated Patient #3 had been outside smoking a cigarette the last time she saw and spoke to her, and this was apparently right before the patient decided to leave. The ED Director stated the patient left the ED without talking to any of the nursing staff before leaving in the early morning (exact time unknown) on 11/14/21. The ED Director confirmed Patient #3 left the ED on 11/14/21 without an MSE being provided and without signing an Against Medical Advice (AMA) release form. Continued interview confirmed there was no MSE documented in Patient #3's 11/13/21 medical record.

Physician #1 was the physician on duty in the ED on 11/13 to 11/14/21. Physician #1 was interviewed by telephone on 11/17/21 at 5:09 PM. Physician #1 confirmed he was the ED physician on duty at Cumberland Medical Center on 11/13/21 when Patient #3 presented there. Continued interviewed confirmed Physician #1 never saw, examined, treated, or spoke to Patient #3 on 11/13 to 11/14/21.

The Quality Director was interviewed in the Administration Conference Room on 11/17/21 at 9:50 AM. The Quality Director confirmed there was no documentation of Patient #3 being provided an MSE on the 11/13/21 ED visit. Continue review revealed Patient #3 had not signed an AMA release form prior to leaving on 11/14/21.

Based on review of the facility's Medical Staff By-Laws, review of facility policies, review of medical records, and interviews the facility failed to provide Stabilizing Treatment for one (#3) patient of 33 patients reviewed. This failure resulted in Patient #3 leaving Hospital A's Emergency Department (ED) after waiting 8 hours 22 minutes with no stabilizing treatment being provided and driving 40 miles to Hospital B where she was admitted and treated with diagnosis of Dog Bite and Cellulitis (infection) of Right Hand.

The findings included:

Review of the facility's Medical Staff Rules and Regulations dated 6/23/2008 revealed, "...All Medical Staff members must comply with Emergency Medical Treatment and Active Labor Act (EMTALA) regulations and must comply with all applicable state laws..."

Review of the facility's policy titled "Emergency Medical Treatment and Active Labor Act" dated December 2015, revealed, "...If an individual has an emergency medical condition, further medical examination and treatment as is within the hospitals capacity and capability will be administered as required to stabilize the medical condition. The hospital must continue to provide care until the condition ceases to be an emergency or until the individual is properly transferred to another facility..."

Review of the facility's policy titled "Patient Discharge Against Medical Advice" dated December 2015 revealed, "...Each competent patient wishing to leave the hospital against the advice of a physician can expect to receive an explanation of release from liability...the RN [Registered Nurse] in charge (team leader, charge nurse, nursing supervisor etc.) will explain and clarify the potential risks involved on leaving the hospital against the medical advice of the attending physician and document this in the medical record...RN in charge will explain the need for the patient's signature on a release form, Request for Discharge Against Medical Advice...Should the patient refuse to sign the Request for Discharge Against Medical Advice form, or refuse to wait and speak to the physician, this fact shall be documented on the release form and in the patient's medical record..."

Medical record review revealed Patient #3 presented to the ED at Hospital A on 11/13/21 at 5:08 PM. Continued review revealed the patient was triaged by Registered Nurse (RN) #1 on 11/13/21 at 5:19 PM. Continued review of RN#1's assessment note revealed, "...dog bite to right hand...Pt [patient] was seen here yesterday and given tetanus along with an antibiotic. Pt feels like it is getting worse..."

Review of an Against Medical Advice/AMA/Refusal Medical screening Form dated 11/14/21 at 1:30 AM revealed, "...Patient offered medical screening but refused to sign/left without signing..." Continued review revealed this form was witnessed by the ED Director.

Continued review of the medical record revealed no documentation of Patient #3 being provided any stabilizing treatment while at Hospital A on 11/13 to 11/14/21.

Review of Patient #3's Medical Records from Hospital B revealed the patient arrived at the ED there on 11/14/21 at 2:30 AM for complaint of dog bite to right hand.

Review of a Physician's Note dated 11/14/21 at 4:34 AM revealed, "...R [right] HAND DORSAL [top] ERYTHEMA [redness], EDEMA [swelling], TENDERNESS, PUNCTURE MARKS...FINGER TIPS PINK, WARM...AROM [active range of motion] AND PROM [passive ranger of motion] OF THE FINGERS PAINFUL..."

Continued review revealed on 11/14/21 at 6:53 AM Patient #3 was admitted to Hospital B as an Observation Patient, with diagnosis of Cellulitis Right Hand.

Review of an Orthopedic Consult note dated 11/15/21 at 1:33 PM revealed, "...Noted TTP (tender to touch) mostly overlying dorsal aspect of right distal hand...Noted decrease in erythema and edema to affected area...Able to fully flexion all digits...

Continued review revealed the patient was discharged home from Hospital B in stable condition on 11/15/21 at 3:08 PM.

Patient #3 was interviewed by telephone on 11/18/21 at 9:00 AM. The patient did confirm that she presented to the ED at Hospital A on 11/12/21 and again on 11/13/21 for complaint of dog bite. The patient stated she had to wait 9 hours on 11/13/21 at Hospital A and was never provided any medical treatment by a physician or other provider. The patient stated after waiting 9 hours she left the ED at Hospital A and immediately drove herself to Hospital B. The patient stated she was seen immediately at Hospital B and was admitted to the hospital. The patient stated she remained at Hospital B overnight and was given 5 doses of intravenous (IV) antibiotics. The patient stated she was currently on oral antibiotics and has an appointment to see an orthopedist.

RN #1 was the nurse on duty at Hospital A's ED on 11/13/21. RN #1 was interviewed by telephone on 11/17/21 at 11:00 AM. RN #1 stated she remembered Patient #3's 11/13/21 ED visit and stated she had triaged the patient. RN #1 stated the ED was very busy on 11/13/21 and all non-acute patients were having long waits for Medical Screening Exam (MSE). RN #1 stated the ED Director and the nursing supervisor both went to talk to Patient #3 due to the patient having multiple complaints and demanding to speak to a supervisor. RN #1 confirmed Patient #3 left the hospital on 11/14/21 without any stabilizing treatment being provided.

The ED Director was interviewed in the Administration Conference Room on 11/17/21 at 9:30 AM. The ED Director stated she remembered Patient #3's visit to the ED on 11/13/21. The ED Director stated she spoke with the patient several times during her wait in the ED and encouraged her to remain in the ED to be screened. The ED Director stated Patient #3 had been outside smoking a cigarette the last time she saw and spoke to her, and this was apparently right before the patient decided to leave. The ED Director stated the patient left the ED without talking to any of the nursing staff before leaving in the early morning of 11/14/21. The ED Director confirmed Patient #3 left the ED on 11/14/21 without any stabilizing treatment being provided and without signing an Against Medical Advice (AMA) release form. Continued interview revealed there was no stabilizing treatment documented in Patient #3's 11/13/21 medical record.

Physician #1 was the physician on duty in the ED on 11/13 to 11/14/21. Physician #1 was interviewed by telephone on 11/17/21 at 5:09 PM. Physician #1 confirmed he was the ED physician on duty at Cumberland Medical Center on 11/13/21 when Patient #3 presented there. Continued interviewed confirmed Physician #1 never examined, treated, or spoke to Patient #3 on her 11/13/21 ED visit.

The Quality Director was interviewed in the Administration Conference Room on 11/17/21 at 9:50 AM. The Quality Director confirmed there was no documentation of Patient #3 being provided any stabilizing treatment on her 11/13/21 ED visit. Continued interview revealed Patient #3 had not signed an AMA release form prior to leaving on 11/14/21.