HospitalInspections.org

Based on policy review, review of the Emergency Department (ED) log, medical record reviews, review of a facility letter, observations of a security video, and interviews, the facility failed to provide a medical screening evaluation (MSE) for one patient (#28) of twenty-eight patients reviewed.

Review of the facility's communications, investigations, and action plans revealed the facility has placed interventions in place and the facility is currently in compliance with 42 CFR 489.20 and 489.24, Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

The findings included:

Refer to A2406 for failure to provide a Medical Screening Exam (MSE).

Based on policy review, review of the Emergency Department (ED) log, medical record reviews, review of a facility letter, observations of a security video, and interviews, the facility failed to provide a medical screening evaluation (MSE) for one patient (#28) of twenty-eight patients reviewed.

Review of the facility's communications, investigations, and action plans revealed the facility has placed interventions in place and the facility is currently in compliance with 42 CFR 489.20 and 489.24, Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

The findings included:

Review of the facility's EMTLALA Medical Screening Stabilization Policy revised 9/1/13, revealed, "...when an individual comes...to the Dedicated Emergency Department of the Hospital and a request is made on the individual's behalf for a medical examination or treatment, the Hospital must provide an appropriate Medical Screening Examination within the capability of the Hospital...Hospitals are obligated to perform the Medical Screening Examination to determine if an Emergency Medical Condition exists...".

Review of the facility's Emergency Department (ED) log revealed on 5/20/15 at 9:08 AM, a female patient (Patient #28) identified as "Female, White" was registered. Further review of the ED log revealed the patient "eloped LWBS [left without being seen]" on 5/20/15 at 9:28 AM.

Review of ED records revealed there was no medical record for Patient #28 and no documentation that she was provided a Medical Screening Exam (MSE).

Review of a facility letter dated 5/27/15 to the Center for Medicare and Medicaid Services (CMS) regarding an "EMTALA Self-Report" revealed, " ...The patient presented to our ED registration desk around 9:00 a.m. on Wednesday, May 20, 2015. She stated that she was 36 weeks pregnant and having contractions four minutes apart...The registration clerk asked the patient where her OB [obstetrics] doctor was located. The patient responded in Knoxville. The registration clerk told the patient that our facility does not have OB services. The patient immediately left before the registration clerk could get her name or offer a medical screening examination. The clerk did not try to stop the patient from leaving. We reviewed video and confirmed that the entire encounter lasted 16 seconds...".

Observations of a security video filmed at approximately 9:00 AM on 5/20/15, revealed an unknown female patient entered the ED with an unknown male. The female presented at the registration desk and could be seen speaking briefly to someone at the desk. The patient then immediately turned to the male and they both left the ED. The amount of time from entrance to exit was 16 seconds observed on a timer.

Telephone interview with RN #1 on 7/14/15 at 10:00 AM, revealed she was the charge nurse on 5/20/15 and remembered Patient #28 presenting to the ED that day. RN #1 stated she arrived at the nurses' station and heard the registration clerk say, "a pregnant girl came in...I told her we don't have OB...she cursed and left..." RN #1 stated she told the registration clerk, "...we are not allowed to say anything like that...". Further interview with the RN confirmed Patient #28's name and where the patient went after leaving the ED was unknown. Further interview with RN #1 confirmed all patients coming into the ED were to be seen and provided a MSE, including patients in labor. Further interview with RN #1 confirmed she had experience in the ED with caring for patients in labor and had assisted in delivery of babies in the ED at the facility.

Telephone interview with Registration Clerk #1 (RC #1) on 7/16/15 at 9:05 AM, revealed she was working in the facility's ED on 5/20/15, and remembered Patient #28 presenting to the ED. RC #1 stated, "...she came in and said she was pregnant...I said ok, you realize we don't have OB at this hospital?...she rolled her eyes at me...she was not even up to my desk yet...she turned to her boyfriend and said come on, I don't want to be here anyway...". RC #1 also stated, "...I did not have time to ask her to stay...she just turned around and left...she told me she didn't want to be here...she walked out the door before I could call the triage nurse...I told the nurse right away and they reported me...". Further interview with RC #1 revealed she had worked in the ED for 11 years and had seen many patients in labor treated at the ED.

Interview with the facility's Risk Manager on 7/14/15 at 11:00 AM, in the facility's administrative conference room, revealed, "...a patient complaining of labor presented to the ED 5/20/15, at around 9:00 AM, and was told we don't have OB services here, and the patient left without being seen...this incident was reported to me on the 20th right after it happened...[the ED Director and Chief Nursing Officer] had already talked to the staff, terminated the employee responsible, all the ED and registration staff were immediately educated...the incident was reported to corporate that day..." Further interview with the risk manager revealed a Plan of Correction was put in place and included:

1. A review of all policies regarding registration, MSE, triage, treatment, and transfers of pregnant patients that present to the ED was completed by 5/26/15. A record audit of the registration and MSE of patients in labor to monitor the registration and MSE was begun on 5/27/15 and was ongoing.
2. On 5/26/15 a folding tent sign was placed on the registration desk which stated, "Regardless of whether the hospital offers a particular service, we are an emergency department and we will see you."
3. All ED and registration staff had detailed EMTALA training provided during which staff discussed situations that might arise, including pregnant/labor patients, with a practical test given afterward. The education was completed by 6/12/15.
4. The ER staff were and continue to do audits of the Quick Triage sheets to monitor timeliness and completeness of the triage process, which began 5/27/15.
5. Beginning 5/27/15, each week the ED Manager and Charge Nurses do 21 observations of the ED registration process (actually watch the process in the ED) and complete a monitoring form.
6. Beginning 5/28/15, each morning at 7:00 AM both shifts of the ED and registration staff meet for a "daily safety huddle" in which EMTALA topics are reviewed.
7. Beginning 5/27/15, the ED Director or designee reviews each week 100% of the cases that elope or leave without being seen and complete an audit form.
8. Beginning 5/27/15, the quality manager reviews 100% of patient complaints and event forms each week to determine if any EMTALA related complaints or events have occurred.
9. Beginning 5/27/15, results of all the audits and monitoring are reported the quality committee each week.

To verify the Plan of Correction, RN #1 and three random nurses in the ED were interviewed on 7/14/15 (RN #2, #3, and #4) and all were knowledgable of EMTALA requirements and hospital policies. All four nurses stated they had helped treat patients in labor and RN #4 stated she had assisted in the delivery of 2 babies in the ED in the last 10 months.

Interview with the physician (MD #1) on duty in the ED on 7/13/15 and 7/14/15 revealed he was also the medical director. Further interview confirmed MD #1 and the other ED physicians had recently recieved education regarding EMTALA requirements and he had this education yearly. Further interview confirmed all patients presenting to the ED recieved a MSE and all recieved any treatment they may need. Further interview confirmed he and the other physicians had all provided MSEs to patients in labor and had delivered babies in the ED.

Review of Personnel Files of ED Staff and Registration Staff and review of Credentialing Files for Medical Staff revealed all had recently been re-educated on EMTALA requirements, were trained on EMTALA requirements when hired, and recieved yearly EMTALA training.