HospitalInspections.org

Based on policy review, document review, observation and interview, the facility failed to implement additional precautions intended to mitigate the transmission and spread of COVID-19 for 2 of 3 (Registered Nurse #1 and Phlebotomist #1) unvaccinated staff members observed in the facility and 5 of 6 (Registered Nurse #2, 3, 4, 5, and 6) employed in the Emergency Department.

The findings included:

1. Review of the facility's "COVID-19 Vaccination Requirements" policy dated 1/18/22 and revised 2/7/22 revealed vaccination deadlines by January 27, 2022, "All covered staff must have received a single-dose COVID-19 vaccine unless the person has submitted an application for medical or religious exemption which is still pending or has been approved.... E. ...At this time, all staff, regardless of vaccination status or exemption, within sites that provide patient care must wear a mask, all staff providing patient care must wear a surgical mask, and staff caring for COVID or COVID-suspect patients must wear an N 95 mask and appropriate PPE [Personal Protective Equipment] ..."

2. Review of the facility Employee Demographics Report provided on 2/14/22 at 9:10 AM by the Quality Outcome Director revealed 32 Emergency Department employees. Of the 32, six were not vaccinated for COVID-19 (RN #2, 3, 4, 5 and 6) and one had an approved exemption, resulting in a 78.12% vaccination rate.

3. Observation on 2/14/22 at 12:30 PM revealed RN #1 exiting a patient room in the Emergency Department. She was wearing a yellow paper mask and face shield, not a surgical mask as per policy.

Observation on 2/14/22 at 12:37 PM revealed Phlebotomist #1 outside a patient room in the Emergency Department preparing supplies to a blood sample. She was observed wearing a regular paper mask not a surgical mask per policy.

4. In an interview on 2/14/22 at 12:27 PM in the Emergency Department conference room, RN #1 stated she had not been vaccinated for COVID-19 and had applied for exemption on 2/7/22.

In an interview on 2/14/22 at 12:37 PM in the Emergency Department hallway, Phlebotomist #1 stated she had not received the COVID-19 vaccine and had not applied for exemption. She stated she had COVID in August 2021 and had been employed at the facility for a year.

In an interview on 2/14/22 at 3:33 PM, the Chief Nursing Officer stated, "[RN #2] has no vaccines or exemption. She's new here and did not know how to request an exemption. She does now."

An Emergency Medical Treatment and Labor Act (EMTALA) federal complaint survey was conducted from 2/14/2022 through 2/17/2022 for complaint TN00056584. The facility was found out of compliance with Federal Regulations at 42 CFR 489.20 and 489.24, Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Based on facility policy review, medical record review and interview, the facility failed to ensure all patients presenting to the hospital's emergency department (ED) were provided an appropriate and ongoing medical screening examination (MSE) within the hospitals capabilities for one (1) of 20 (Patient #2) patients.

The findings included:

Patient #2 presented to Hospital #1's ED via personal vehicle on 2/7/2022 at 3:53 PM with the chief complaint of difficulty breathing due to tracheal (also known as 'windpipe') narrowing. The patient stated she was always short of breath but had become worse over past few weeks. The patient reported she was scared her trachea was about to collapse. Upon triage, the patient was assigned an acuity of 3 (the patient's condition could progress to a serious problem requiring emergency treatment). The physician's note revealed the assessment was unremarkable. The physician went into the patient's room to tell her to keep scheduled appointment with Ear, Nose, Throat physician (ENT). When the physician entered the room, Patient #2 had eloped from Hospital #1.

Patient #2 presented to Hospital #2's ED via personal vehicle on 2/8/2022 at 2:28 PM with chief complaint of tracheal narrowing (stenosis). Upon triage the patient was assigned an acuity of 3. The patient stated she had oxygen saturations in the 70% range this morning, accompanied with lightheadedness and shortness of breath. The ED physician consulted with ENT physician and the patient was admitted. The patient received a Computerized Tomography (CT) which verified tracheal narrowing.

See findings in Tag A 2406

Based on facility policy review, medical record review and interview, the facility failed to ensure all patients presenting to the hospital's emergency department (ED) were provided an appropriate and ongoing medical screening examination (MSE) for one (1) of 20 (Patient #2) sampled patients presenting to the ED.

The findings included:

1. Review of Hospital #1's "Emergency Medical Treatment and Labor Act ("EMTALA")" documented "PURPOSE: To ensure compliance with the Emergency Treatment Labor Act ("EMTALA") requirement to conduct Medical Screening Examinations on individuals that present to a [Name of hospital ED] and request emergency services. POLICY: All individuals presenting to a Hospital Emergency Department ("ED") or other Hospital property requesting examination or treatment are entitled to receive an appropriate Medical Screening Examination ("MSE") performed by qualified individuals to determine whether or not an Emergency Medical Condition exists ...In relation to these medical screening responsibilities: 1. The MSE will be performed without delay and in accordance with applicable federal and state laws. 2. In no event will the provision of the MSE and stabilizing treatment be based upon, or affected by, an individual's... preexisting medical condition... PROCEDURE: A. Medical Screening Examination Requirement 1. Any individual presenting to the ED or other Hospital property and requesting emergency care will receive a MSE within the capabilities of the Hospital's ED to determine whether or not an Emergency Medical Condition exits. These capabilities include the utilization of ancillary services, diagnostic methods and specialist physicians routinely available to the Hospital and the ED..."

2. Medical record review for Patient #2 revealed the patient presented to Hospital #1's ED via personal vehicle on 2/7/2022 at 3:53 PM with complaint of difficulty breathing due to tracheal stenosis (The trachea, commonly called the windpipe is the airway between the voice box and the lungs. When this airway narrows or constricts, the condition is known as tracheal stenosis, which restricts the ability to breathe normally.) The patient had a past medical history including Cleft lip, tracheotomy in 2021 and born with tracheal stenosis with history of tracheotomy times three.

Review of the triage note dated 2/7/2022 at 4:03 PM, revealed the patient was assigned an acuity level of 3 (Patients in this category have conditions that could potentially progress to a serious problem requiring emergency interventions) and vital signs were documented as: Temperature 98.4, Respiratory rate: 18 breaths/minute, Heart rate: 82 beats per minute, Blood Pressure: 121/64 and Oxygen Saturation: 100 percent (%) on room air. Subjective complaint: [the patient] stated has tracheal stenosis so she's always short of breath but it has been worse for about four (4) weeks. Respirations unlabored and regular, lungs clear, nail bed color: pink."

Review of ED Physician #1's notes dated 2/7/2022 at 4:14 PM revealed, "... patient presents with difficulty breathing and "tracheal problem." The onset was 30 minutes ago. The course duration of symptoms is constant. Degree at onset moderate. Exacerbation factors is none. The relieving factors is none. Risk factors consist of history of tracheal stenosis. Prior episodes: rare. Associated symptoms chest pain and denies fever. Patient presents saying that she thinks her trachea is about to collapse. Said she was having some chest tightness. Nasal congestion. Apparently had history of tracheal stenosis with a few reconstructive surgeries. The last one was two years ago and was done in Saint Louis. Prior to that [patient] had one in 2017 at which time she had a car accident. From what I understood [patient] said that was the cause of her accident. That time [patient] was seen by [name of local Ear, Nose and Throat (ENT) physician #1]. [Patient] said [named local ENT physician] 'wouldn't touch me' without medical records from other specialist... So something happened 30 minutes ago were (sic) which made her very scared that her trachea was about to collapse..." Further review of physician notes revealed, "...No signs of acute significant airway obstruction. Moving air well. No significant strider. No significant wheezing. No accessory muscle use... Lungs clear to auscultation; respirations are non-labored..."

Review of the chest X-ray dated 2/7/2022 at 5:07 PM revealed the lungs were clear. The heart and mediastinal structures were normal. No pneumothorax or pleural effusion is seen..."

Review of the physician's notes dated 2/7/2022 at 5:34 PM revealed, "...patient has remained stable and comfortable in the ER. No signs of impending airway obstruction. Clear speech. No significant strider. No hypoxia. At this point I feel patient can be discharged with follow up with ENT as already arranged. When I walked in to tell the patient about [patient] results, [patient] was not in the room. [Patient] had eloped..."

3. Medical record review at Hospital #2 for Patient #2 revealed the patient presented on 2/8/2022 at 2:28 PM via private vehicle with complaint of tracheal stenosis. Patient was triaged and assigned a patient acuity of 3. Review of the ED provider note on 2/8/2022 at 9:32 PM revealed, "Patient with PMH [past medical history] of laryngeal web as child with subsequent multiple surgeries, tracheostomy with revision when she was in second grade, followed by MVC [motor vehicle collision] trauma leading to another tracheostomy in 2017 in Memphis, subsequent subglottic stenosis, comes to the ED today stating that [ENT Physician #2] told her to come to the ED after she was seen yesterday by [ED Physician #1]... for shortness of breath since early Jan [January], and had a neg [negative] CXR [chest x-ray] and COVID swab. She states that she noted an O2 [oxygen] sat [saturation] at home of 73% last night and a sat of 76 % today that each lasted about an hour and she states that she did feel somewhat lightheaded and short of breath, but denies choking, loss of consciousness, fever, purulent sputum..." The ED provider documented on 2/8/2022 at 10:46 PM discussed with ENT physician #2 who requested the patient be admitted to Hospital #2. The patient was notified of admission plans at 11:08 PM.

On 2/9/2022 at 3:16 PM, a Pulmonology consult revealed, "CT [computerized tomography]: Findings: There is narrowing of the trachea at the level of the prior tracheostomy stoma, which measure 12 mm [millimeters] in narrowest dimension and 5 mm in narrowest transverse dimensions. This tapered stenosis extends over a craniocaudal distance of approximately 1.6 cm [centimeters]..."

On 2/15/2022 the patient underwent a Direct Laryngoscope and Bronchoscopy (DLB) and balloon dilation with Kenalog injection. Findings included 60-70% proximal tracheal stenosis that was about 1.75 cm in length involving a collapsible segment that partially responded to balloon dilation to about 50%. The ENT physician documented the patient would need an open procedure in the near future with possibly tracheal resection versus tracheostomy. The patient was discharged stable on 2/16/2022.

4. On 2/14/2022 at 1:45 PM, ED physician #1, who provided care to Patient #2 on 2/7/2022 stated, "...I remember the patient. She came in with a history of tracheal stenosis thinking trachea was closing and she told me she was maybe panicking. She had seen and ENT in town and had an appointment for follow up. The exam by me was benign, airway was good. COVID and chest x-ray were good, no signs and symptoms of distress. I read the chest x-ray and went back to her room to discuss results and she had left. She didn't tell anyone she was leaving. There wasn't anything to do here in the ED for her. No distress. No signs and symptoms of stenosis. Would have seen shortness of breath, strider, abnormal breath sounds. None of these occurred. If happened would need to see ENT for possible scope ..."

5. Hospital #1 failed to provide an appropriate MSE of Patient #2 while in the hospital's ED. An ENT consult was not provided nor a CT of the neck. The patient had stated she felt like her trachea was closing which would have met the definition of an Emergency Medical Condition. The patients throat could not be adequately evaluated without further imaging evaluation with an ENT specialist.