HospitalInspections.org

Based upon record review and interview, the facility failed to ensure 2 of 24 (#1 and #2) patients' medical records reviewed had not received an appropriate medical screening examination in the Emergency Department and the facility policy was not followed.

Review of policy titled "Medical Screening Exam; POLICY NO: 1103, DATE REVISED: 12/11" revealed
"Purpose: Any individual presenting to the Emergency Department will be provided a medical screening exam to determine the presence or absence of an emergency medical condition. Based on the patient's presenting symptoms the screening may consist of a simple exam or a complex process that involves ancillary studies in accordance with federal EMTALA guidelines.
Policy: It is the policy of TRMC to provide services to any individual seeking treatment for an emergency medical condition. This policy will define guidelines to determine if an emergency condition exists.
Disclaimer: This procedure allows for professional discretion and deviation on the part of the individual healthcare provider when the nurse or provider deems such variation is appropriate to the circumstances.

DEFINITIONS:
Emergency Medical Condition:
A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:
? placing the health of the individual in serious jeopardy
? Serious impairment to bodily functions
? Serious dysfunction of any bodily organ or part

Medical Screening:
MSE is a process utilized by qualified staff to determine if an emergency medical condition exists in individuals presenting to the ED seeking medical treatment. The process will include a minimum of a physical assessment related to the presenting chief complaint, signs and symptoms, vital signs including 02 Saturation, history of complaint, past medical history and any further information needed to determine patient's condition.

Responsibility: RN. ER Physician. Physician Assistant

Procedure:
Note: The RN MSE will only be utilized on patients presenting with a non-urgent complaint as outlined in the guidelines approved by the medical staff at TRMC. Patients determined to have a semi-urgent, urgent or emergent condition during triage will be screened by the ER physician.
1. Patient's presenting to the ED with a non-urgent complaint shall receive a screening exam by a qualified RN. At a minimum a physical assessment related to the presenting chief complaint, signs and symptoms, vital signs including 02 saturation, history of complaint, past medical history and any further information needed to determine patient's condition will be obtained.
2. The RN will use the approved guidelines provided to determine any exclusions to ensure the patient does not meet criteria for admission to the ED. The RN should use subjective and objective data to assist in this determination.
3. If any exclusions are discovered, the patient will continue with the screening/registration process.
o Patients classified as Level 1 will be taken directly to a room.
o Patients classified as Level 2 will be taken directly to a room unless no bed is available, then placed in the first available room.
o Patients classified as Level 3 will be seen in the order of arrival before patients classified as Level 4 and Level 5,
o Any patient presenting via EMS will be assumed to have an emergency condition until otherwise determined by a screening exam.
o A pregnant patient suspected of being in labor is considered to have a medical emergency and will be transported to the L&D department.
4. Once the medical screening exam is complete, those without an emergency condition will be referred to the registration area. Patients with a no exclusion complaint will be informed of the financial obligation and options.
o Patient Access will complete registration and discuss financial arrangements as appropriate.
o Patients determined to not have a medical emergency will be asked to verify insurance information and pay copay amount, deductibles or, if self-pay a deposit, if they want to continue their visit. Those who chose not to be seen will be referred to their primary care physician or the Rural Health Clinic.
o If the patient indicates they do not have the financial means to pay for a visit, they will he provided an indigent care packet. (refer to financial policy)
o If the patient chooses not to be treated in the ED. the file will he discharged out of the system and filed in the electronic screening folder.

Special Consideration: Triage is not equivalent to a medical screening exam. Patients that receive a triage assessment only due to high census or high acuity in the ED will be processed through the ED. Financial obligations will be addressed on discharge.

Qualifications: Any RN completing the medical screening will have a minimum of one year experience in the ED or ICU and be current in Basic Life Support and Advanced Life Support. The RN has the discretion to defer screening to the ED physician. An annual competency on EMTALA will required by every qualified RN.
Medical Screening will include but not limited to:
o Vital signs including pulse oximetry (if applicable)
o System review applicable to chief complaint
o History of complaint, signs and symptoms
o Past medical history
o Pain assessment
o Allergies
o Any further information as needed to determine condition

Exceptions: Any child under the age of two (2) or adult over the age of sixty-five (65) will be considered an automatic exclusion and evaluated in the ED."

Review of patient #1 medical record revealed patient presented to facility emergency department on 08/22/12 at 16:19 (4:19 pm). The triage record was timed 16:21 (4:21 pm) and revealed Level 5, chief complaint as "Other: pt here requesting West Nile testing". Review of the document titled "Emergency Department Triage Report" revealed patient #1 had not received a medical screening examination per documentation of the record and disposition of the patient is not documented. Patient complained of muscle cramps, weird dreams and my primary doctor is out of town. Discharge documentation in the medical record reveals the patient #1 left after triage completed.

Review of patient #2 medical record revealed patient presented to facility emergency department on 08/22/12 at 16:05 (4:05 pm). The triage record was timed 16:07 (4:07 pm) and revealed Level 5, chief complaint as "Other: pt wanting her and her husband tested for West Nile virus". Review of the document titled "Emergency Department Triage Report" revealed patient #2 had not received a medical screening examination per documentation of the record and disposition of the patient is not documented. Patient complained of having intermittent muscle cramping, weird dreams, and she did not want to wait til her doctor came back from vacation. Discharge documentation in the medical record reveals the patient #2 left after triage completed.

An interview with the Chief Nursing Officer on 08/27/2012 at approximately 4:00 PM confirmed, the triage nurse had called her and reported she had patients (husband and wife) in the Emergency Room requesting the West Nile test. The Triage Nurse reported to me the patients had no symptoms of the West Nile Virus and agreed with her the patients could be seen in the rural health clinic or a physician's office.

An interview with the staff #7 on 08/28/2012 10:00 AM confirmed, patient #1 and #2 had been in the Emergency Room on 08/22/2012. Staff #7 reported the Triage nurse had called me and informed me that she had called the Director of Nurses to check and see if it was okay to send these patients home or should they be checked into the Emergency Room. The patients were requesting a West Nile test. The Triage Nurse was telling me this information because I was the Charge Nurse in the Emergency Room on 08/22/2012; she wanted to let me know that she had called the Director of Nurses.

An interview with the Director of the Emergency Department on 08/28/2012 11:00 AM confirmed, 2 patients presenting to the emergency room had not had medical screening examinations and the facility policy had not been followed for medical screening examinations.