HospitalInspections.org

Based on review of facility policy, medical record review, and interviews, the facility failed to ensure a Medical Screening Examination (MSE) was performed for 1 patient (#4) related to abnormal labs of 30 patients reviewed.

The findings included:

During the investigation it was found Patient #4 presented to the Emergency Department (ED) at Facility B on 8/20/2021 related to abnormal labs. She had been admitted to (Facility A) on 8/16/2021 with shortness of breath related to COVID 19 and had active bleeding which required 2 units of Packed Red Blood Cells. She was discharged on 8/19/2021. On 8/20/2021 at 3:45 PM, the patient presented to (Facility B) after her Primary Care Physician had told the patient to come to Facility B related to her abnormal labs. She was triaged and found to have a blood pressure of 93/51 and heart rate of 100. She was assigned an Emergency Severity Index score of a 2 indicating potentially high risk and life threatening illness. She was sent back to the ED waiting lobby until a bed was available for the patient. The patient left the ED at 10:41 PM (6 hours and 56 minutes) prior to seeing a Qualified Medical Provider (QMP). There was no documentation of a reassessment of the patient or additional vital signs to ensure the patient was stable.

Refer to A-2406

Based on review of facility policy, medical record review, and interviews, the facility failed to ensure a Medical Screening Examination (MSE) was performed for 1 patient (#4) related to abnormal labs of 30 patients reviewed.

The findings included:

Review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA) guideline, last reviewed 1/2021, showed "...triage: refers to clinical assessment of the individuals presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual will be seem by a physician or other QMP [Qualified Medical Provider] for completion of the Medical Screening Examination...each designated emergency department will follow their normal triage and evaluation/treatment policy and procedures, perform the emergency medical screening examination, and initially stabilize the patient within the Emergency Department's capabilities...the emergency department record shall accurately reflect the individual's triage, assessment, and treatment until such time he/she admitted, discharged, or appropriately transferred. Documentation should include monitoring according to the patient's needs throughout the patient's stay and prior to discharge or transfer..."

Review of facility policy "Documentation and Nursing Care of the Patient in the Emergency Department" last revised 1/2020, showed "...Emergency Severity Index [ESI] Five Level Triage is a national standard, evidence based triage acuity system...is an acuity determination. The definition of a resource is a hospital service, test, procedure, consult or intervention...Level 2: stable but high risk situation, newly confused, lethargic or disoriented, or severe pain/distress, time sensitive conditions. Potentially life-threatening illness. Patient could easily deteriorate if left to wait. Patient is physiologically stable but should not wait..." Further review showed "...Nursing Assessment and Updates: Nursing assessment should be updated as appropriate for the patient's condition/acuity...pertinent vital signs will be obtained and documented after treatments or interventions, with a significant change on condition, and repeated according to patient's condition/acuity..."

Medical record review showed on 8/16/2021 at 1:13 PM the patient presented to (Facility A's) Emergency Department (ED) with shortness of breath and worsening symptoms related to COVID 19. Her Hemoglobin was 6.9 (normal 14-18) and Hematocrit 21.3 (normal 37.7-47.9). She had no signs of active bleeding and denied any blood in the urine or stool. She was given 2 units of Packed Red Blood Cells while in the ED. She received a MSE by the ED Physician. The Hospitalist was consulted, and the patient was admitted to the facility on 8/17/2021. She was discharged home on 8/19/2021.

Medical record review showed the patient was admitted to Facility B's ED on 8/20/2021 at 3:45 PM related to previously abnormal labs, diarrhea, and dark stools.

Medical record review of an ED Nursing Triage record dated 8/20/2021 at 5:01 PM showed "...pt. [patient] here for abnormal labs, low hemoglobin, on Monday [8/16/2021]. Pt. had diarrhea and dark stools and was sent to ER...[named family physician] told pt. to come here. Pt. on blood thinners. Positive for COVID and quarantine was up on 8/18/2021..." The patient's vital signs were as follows: blood pressure 93/51, Pulse 100, Respirations 19, (on 3 liters of oxygen by nasal cannula), pulse oximeter 100%, and temperature 97.9 degrees F. She was assigned a Emergency Severity Index (ESI) score of a 2 (indicating stable but high risk situation, potentially life-threatening illness).

Medical record review showed no MSE was performed for the patient by a QMP.

Medical record review showed no further assessments or vital signs were obtained for the patient after the patient was triaged.

Medical record review of a Discharge Depart Reassessment dated 8/20/2021 at 10:41 PM (6 hours and 56 minutes after the patient arrived at the ED) showed the patient left the ED without being seen.

During an interview on 4/28/2022 at 3:15 PM, Registered Nurse #1, stated the patient presented for abnormal labs recently and had a low hemoglobin on Monday and she was on blood thinners. The patient had stated she recently had COVID 19, dark stools, and diarrhea per her history. RN #1 stated "...the patient's blood pressure was a little low and I knew she would need more than 2 resources, so I triaged her with an ESI score of a 2. She was triaged back to the lobby until a room was available for the patient..." She confirmed no diagnostic testing was completed for the patient and the patient left the ED prior to being evaluated by a physician.

During an interview on 4/28/2022 at 4:00 PM, the ED Director, confirmed the patient did not receive a Medical Screening Examination prior to leaving the ED. She confirmed no additional assessment or vital signs were obtained for a patient with an ESI score of a 2.

During an interview on 4/29/2022 at 10:15 AM, Physician #1 stated the patient's heart rate was 100 and her blood pressure was 93/51. He stated "...I am not sure why the patient had an ESI score of a 2...it looks like she only got one set of vital signs during the triage and no other vital signs were obtained...it would have been good to have other vital signs...she left the facility prior to seeing a physician..."