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Tag No.: A2400
Based on medical record (MR) review, Medical and Dental Staff Rules and Regulations review, policies and procedures review, video surveillance footage review, Hospital B, receiving hospital, MR review, and staff interviews, it was determined the facility failed to ensure that individuals coming to the emergency department (ED) were provided a medical screening examination appropriate to the individuals presenting signs and symptoms within the capability and capacity of the hospital's ED to include ancillary services routinely available to the hospital's ED to determine whether or not an emergency medical condition existed.
This affected one of twenty MRs reviewed including Patient Identifier # 1, and had the potential to affect all patients presenting to this ED.
Findings include:
Refer to A 2406 for findings.
Tag No.: A2406
Based on medical record (MR) review, Medical and Dental Staff Rules and Regulations review, policies and procedures review, video surveillance footage review, Hospital B's Emergency Department (ED) MR review, and staff interviews, it was determined the facility failed to ensure that individuals coming to the ED were provided a Medical Screening Examination (MSE) appropriate to the individuals presenting signs and symptoms within the capability and capacity of the hospital's ED to include ancillary services routinely available to the hospital's ED to determine whether or not an emergency medical condition existed.
This affected one (1) of twenty (20) MR reviewed including Patient Identifier (PI) # 1, and had the potential to affect all patients presenting to the ED with complaints and signs and symptoms of headaches, cervical spine pain, blurred vision, sinus pressure, and prior medical history of Subdural Hematoma (SDH - a type of bleeding in the brain that can happen after a head injury).
Findings include:
Hospital Policy: Medical & Dental Staff Rules and Regulations
Approved 7/24/23
... 11.3 A ... MSE will be conducted on every patient who comes to the Hospital...requesting emergency examination or treatment of an emergency medical condition...
Hospital Policy: Emergency Medical Treatment and Labor Act (EMTALA) Policy.
Policy Number: Not Listed
Revised: 5/17/24
Purpose: To set for the guidelines for UAB (University of Alabama Birmingham) Hospital to comply with the Emergency Medical Treatment...
Policy:
...B. Emergency Department Medical Screening Examination (MSE).
1. UAB Hospital shall provide a MSE for every person who comes to the Hospital Campus and makes a request for examination of treatment of an Emergency Medical Condition.
...3. Within the capability of UAB Hospital, the MSE shall determine whether or not an Emergency Medical Condition exists...
1. PI # 1 presented to the ED on 9/1/24 at 2:15 PM with complaints of headache, cervical spine pain, blurred vision, and prior medical history of SDH.
Review of the Triage assessment conducted on 9/1/24 at 2:51 PM revealed Employee Identifier (EI) # 12, Registered Nurse (RN), documented vital signs including blood pressure of 131/85, pulse 102, respirations 18, temperature 97.9, oxygen saturation 96 %, and a pain level of 7 out of 10.
Review of the Nurse Assessment dated 9/1/24 at 4:44 PM revealed EI # 10, Licensed Practical Nurse (LPN), documented PI # 1 was upset due to having to wait for imaging, EI # 8, RN, Charge Nurse, was notified.
Review of the Nurse Assessment dated 9/1/24 at 5:57 PM revealed EI # 10 documented PI # 1 stated he/she was leaving and would be back in an ambulance.
Review of the Nurse Assessment dated 9/1/24 at 6:12 PM revealed EI # 11, RN, documented PI # 1 left without being seen (LWBS).
PI # 1 was in the ED for a total of four (4) hours and fifty seven (57) minutes. There was no MSE documented.
A review of the video recordings was conducted on 9/25/24 at 1:30 PM with EI # 3, Director of Emergency Services, the following is a summary of the video review:
On 9/1/24 at 2:10 PM, PI # 1 entered the ED accompanied by an adult female and a dog on a leash and walked to the registration desk.
At 2:43 PM was taken to the triage area.
At 2:52 PM, PI # 1 returned to the ED waiting area.
At 5:58 PM, PI # 1 exited the ED.
Review of Hospital B, receiving hospital, medical record revealed PI # 1 arrived at the ED on 9/1/24 at 7:36 PM.
Review of the Triage Assessment dated 9/1/24 at 7:36 PM revealed PI # 1 complained of a headache and blurred vision which started three (3) days prior to arrival. PI # 1 complaints also included a history of Subdural Hematoma with surgery eighty two (82) days prior to arrival, nausea, photophobia, and joint pain. The vital signs were blood pressure 125/82, heart rate 89, respirations 89, temperature 97.9, oxygen saturation 98 %, and a pain level of 8 out of 10.
Review of the MSE dated 9/1/24 and signed at 9:49 PM revealed PI # 1 was seen by the provider at 7:45 PM. Diagnostic test were ordered including a Cervical Spine x-ray and Computerized Tomography (diagnostic computerized procedure that produces images inside the body) of the head.
PI # 1 was discharged from Hospital B ED on 9/1/24 a 9:51 PM with diagnoses including Acute Left Cervical Radiculopathy and Episodic Tension-Type Headache.
An interview was conducted on 9/26/24 at 8:55 AM with EI # 8, RN, who stated he/she was contacted by EI # 10, LPN, to come speak to PI # 1 due to him/her having to wait in the lobby. EI # 8 stated he/she was busy at the time of the call and did not speak to PI # 1.
An interview was conducted on 9/26/24 at 9:25 AM with EI # 10, LPN, who stated he/she remembered PI # 1 was upset that he/she had to wait and frustrated because nobody would come out to speak to him.
An interview was conducted on 9/26/24 at 1:45 PM with EI # 4, Senior Director Emergency Services, who confirmed PI # 1 did not have a MSE performed and no diagnostic tests were ordered.
The facility failed to ensure that their policy and procedure, and Medical and Dental Staff Rules and Regulations were followed as evidenced by failing to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department including ancillary services ( Clinical laboratory tests, CT scans, and other diagnostic tesst and procedures) routinely available to the ED to determine whether or an emergency medical condition existed for patient #1 on 9/26/2024.