HospitalInspections.org

Based on record review, review of documents, and interviews it was determined that the hospital failed to provide emergency medical assistance to an injured trauma patient who was on the ED (Emergency Department) ramp. This finding is noted in 1 of 40 records reviewed.


Findings include:


Review of MR#1 and the ACR (ambulance call report ) on 8/2/13 at 11:00 AM found that a 29 year old patient presented to the hospital emergency department (ED) ramp by private automobile on 4/8/13 after a motorcycle accident and was unable to walk into the ED without assistance. The time of the patient's arrival on the hospital's ED ramp is not documented.

The ambulance was dispatched on 4/8/13 at 2001 hours (8:01 PM) from the EMS (Emergency Medical Services ) base, which is located on hospital property. The ambulance arrived on the scene at 2004 hours (8:04 PM). The incident address on the ACR form is noted at "1300 Pelham Parkway", which is the address of the hospital.

Review of the ACR (ambulance call report ) in the medical record (MR #1) on 8/2/13 at 11AM noted that on 4/8/13 "a 24 year old male found in front of the ER needing a stretcher to transport him into the ER." Review of the ACR found that the EMT's noted that the patient was "patient was never in ambulance; moved to ER."

Further review of the ACR found that the patient was found in the automobile with leg trauma by EMS at 2004 hours (8:04PM), who then placed the patient on their stretcher and transported that patient into the ED ambulance entrance. There was no documentation on the ACR of vital signs other than respiration.

Interview with the EMS Chief on 8/2/13 found that he referred to a CAD (computer assisted dispatch) report in which he stated that the patient's friend dialed 911 as directed by ED personnel, who refused to come out of the ED to assist the patient. This staff confirmed that the patient's friend had stated to the 911 operator that the hospital staff refused to assist with transport and told him to dial 911.

Interview with the Nursing Supervisor of the ED on 8/2/13 found that she was not notified of this event. Interview with the ED Administrator on 8/2/13 found that the facility could not identify the staff who was involved. with this event.

Review of the ED record (MR #1) found that the hospital ED triage note recorded the triage event time as 8:46 PM on 4/8/13 in which it was noted the patient fell off the motorcycle and reported right knee pain. The patient was registered at 20:23 (8:23 PM).

Review of the "Unscheduled ED Provider Initial note" dated 4/9/13 noted the examination event time of 0510 (5:10 AM). The nursing documentation was reviewed and noted "patient here after motorcycle accident in which he lost control of motorcycle and hyperflexed right knee under his body." Under the section titled assessment and plan , the physician noted "right tibial plateau fracture; ortho aware. Will board to orthopedics floor for further management."

Review of the CT scan interpretation of the right knee dated 4/9/13 found that the impression noted "severely comminuted depressed fracture of the proximal tibia plateau". This right tibial plateau fracture required open reduction and fixation with metal rods (surgery), which was performed on 4/9/13. Weight bearing on this injury would be contraindicated.

Review of the facility policy #H-3.0, titled "Hospital Police Aiding in Removing Patients from Cars", revised 2/25/13, indicates that Hospital security is to assist in the removal of patients from automobiles as requested. The policy notes: " Officers are to be accompanied by a member of the medical staff, such as the MD, RN, or Nurse practitioner, in order to ensure the patient's clinical needs are properly addressed during the extrication from vehicle."

Based on record review, review of policies, and interviews, it was evident that the hospital failed to:
1) conform to facility procedures to provide a patient with a timely triage examination;
2) provide a medical screening examination in accordance with facility procedures;
3) implement triage procedures that describe objective parameters for pretriage assessment and to address actions to be taken for delays between pre-triage and triage. (MR#2)
This finding was identified in 1 of 40 emergency records reviewed.

Findings include:

1. Review of MR#2 on 8/2/13 found that the patient presented to the emergency department (ED) walk in triage area complaining of severe "lung" pain, shortness of breath and increasing weakness on 6/3/13 at 4:28 PM. He was seen by a pre-triage RN at 1628 hours (4:28PM) where there were no vital signs taken and no assessment of respiratory status.

The patient was triaged at 5:35 PM (1 hour and 7 minutes after pre-triage). He was assigned a triage category of ESI = 4, which corresponds to a "non-urgent" status. Emergency severity index (ESI) is a classification scale that prioritizes emergency patients and which assigns a number of resources anticipated to meet patient needs while in the ED. Review of the triage note found that he was noted to have a pain index of 9 out of 10. There was no reference as to the location of pain on the triage note.

At 9:52 PM on 6/3/13, (4 1/2 hours later) there was a re-assessment nursing note that contained no vital signs and no re-assessment of the pain. It was noted that the patient had "unlabored breathing," and was " non diaphoretic, still in adult waiting area. " At 11:15 PM on 6/3/13, there was a nursing note that the patient was classified a "no answer-voluntary walkout." The patient left without being seen after waiting 6.7 hours.

2. The patient never had a medical screening examination by medical staff. At interview with the ED Nursing Director on 8/2/13 it was stated that the vital signs were stable and that the triage category was correct for the patient referenced in MR #1. It was stated by this staff the patient did not want to stay for treatment. The facility did not adhere to hospital policy for "Triage of Adult/Pediatric Emergency Department Patients", which requires patients with ESI rating of 4 should have initiation of treatment within 2 to 3 hours.

3. Pre- triage procedures are incomplete. Review of ""E-fast" assignment" procedure on 8/2/13 found it requires patients to be quickly screened while waiting for triage evaluation and treatment in the Adult ED. This procedure describes that patients in distress are brought directly into the ED but does not identify the specific activities to make this determination .

The nurse screener documents the chief complaint, name, and date of birth as well as time frames required for reassessment of patients in the waiting area.

Review of ED policies titled "Triage of Adult/Pediatric Emergency Department Patients" on 8/2/13 found that patients who are classified as ESI level 4 should have a timeframe of initiation of treatment within 2 to 3 hours. It further stated that patients who are assigned this category should have conditions that would not deteriorate if treatment is not initiated for 2 to 4 hours. Further, these should be patients that could be treated in Urgent Care/ Fast Track area.

There is currently no policy that addresses what actions are to be taken by staff when there is a significant delay between E-fast (pre triage assessment) and complete triage.
At interview with the ED Nursing Director on 8/2/13 it was stated that triage becomes backed up because of the increased documentation requirements of a complete triage assessment, which includes domestic violence history, documentation of allergies, and the patient's current medications.