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Based on policy reviews, patient and staff interviews, the hospital failed to ensure 2 (Patient 6 and Patient 22-no record) of 22 sampled patients was provided a Medical Screening Examination (MSE) to determine within the hospital's capabilities whether an Emergency Medical Condition (EMC) existed, in accordance with the facility Emergency Medical Treatment and Transfer Policy. Patient 6 presented to the Emergency Department twice for medical care/pain control for blistered feet, eye irritation and smoke inhalation following a house fire and Patient 22 presented to the Emergency Department requesting clarification of her spouses script and seeking medical care due to a panic attack and the staff failed to provide a MSE upon request. The failure to follow the hospital's policy and procedures for performing a MSE to determine an EMC has the potential to cause harm or death due to a delay in treatment. According to the facility provided information the ED sees an average of 1418 patients per month.

Findings are:

See also A 2406.

A. Review of the 9/23/04 policy titled, EMTALA (Emergency Medical Treatment and Transfer) Medical Screening revealed:
-All individuals coming to the emergency department requesting emergency services receive a medical screening examination (MSE).
-The MSE is the process required to reach with reasonable clinical confidence, a determination of whether an EMC exists.
-Obligation to Provide MSE. Any individual who "Comes to the emergency department" requesting examination or treatment (or on whose behalf examination or treatment is requested) is entitled to and shall be provided an appropriate MSE to determine whether an EMC exists. An individual how is not an inpatient or a scheduled outpatient will be considered to have "come to the emergency department" if he/she: 1) has presented to the dedicated emergency department and requested examination or treatment for a medical condition, or has had such a request made on his/her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition.

B. The hospital failed to follow policy 8210-0231 "EMTALA (Emergency Medical Treatment and Transfer) Medical Screening" and did not provide Patient 6 with pain control on 2 visits on 10/11/22 for burns to bilateral feet, bilateral eye burning/irritation and breathing discomfort following smoke inhalation; and Patient 22 with a medical screening exam when the patient presented to the dedicated emergency department on 10/11/22 at approximately 9:00 AM seeking clarification of a prescription for spouse and request for medical care due to a panic attack with the inability to calm down.

C. In an interview on 1/12/23 at 9:00 AM, ED RN B, "she [Patient 22] never checked in, so she was not seen in ED and would not have a chart or be on the log."

Based on policy review, patient and staff interviews, the hospital failed to ensure 2 (Patient 6 and Patient 22-no record) of 22 sampled patients was provided a Medical Screening Examination (MSE) to determine within the hospital's capabilities the presence of an Emergency Medical Condition (EMC). Patient 6 presented to the Emergency Department twice for medical care/pain control for blistered feet, eye irritation and smoke inhalation following a house fire and Patient 22 presented to the Emergency Department (ED) requesting clarification of her spouse's script and requesting medical care due to a panic attack, and the staff failed to provide a MSE when she would not calm down. The total sample of 22 patients were reviewed. This failure has the potential for all patients presenting to the Emergency Department (ED) to have an untreated MSE which could result in harm or death due to delay in treatment. According to the facility provided information the ED sees an average of 1418 patients per month.

Findings are:

A. In an interview with Patient 22 on 1/12/23 at 8:20 AM, she revealed that she arrived into the emergency department on 10/11/22 at approximately 9:00 AM, after trying to fill her spouse's prescription from an earlier ED visit leaving at 7:30 AM. Patient 22 stated, that as she pulled into the ED parking lot and she started having a panic attack. "It was the first time I had been alone since the fire at 11:00 PM the night before that had burnt my house down, I had been at the hotel trying to care for my daughter and my husband between his 2 ED visit that night." "I walked into the ED and the security guard noticed me as I was shaking, crying and emotionally distraught. I walked up to the registrar desk and placed the prescription that they gave my husband 1.5 hours ago on discharge for some cough syrup with codeine to help him due to his smoke inhalation. I had driven to 2 pharmacies and the medication was not available. I told the registrar that this is ridiculous and I needed help, my husband was in pain and needed to talk to someone. The security guard took the script from me and was looking at it and hovering over me. Which made me more panicky and anxious. The guard told me that it was not a prescription and I needed to calm down or they COULD NOT help me. Then someone came up behind me which I didn't realize (I later was told that she was an RN). She intervened and again told me "If I didn't calm down they COULD NOT help me." I thought well its time I switch gears and get this panic attack under control, again I was shaking, yelling, crying all that is not my normal behavior. I told the RN that I would not be able to calm down without help. I recall asking at least 8 times for them to help me. I tried to tell them that I had a life long history of mental illness including (anxiety, bi polar, depression) and when I am like this, I need to take ativan (antianxiety) or risperdal (mood stabilizing medication) but all my medication burnt up in the house fire hours ago. I started fumbling through my wallet looking for my medicare card to show them I was on disability, thinking then they would help me. Again I said, I needed Ativan or something to calm down. The nurse than said, "Well that's not going to happen." After she said that I was shocked, usually in the past when I was falling apart and having a panic attack and I ask for help, the nurse would say, let me help you, or do you feel suicidal or homicidal." Had they asked me that at the time, I would have said "YES, I had the idea when I was in the parking lot to just crash my car, I felt suicidal at that time, but I did not have a plan. That probably also triggered such a bad panic attack." No one was listening to me, I said, I am anxious and need help "admit me". I meant, take me into the ED and help me, I maybe chose the wrong words but it relayed the same thing, "I NEEDED HELP". After it was apparent I wasn't going to get help I thought, "I need to get out of here before I get in legal trouble because I couldn't control my emotions and they weren't going to listen, I just got up and ran out."

B. In an interview with the Registrar on 1/11/23 at 8:35 AM revealed, Yes, I worked on 10/11/22 and I remember the patient [Patient 22] that came in, security brought her to my desk. She was upset she couldn't get a prescription filled and was very upset, yelling and screaming about that. I called the RN Charge (RN B) to come out and help her. When she came they moved into the lobby farther and I could no longer hear the conversation. I saw her leave after a little bit.

C. In an interview with RN B on 1/11/23 at 9:00 AM revealed, "Yes, I was the Charge RN on 10/11/22 and the Registrar called me from the desk and asked me to come up to help [Patient 22], I could hear her yelling when the registrar called. RN B reported that she came to the Registrar area and found [Patient 22] sitting at the 2nd desk in the chair with security present. Her initial yelling was that the medication that was ordered a little earlier for her spouse was not available to be filled. She then switched to demanding I give her some (expletive F-ing) Ativan, she was disabled and all her medication burnt in the house fire. She then said, "you don't care my meds burnt up". RN B said, I asked her to calm down, and told her I couldn't give her ativan in the lobby, she would need to check in to get ativan. She just kept repeating she was disabled and no one cares her house burnt and all her meds. This hospital doesn't care. She than just got up and ran out.

When inquired why [Patient 22] was not seen on the ED log or have a chart, RN B said, "she never checked in, so she would not have a chart or be on the log."

D. Review of an entry in [Patient 6's medical record] about the spouse (Patient 22) by RN B on 10/11/22 at 9:52 AM revealed, "Patient's SO (significant other of Patient 6-Patient 22) came to ER in regards to prescription that was sent with patient. Patient's SO was screaming at registration, security, and this nurse stating "the (expletive F-ing) pharmacy doesn't have this (expletive F-ing) medication. Are you guys (expletive f-ing) with me or what. My house burned down and my medication (expletive f-ing) burned. I am (f-ing) disabled and you aren't (f-ing) helping me. You need to give me some (expletive F-ing) Ativan." This nurse explained to the patient that I needed her to stop yelling and to calm down so I could try to help them. Patient's SO continued to scream and ran out of the hospital screaming "(expletive F) this hospital and (expletive F) you." Dr S notified and a new prescription was called to the (pharmacy). The patient [Patient 6] was called by this nurse to notify him about the new prescription."

E. Review of Patient 6's medical records, showed that the patient presented twice to the ED on 10/11/22. The first presentation to the ED was on 10/11/22 from 1:02 AM - 2:20 AM and the second presentation to the ED was on 10/22/22 from 5:46 AM - 7:30 AM.
1) Review of the 10/11/22 1:02 AM- 2:20 AM medical record revealed:
-Patient 6 presented with complaint of bilateral eye irritation and pain on bottom of the feet from walking on hot ashes.
-Review of ED MD (Dr H) Note, revealed that the patient arrived approximately 2 hours after being in a house fire. (Patient 6) did take oxygen from the EMS (Emergency Medical Service) at the site of the house fire. The patient identified coughing up some soot at home and some labored breathing. Both eye are uncomfortable and burning and blurry. -Review of symptoms identified, "Eyes: Positive for pain and redness; Respiratory: Positive for cough and shortness of breath.; Musculosketetal: Bilateral feet pain from blistering from ashes that was stepped on."
-Physical Exam identified: "Soot all over body and face and smells like a campfire."; "Singeing noted of the hair in the beard as well as on the head. No eyebrows singeing, no first or second degree burns noted on the face."; Soot in the nares bilaterally. Pharyngeal (back of throat) soot noted, no intraoral (inside mouth) burn otherwise, no erythema (redness) or edema (swelling) noted."; "Eyes injected with some mattering and heaping of the cornea."; "Pulmonary-Slight increased effort of breathing. Occasional coughing otherwise, good air movement noted."; "Right foot plantar aspect great toe with moderate sized blister. Several satellite lesions noted on the plantar aspect of the foot that are quite small less than 0.5 cm with blistering as well. Left foot plantar (bottom of foot) aspect great toe with similar blister. Both are intact. no other burns or lesions noted.
-Number of Diagnoses or Management Options: "Total BSA (body surface area of burns) is 1% of second-degree type 1 burns (burns that include 2 layers of the skin and can develop blisters and be very painful). Eyes without any obvious findings but for inflammatory changes noted. no foreign material or anything of this nature noted. Reactive pupils. No specific blunt trauma. patient given tetracaine drops (eye drops used to numb the eye) with excellent result. Gave some erythromycin ointment (eye ointment used to lubricate eye and prevent infection) for lubrication as well. Subjectively feeling much improved with this. I did observe him for about an hour and do a co-oximetry of his CO levels (blood test to measure levels of hemoglobin including oxygen and carbon dioxide). They were below threshold. He is having some occasional coughing. it has been about 3 hours since incident. I am comfortable letting him go home, he will be with wife, he does agree to return if acute worsening."
-Diagnoses include: SMOKE INHALATION; PARTIAL THICKNESS BURN OF RIGHT FOOT AND LEFT GREAT TOE AND PLANTAR ASPECT OF FOOT, RIGHT GREAT TOE; CORNEAL IRRITATION OF BOTH EYES.

Review of the 10/11/22 1:02 AM - 2:20 AM revealed:
-Pain scale documented once during stay at time of discharge at 2:14 AM as a 5 (with 0 being no pain and 10 being worse pain ever had)
-Treatment rendered included- 1) Erythromycin 5 mg (milligram)/gm (gram) (0.5%) ophthalmic ointment to both eye; 2) Tetracaine ).5% ophthalmic drops 1 drop both eyes; 3) Co-Oximetry lab test.
-Discharge Instructions included 1) Use erythromycin ointment a small ribbon in each eye every 6 hours while awake. 2)Use 1 drop in each eye as needed for pain of tetracaine. 3) Take Tylenol as needed for discomforts. 4) Keep blisters intact on feet unless they become too tense and uncomfortable. Keep feet clean. Use triple antibiotic ointment on feet if blisters rupture. 5) Follow up with ophthalmology around 10/12/22 and follow up with primary care physician as needed.

The evidence in the medical record showed the patient had burns to his feet, singed facial hair, soot on his face and eyes and complained of a cough, suggestive of smoke inhalation that can worsen over time. A chest x-ray was not performed to determine any damage to the patient's lungs or consultation with a burn specialist to evaluate for further treatment or to establish follow-up. The medical record lacked documentation that the patient received medication for pain control or that staff assisted in cleaning the soot from the patient's face, or lips or clean the bottom of his feet. The patient arrived to the ED without any type of foot covering and was discharged without any foot covering despite the burns to his feet.

Interview with ED RN T on 1/10/23 at 3:00 PM revealed, that RN T recalled (Patient 6) from 10/11/22 1:02 AM- 2:20 AM. Stated, "only complained of eye hurting to me, no complaint about respiratory system, and I did not see the bottom of his feet." I just focused on eyes, rinsed them and gave drops and ointment." "I walked the patient, spouse and child to the ED Lobby doors. The patient had a emesis bag to spit in." ED RN T did not recall offering to assist in cleaning patient, providing clean clothing or feet cover.

2) Review of the 10/11/22 5:46 AM - 7:30 AM medical record revealed:
-Patient returned with the complaint that throughout the night was experiencing increased shortness of breath with exertion, burning in throat and hard to breath, pain is continuous and burning.
-Pain assessment flow sheet at 5:56 AM did not give a numeric pain level, though identified a new onset of chest pain described as continuous burning at rest and with activity. On discharge identified pain as a 2 mild.
-Review of ED MD (Dr S) Note, revealed that the patient had been in a house fire last night where he had burns to his feet and some other places. No oral burning. Patient did have smoke inhalation. Was discharged from ED at 2:20 AM and returns with burning in throat, finds it hard to breath and eye irritation. Patient identified having increasing discomfort in posterior thorax and midsternal region. Has also has a cough that is productive of large amount of clear sputum. Complaining of bilateral burning eye pain moderate in intensity. Predominantly having discomfort in mid chest region. Denies coughing up blood or soot at this time.
-Review of symptoms identified, "Eyes: Positive for pain, redness and itching.; Respiratory: Positive for cough, chest tightness and shortness of breath.; Skin: Burns to bottom of feet."
-Physical Exam identified: "No oral airway edema noted. No soot in posterior pharynx. does have some mild singeing beard and hair.; "Bilateral sclera and conjunctival erythema (eyes red and irritated). No photophobia (light sensitivity)."; "Patchy blisters on the bottom of both feet as documented previously."
-Number of Diagnoses or Management Options: "chest x ray imaging is negative, O2 (oxygen) saturations are normal. Will give the patient a prescription for some Hycodan syrup for cough and chest discomfort. Discharged in stable condition."
-Diagnoses include: SMOKE INHALATION

Review of the 10/11/22 5:46 AM - 7:30 AM revealed :
-Treatment rendered included 1) Lidocaine nebulizer treatment 2) Chest X-Ray
-Discharge Instructions included 1) Pick up medication at the pharmacy the prescription of hydrocodone homatropine/Hycodan 2) Follow up with primary care physician in 3 days as needed.

The medical record contained evidence that the patient complained of worsening symptoms including continued chest pressure, a productive cough suggestive of pulmonary (lung) involvement. There was no evidence of a consultation with a burn specialist to evaluate for further treatment and to establish follow-up, or that the patient did not have coverings for the burns on his feet. The medical record lacked documentation of a reassessment or dressings applied to the patient's blistering feet; or any lab testing, including a repeat Co-oximetry, or consultation with a social worker/case manager to assist with housing or clothing, or proper footwear before the patient left the hospital.

Interview with Patient 6's spouse on 1/12/23 at 8:20 AM revealed, that when they came to the hospital for the 1st visit on 10/11/22 (1:02 AM - 2:20 AM) after their house burnt down the hospital checked over their child and her spouse. The spouse stated that they were in their pajamas, no shoes. She identified that the staff offered no help to clean the soot off of Patient 6 or the burns on his feet. The spouse requested some socks to cover the burnt feet to try and keep them clean. They were dismissed at 2:20 AM, they had no ibuprofen or tylenol or supplies, and drove around until they checked into a hotel. The wife identified assisting Patient 6 with showering trying to get the soot washed from his body. She indicated that Patient 6's eyes were swelling and nearly swollen shut. His breathing started to be strained and he was coughing up soot. He was in pain and he was in tears and requested to go back to the hospital because he was having chest pain and trouble breathing. On their return to the ED (5:46 AM - 7:30 AM) she stated, "(Patient 6) was crying and asked for something for the pain he was experiencing in his eye, feet and lungs. That he had a headache and asked for something for pain. HE DID NOT RECEIVE ANYTHING FOR PAIN. He was given a lidocaine breathing treatment "which made him feel worse" and we were dismissed with a prescription for Hycodan. We went back to the hotel and (Patient 6) continued to cry in pain and cough up black soot and waited for the pharmacies to open in an attempt to fill the prescription for hycodan." When the pharmacies opened I could not find a pharmacy with this medication and returned to the hospital for help.

F. Review of the 9/23/04 policy titled, EMTALA (Emergency Medical Treatment and Transfer) Medical Screening revealed:
-All individuals coming to the emergency department requesting emergency services receive a medical screening examination (MSE).
-The MSE is the process required to reach with reasonable clinical confidence, a determination of whether an EMC exists.
-Obligation to Provide MSE. Any individual who "Comes to the emergency department" requesting examination or treatment (or on whose behalf examination or treatment is requested) is entitled to and shall be provided an appropriate MSE to determine whether an EMC exists. An individual how is not an inpatient or a scheduled outpatient will be considered to have "come to the emergency department" if he/she: 1) has presented to the dedicated emergency department and requested examination or treatment for a medical condition, or has had such a request made on his/her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition.