HospitalInspections.org

Based on policy review, ambulance run report review, medical record review and interviews the hospital failed to ensure that an adequate medical screening examination was provided for a patient who presented to the hospital's Dedicated Emergency Department (DED) for evaluation on 12/27/2020.

The findings include:

1. The hospital failed to ensure that an adequate medical screening examination was provided for a patient (Patient #16) who presented to the hospital's DED for evaluation of stroke-like symptoms on 12/27/2020.

~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

Based on policy review, ambulance call report review, medical record review and interviews the hospital failed to ensure that an adequate medical screening examination was provided for a patient (Patient #16) who was on hospital property in a ground ambulance for evaluation of stroke-like symptoms on 12/27/2021.

The findings included:

Review of facility policy titled "EMTALA (Emergency Medical Treatment and Labor Act) Policy" last revised 05/2019 revealed, "...Emergency Department Patient Medical Screening ... An individual is considered to have 'come to the Emergency Department' if the individual is not an Existing Patient and ... The individual has presented at a Dedicated Emergency Department and requests examination or treatment for a medical condition ... The individual is in a ground ... ambulance on Hospital Property ... Qualified Medical Personnel Procedures ... A Qualified Medical Person shall provide a Medical Screening Examination to all patients who come to the Emergency Department ..."

Review of an ambulance call report written by Paramedic #1 on 12/28/2020 at 0837 revealed an ambulance was called on 12/27/2020 at 1946 for a 61-year-old female (Patient #16) complaining of numbness and tingling of the right side from her head to her toes. Review revealed Patient #16 was transported to Hospital A. Review revealed, "...EMS (Emergency Medical Services) staff was in doubt of the traffic just relayed so to confirm same the noted statement above was repeated. (Hospital A) ECC (Emergency Care Center) staff then stated 'The information was relayed and confirmed correctly. We currently have a protest in progress and we cannot provide appropriate care to your patient. Please remain in the ambulance bay until further.' EMS was direct on this same traffic. The voice communicating with EMS staff onboard EMS unit 603 was believed to be (Charge Nurse #1 Named) ... While waiting in the ambulance bay for further direction, ES300 was contacted via public service to be made aware of this dilemma ... EMS Unit 603 remained at (Hospital A) during this time. The patient's husband, son, and daughter are now at the rear entrance of EMS Unit 603. They were advised of the delay in turning care over to nursing staff at this facility. The family became very concerned at this time ... ES 300 contacted EMS staff again at 2030 stating, 'ES 100 is making phone calls as we speak as soon as I hear further direction I will contact you again.' EMS Unit 603 remained at (Hospital A) in the ambulance bay with the patient still onboard. Also, during this time 642 (EMS staff member designation) went inside to see if he could help render care and alleviate stress on nursing staff so that the noted patient could be treated and cared for. However, 642 only made it to the charge nurse, (Charge Nurse #1 Named), where he was asked about the patient, her condition, and the treatment administered while enroute to their facility. He relayed same. (Charge Nurse #1 Named) then stated, 'If the patient does not have an IV, place her in triage.' 642 returned to EMS Unit 603 where he then received a call from ES 200. Permission to redirect to (Hospital B Named) was granted. The patient's family was made aware of this decision ... A lapsed time of 13 minutes was noted from the arrival at (Hospital A Named) to the decision to redirect to (Hospital B Named) was made. Light and sirens were utilized during the lengthy transport for the benefit of this patient ... The patient's numbness and tingling continued to present itself intermittently while enroute to (Hospital B Named) ... UOA (Upon Arrival) at (Hospital B Named), EMS staff unloaded this patient out of EMS Unit 603 while remaining secured to the EMS stretcher, and then wheeled this patient into this facility. Once inside of same, EMS staff then wheeled patient to CT (Computed Tomography - a radiologic diagnostic scan) as directed by nursing staff. Upon entering this room, EMS staff unloaded patient ... to a CT exam table ... Patient care and patient report was given ..."

Review of Hospital A's Electronic Medical Record system revealed no evidence Patient #16 was registered in the facility, and no evidence that a Medical Screening Examination was provided by a Qualified Medical Person.

Review revealed Patient #16 was evaluated at Hospital B and admitted to the hospital until she was discharged on 12/29/2020. Review of a Discharge Summary written on 12/29/2020 at 1401 by Nurse Practitioner #1 revealed, "...Hospital Course: Per admission H&P - (Patient #16 Named) is a 61 y.o. female with PMHx (Past Medical History) as reviewed in the EMR (Electronic Medical Record) who presented to (Hospital B Named) with right-sided numbness and weakness from home. Past medical history significant for hypertension, hyperlipidemia, type 2 diabetes, recent diagnosis of COVID-19. Patient states that she had this acute onset of right-sided numbness and tingling involving both of her extremities and her right half of the face, that lasted for about 4 to 6 minutes, resolved on its own. She states that she had another 1 of this episode (sic) while being at home which is when they decided to call the EMS. She states that she had another 2 of those episodes while being in the EMS van. She denies any previous such episodes or any previous episodes of other strokelike (sic) symptoms..."

Telephone interview was conducted with Paramedic #1 on 01/06/2021 at 1245. Interview revealed approximately 4 minutes prior to EMS arrival to Hospital A during transport of Patient #16, Paramedic #1 was told to remain with Patient #16 in the ambulance bay. Paramedic #1 was told "they were in the middle of a protest and wouldn't immediately provide care." Paramedic #1's partner went inside the DED to see if he could assist hospital staff. He returned to the ambulance stating nurses were not taking patients. Paramedic #1 had been in telephone communication with EMS leadership advising they were "teetering" on taking Patient #16 to Hospital B. EMS leadership said, "If you need to take the patient to (Hospital B), go ahead." Interview revealed they then transported Patient #16 to Hospital B.

Telephone interview was conducted with the EMS Manager on 01/06/2021 at 1305. Interview revealed Paramedic #1 contacted him on the evening of 12/27/2020 informing him that Hospital A DED staff were telling her to wait outside with her patient, who had displayed stroke-like symptoms. Paramedic #1 advised him "they were not taking patients." The EMS Manager instructed Paramedic #1 to take Patient #16 to the next closest facility (Hospital B). Interview revealed he has never had to do this before.

Telephone interview was conducted with Charge Nurse (CN) #1 on 01/06/2021 at 1348. Interview revealed CN #1 was the day shift charge nurse for the DED on 12/27/2020 and at approximately 1830 she was notified a scheduled travel nurse for the night shift would not be coming in, as they were waiting for results of a COVID test. Interview revealed the absence would result in 3 nurses on duty for the night shift. Interview revealed the scheduled oncoming Charge Nurse (CN #2) advised CN #1 and stated she would not clock in and take over with only 3 nurses, including CN #2. Interview revealed 2 other nurses came in and "said the same." Interview revealed CN #1 was communicating with the House Supervisor and DED management to attempt to get more staffing. Interview revealed she informed 2 ambulances that were enroute to the DED to wait in the ambulance bay with their patients until CN #1 could figure out what to do with their patients. (Note = the second ambulance patient did enter the DED and receive a medical screening examination and stabilizing treatment.) Interview revealed sometime later someone came to CN #1 and informed her one of the ambulances was gone. Interview revealed CN #1 had intended to potentially place Patient #16 in triage and put in a Head CT order to get some diagnostics in progress. Interview revealed, "I never told them to leave." Interview revealed CN #1 eventually agreed to remain until 2300 hours to assist with patient care.

Telephone interview was conducted with Paramedic #2 on 01/06/2021 at 1611. Interview revealed Paramedic #2 was not part of any of the radio traffic that occurred prior to the ambulance's arrival to Hospital A, but she did overhear CN #1 telling the crews to not immediately bring their patient's inside upon their arrival. Paramedic #2 advised she was working in the DED triage area and an irate family member came and banged on a window, so Paramedic #2 went outside to "see what was going on." Paramedic #2 spoke with Paramedic #1 and asked her if she was allowed to divert to Hospital B and she said they were on the phone with a supervisor who said they could divert, and they left. Interview revealed Paramedic #2 apologized to the family and informed them she "didn't really know what was going on." Paramedic #2 advised, "I didn't know what else to do" and "felt at that point that was best for the patient."

Telephone interview was conducted with Registered Nurse (RN) #1 on 01/06/2021 at 1645. Interview revealed on the evening of 12/27/2020 she refused to accept any patient assignment at the beginning of the night shift until more staff was available. Interview revealed she heard conversation about ambulances with patients on board in the ambulance bay. RN #1 felt there was too few staff coming on for the night shift to safely accept patient assignments. At 2030 hours RN #1 accepted a patient assignment upon the arrival of more staff.

Telephone interview was conducted with RN #2 on 01/07/2021 at 0945. Interview revealed on the evening of 12/27/2020 the DED appeared full and only three nurses were going to come on duty for the night shift. They were going to have 10 to 12 patients a piece. Interview revealed according to the nursing board, if you feel a situation is unsafe and you do not accept report on those patients, you are not responsible for those patients. Interview revealed RN #2 did not feel the situation was safe. Interview revealed RN #2 heard CN #1 communicating with the EMS crews and she never told them to leave. RN #2 advised, "I specifically heard her say keep charge of your patient we are trying to find a bed." Interview revealed some of the day nurses were still there to continue providing patient care, and "we were trying to figure it out."

Telephone interview was conducted with CN #2 on 01/07/2021 at 1026. Interview revealed when she was preparing to come on duty she noted they were going to be 2 nurses short for the shift, which made CN #2 feel the staff to patient ratio would have been unsafe. CN #2 knew there were ambulances enroute, and she did hear CN #1 tell them to hold their patients in the ambulance bay while they attempted to find a room. CN #2 realized one of the ambulances had left approximately 30 to 45 minutes later. Interview revealed CN #2 felt safe to take her assignment when some day shift nurses agreed to stay and another nurse agreed to come in, leaving them only 1 nurse short.