HospitalInspections.org

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Based on interview and review of documents and policies and procedures, the facility failed to ensure compliance to EMTALA regulations, CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases.

Failure to do so created risk for a adverse patient outcome(s) and harm in the delivery of emergency services at complainant's and/or respondent's emergency departments.

Findings:

As detailed in Tag 2406 and Tag 2407, it was determined that the hospital failed to provide an appropriate medical screening examination and stabilizing treatment in 1 of 25 patients whose emergency department (ED) medical records were reviewed and therefore, failed to comply with CFR §489.24.
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Based on interview, review of policy and procedure and document review, the facility failed to demonstrate that it provided a medical screening exam (MSE) for 1 of 1 patients upon presentation to the hospital emergency department (ED), for determination of whether or not an emergency medical condition existed.

Failure to do so created risk for patient harm during the health emergency event.

Findings:

1. a. In review of facility policy titled, "EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT (EMTALA): ASSESSMENT AND TREATMENT OF PATIENTS IN THE EMERGENCY DEPARTMENT" (August 2014), on page 1 of 4 under "Policy" it stated, "SMC [Swedish Medical Center] provides an appropriate medical screening exam by qualified medical personnel for any individual who comes to the ED and related hospital property requesting examination or treatment for an emergency medical condition. . . A medical screening examination will consist of a history and physical appropriate for the presenting problem and the appropriate studies (laboratory and imaging) based on the history and physical to evaluate whether an emergency medical condition is present."

b.In review of facility job description titled, "Charge Registered Nurse Emergency Department" (Job Code 7011, Effective 8/1/2016)) on page 6 of 14 under "Triage" item 21 stated, "Assesses patient in a timely manner according to established triage criteria inclusive of EMTALA regulations." On the same page under item 23 stated, "Communicates pertinent data to the appropriate members of the ED health care team". And item 25 stated, "Ongoing assessment and monitoring of patients waiting for treatment room placement."

c. In review of the Medical Staff Rules and Regulations for Swedish Medical Center (May 25, 2016) on page 26, "Section X", item 10.3 provided a description of patient evaluation that occurred in the Emergency Services Department. It stated, "All patients who present for emergency services will receive a Medical Screening Examination and appropriate evaluation performed by a credentialed and appropriately privileged licensed independent professional, or by a Physician Assistant or nurse under the supervision of an Emergency Medicine physician."

2. a. During an interview with investigator #1 and #2 on 1/11/2017 at 8:45 AM, a charge RN (Staff Member #1) described her/his actions related to the care of a patient (Patient #1) who arrived at the Emergency Department's ambulance bay (while inside of the ambulance) at Swedish Medical Center- First Hill. The patient was under the direct care of emergency ALS (Advanced Life Support) staff upon arrival.

The charge RN stated that when the patient arrived at the hospital between 4:30 - 5:00 AM on 12/13/2016, s/he went outside to ambulance bay and communicated to the ALS ambulance staff the option of taking the patient to a nearby hospital for faster care. S/he stated that the ALS staff did not express objection and subsequently took the patient to a nearby hospital's ED for care. The charge RN did not involve an ED physician at any point once the patient arrived on the hospital premises. There were ED physicians on duty at the time of the occurrence. The patient did not receive a medical screening exam from the facility's ED designated staff.

The charge nurse stated that s/he thought that the approach employed was the best for the patient's health under the set of circumstances at SMC - First Hill ED's care environment when the patient arrived. S/he was concerned that the patient had an "unstable pneumothorax" (lung collapse), independent of whether it was a traumatic or non-traumatic event, and needed an emergency chest tube placement. S/he also stated that the facility's supplies for chest tube insertion were not centrally located for ease of access.

When shown a facility procedure titled, "CHEST TUBES: SET-UP, ASSISTING WITH INSERTION, AND INITIATION OF SUCTION" (Approved June 2104) and asked if s/he was familiar with a facility policy titled, s/he stated no. Additionally, the charge RN confirmed that there were no policies and procedures to guide facility charge nurses in phases of decision making (prior to patient arrival and/or upon patient arrival) with the emergency transport staff.

The description of events described by the charge RN was in alignment with an interview conducted the day before on 1/10/2017 at 4:00 PM with the Director of Acute Care Services (Staff Member #2).

2. b. On 1/11/2017 at 1:15 PM during an interview with the Chief Medical Officer (Staff Member #3) s/he indicated that the language in the medical staff Rules and Regulations (May 25, 2016) about a nurse performing a MSE "under the supervision of an Emergency Medicine physician" was incorrect and needed to be removed from the document. Accordingly, s/he stated that only physicians and physician assistants were authorized to perform MSEs in the facility's ED.
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Based on interview and document review, the facility failed to provide necessary stabilizing treatment for an emergency medical condition that was determined at a later time by care providers at another facility.

Failure to do so created risk for patient harm.

Findings:

1. During an interview with investigator #1 and #2 on 1/11/2017 at 8:45 AM, a charge RN (Staff Member #1) described her/his charge nurse actions related to the care of a patient (Patient #1) who arrived at the Emergency Department's ambulance bay (while inside of the ambulance) at Swedish Medical Center- First Hill (respondent) on December 13, 2016 between 4:30 AM and 5:00 AM. The patient was under the direct care of emergency ALS (Advanced Life Support) staff upon arrival.

The charge RN stated that when the patient arrived at the hospital, s/he went outside to ambulance bay and communicated to the ALS staff the option of taking the patient to a nearby hospital for faster care. S/he stated that the ALS staff did not express objection and subsequently took the patient to a nearby hospital's ED for care. The charge RN did not involve an ED physician at any point once the patient arrived on the hospital premises. There were ED physicians on duty at the time of the occurrence. The patient did not receive a medical screening exam from the facility's ED designated staff.

The description of events described by the charge RN was in alignment with an interview conducted the day before on 1/10/2017 at 4:00 PM with the Director of Acute Care Services (Staff Member #2).

2. In review of Seattle Fire Department ambulance report (incident #136976) from December 13 (no year provided), the patient (Patient #1) was transported to Swedish Medical Center-First Hill. (No times are recorded in any location on the report and several data fields regarding the patient's status were left blank.) Documentation included the following: the patient had a history of a pneumothorax in December 2105; the blood pressure was stable at 104/70; respiratory rate was 36/minutes (elevated); lungs were recorded as "good TV [tidal volume], slightly diminished on the right"; "rule out spontaneous pneumothorax". The report said that the vehicle arrived at "1st Hill" [Swedish First Hill] and was "redirected" to the complainant facility.

3. The patient's (Patient #1) medical record from care at the second facility showed an initial triage on 12/13/2017 at 5:13 AM with a chief complaint of acute shortness of breath (with a past episode 1 year ago of spontaneous pneumothorax) and "diverted from Swedish." The acuity level was noted as 1 (high level). The patient was noted to have severe shortness of breath and pain to the patient's right side. At 5:07 AM the respiratory rate was 22/minute (somewhat elevated) and at 5:26 AM it was 12/minute (slightly low). The physician note indicated a diagnosis of a right sided spontaneous pneumothorax per portable chest x-ray result. A right sided chest tube was placed for treatment (time unknown). Stable vital signs at the second facility were recorded from 5:38 AM and onwards, with the last set completed at 7:30 AM. The second facility completed a form to transfer the patient back to the respondent facility at 6:55 AM per patient request and lack of capacity at the second facility.
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