HospitalInspections.org

Based on the EMTALA complaint investigation (PR00000522), review of fifty emergency room closed and active records reviewed (R.R), policies/procedures manual, interview with the emergency room medical director (employee #2) and emergency room manager (employee #3), it was determined that the facility failed to have policies and procedure in effect to ensure that the staff complies with the requirement of Medicare Participating Hospitals in Emergency Cases (EMTALA) 42 CFR 489.24 and the related requirement of 42 CFR 489.20.

Findings include:

The hospital failed to have policies and procedures in effect to ensure compliance with the reqirements or 42 CFR 489.24 cross reference to Tag A2407

Based on the EMTALA complaint investigation (PR00000522), review of fifty closed and active records reviewed (R.R), policies/procedures manual, interview with the emergency room medical director (employee #2) and emergency room manager (employee #3), it was determined that the facility failed to offer stabilization of a medical condition within the capabilities and capacity of the facility for 2 out of 50 records reviewed (R.R #18 and #45).

Findings included:

1. R.R #18 is a 37 years old male, who visited the Emergency Room on 2/9/14 at 5:41 am. The patient referred acute and persistent chest pain after car accident that occurs on 2/9/14 at 4 am approximately. The patient arrived to the emergency room with his mother and father in a private care.
This case was triaged at 5:46 am, the triage nurse classified the patient as a category "3" urgent who accordingly with screening and triage classification policy # 013 revised on 06/01/12 reviewed on 7/17/14 at 2:30 pm with emergency room manager (employee #1) established that a patient classified as urgent case must be screen and receive treatment with expedition and promptness due to their acute condition determined during the triage process.
However the patient was sent to the waiting room. At 6:04 am an EKG was performed due to patient chief complaint of chest pain, the EKG was evaluated by physician in charge, and patient was sent to the waiting room. No information was found documented of EKG, clinical impression or provisional diagnosis informed by the physician to the patient after evaluation of the EKG.
According with information provided by the emergency room manager (employee #1) on 7/16/14 at 2:49 pm and the disposition documented on the emergency room patient registration log book during review of the medical record this patient elope from emergency room on 2/9/14. The hour were the patient elope is not documented on the medical record.
Since 2/9/14 through 2/10/14 at 9:00 am no information of patient services, if offered at the emergency room, was found documented. The time when the patient was located on the waiting room could not be determined.
On 2/10/14 at 9:00 am patient was contacted by phone by emergency room department personnel to ask him about his health status. Patient refers that he elopes from emergency room before medical examination; however did not explain the reason for the elopement.
Case # 18 was discussed with medical director (employee #2) on 7/18/14 at 10:35 am and she stated that she was going to present the case to the physician who intervene with the patient because she agree that if the patient was classified as urgent case must be screen and receive treatment with expedition and promptness and if based on the review of the EKG results acute condition are not determined he must document and orient the patient about his health status.
The facility failed to provide treatment to this patient as required; to stabilize the medical condition for which he went to the emergency room. No evidence was found that the facility stabilized this patient who was described as having acute, persistent and continuous chest pain after a car accident and seek medical attention to ensure that further injury has not occurred. Facility failed to evaluate the patient to determine if further testing are need to diagnose and offer stabilizing treatment to the patient during 2/9/14 visit to the emergency room.


20423


2. R.R #45 is a 44 years male patient, who visited the Emergency Room on 7/6/14. The patient was diagnosed with Seizure. This case arrive to the emergency room at 4:37 am transfer form primary diagnosis and treatment center (CDT) of Yabucoa by ambulance and was triage by the registered nurse at 4:40 am the vital sign was Temperature 36.7, Pulse 74 bits/minute, respiratory rate 17 per minute, Blood Pressure 115/67 millimeter of Mercury mmHg, Saturation 98% and Weight 201 pound, pain assessment refers no pain.
This patient was classified as Urgent and place in Observation area. Accordingly with Screening and triage classification policy # 013 revised on 06/01/12 reviewed on 7/17/14 at 2:30 pm with emergency room manager (employee #1) established that a patient classified as urgent case must be screen and receive treatment with expedition and promptness due to their acute condition determined during the triage process.
The patient signs the treatment consent. No evidence of allergies history, medication that patient was taken in the triage. No evidence was found related to patient registration. No evidence was found of a neurologic evaluation by the physician.
No evidence of documentation of the patient status between 4:40 am until 7:30 am that the physician performed the first call.
No evidence was found related to the triage registered nurse notified the physician of the arrival of the patient.
No evidence was found related if patient arrive with Intravenous fluids.
At 7:30 am and 7:45 am the physician calls the patient, 3 hours after the triage, and this patient elope the emergency room on 7/6/14.
The physician of primary diagnosis and treatment center indicate that the reason to be transferred to this hospital was for a workup of seizure de novo and Head CT.
On this case was it is identified that facility failed to offer stabilization of a medical condition within the capabilities and capacity of the facility.
Case # 45 was discussed with medical director (employee #2) on 7/18/14 at 10:45 am and she agrees that the records do not have sufficient documentation to determine what happen with the patient between triage and physician call for evaluation.
No evidence was found that the facility stabilized this patient who was classified as Urgent
The facility failed to follow its policies and procedure for the classification of patients as urgent which According with the screening and triage classification policy # 013 revised on 06/01/12 reviewed on 7/17/14 at 2:30 pm with emergency room manager (employee #1) established that a patient classified as urgent case must be screen and receive treatment with expedition and promptness due to their acute condition determined during the triage process. This patient first call after triage was perform 3 hours later.
No evidence was found that the emergency room department personnel contacted the patient by phone to ask him about his health status and reason for leaving the emergency room.