HospitalInspections.org

Based on review of records, policies/procedures, and staff interviews, the hospital failed to follow facility policy and did not provide a medical screening exam within the capabilities of the hospital for 1 patient (Patient #1) who presented to the emergency room requesting care out of 60 cases selected for review from October 2010 to June 29, 2011. The hospital ED staff identified an average of 1708 emergency department visits per month.

Failure to provide an appropriate medical screening exam could potentially result in patients with an emergency medical condition not receiving appropriate care, leading to disability, loss of limb, or death.

Findings include:

1. According to the policy, "Emergency Medical Screening, Treatment, Transfer & On-Call Roster" reviewed/revised 6/11, revealed in part, "...The objective of the MSE [Medical Screening Examination] is to determine whether an EMC [Emergency Medical Condition] exists. Once the MSE is completed and it is determined that the individual presented for a non-emergency purpose, the Hospital's EMTALA obligations end for that individual. The scope of an individual MSE depends upon presenting symptoms. The scope of the MSE may range from a simple process involving only a brief history and physician examination to a complex process involving ancillary studies and procedures, such as clinical laboratory tests, CT scans and other diagnostic tests and procedures. . . ."

2. Review of the medical record revealed Patient # 1 presented to the emergency department (ED) by ambulance on 10/29/2010 at 5:50 PM. The ED nurse documented that Patient # 1 fell backwards down approximately 10 steps and complained of severe upper mid back pain between her shoulder blades, anterior rib cage and right shoulder. The ED nurse documented Patient # 1 took a medication to control high blood pressure and two different anti-diabetic medications. ED Physician A documented in the medical record that Patient # 1 fell down 10 steps and was unable to get up. At 6:40 PM Patient # 1 had x-rays of her chest, shoulder, and neck, all of which were normal. At 7:09 and 7:41 PM Patient # 1 received pain medication by injection and at 7:48 PM, ED Physician A diagnosed the patient with contusion of the chest wall and back and ordered discharge with instructions to follow up with Dr [diabetes specialist] in 3 days. Patient # 1 left the ED at 8:25 PM.

The medical record did not contain evidence of an examination that included a CT scan of the head or lab work to evaluate whether complications of Patient # 1 ' s medical conditions (diabetes, hypertension) contributed to her fall or an EKG to evaluate Patient # 1's pain in her chest.

Review of the medical record revealed Patient #1 returned to the ED 2 days later (10/31/2010) at 11:03 PM in severe distress. Laboratory work revealed the patient was in acute renal failure, respiratory failure and a CT scan of the head revealed the patient had a subarachnoid hemorrhage. The ED physician documented that the patient's family reported that Patient # 1 had not been feeling well and complained of weakness and dizziness prior to her fall on 10/29/10. Patient #1 was subsequently admitted to the ICU where she later expired.

3. During an interview on 7/6/11 at 2:50 PM, ED Physician A stated he does not routinely order labs on patients presenting with falls and confirmed he did not order any laboratory tests or an EKG on Patient #1 when the patient presented to the ED on 10/29/11.

4. During an interview on 7/6/11 at 12:20 PM, Physician B, Vice President of Medical Affairs acknowledged ED Physician A did not do laboratory tests during Patient #1's first ER visit on 10/29/2010. Physician B stated generally the emergency room physicians do laboratory tests.

The hospital failed to follow their policy, and did not provide an appropriate medical screening exam within the hospital's capability prior to discharging Patient # 1. Refer to tag A-2406 for further details.

Based on document review and interviews, the hospital failed to provide an adequate medical screening examination (MSE) to determine if an individual (Patient #1), who presented to the emergency department (ED) on 10/29/2010 requesting care, had an emergency medical condition (EMC) out of 60 cases reviewed from October 2010 to June 29, 2011. The hospital ED staff identified an average of 1708 emergency department visits per month.

Failure to provide an appropriate medical screening exam could potentially result in patients with an emergency medical condition not receiving appropriate care, leading to disability, loss of limb, or death.

Findings include:

1. Review of the medical record revealed Patient # 1 presented to the emergency department (ED) by ambulance on 10/29/2010 at 5:50 PM. The ED nurse documented that Patient # 1 fell backwards down approximately 10 steps and complained of severe upper mid back pain between her shoulder blades, anterior rib cage and right shoulder. The ED nurse documented Patient # 1 took a medication to control high blood pressure and two different anti-diabetic medications. ED Physician A documented in the medical record that Patient # 1 fell down 10 steps and was unable to get up. At 6:40 PM Patient # 1 had x-rays of her chest, shoulder, and neck, all of which were normal. At 7:09 and 7:41 PM Patient # 1 received pain medication by injection and at 7:48 PM, ED Physician A diagnosed the patient with contusion of the chest wall and back and ordered discharge with instructions to follow up with Dr [diabetes specialist] in 3 days. Patient # 1 left the ED at 8:25 PM.

The medical record did not contain evidence of an examination that included a CT scan of the head or lab work to evaluate whether complications of Patient # 1 ' s medical conditions (diabetes, hypertension) contributed to her fall or an EKG to evaluate Patient # 1 ' s pain in her chest.

Review of the medical record revealed Patient #1 returned to the ED 2 days later (10/31/2010) at 11:03 PM in severe distress. Laboratory work revealed the patient was in acute renal failure, respiratory failure and a CT scan of the head revealed the patient had a subarachnoid hemorrhage. The ED physician documented that the patient's family reported that Patient # 1 had not been feeling well and complained of weakness and dizziness prior to her fall on 10/29/10. Patient #1 was subsequently admitted to the ICU where she later expired.

2. During an interview on 7/6/11 at 7:45 PM a family member present at the time of Patient # 1 ' s fall and while she was in the ED on 10/29/11 stated that Patient # 1 was " lying on the floor, her head and back were on the floor and her hips and tailbone were on the steps with her legs sideways on the bottom of the steps sticking up towards the top of the stairs. " The family member stated that Patient # 1 " complained of her side hurting and swelling up, she was in a lot of pain. " " I could not get her up and we had to call an ambulance. " " She fell down 12 steps total. "

3. During an interview on 7/6/11 at 2:50 PM, ED Physician A stated he does not routinely order labs on patients presenting with falls and confirmed he was aware Patient # 1 was a diabetic but did not order any laboratory tests or an EKG on Patient #1 when the patient presented to the ED on 10/29/11, " seemed like at the time it was not indicated, the patient ' s chief complaint was trauma, I did x-rays to clear for any broken bones and things like that. "

4. According to the statutorily mandated QIO physician peer review conducted on 7/15/11, the hospital did not provide Patient # 1 with a medical screening examination that was appropriate or sufficient to determine the presence of an emergency medical condition prior to discharge on 10/29/11.