HospitalInspections.org

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Based on interview and record review, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements when they did not provide an appropriate medical screening exam (MSE) for one out of 20 patients (Patient #1).
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On 10/02/2024 and 10/03/2023, Patient #1 presented to the emergency department with complaints of lethargy and dizziness in a 3-year-old and possibly still being intoxicated/affected by the pills (possibly Ativan or Adderall) taken (by accidental ingestion) the night before. Medical records show that Patient #1 was not provided with an appropriate MSE (medical screening examination) at either ED visit, and left from the ED without being seen (LWBS) without ever being examined by a physician/medical provider. There were no documented follow-ups to the patient's status during either visit and there were no reassessments of patient vital signs during the second visit. Furthermore, there was no thorough history and physical examination identified in the provided medical records that could have identified the underlying cause of lethargy and dizziness, no onset or duration of symptoms was noted, no pre-existing or chronic conditions were identified, no documented developmental delays were found, and no feeding history, etc.
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Cross reference to Tag A2406 CFR §489.24(c).

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Based on interview and record review, the hospital failed to provide an appropriate medical screening exam (MSE) for one out of 20 patients (Patient #1). Patient #1 presented to the emergency department (ED) with complaints of lethargy and dizziness in a 3-year-old and possibly still being intoxicated/affected from an accidental ingestion (possibly Ativan or Adderall). Patient #1 was not assessed by a physician or qualified medical person (QMP) to determine if they had an emergency medical condition (EMC) and left from the ED without being seen (LWBS) without ever being examined by a physician/medical provider.
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The Findings Included:
Medical Record Review, Visit #1:
A medical record for Patient #1 for a visit on 10/02/2023 at 2358 PM was conducted. The medical record shows that Patient #1 arrived via EMS (Emergency Medical Services) at 2358 PM following complaints of lethargy and dizziness in a 3-year-old. Patient #1 was thought to have possibly taken some of the grandfather's pills the night before, possibly Ativan. A Medical Screening Exam (MSE) was initiated by ED RN (Staff #10) and vital signs were obtained. The vital signs were as follows: Blood pressure 114/71, pulse 132, respirations 28, temperature 98.5, oxygen saturation 98% on room air (RA). FLACC Score = 0, and a Glasgow Coma Scale = 15.
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Staff #10 did not complete the focused triage assessment per their policy. Staff #10 did not document medications or allergies, a weight or height, and there was no documented pain assessment per the facility's policies. Staff #10 documented that there was no Emergency Medical Condition (EMC). No ED Physician ever evaluated Patient #1. There was insufficient data to make the determination that an EMC did not exist.
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There was no evidence found that a Primary QMP (qualified medical personnel) was readily available and an ED physician/provider did not provide a medical screening exam or evaluate Patient #1 for symptoms per the facility's policies. There was no thorough history and physical examination identified in the provided medical record that could have identified the underlying cause of lethargy and dizziness, no onset or duration of symptoms was noted, no pre-existing or chronic conditions were identified, no documented developmental delays were found, and no feeding history etc. There was no documented physical assessment or reassessment per the facility's policies, and no testing was ordered or completed during this visit. There was insufficient data to make the determination that an EMC did not exist.
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The acuity was not documented during this visit per the facility's policies.
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Patient #1 was taken by her mother and the medical record notes it as a "LWBS" (left without being seen) on 10/03/2023 at 0324 AM after waiting three hours and 25 minutes to be seen.
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Medical Record Review, Visit #2:
Patient #1 returned with her mother the following morning, 10/03/2023 at 1134 AM. Patient #1's mother was concerned that the child woke dizzy and possibly was still intoxicated/affected by the pill taken the night before. The chief complaints were noted as "accidental substance ingestion at 9 PM. Vital signs documented at 1135 AM are as follows: blood pressure 108/65, pulse 122, and respirations 18. It was documented that a MSE was initiated at 1135 AM by an ED RN (Staff #11). Vital signs were obtained again at 1349 PM and 1641 PM. The acuity documented on 10/03/2023 at 1138 AM was (3) Emergent and at 1144 AM (2) Critical.
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Staff #11 did not complete the focused triage assessment per their policy. Staff #11 did not document medications or allergies, a weight or height, and there was no documented pain assessment per the facility's policies. Staff #11 documented that "Emergency Medical Condition (EMC) does not exist". No ED Physician ever evaluated Patient #1. There was insufficient data to make the determination that an EMC did not exist.
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There was no evidence found that a Primary QMP was readily available, and an ED physician/provider did not provide a medical screening exam or evaluate Patient #1 for symptoms per the facility's policies. There was no thorough history and physical examination identified in the provided medical record that could have identified the underlying cause of lethargy and dizziness, no onset or duration of symptoms was noted, no pre-existing or chronic conditions were identified, no documented developmental delays were found, and no feeding history etc. There was no documented physical assessment or reassessment per the facility's policies, and no testing was ordered or completed during this visit.
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Patient #1 was again taken from the ED by her mother, and it was documented at 1801 PM that Patient #1 departed the ED (left without being seen) LWBS after waiting six hours and 27 minutes to be seen. During that time, no thorough history and physical examination identified in the provided medical record that could have identified the underlying cause of lethargy and dizziness, no onset or duration of symptoms was noted, no pre-existing or chronic conditions were identified, no documented developmental delays were found, and no feeding history etc. There was no documented physical assessment, and no testing was ordered or completed.
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Policy Review:
The Medical Staff Bylaws, last reviewed, amended, and effective on October 3, 2023, includes a process by which a Nurse may be a QMP and do the MSE. On page 57 it states the following:
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" ...15.1 Definition of Qualified Medical Personnel. The term "Qualified Medical Personnel" (QMP) means individuals who are qualified to perform a Medical Screening Examination ("MSE") pursuant to (Facility's name) Medical Screening Exam EC/OB
Procedure (Procedure #1357) ...
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...15.1.2 Secondary QMP. In order to qualify to be a Secondary QMP in the Emergency Center department (EC) or the Women's Assessment Center (WAC), an individual must be a:
15.1.2.1 Registered Nurse - a registered nurse authorized by the Texas Board of Nursing to practice nursing who:
15.1.2.1.1 is a member of the core QMP group as designated by Emergency Center, Labor, Delivery, Recovery and Postpartum ("LDRP") Triage and/or WAC leadership;
15.1.2.1.2 has one-year minimum experience as a RN;
15.1.2.1.3 has a minimum of six months of triage experience at an Emergency Center department ("EC") or an obstetric triage department;
15.1.2.1.4 has no performance issues;
15.1.2.1.5 has approval by the RN's Manager;
15.1.2.1.6 has completed the required QMP training which includes case scenarios, online modules, and chart audits.
15.1.2.1.7 successfully performs the yearly QMP maintenance training.
15.1.2.1.8 has a Primary QMP readily available to answer questions or perform a MSE ..."
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The Medical Screening Exam EC/OB Procedure, last reviewed and effective on 09/11/2023, states on pages 1 & 2 of 3:
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" ...1.2. In order to qualify to be a Secondary QMP, an individual must be a:
1.2.1. Registered Nurse- a registered nurse authorized by the Texas Board of Nursing to practice nursing who:
1.2.1.1. is a member of the core QMP group as designated by Emergency Center (EC)/Obstetric (OB) Leadership;
1.2.1.2. has one-year minimum experience as a RN;
1.2.1.3. has a minimum of six months of triage experience at an Emergency Center ("EC"), or Pavilion for Women OB Triage;
1.2.1.4. has no performance issues;
1.2.1.5. has approval by the RN's Manager;
1.2.1.6. has completed the required QMP training which includes case scenarios, online modules, and chart audits;
1.2.1.7. successfully performs the yearly QMP maintenance training;
1.2.1.8. has a Primary QMP readily available to answer questions or perform a MSE; ..."
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And on page 2 of 3:
" ...2. A medical screening exam will be performed on all individuals who:
1.1. present to a (Facility's name) dedicated EC, or Pavilion for Women OB Triage and request care for a medical condition;
1.2. are outside the dedicated emergency department but on hospital property within 250 yards of the main building and presents with an emergency medical condition;...
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2.3. are in a hospital-owned and operated ambulance for purposes of examination or treatment of a medical condition even if the hospital is not on hospital property; or
2.4. are in a non-hospital-owned ambulance that has arrived on hospital property for examination and treatment of a medical condition at the hospital's dedicated emergency department ..."
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The facility's Triage Assessment Reassessment EC Procedure, last reviewed and effective on 09/20/2023, stated:
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"PROCEDURE STATEMENT:
A Registered Nurse (RN), who has successfully completed the departmental requirements needed to assume the role of a triage nurse, will provide triage to patients presenting to the Emergency Center (EC). Decisions of acuity ratings are made in response to the patient's presenting signs or symptoms, necessity for time, critical interventions, potential to life/limb, or need to relieve suffering. Emergency Severity Index (ESI) triage guidelines assist the RN in assignment of acuity. Documentation of the triage process will be done utilizing the EC computerized system.
1. Focused Triage Assessment
1.1. Patients presenting to the EC should have a focused triage assessment completed by a RN.
1.2. The focused triage assessment and documentation consists of:
Time of arrival
Patient name
Date of birth
Chief complaint
Risk Assessment
Focused assessment related to presenting complaint
Pertinent vital signs that will assist in making triage decision
Allergies
Weight
Pain assessment
Triage location decision
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Triage Reassessment ...
...2.2. The protocol/designee nurse and/or reassessment nurse is responsible for the reassessment, including vital signs as necessary, and documentation of reassessment findings for patients in the waiting area.
2.3. Guidelines for reassessment at triage are:
2.3.1. Emergent patients: Every hour or as determined by the nurse/provider
2.3.2. Urgent/ Non-urgent patients: Every 4 hours or more frequently as determined by the nurse/provider ..."
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Interviews:
During an interview the afternoon of November 30, 2023, ED RN (Staff #11) confirmed that an EMC was based on a focused history and physical assessment, which were not found during medical record reviews. Staff #11 confirmed that there needs to be a primary QMP available to answer any questions that might come up. Staff #11 was asked if she could see by the documentation in Patient #1's medical record that a primary QMP was present. Staff #11 stated that she did not.
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During an interview the afternoon of November 30, 2023, ED RN (Staff #10) confirmed that an MSE was "an ongoing process that starts with the first look at the patient, whether it be on paper or face to face, and ends once the emergent condition has been stabilized" and that this was not found for Patient #1 during medical record reviews. Staff #10 further confirmed that if the patient was not medically screened by the ED and was sent away it would create an EMTALA violation.
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