HospitalInspections.org

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Based on interview and record review, Facility B 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.
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Based on review of observation, documentation review and staff interviews, Facility B failed to:
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a) Maintain a central log on all individuals who came to the emergency department seeking assistance for 1 of 20 patients (Patients #2) who presented to the Emergency Department (ED).
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b) Conduct a complete an appropriate medical screening examination (MSE), to determine whether an emergency medical condition existed for 2 of 20 patients (Patient #1 and Patient #2) who presented to the emergency department (ED) seeking treatment. Facility B failed to assess Patient #1's left hip pain and Patient #2's reported dizziness.
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c) Provide stabilizing treatments within the capabilities of the staff and facilities for 1 of 20 patients (Patient #1) whose records were reviewed. The facility failed to treat hip necrosis for Patient #1.
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Cross reference to Tag A2405 CFR §489.20(r)(3. A2406 CFR §489.24(a) and §489.24(c) and Tag A2407 CFR §489.24(d)(1-3).
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Based on observation, documentation review, and staff interviews, Facility B failed to maintain a central log on all individuals who came to the emergency department seeking assistance for 1 of 20 patients (Patients #2) who presented to the Emergency Department (ED).
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Findings Included:
Observations
A review of Facility B's Emergency Department (ED) lobby security footage was conducted on the afternoon of 08/07/2024 with Staff #1 (Vice President of Quality and Staff #16 (Chief Nursing Officer. On 06/08/2024 at 8:22 PM, Patient #2 was observed presenting to the facility for treatment. Patient #2 could be seen ambulating to the Triage/Reception area and was handed a clipboard by Staff 18 (ED Triage Nurse). Patient #2 began filling out the papers. A man later joined Patient #2 and he walked up and began filling out the paperwork for Patient #2 on the clipboard. Patient #2 walked toward the lobby seating with an unsteady gait (as evidenced by careful footing, taking slow and deliberate steps, and holding on to furniture for assistance) to sit down in the lobby area. At 8:24 PM the man handed the clipboard to Staff #18. Staff #28 (ED Physician Assistant) and Staff #18 (ED Triage Nurse) were observed to be having a conversation. At 8:36 PM Patient #2 was observed departing the ED after a four-minute conversation with Staff #18 at the triage window.
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Documentation Review
Facility A and B's policy titled "Triage Assessment and Acuity Level Assignment", last revised and implemented on 08/23, stated on page 1 of 9:
" ...1. Central Log
All patients presenting to the Emergency Department will be entered into an electronic Central Log in accordance with the hospital policy titled "EMTALA-Central Log ..."
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Facility A and B's policy titled, "EMTALA - Central Log", last revised and implemented on 04/23, stated on page 1 of 3:
" ...POLICY: The hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination ("MSE") could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged ..."
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Facility B's ED central log for the past 6 months was provided on the afternoon of 08/06/2024 and was reviewed with Staff #1 (Vice President of Quality) and Staff #16 (Chief Nursing Officer) on the afternoon of 08/07/2024. Patient #2's name did not appear on the central log.
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Interviews
In an interview on the evening of 08/07/2024, Staff #18 (ED Triage Nurse) was provided a detailed description of ED video security footage that occurred on 06/08/2024 at 8:22 PM; when asked why Patient #2 did not appear on the central log, Staff #18 stated that she did not recall the incident.
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In an interview on the afternoon of 08/07/2024 with Staff #18 (Chief Nursing Officer), when asked what happened to Patient #2's paperwork observed being handed to the ED triage nurse in the ED video security footage on 06/08/2024 at 8:24 PM and missing name (Patient #2) on the ED central log, she stated that the paper records should have been scanned into the EHR (electronic health records) but in this case the records could not be found for Patient #2.
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Based on observation, record review, and interview, Facility B failed to conduct a complete an appropriate medical screening examination, to determine whether an emergency medical condition existed for 2 of 20 patients (Patient #1 and Patient #2) who presented to the emergency department (ED) seeking treatment. Facility B failed to assess Patient #1's left hip pain and Patient #2's reported dizziness.
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Findings include:
Observations:
Patient #1
A review with Staff #1 (Vice President of Quality) and Staff #16 (Chief Nursing Officer) took place on the afternoon of 08/07/2024 of Facility B's Emergency Department (ED) lobby's security footage for 06/08/2024. Patient #1 was observed arriving at 7:01 PM at window of the Triage/Reception area. Patient #1 was observed obtaining aclip board from Staff #18, Triage RN. Patient #1 was filling out papers while standing. Patient #1 handed the clipboard back to Staff #18. At 7:16 PM, Staff #18 was seen bringing a vital sign machine toward Patient #1. Staff #18 and Patient #1 had conversation lasting through 7:20 PM (four minutes). At 7:21 PM, Staff #18 walked away from Patient #1. Patient #1 stood, gathered her crutches, and started walking out as Staff #18 and Staff #28 (ED Physician Assistant) started a conversation with a new person at the Triage/Reception window.
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Per the security video review, Patient #1 was on the premises of Facility B for 20 minutes.
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Patient #2
A review of Facility B's Emergency Department (ED) lobby security footage was conducted on the afternoon of 08/07/2024 with Staff #1 (Vice President of Quality and Staff #16 (Chief Nursing Officer. On 06/08/2024 at 8:22 PM, Patient #2 was observed presenting to the facility for treatment. Patient #2 could be seen ambulating to the Triage/Reception area and was handed a clipboard by Staff 18 (ED Triage Nurse). Patient #2 began filling out the papers. A man later joined Patient #2 and he walked up and began filling out the paperwork for Patient #2 on the clipboard. Patient #2 walked toward the lobby seating with an unsteady gait (as evidenced by careful footing, taking slow and deliberate steps, and holding on to furniture for assistance) to sit down in the lobby area. At 8:24 PM the man handed the clipboard to Staff #18. Staff #28 (ED Physician Assistant) and Staff #18 (ED Triage Nurse) were observed to be having a conversation. At 8:36 PM Patient #2 was observed departing the ED after a four-minute conversation with Staff #18 at the triage window.
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Documentation Review for Patient #1:
Facility B's Internal Investigation of Patient #1's ED visit on 6/08/2024, initiated on 06/11/2024 and completed on 06/14/2024, stated on page 4 of 8:
"Called (Patient #1) and her paraphrased statement is below:
Patient states that came to the hospital for necrosis of the hip and her hip was really bothering her. States that she gave the nurse her information and was the only patient in the lobby. States that the nurse took her vitals and said she least be a two hour wait because the emergency room and that the ED staff would see her up front and not in the back because of emergencies that had just come in the ED. States that the nurse said that (Facility B) was a small hospital but that there was a hospital up the street that was more equipped for orthopedics and suggested that she go there. Patient asked if she needed to sign anything, and the nurse said no. Patient states she
arrived at (Facility C) and told the staff that (Facility B) had sent her there. The staff at (Facility C) stated that this was the third patient that night that had told them that. When asked to recall any physical description of the nurse, patient stated that she was an African American nurse but could not recall her name."
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Medical Record from Facility B
Patient #1 arrived at Facility B by private vehicle on 06/08/2024 at 7:07 PM with the chief complaint of hip and pelvis pain. A partial triage assessment was documented at 7:46 PM by Staff #18 (triage nurse) in which an indicated acuity of 4 and it was documented. It was also documented that Patient #1 left against medical advice (AMA). Per nursing documentation, Patient #1 was on the premises for 41 minutes. There were no AMA papers, signed or otherwise, found within the medical record.
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There was no medical screening exam (MSE) and no medical provider notes documented for Patient #1.
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Facility B's ED Central Log
Facility B's ED log shows that Patient #1 arrived at Facility B by private vehicle on 06/08/2024 at 7:07 PM and left the ED at 7:20 PM.
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Medical Record from Facility C
Patient #1 arrived at Facility C by private vehicle on 06/08/2024 at 7:38 PM with chief complaints of hip pain. Documentation shows that Patient #1 has a known history necrosis of the left hip. A medical screening examination (MSE) was initiated by Staff #26 (ED Physician) at 7:50 PM. The "History of Present Illness" indicated the following:
"(Patient #1) is a 49 y.o. (year old) female with history of osteonecrosis, renal cell CA (cancer), and right hip replacement who presents to the ED c/o (complaining of) left hip pain that has been worsening over the past 3 weeks. Associated sx (symptoms) includes of left hip swelling and left foot tingling. Pt states that she was told she had osteonecrosis of multiple bones. She had a right hip replacement in May of 2022 per patient due to the osteonecrosis. Pt's current hip pain is a throbbing pain when staying still and a shooting pain when moving the extremities. She reports having an appointment to see a joint specialist this coming week. She has been taking Gabapentin 800 Mg and Hydrocodone at 8 AM today. Pt denies dysuria or any other sx at this time."
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At 9:25 PM a 2-3 view x-ray of the left hip and pelvis revealed the following:
"Impression:
No acute osseous abnormality.
Findings:
No acute fracture or malalignment is identified. Joint spaces are preserved. There is a partially imaged right hip prosthesis."
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At 10:55 PM a CT (computed tomography) scan of the left lower extremity revealed the following:
"Findings:
Avascular necrosis noted of the left femoral head. Otherwise, no acute concerning abnormality."
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Medications Administered in the ED:
8:43 PM - Saline flush, 10 ml IV
8:44 PM - Morphine solution, 4 mg IV
8:43 PM - Zofran solution, 4 mg IV
8:49 PM - Dexamethasone sodium phosphate, 6 mg IV
10:13 PM - Fentanyl solution, 25 mcg IV
10:15 PM - Robaxin solution, 500mg IV
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At 12:05 AM - Patient #1 departed the ED.
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Documentation Review for Patient #2:
Medical Record from Facility B
Patient #2 had no parts or pieces of a medical record at Facility B that could be located.
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Facility B's ED Central Log
Patient #2's name did not appear on the Emergency Department's (ED's) Central Log, nor did any other patient appear on 06/08/2024 at 8:22 PM.
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Medical Record from Facility C
Patient #2 arrived at Facility C by private vehicle on 06/08/2024 at 8:46 PM with chief complaints of dizziness that was progressively worsening since Thursday. At 8:58 PM, an EKG (electrocardiogram) was obtained and interpreted by Staff #26 (ED Physician) in the absence of a cardiologist. Sinus bradycardia was noted without STEMI (heart attack). The History of Present illness documented by Staff #26 stated the following:
"(Patient #2) is a 71 y.o. (year old) female with a h/o (history of) vertigo and cardiac arrhythmias who presents to the ED for worsening dizziness that started 2 days ago. Pt states that she has been having episodes of a spinning sensation for the past 2 days. She reports having vertigo intermittently throughout the year. Pt states that the episodes usually subside after she takes some rest. She adds that the vertigo also improves when she lays on her right side. Pt does report playing pickle ball yesterday which may have exacerbated her dizziness. She is currently taking 100 Mg of Metoprolol BID (twice daily) due to prior arrhythmias per patient. Husband states that he wants pt to be cleared as they have plans for a 5-day road trip next weekend.
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Pt denies syncope, fever, chills, CP (chest pain), abdominal pain, NVD (nausea, vomiting, diarrhea), urinary symptoms, numbness, tingling or any other symptoms or injuries."
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The initial vital signs obtained by Staff #25 (ED RN) during triage were as follows:
Blood pressure 177/72, pulse 57, respirations 21, and oxygen saturation 98% on room air.
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At 9:54 PM labs were significant for the following:
Component Value Reference Range
Neutrophil # 0.63 k/uL ? 2.02 - 7.46 k/uL
White blood count 12.8 k/uL ? 3.9 - 10.9 k/uL
Red blood count 5.71 M/uL ? 3.70 - 5.50 M/uL
Hematocrit 49.2% ? 33.0 - 47.0 %
Glucose 105 mg/dL ? 70 - 100 mg/dL
BUN/creatinine ratio 20.7 ? 10.0 - 20.0
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At 9:00 PM, Vital signs were again obtained: blood pressure 161/70, pulse 46, respirations 20, and oxygen saturation 97% on room air.
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A CT (computed tomography) scan of the head without contrast was obtained and at 10:16 PM showed, "No CT evidence for acute intracranial process." At 10:36 PM a chest X-ray was obtained showing no acute processes.
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Patient #2 was diagnosed with vertigo, was noted by Staff #26 as bradycardic but on a significant amount of beta blocker for her arrhythmia and at her baseline. Patient #2 was feeling better after Meclizine and IV fluids.
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Medications received in the ED:
10:00 PM - Normal Saline 1,000 ml IV bolus
10:00 PM - Meclizine 25mg tablet
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At 11:50 PM, Patient #2 was discharged home.
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Interviews
During Interviews on the afternoon of 08/06/2024 and the morning of 08/07/2024 with the Vice President of Quality (Staff #1), Chief Nursing Officer (Staff #16), Director of Emergency Services (Staff #19), and the involved Triage Nurse (Staff #18), it was confirmed that Patient #1 and Patient #2 did not receive appropriate medical screening examinations (MSEs) by any of the staff physicians or mid-level providers on duty at the time of their presentation to the Emergency Department. The Vice President of Quality stated that the security video footage which was reviewed caused those staff members reviewing it to "felt strongly" that the facility had errored regarding Patient #1 confirming Patient #1 had not received an MSE or triage assessment per Facility B's policy. After a second review of the security video footage of Patient #2, the Chief Nursing Officer indicated his belief that the patient seen "fit the description" of Patient #2 and the facility had failed to provide an appropriate care for her.
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Based on record review and interview, Facility B failed to provide stabilizing treatments within the capabilities of the staff and facilities for 1 of 20 patients (Patient #1) whose records were reviewed. The facility failed to provide stabilizing treatment for Patient #1's hip necrosis.
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Findings include:
Observations:
Patient #1
A review with Staff #1 (Vice President of Quality) and Staff #16 (Chief Nursing Officer) took place on the afternoon of 08/07/2024 of Facility B's Emergency Department (ED) lobby's security footage for 06/08/2024. Patient #1 was observed arriving at 7:01 PM at the window of the Triage/Reception area. Patient #1 was observed obtaining a clip board from Staff #18, Triage RN. Patient #1 was filling out papers while standing. Patient #1 handed the clipboard back to Staff #18. At 7:16 PM, Staff #18 was seen bringing a vital sign machine toward Patient #1. Staff #18 and Patient #1 had conversation lasting through 7:20 PM (four minutes). At 7:21 PM, Staff #18 walked away from Patient #1. Patient #1 stood, gathered her crutches, and started walking out as Staff #18 and Staff #28 (ED Physician Assistant) started a conversation with a new person at the Triage/Reception window.
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Per the security video review, Patient #1 was on the premises of Facility B for 20 minutes.
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Documentation Review:
A review of Facility B's Internal Investigation of Patient #1's ED visit on 6/08/2024, initiated on 06/11/2024 and completed on 06/14/2024 stated on page 4 of 8:
"Called (Patient #1) and her paraphrased statement is below:
Patient states that came to the hospital for necrosis of the hip and her hip was really bothering her. States that she gave the nurse her information and was the only patient in the lobby. States that the nurse took her vitals and said she least be a two hour wait because the emergency room and that the ED staff would see her up front and not in the back because of emergencies that had just come in the ED. States that the nurse said that (Facility B) was a small hospital but that there was a hospital up the street that was more equipped for orthopedics and suggested that she go there. Patient asked if she needed to sign anything, and the nurse said no. Patient states she
arrived at (Facility C) and told the staff that (Facility B) had sent her there. The staff at (Facility C) stated that this was the third patient that night that had told them that. When asked to recall any physical description of the nurse, patient stated that she was an African American nurse but could not recall her name."
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Medical Record from Facility B
Patient #1 arrived at Facility B at 7:07 PM by private vehicle with the chief complaint of hip and pelvis pain. A partial triage assessment was documented at 7:46 PM by Staff #18 (triage nurse) in which she indicated acuity of 4 per the documentation. It was also documented that Patient #1 left against medical advice (AMA). Per nursing documentation, Patient #1 was on the premises for 41 minutes. There were no AMA papers, signed or otherwise, found within the medical record. A review of the medical record for Patient #1 revealed there was no documentation of stabilizing treatments provided.
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Facility B's ED Central Log
Facility B's ED log shows that Patient #1 arrived on 06/08/2024 at Facility B at 7:07 PM and left the at 7:20 PM.
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Medical Record from Facility C
Patient #1 arrived at Facility C by private vehicle on 06/08/2024 at 7:38 PM with chief complaints of hip pain. Documentation shows that Patient #1 has a known history necrosis of the left hip. A medical screening examination was initiated by Staff #27 (ED Physician) at 7:50 PM. The "History of Present Illness" indicated the following:
"(Patient #1) is a 49 y.o. (year old) female with history of osteonecrosis, renal cell CA (cancer), and right hip replacement who presents to the ED c/o (complaints of) left hip pain that has been worsening over the past 3 weeks. Associated sx (symptoms) includes of left hip swelling and left foot tingling. Pt states that she was told she had osteonecrosis of multiple bones. She had a right hip replacement in May of 2022 per patient due to the osteonecrosis. Pt's current hip pain is a throbbing pain when staying still and a shooting pain when moving the extremities. She reports having an appointment to see a joint specialist this coming week. She has been taking Gabapentin 800 Mg and Hydrocodone at 8 AM today. Pt denies dysuria or any other sx at this time."
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At 9:25 PM a 2-3 view x-ray of the left hip and pelvis revealed the following:
"Impression:
No acute osseous abnormality.
Findings:
No acute fracture or malalignment is identified. Joint spaces are preserved. There is a partially imaged right hip prosthesis."
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At 10:55 PM a CT (computed tomography) scan of the left lower extremity revealed the following:
"Findings:
Avascular necrosis noted of the left femoral head. Otherwise, no acute concerning abnormality."
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Medications Administered in the ED:
8:43 PM - Saline flush, 10 ml IV
8:44 PM - Morphine solution, 4 mg IV
8:43 PM - Zofran solution, 4 mg IV
8:49 PM - Dexamethasone sodium phosphate, 6 mg IV
10:13 PM - Fentanyl solution, 25 mcg IV
10:15 PM - Robaxin solution, 500mg IV
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At 12:05 AM - Patient #1 departed the ED.
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Interviews
On the afternoon of 08/06/2024 and the morning of 08/07/2024, interviews were conducted with the Vice President of Quality (Staff #1), Chief Nursing Officer (Staff #16), Director of Emergency Services (Staff #19), and the involved Triage Nurse (Staff #18). It was confirmed that Patient #1 did not receive appropriate medical care by any of the staff physicians or mid-level providers on duty at the time of their presentation to the Emergency Department. The Vice President of Quality stated that the security video footage which was reviewed caused those staff members reviewing it to "feel strongly" that the facility had errored regarding Patient #1 confirm the inappropriate or lack of care.
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