HospitalInspections.org

Based on interview, record review and policy review the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#5) of 33 Emergency Department (ED) records reviewed from 09/13/2022 to 03/13/2023 and the month of 09/2021. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 8,065.

Findings included:

Review of the hospital's policy titled, "Ministry Wide EMTALA Requirements." dated 08/24/21, defined, "Come to the ED," as when a patient presents to the ED, and either requests examination or treatment for a medical condition, has such a request made on their behalf, or comes in by ambulance, or a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition. A MSE is a process required in determining with reasonable clinical confidence whether an EMC exists. The screening must be completed within the capabilities of the hospital and must determine what if any further medical examinations and/or treatments may be required to stabilize the patient.

Review of the hospital's document titled, "Medical Staff Bylaws," dated 05/18/20, showed a MSE is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. A MSE is not an isolated event. It is an ongoing process that begins, but typically does not end with triage.

Review of the hospital's policy titled, "Adult Triage Process and MSE," dated 04/09/20, showed all patients who present to the ED will receive a MSE by a physician or nurse practitioner to determine if an EMC exists.

Review of the hospital's policy titled, "ED Adult Standards of Emergency Nursing Care," dated 04/07/20, showed the ED Registered Nurse (RN) is accountable for all nursing care rendered in the ED and based on the initial assessment, the ED RN will identify the appropriate patient care needs or problems that will serve to focus the provision of nursing care.

Review of Patient #5's medical record, dated 09/27/21, showed:
- He was a 24-year-old male that had a motorcycle accident one month prior and sustained a traumatic brain injury (TBI) and spinal fractures (a break in a bone) that left him a paraplegic (paralysis of the legs and lower body, typically caused by spinal injury or disease). The patient had surgical repair to his spine on 09/03/21.
- At 12:21 PM, Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) called that they were en-route with a patient that had exposed spinal bones.
- At 12:40 PM, the patient arrived by ambulance from Hospital B (a long term acute care [LTAC] hospital) with a chief complaint of a wound check for infection on his back one month after he had surgery.
- When the patient arrived, the patient's sacral (triangular shaped bone above the tailbone) wound was assessed, a wound care consult was made and care was provided.
- The upper back wound was assessed by the physician, a bandaged was placed over it and the patient was discharged to Hospital B.
- The ED Physician documented the patient had a wound to his buttocks. The physical exam documented the patient had a back incision that was healing well with no signs of infection.
- No wound care or neurosurgical consult was made to address the complication of the exposed bones.
- The patient had a second visit to the ED the next day, 09/28/21, where he had surgical repair of the dehisced wound and was admitted for 21 days.

Please see A-2406 for additional information.

Based on interview, record review and policy review the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#5) of 33 Emergency Department (ED) records reviewed from 09/13/22 to 03/13/23 and the month of 09/2021. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 8,065.

Findings included:

Review of the hospital's policy titled, "Ministry Wide EMTALA Requirements." dated 08/24/21, defined, "Come to the ED," as when a patient presents to the ED, and either requests examination or treatment for a medical condition, has such a request made on their behalf, or comes by ambulance, or a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition. A MSE is a process required in determining with reasonable clinical confidence whether an EMC exists. The screening must be completed within the capabilities of the hospital and must determine what if any further medical examinations and/or treatments may be required to stabilize the patient.

Review of the hospital's document titled, "Medical Staff Bylaws," dated 05/18/20, showed a MSE is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. A MSE is not an isolated event. It is an ongoing process that begins, but typically does not end with triage.

Review of the hospital's policy titled, "Adult Triage Process and MSE," dated 04/09/20, showed all patients who present to the ED will receive a MSE by a physician or nurse practitioner to determine if an EMC exists.

Review of the hospital's policy titled, "ED Adult Standards of Emergency Nursing Care," dated 04/07/20, showed the ED Registered Nurse (RN) is accountable for all nursing care rendered in the ED and based on the initial assessment, the ED RN will identify the appropriate patient care needs or problems that will serve to focus the provision of nursing care.

Review of the document titled, "Urgent Care Log," dated 09/27/21 at 11:19 AM, showed report was taken by Staff P, ED Communication RN (an RN that takes reports from Emergency Medical Services [EMS, emergency response personnel, such as paramedics, first responders, etc.] prior to their arrival), from EMS that a patient was en-route with a surgical wound dehiscence (separation of previously approximated wound edge, due to a failure of proper wound healing) and exposed spinal bones post-surgery from a motorcycle accident one month prior.

Review of Hospital B's (a long term acute care [LTAC] hospital), "Physician Progress Notes," dated 09/27/21 to 09/28/21, showed on 09/27/21, the wound care nurse noted the patient's incision had opened on his upper back and three spinal bones were exposed. The patient's surgeon was contacted and the hospital was instructed to send the patient to Mercy Hospital St. Louis for an evaluation. The patient was returned to Hospital B the same day with no care provided to the wound dehiscence. On 09/28/21, the case manager contacted the surgeon's office a second time and reported the wound was still open. Again, Hospital B was instructed to send the patient back to the hospital for further evaluation and management of the wound.

Review of the EMS report titled, "Patient Care Report-Run number 51993," showed on 09/27/21 that Patient #5 was a 24-year-old with a history of a motorcycle accident that left the patient paralyzed from the waist down and had surgery on his spine a month previous. The report that the ambulance staff received from Hospital B was that the patient had a surgical wound on his spine that was open and deteriorated. The patient's physician instructed Hospital B to send the patient to the ED for evaluation. Report was given and the transfer of care paperwork was signed by Staff R, ED RN.

Review of Patient #5's medical record, dated 09/27/21, showed:
- He was a 24-year-old male that had a motorcycle accident one month prior and sustained a traumatic brain injury (TBI) and spinal fractures (a break in a bone) that left him a paraplegic (paralysis of the legs and lower body, typically caused by spinal injury or disease). The patient had surgical repair to his spine on 09/03/21.
- At 12:21 PM, EMS called that they were en-route with a patient that had exposed spinal bones.
- At 12:40 PM, the patient arrived by ambulance from Hospital B with a chief complaint of a wound check for infection on his back one month after he had surgery.
- When the patient arrived, the patient's sacral (triangular shaped bone above the tailbone) wound was assessed, a wound care consult was made and care was provided.
- The upper back wound was assessed by the physician, a bandaged was placed over it and the patient was discharged to Hospital B.
- The ED Physician documented the patient had a wound to his buttocks. The physical exam documented the patient had a back incision that was healing well with no signs of infection.
- No wound care or neurosurgical consult was made to address the complication of the exposed bones.

There was no documentation that a wound consult or a neurosurgery consult was made specifically for Patient #5's surgical wound dehiscence on his upper back area.

Review of the document titled, "Mercy Clinic Neurosurgery Weekend and ED Call," for the month of 09/2021, showed there was a neurosurgeon on-call on 09/27/21.

Review of Patient #5's ED record dated 09/28/21, showed the patient arrived by ambulance at 11:55 AM, with a chief complaint of a wound check. Staff Q, ED Medical Director, documented that the patient presented by the recommendation of his neurosurgeon, Staff M, for an evaluation prior to surgical cleansing and closure of the dehisced back wound later that day. Review of systems showed the patient had a surgical wound with dehiscence as well as a sacral "bed sore." At 12:17 PM, neurosurgery was consulted and the patient was evaluated by Staff L, Neurosurgical PA. At 1:24 PM, Staff M evaluated the patient and planned a surgical repair as soon as possible.

Review of Patient #5's, "Neurological Surgery Operative Report," dated 9/28/21, showed the patient had spinal bones that were exposed over a span of three inches. The patient was sent to the ED the previous day, 09/27/21, for the same issue, but the sacral wound was attended to and the patient was returned to Hospital B from the ED. After his return to the ED on 09/28/21, it was quickly determined that the patient required wash out, debridement and closure of the upper back wound. The patient was taken to surgery on 09/28/21 at 5:37 PM, and then was admitted to the hospital for 21 days.

During an interview and concurrent record review on 03/15/23 at 12:08 PM, Staff P, ED Communication RN, stated that as the communications nurse, she took calls from EMS who reported why a patient was coming to the ED. She stated that the documentation showed that she was told by EMS that the patient was a paraplegic after a recent motorcycle accident and had a wound dehiscence with spine exposure. She stated that all calls were placed on an ED urgent care log and everyone had access to it. She added that the information was also placed on the track board (a communication board that shows the patient's name, location, and what the patient's chief complaint was according to EMS) that everyone could have seen and it flowed directly into the chart; a person would have had to look for the information in the chart to find it. She stated that EMS should have given the same report at the bedside to the primary nurse.

Staff R, ED RN, patient's primary nurse on 09/27/21, was no longer employed by Mercy Hospital St. Louis and the hospital had no contact information available.

During an interview on 03/15/23 at 10:15 AM, Staff H, ED Nurse Manager, stated that ED nurses were not to perform a head to toe assessment of patients, they only performed a focused assessments based on the patient's chief complaint. She went on to say that nurses would assess only the wounds identified by the patient. She stated that every call that came through the communication nurse would have been placed on the call log and a comment placed on the tracking board where all staff could have seen. She added that nurses would not always see those comments, they would have had to look for them. She stated that nurses relied upon report that was received directly from EMS at the bedside.

During an interview on 03/14/23 at 3:00 PM, Staff O, ED Physician, stated that EMS and the patient stated that he came in for the sacral wound; and the patient was questioned about this multiple times. The wound nurse was consulted and gave recommendations on how to treat the sacral wound. He stated that Staff R, ED RN, questioned if he had seen the dehisced wound on the upper back just prior to the patient's discharge. He stated that he assessed the wound and the patient and family insisted that his neurosurgeon was aware and that he was to see him in two days. He explained that the open wound was approximately one inch long, it had not appeared infected, it was cleaned and a dressing was placed over it. The patient was then discharged and transported back to Hospital B.

During an interview on 03/14/23 at 2:00 PM, Staff N, Wound Care Director, stated that she remembered the patient after she reviewed the ED record. She stated that the patient came in for a wound check and she had received a call from the ED for recommendations for treatment of a pressure wound. She added that the picture that was reviewed was for a sacral wound and the physician specifically requested review of the sacral wound, never a wound on the upper back. She stated that if a wound nurse saw that type of wound dehiscence, the recommendation would have been to call surgery.

During an interview on 03/15/23 at 10:00 AM, Staff Q, ED Medical Director, stated that he recalled the patient after review of the ED record. He stated the patient came in on 09/28/21, with a neck wound after a recent surgery. He stated that photos were taken of the wound. He was informed that the patient's neurosurgeon instructed Hospital B to send the patient back to the ED. He stated that he spoke to Staff L, neurosurgical PA, and discussed the patient's condition. The plan was for the patient to have surgery for wound closure. He stated that he would have expected the neurosurgeon to have been consulted if the wound was there the previous day.

During a telephone interview and concurrent record review on 03/14/23 at 1:25 PM, Staff L, Neurosurgical PA, stated that she recalled the patient after review of the record. She stated that she had evaluated the patient in the ED on 09/28/21, after his arrival. She stated she initially received a call from Hospital B on 09/28/21, and they informed her that the open wound had not been addressed on the previous day's ED visit and would have liked care recommendations. She had reviewed the photo taken of the neck the day prior in the ED and instructed Hospital B to send the patient back for further evaluation. She stated the wound looked horrible. Staff L then verified in the record that Staff R, ED RN, had taken the photo of the dehisced wound on 09/27/21 at 3:18 PM, prior to the patient's discharge. She added that she was unsure if the ED physician saw the wound, but would have expected him to have consulted neurosurgery.

During a telephone interview and concurrent record review on 03/14/23 at 1:00 PM, Staff M, Neurosurgeon, stated that he remembered the patient after he reviewed the ED record and his surgical note. He stated that the patient had several spinal fractures that were surgically repaired on 09/03/21. He stated that on 09/28/21, he had received a call from Hospital B who reported that the surgical wound was completely open. He recalled that he instructed Hospital B to send the patient to the ED for an immediate assessment and surgical repair. He stated that he was never consulted on 09/27/21, during the patient's first ED visit. He added that his service had 24-hour on-call and he would have expected a call; poor communication was likely the cause.