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Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the RN to measure, mark and record limb circumference and assess bite area every 15-30 minutes for characteristics for 1 of 1 (#20) patients being monitored for snake bite out of a total sample of 20 medical records reviewed.
Findings:

Review of Patient #20's Physician Orders dated 04/27/2022 at 9:51 p.m. revealed in part: Measure, mark and record limb circumference every 15- 30 minutes. Assess bite area every 15-30 minutes for characteristics. Notify MD of current state of snakebite wound; Notify MD of any progression for decision to repeat antivenin therapy.

Review of Patient #20's Medical Record failed to reveal the patient's arm circumference was measured, marked and recorded every 15-30 minutes as ordered. Continued review of the medical record failed to reveal the bite area was assessed for characteristics every 15-30 minutes as ordered.

In an interview on 6/8/22 at 10:25 a.m. following review of the medical record, S6RN Emergency Department Director confirmed and acknowledged the RN failed to assess the bite area and arm as ordered by the physician.

Based on record review and interview, the hospital failed to provide a medical screening exam for 1 (#3) of 6 (#1, #3, #7, #10, #11, #12) reviewed patients who presented to the emergency department and left prior completing treatment. This patient left on the suggestion of a nurse from a 24-hour help line found on the hospital's official website.
Findings:

Review of the ED record for Patient #3 revealed he presented to the ED at Our Lady of the Lake Regional Medical Center (OLOLRMC) on 05/18/2022 at 7:23 p.m. with a chief complaint of chest pain and shortness of breath. Triage was started on Patient #3 at 7:26 p.m. and he was assigned an ESI level 3- Urgent. At 7:27 Patient #3 was transferred to the waiting room because there were no available beds. At 7:28 p.m. S13MD placed orders for laboratory studies, chest x-ray and EKG. A chest x-ray was performed at 8:15 p.m., an EKG was performed at 8:23 p.m., and labs were collected at 8:39 p.m. Between 9:15 p.m. and 9:43 p.m. abnormal results including an elevated white blood cell count- 12.2, potassium level- 2.92 mmol/L, creatinine level-1.45 mg/dl, anion gap-28 mmol/L and a critical result for a CO2 level-11mmol/L were reported. The next entries between 10:40 p.m. and 10:41 p.m. S11RN documented, "ED Disposition set to Discharge."

Further review of the electronic medical record revealed documentation of a telephone conversation accessible through the medical record noted as "Care Advice Information." The note contains the heading, "Nurse Triage, 5/18/2022." The documentation revealed the mother of Patient #3 contacted Call Center AA on 05/18/2022 at 10:06 p.m. and at 10:07 p.m. a message was sent to S12RN. At 10:25 p.m. S12RN documented, "Caller states her son's boss brought him to OLOL at 4 p.m. and he is still in the waiting room...Caller instructed to wither (probably meant to type "either") wait there or go to 'Hospital B' since his cardiologist is affiliated with 'Hospital B'. "

In interview on 06/08/2022 at 6:02 p.m. Patient #3's mother stated she found the number for Call Center AA by internet search for Our Lady of the Lake's emergency number. She stated she contacted someone at the hospital (OLOLRMC). Patient #3's mother stated she left Our Lady of the Lake Regional Medical Center (OLOLRMC) and went to the affiliated hospital, Hospital B, after talking to S12RN. Patient #3's mother stated when they arrived at Hospital B they were told Hospital B would evaluate her son but he was 19 years old would have be transferred back to their affiliated hospital, OLOLRMC, if admission was indicated.

Review of the emergency department records from Hospital B revealed Patient #3 arrived on 05/18/2022 at 10:42 p.m. and assigned an ESI triage level 2- Emergent. S15DO ordered additional blood tests, repeat EKG and chest x-ray, CT of the abdomen, I.V. fluid hydration, morphine and ondansetron. Patient #3 received a complete medical screening exam and was diagnosed with abdominal pain, severe dehydration and lactic acidosis. At 12:14 a.m. S15DO placed orders to request transfer back to OLOLRMC. Patient #3 was then transported back to OLOLRMC and arrived on 05/19/2022 at 1:44 a.m.

Review of the medical record for Patient #3 revealed he was then admitted to OLOLRMC critical care unit for hydration and correction of his electrolyte abnormalities. Patient #3 was discharged from OLOLRMC on 05/19/2022.

In interview on 06/07/2022 at 10:30 a.m. S7MD verified Patient #3 did not receive a medical screening exam on 05/18/2022 at OLOLRMC main campus by a physician or other qualified personnel.

In interview on 06/07/2022 at 10:45 a.m. S6RN verified she did not know S12RN and she did not know if Call Center AA represented the hospital. S6RN verified if Call Center AA was associated with the hospital, the situation presented an EMTALA violation.

In interview on 06/07/2022 between 3:43 p.m. and 3:47 p.m. S2SDR and S8VPO denied any association of Our Lady of the Lake Regional Medical Center with Call Center AA.

Internet search by the surveyor revealed when "OLOL emergency number" is entered in the search field, Call Center AA is a search result. The search revealed Call Center AA had an OLOLRMC web address.

Review of the web page for Call Center AA reveals it is a part of Our Lady of the Lake Regional Medical Center's website. The page has the hospital logo at the top and the heading, " Call Center AA (24-hour Advice and Help ... Your free, 24-hour resource for health information ...From simple questions to big decisions. We can help connect you with the appropriate service or facility in our network." It does not contain a disclaimer that Call Center AA is not affiliated with Our Lady of the Lake Regional Medical Center. The page also contains "Copyright 2022 Our Lady of the Lake Regional Medical Center."

In an interview on 06/09/2022 at 8:30 a.m. S1VPN and S8VPO stated Call Center AA is owned and operated by a physician group that is affiliated with OLOLRMC. Call Center AA is not owned or operated by OLOLRMC. They also confirmed that Call Center AA utilizes the electronic medical record EPIC as does OLOLRMC. Therefore, Call Center AA can access and view medical records for facilities utilizing EPIC such as OLOLRMC.

In an interview on 06/09/2022 at 9:00 a.m. S14RM was shown Our Lady of the Lake Regional Medical Center's official website and where Call Center AA information was located. S14RM verified the website was that of OLOLRMC and Center AA was located on the website without any disclaimer noting that Call Center AA was not owned or operated by OLOLRMC. She also acknowledged anyone accessing the site would be led to think they were accessing a service by OLOLRMC.