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415 SIXTH STREET

LEWISTON, ID 83501

EMERGENCY ROOM LOG

Tag No.: A2405

Based on review of transfer center logs, review of medical records, review of nursing notes, and staff interview, it was determined the hospital failed to ensure patients who came to the ED were documented in the ED log for 1 of 21 patients (Patient #21) whose records were reviewed. This caused a lack of documentation of Patient #21's visit to the hospital. This also caused the hospital to be unaware of a patient who presented to their ED but was turned away. Findings include:

A hospital policy titled "EMTALA - Central Log," reviewed 6/03/20, stated, "Each hospital must maintain a central log to identify each individual who either comes to the Dedicated Emergency Department seeking treatment for any medical condition or presents on Hospital Propery or Premises seeking care for an emergency medical condition ... The log must contain:

- the name of the individual who comes to the emergency department seeking assistance; and
- whether the individual:
- refused treatment
- was refused treatment
- was transferred
- was admitted and treated
- was stabilized and transferred, or
- was discharged"

This policy was not followed. An example includes:

Patient #21's medical record was obtained from the sending facility and reviewed. The medical record stated Patient #21 was an 80 year old female who presented to the sending facility on 9/08/21 for a routine mammogram. Her record indicated she had a cardiac arrest during the mammogram and was transferred to the sending facility's ED. The ED note stated, "80-year-old female status post return of spontaneous circulation after cardiac arrest. Patient is noted to have a leaking aorta. I discussed patient [sic] [Physician Name] at St. Joseph and an interventional radiology graciously agreed to accept the patient in transfer patient will be transferred via [name] ambulance."

Patient #21's record from the sending facility also included a note from EMS, dated 9/08/21, which stated, "dispatched to [sending facility] ED for an emergent transfer to SJRMC cath lab [catheterization laboratory] with an 80 yof [year old female] who had a cardiac arrest during mammogram ...Pt slid to gurney, seat belted in and moved to ambulance. Vitals and assessment continued en route to SJRMC. Once in ambulance bay at SJRMC, staff met M81 stating that surgeon did not have equipment necessary for surgery and so they could not accept pt. Pt was to be returned to [sending facility] ED."

The transfer center notes regarding Patient #21 on 9/08/21 were reviewed. The notes stated, "Called to St Joseph's HS [hospital] ...Informed Dr [name] accepted to do procedure. Will go ed [emergency department] to ed."

The House Supervisor's daily note from 9/08/21 was reviewed. The note stated, "Had a call from the transfer center stating [sending facility] had a patient with a hole in her aorta that they coded and were wanting to talk to Dr. [name]. Informed them that we had no ICU beds but that they could still bring the patient for the procedure if Dr. [name] accepted. Dr. [name] accepted and was bringing that patient straight over to the cath lab. ER called about the patient and I informed them that [sending facility] would take the patient back after the procedure. Cath lab called and asked if we would have any bed and I informed them no. Shortly after the cath lab called ER and told them to stop the transfer because they didn't have the equipment for the procedure. At that time ER had the cath lab call [sending facility]. The patient had already left but when the ambulance arrived to our ER we had to have them turn around and take the patient back to [sending facility]. That is just a little messed up."

The ED log from 9/08/21 was reviewed. The log did not include Patient #21. Additionally, medical records for Patient #21 on 9/08/21 were requested, however no medical records for Patient #21 on 9/08/21 were provided.

The House Supervisor who was working on 9/08/21 was interviewed by phone on 3/30/22 at 4:47 PM. Her note from 9/08/21 was reviewed, and she confirmed the incident with Patient #21 sounded familiar to her. She stated, "I know they had just arrived when we found out that they didn't have the equipment ... in fact they met the ambulance out in the ambulance bay area ... and told them ... they would have to take the patient back," and, "I knew we couldn't keep the patient ... I know the lady was really critical."

The CNO was interviewed on 3/31/22 at 1:00 PM. She stated she was the CNO on 9/08/21. The transfer center log and the House Supervisor's notes from 9/08/21 were reviewed in her presence. When asked if it appeared, based on the documentation, that Patient #21 presented to the ED at SJRMC she stated, "yeah it does." When asked if Patient #21 was documented in the SJRMC ED log she stated, "not that I know of."

The hospital failed to ensure Patient #21 was documented in the ED log when she presented to the ED.

MEDICAL SCREENING EXAM

Tag No.: A2406

Based on staff interview, and review of transfer records, hospital policies, and clinical records, it was determined the hospital failed to provide an MSE to 1 of 1 patient (Patient # 21), who came to the ED via EMS as a transfer from another facility. This resulted in delayed assessment, stabilization, and treatment of this patient. This had the potential to cause a negative outcome for this and other patients presenting to the ED. The findings include:

1. A hospital policy, "EMTALA - Medical Screening and Treatment of Emergency Medical Conditions," reviewed by the hospital 8/29/20, was reviewed.

The purpose of the policy was stated as, "To ensure that individuals coming to an affiliated Hospital's Dedicated Emergency Department seeking assessment or treatment for a medical condition, or coming to Hospital Property requesting ... treatment for an Emergency Medical Condition receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Labor Act (EMTALA), 42 U.S.C., Section 1395 and all Federal regulations and interpretive guidelines promulgated thereunder, and, if an Emergency Medical Condition is determined to exist, such individuals are offered stabilizing treatment within the Hospital's capabilities and/or are transferred if appropriate ..."

The policy included the definition, "Hospital Property or Premises means the entire Hospital campus, including the parking lot, sidewalk, driveway, and hospital departments ... "

The policy included the definition, "Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor. Such screening must be done within the facility's capability and available personnel, including on-call physicians. The Medical Screening Examination must be performed by a Physician or other Qualified Medical Personnel."

2. Patient #21's medical record was obtained from the sending facility and reviewed. The medical record stated Patient #21 was an 80 year old female with a diagnosis of penetrating ulcer of aorta. She was transferred on 9/08/21 to the hospital's ED from the sending facility's ED for a surgical procedure.

Patient #21's EMTALA/Transfer Consent Form from the sending facility, dated 9/08/21, stated Patient #21 was accepted by the hospital's interventional radiologist at 9:53 AM, and the hospital's "Cath Lab RN" received the report.

3. Patient #21's ED notes received from the sending facility, dated 9/08/21, included the following RN notes:

10:07 AM - "Pt accepted by Dr. [name] at cath lab ... EMS here to transport pt at this time. Report given."
10:11 AM - "Report called to [RN] at cath lab"
10:34 AM - "[St. Joseph's] cath lab unable to take pt. Call to [another receiving facility] at this time."
11:41 AM - "Esmolol infusing at time of transfer ... Lifeflight here to transport pt to [another receiving facility]. Report given to them."

3. Patient #2's EMS report, dated 9/08/21, stated, "M81 [ambulance] dispatched to [transfer facility] for an emergent transfer to SJRMC cath lab with an 80 yof who had cardiac arrest during mammogram... Once in ambulance bay at SJRMC, staff met M81 stating that surgeon did not have equipment necessary for surgery and so they could not accept pt. Pt was to be returned to [sending facility] ED. Pt placed in room T1..."

The hospital's CNO was interviewed on 3/31/22 beginning at 1:00 PM and Patient #21's records were reviewed in her presence. When asked if it appeared that Patient #21 had an MSE upon arrival to the ED on 9/08/21, she replied, "I don't know that." When asked if she was aware of Patient #21's incident on the morning of 9/08/21, she replied "I was not, because I was not the AOC on call".

The hospital failed to perform a medical screening exam for patient #21 who presented to their ED.