HospitalInspections.org

Intakes: TN00035826


Initial Comments


An unannounced onsite EMTALA investigation began on 3/17/15 and continued through 03/23/2015 for complaint # TN00035826. The hospital's Chief Executive Office was notified on 11/05/2015 by e-mail and on 11/09/2015 by overnight mail that a 90 day termination track was initiated with a termination date of February 3, 2016. This decision was based on review of a letter from the hospital, policy review, medical record review and interview which revealed the hospital failed to ensure an appropriate MSE was provided for 3 of 21 (Patients #3, 5 and 21) sampled patients.

Based on review of the hospital's Emergency Department (ED) Central log, the Emergency Medical Services (EMS) ambulance report, the hospital's ED policy and interview, it was determined the hospital failed to ensure that each patient who presented to the hospital's ED was documented on the hospital's ED central log for 1 of 21 (Patient #21) sampled patients who had presented to the hospital's emergency department.

The findings included:

1. Review of the hospital's policy, "EMTALA", documented, "...Central Log...The Hospital should maintain a Central Log on each individual who 'comes to the emergency department,'...seeking assistance..."

2. Review of the hospital's ED central log dated 3/11/15 revealed no documentation that Patient #21 had presented to the hospital's ED seeking care.

3. Review of the EMS ambulance Prehospital Care Report dated 3/11/15 documented Patient #21 was transported to and arrived at the hospital's ED at approximately 1:12 PM and was informed to divert the patient to another hospital.

4. Review of the hospital's security video of 3/11/15 at 1:12 PM revealed that EMS #1 arrived on the hospital's property and later left the hospital's property.

Based on the hospital's Emergency Department (ED) policies, the hospital's Medical Staff By-Laws, Emergency Medical Services (EMS) ambulance record review, medical record review and interview, it was determined the hospital failed to ensure a medical screening examination (MSE) was performed on 3 of 21 (Patients #3, 5 and 21) sampled patients who presented to the hospital's ED seeking medical care.

The findings include:

1. Review of the hospital's ED policy, "EMTALA", documented, "...Procedures: General Requirement: If an individual 'Presents'...with an apparent emergency medical condition...then EMTALA procedures should be initiated pursuant to this Policy as noted below: A. Procedures for Individuals Directly Presenting Directly to the Hospital Emergency Department: The Hospital's Qualified Medical Person should provide a medical screening examination appropriate to the individual's presenting symptoms...to determine whether or not an emergency medical condition exists...Ambulances...If any ambulance (regardless of whether or not owned by the Hospital)...brings the individual onto Hospital campus, the individual has 'come to the emergency department' and the hospital has incurred an obligation to conduct a medical screening examination..."

2. Review of the Hospital A's Medical Staff By-Laws, documented, "...All patients presenting to the ED for care will receive a medical screening exam..."

3. Review of the Emergency Medical Services (EMS) Prehospital Care Report dated 3/11/15 documented Patient #21 was experiencing Chest Pain. (CP) The report documented, "...Pt was placed/secured onto the stretcher and moved inside of the unit [ambulance]...Pt [patient] rated the CP as a 10 on the 0 to 10 pain scale...Pt info comm. [communicated] to [Hospital #A] en route...Dispatch had given a general announcement regarding [hospital #A] being on diversion after pt had been accepted by Hospital charge nurse. [Hospital #A] was notified in regards to their status after pt report had been accepted several minutes earlier and informed that [number of the ambulance unit] was on the lot w/pt. [Hospital #A] nurse informed that the unit should be diverted to another hospital..." The patient was transferred to Hospital #B.

4. Review of the 3/11/15 audio communication between EMS #1 and Hospital A, regarding Patient #21 at approximately 1:00 PM, revealed the following:

EMS #1 stated, "Good afternoon...this is [name of EMS #1]...59 year old...left side chest pain...8 on the 0 to 10 pain scale...she rates it a 10...when she coughs...pulse 143..." EMS #1 reported the patient's 12 lead EKG shows sinus tachycardia and was transmitted to the hospital. Estimated time of arrival approximately 10 minutes.
Review of the EMS ambulance Pre-hospital Care Report dated 3/11/15 revealed the ambulance arrived at Hospital A's ED at approximately 1:12 PM.

Review of the 3/11/15 audio communication between EMS #1 and Hospital A at approximately 1:12 PM revealed the following:

EMS #1 contacted Hospital A and reported, "...this is [EMS #1]..."

Hospital A responded, "[EMS #1 unit name] you got [name of Hospital A] be advised we are on diversion, we have an internal emergency..."

EMS #1 responded, "...trying to get an update...was informed [by EMS #1 dispatch] you were on diversion...called in a report approximately 10 minutes [ago] and the patient was accepted, just trying to check and see if anything has changed..."

Hospital A responded, "...be advised if your patient will choose another facility, I would go that route..."

EMS #1 responded, "...patient stated she will go to [name of Hospital B].."

Review of Hospital A's security video, in the central communications system, revealed on 3/11/15 at approximately 1:12 PM EMS #1 was observed driving into the designated ED ambulance entrance of Hospital A. EMS #1 was observed parked at the ED ambulance entrance and a few seconds later drove away with with emergency flashing lights on.

5. Review of audio radio communications between EMS #1 and Communication #1 on 3/11/15 at approximately 1:12 PM revealed the following:
EMS #1 reported they were "initially transporting [Patient #21]...to [name of Hospital A] but they are on diversion. We are now leaving [name of Hospital A]."
Communication #1 responded, "...stand by...we'll get you into medicine...you'll just have to wait in line, there's 2 [ambulances] in front of you..."

Review of the audio between EMS #1 and hospital B revealed the following:
EMS #1 reported Patient #21 was a 59 year old female with "...left sided chest pain...shortness of breath...pulse 144...ETA [estimated time of arrival] 2 to 3 minutes..."

Review of Hospital B's ED record dated 3/11/15 documented Patient #21 arrived by EMS ambulance at 1:21 PM with complaints of Chest Pain and Tachycardia. The ED Physician at Hospital B, performed a MSE at 5:53 PM and stabilized the patient. The ED Physician documented, the patient was "...tachycardic, actual rate is 147 bpm [beats per minute]...mild respiratory distress is noted..." The patient was admitted to the facility's Intensive Care Unit.

Review of Hospital B's hospital record revealed Patient #21 was admitted to the Intensive Care Unit on 3/11/15 in critical condition with the disposition of Pneumonia, Hypoxia and Supraventricular Tachycardia.

Review of Hospital B's Physician Progress Note dated 3/14/15 revealed Patient #21 was discharged from the hospital and had the diagnoses of COPD exacerbation, Hypoxic Respiratory Failure and Diabetes Mellitus.

6. During a telephone interview on 3/23/15 at 9:30 AM the Director of Quality and Performance Improvement stated the hospital "did not know [name of EMS #1] was on the [hospital] property" with Patient #21 and no one told EMS to leave the hospital property (campus).

7. During a telephone interview on 3/23/15 at 2:40 PM Emergency Medical Technician (EMT) #1 verified he transported Patient #21 from Hospital A to Hospital B on 3/11/15.

8. During a telephone interview on 3/23/15 at 5:35 PM Paramedic #1 stated he called Patient #21's report in to Hospital A on 3/11/15 and the patient was accepted. Paramedic #1 stated he again spoke with Hospital A after he had arrived at Hospital A's ED ambulance entrance and was told the hospital was on diversion. Paramedic #1 instructed EMT #1 to transport the patient to Hospital B. Patient n#21 did not have a medical screening exam.

9. Review of the medical records for Patients #1, 4, 8, 12, 14 and 15 presented to the ED on 3/11/15, while the hospital was on diversion, and were provided a MSE:

Patient #1 arrived at the hospital's ED on 3/11/14 at 12:10 PM via EMS ambulance with complaints of weakness, altered mental status, headache, confusionnable and unable to ambulate. The ED Physician documented a medical screening examination (MSE) was performed at 1:49 PM, stabilized the patient and admitted the patient to the hospital.

Patient #4 arrived at the hospital's ED on 3/11/15 at 12:47 PM via walk in with complaints of abdominal pain. The patient rated the pain a 10 on a scale of 0 - 10, with 10 being the most intense. ED physician documented a medical screening exam was performed at 5:50 PM and the patient was discharge in stable condition.

Patient #8 arrived at the hospital's ED on 3/11/15 at 3:27 PM via EMS ambulance with complaints of rectal abscess. The Physician's Assistant Certified (PAC) documented a medical screening exam was performed at 4:35 PM, stabilized the patient and discharged from the ED.

Patient #12 arrived at the hospital's ED on 3/11/15 at 4:25 PM via walk in with complaints of shortness of breath, wheezing and coughing. The ED physician documented a medical screening exam was performed at 4:39 PM, stabilized the patient and admitted the patient to the hospital.

Patient #14 arrived at the hospital's ED on 3/11/15 at 3:40 PM via walk in with complaints of having a Pulmonary Embolus and advised by their PCP to go to the ED. The ED physician documented a medical screening exam was performed at 5:40 PM, stabilized the patient and admitted the patient to the hospital.

Patient #15 arrived at the hospital's ED on 3/11/15 at 2:23 PM via walk in with complaints of shortness of breath. The ED physician documented a medial screening exam was performed at 6:45 PM, stabilized the patient and admitted the patient to the hospital.

10. Review of medical records for Patients #3 and 5 presented to the ED on 3/11/15, while the hospital was on diversion, and were not provided a MSE.

Patient #3 arrived at the hospital's ED on 3/11/15 at 12:30 PM via walk in with complaints of feeling hot, anxious and nervous. At 9:30 PM the ED Discharge Forms revealed the patient left without being seen (LWBS) and "...Left facility with Personal belongings, Copy of printed instructions [discharge instructions] given to patient/ caregiver/ guardian..." The discharge instructions were filed in the medical record.

Patient #5 arrived at the hospital's ED on 3/11/15 at 1:05 PM via walk in with complaints of chest pain. At 10:27 PM the ED Discharge Forms revealed the patient LWBS and "...Left facility with Personal belongings, Copy of printed instructions [discharge instructions] given to patient/ caregiver/ guardian..." The discharge instructions were filed in the medical record.

During an interview in the conference room on 3/19/15 at 10:00 AM the Clinical Director stated the nurses are just "pre-clicking" the discharge note and instructions when the patient is triaged.