HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to:
- Follow their internal policy to provide within its capability and capacity, an appropriate medical screening examination (MSE) for two patients (#1 and #21) of 21 Emergency Department (ED) records reviewed from 07/31/23 through 01/29/24;
- Follow their internal policy that addressed discharge for one patient (#1); and
- Identify within the hospital's by-laws or rules and regulations who was a Qualified Medical Person (QMP) to perform a MSE.

These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC).

Findings included:

Review of the hospital's undated policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) Guidelines for Emergency," showed in the absence of an actual request for services, if a "prudent layperson" observer would believe, based on the individual's appearance or behavior, that the individual needs an examination or treatment for a medical condition, EMTALA still applies, and the person must be accepted and evaluated for treatment. MSEs should include at a minimum, an examination of known chronic conditions.

Review of the hospital's policy titled, "Guidelines for Discharge," reviewed 09/2010, showed the purpose of the policy was to discharge patients from the hospital with all possible safety, considerations and courtesy. Nursing personnel should accompany patients to the door and remain with them until he/she has left the hospital. If at discharge or immediately after, a patient develops different symptoms or tells any staff member they have a complaint different than the one they presented with during the initial triage, the ED physician should do a second medical screening. If at any time, the Registered Nurse (RN) determines a patient is not safe for discharge, he/she should discuss their concerns with the ED physician.

Review of the hospital's document titled, "Medical Staff Bylaws," revised 11/28/23, showed no definition of a QMP authorized to perform a MSE.

Review of Patient #1's medical record showed she was a 44-year-old female, presented to the ED with a chief complaint of headache. She was discharged to the waiting room.

During an interview on 01/31/24 at 2:10 PM, Staff T, ED Physician, stated that he expected a patient was discharged to a "reasonably safe situation." He expected staff to speak to a nurse when there was a request for re-evaluation and the nurse would notify the physician.

During an interview on 01/30/24 at 4:00 PM, Staff E, Chief Nursing Officer (CNO), stated that a request for re-evaluation would require a second MSE.

A City Police Officer (CPO) was asked to transport Patient #1. The CPO asked that the patient be re-evaluated. Nursing or Physician staff were not notified of the request for re-evaluation. Patient #1 was homeless and was kicked out of her family home. A County Deputy (CD) attempted to transport the patient to the address of which she was kicked out. The patient asked to be let out of the vehicle before she arrived at the address. The patient was later found dead.

Review of the hospital's untitled document, dated 08/14/23 at 3:30 PM, showed Patient #21 called the hospital with a complaint. She was not feeling well after her discharge, was evaluated at Hospital E and diagnosed with two deep vein thrombosis (DVT, the formation of a blood clot in a blood vessel that is deep under the skin).

Review of Patient #21's medical record showed she was a 70-year-old female, presented to the ED with a chief complaint of cough with spontaneous onset. She had a history or pulmonary embolism (PE, blood clot in the lung). An electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed tachycardia (fast heartrate) of 102 beats per minute. She was discharged home.

During an interview on 01/31/24 at 9:00 AM, Staff S, ED Medical Director, stated that a more thorough physical examination of Patient #21 would have revealed another pathway for diagnosis and treatment. A CT angiogram was appropriate, if the physician felt it would change the outcome, for a patient with tachycardia and a history of PE. A more thorough physical exam was the most important.

Although requested, Patient #21's Hospital E medical record was not provided, the hospital was unable to determine where she was evaluated.

Please refer to 2406 and 2409 for details.

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 two patients (#1 and #21) of 21 Emergency Department (ED) records reviewed from 07/31/23 through 01/29/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC).

Findings included:

Review of the hospital's undated policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) Guidelines for Emergency," showed in the absence of an actual request for services, if a "prudent layperson" observer would believe, based on the individual's appearance or behavior, the individual needs an examination or treatment for a medical condition, EMTALA still applies, and the person must be accepted and evaluated for treatment. MSE's should include at a minimum, an examination of known chronic conditions.

Review of the hospital's policy titled, "Guideline Regarding the MSE for Mental Health Patients in the ED," reviewed 10/2010, showed it is the hospital guideline to provide a MSE to all patients presenting with mental health needs within the capabilities of the hospital.

Review of the hospital's policy titled, "Guidelines for Discharge," reviewed 09/2010, showed if at discharge or immediately after, a patient develops different symptoms or tells any staff member they have a complaint different than the one they presented with during the initial triage, the ED physician should do a second medical screening.

Review of Patient #1's Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) report, dated 01/08/24, showed:
- The man on the scene stated that he wanted Patient #1 to have a mental health evaluation (MHE).
- The man stated that Patient #1 had recently been treated at Hospital B and was treated for a drug overdose. She denied this allegation.
- Patient #1 stated she fell the day before; did not believe she struck her head.
- Patient #1 was alert and oriented to person, place, city, event, recent holiday and the President. She was unsure of the year.

Review of Patient #1's medical record showed:
- On 01/08/24, she was a 44-year-old female.
- Her medical history was congenital hydrocephalus (a condition when CSF builds up in the brain and spinal cord), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), pneumonia (infection in the lungs), anxiety (a feeling of fear or worry experienced intermittently), depression (extreme sadness that doesn't go away) and Post Traumatic Stress Disorder (PTSD, a mental health problem you may develop after experiencing traumatic events).
- Her surgical history was a ventriculoperitoneal (VP) shunt (a narrow plastic tube that drains excess CSF from the brain into the abdomen) was placed three weeks prior, cholecystectomy (surgical removal of the gallbladder; a small organ that stores liquid called bile and helps your body break down food) and a total hysterectomy (surgical removal of the hollow, pear-shaped organ that is located in a woman's lower abdomen between the bladder and the rectum).
- Her current visit assessment showed Patient #1 had no recent surgery and had not been hospitalized within the last 30 days.
- She was homeless.
- She denied falling unexpectedly or frequently. Her Morse Fall Risk Screening (a method of assessing a patient's likelihood of falling) showed she had no history of falls within the last three months.
- At 3:40 PM, her pain scale (a score of 0 means no pain, and 10 means the worst pain you have ever felt) assessment was seven out of ten.
- No MHE was performed.
- At 5:51 PM, the nursing discharge documentation showed the patient's pain was eight out of ten. Smoking cessation information was not given. The patient left the facility by walking.

During an interview on 01/31/24 at 2:10 PM, Staff T, ED Physician, stated that he was not informed the boyfriend had requested a MHE. He expected staff to speak to a nurse with a request for re-evaluation and the nurse would then notify the physician.

During an interview on 01/29/24 at 10:05 AM, Staff C, ED Manager, stated that she was not aware the police officer had requested a second assessment of the patient. The support staff were to report patient needs to the nurse.

During an interview on 01/30/24 at 4:00 PM, Staff E, Chief Nursing Officer (CNO), stated that a request for re-evaluation would require a second MSE.

During an interview on 01/30/24 at 4:15 PM, Staff B, Quality and Risk Director, stated that a request for a re-evaluation would require a second MSE.

During an interview on 01/29/24 at 10:40 AM, and a telephone interview on 01/31/24 at 11:00 AM, Staff J, Registered Nurse (RN), stated that she received a verbal report from the Emergency Medical Technician (EMT), she was not informed the boyfriend requested a MHE.

During an interview on 02/01/24 at 10:50 AM, Staff U, EMT, stated that she was on the crew that transported Patient #1 to the hospital. The man on the scene stated that he wanted the patient to have a MHE.

During an interview on 01/30/24 at 6:25 PM, Staff R, Registration Clerk, stated that Staff W, CPO, came into the ED for an unrelated patient, and was asked to give the patient a ride. Staff W, spoke with the patient. He came back to the registration desk and said, "she's kind of out of it. Can anyone check on her?" Staff R stated that he needed to talk to a nurse. Staff W then went to speak with Staff N, Emergency Room Technician (ERT), who spoke with the patient and confirmed the address for transport. No staff informed a nurse or physician of the deputy's request for re-evaluation.

Review of the hospital's untitled document, dated 08/14/23 at 3:30 PM, showed Patient #21 called the hospital and reported a complaint. She was not feeling well after her ED discharge on 07/31/23, was seen at Hospital E and diagnosed with two deep vein thrombosis (DVT, the formation of a blood clot in a blood vessel that is deep under the skin).

Review of Patient #21's medical record showed:
- On 07/31/23 at 4:45 PM, she was a 70-year-old female who presented to the ED with a chief complaint of cough with spontaneous onset.
- She had a past medical history of coronary artery disease (CAD, the narrowing or blockage of the coronary arteries usually caused by the buildup of cholesterol and fatty deposits on the inner walls of the arteries), asthma (a condition in which the airways narrow and swell making it difficult to breathe), COPD and pulmonary embolism (PE, blood clot in the lung).
- At 4:49 PM, her vital signs (body temperature [T, degree of hotness or coldness of the body, normal is 98.6 °F], blood pressure [BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80], heart rate [HR, the number of times the heart beats within a certain time period, usually a minute], and breathing rate) were BP-131/73, T-97.4 F, HR-110, pulse oximetry (the percentage of oxygen in the bloodstream, a normal reading would be 95 to 100 percent) was 96%.
- Her review of systems showed cough, shortness of breath and dyspnea on exertion (shortness of breath with activity).
- She had been on antibiotics (medications that destroy or slow down the growth of bacteria) for 12 days.
- A chest x-ray (test that creates pictures of the structures inside the body- particularly bones) showed no acute abnormality with her heart or lungs.
- An electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed tachycardia (fast heartrate) of 102 beats per minute.
- Laboratory testing and CT angiography (a type of medical test that combines a CT scan with an injection of a special dye to produce pictures of blood vessels and tissues in a part of your body) were not performed.

During an interview on 01/31/24 at 9:00 AM, Staff S, ED Medical Director, stated that a more thorough physical examination of Patient #21 would have revealed another pathway for diagnosis and treatment. A CT angiogram was appropriate, if the physician felt it would change the outcome, for a patient with tachycardia and a history of PE. A more thorough physical exam was most important.

Based on interview, record review and policy review, the hospital failed to arrange an appropriate transfer for one patient (#1), out of 21 Emergency Department (ED) records reviewed from 07/31/23 through 01/29/24. This failed practice had the potential to cause harm to all patients who presented seeking care at the ED.

Findings included:

Review of the hospital's policy titled, "Guidelines for Discharge," reviewed 09/2010, showed the purpose of the policy was to discharge patients from the hospital with all possible safety, considerations and courtesy. Nursing personnel should accompany patients to the door and remain with them until he/she has left the hospital. If at any time, the Registered Nurse (RN) determines a patient is not safe for discharge, he/she should discuss their concerns with the ED physician.

Review of the hospital's policy titled, "ED Standards of Care," revised 05/01/10, showed appropriate discharge planning included information on available community resources.

Review of the hospital's undated policy titled, "After Hours Social Service Manual," showed the hospital has a contract with Southeast Missouri Transport Services (SMTS) for patients who have absolutely no transportation. In the event of an after-hours discharge, staff can call one of the cell phone numbers of the employees responsible for SMTS transportation.

Review of the hospital's undated document titled, "Daily ED Log from 01/08/24 12:00 AM to 01/09/24 11:59 PM," showed during the time Patient #1 was in the waiting room there were two to five patients receiving care in the ED.

Review of the hospital's undated document titled, "Homeless Shelters," showed the location and contact information for five shelters.

Review of the hospital's undated document titled, "Women's Domestic Shelters and Resources," showed the location and contact information for six shelters.

Review of the hospital's undated documented titled, "Community Resources," showed the location and contact information for 14 resources.

Review of the hospital's undated document titled, "Do You Need a Warm Place to Stay When the Weather is Below Freezing," showed the location and contact information for a warming station.

Review of the hospital's Self-Report to the Department of Health and Senior Services, dated 01/17/24, showed the patient was found deceased.

Review of Patient #1's Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) report, dated 01/08/24, showed she was picked up by the ambulance at Cadet, MO 63630. The man on the scene stated Patient #1 was staying with him after her "family kicked her out."

Review of Patient #1's medical record showed:
- On 01/08/24, she was a 44-year-old female.
- Her home address was Potosi, MO 63664
- Her medical history was congenital hydrocephalus (a condition when CSF builds up in the brain and spinal cord), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), pneumonia (infection in the lungs), anxiety (a feeling of fear or worry experienced intermittently), depression (extreme sadness that doesn't go away) and Post Traumatic Stress Disorder (PTSD, a mental health problem you may develop after experiencing traumatic events).
- Her surgical history was a ventriculoperitoneal (VP) shunt (a narrow plastic tube that drains excess CSF from the brain into the abdomen) was placed three weeks prior, cholecystectomy (surgical removal of the gallbladder; a small organ that stores liquid called bile and helps your body break down food) and a total hysterectomy (surgical removal of the hollow, pear-shaped organ that is located in a woman's lower abdomen between the bladder and the rectum).
- At 5:41 the decision was made to discharge Patient #1.
- At 5:51 PM, the nursing discharge documentation showed the patient left the facility by walking.

During an interview on 01/30/24 at 4:00 PM, Staff E, Chief Nursing Officer (CNO), stated that staff would provide resources if they knew a patient was homeless. She expected discharged patients waiting for rides to be included in shift report. A social work consult could have been placed when the boyfriend refused to pick up the patient. It was "unusual" for a security officer to initiate a deputy transfer; it was not securities "place" to involve law enforcement. Nursing should have been involved; nursing was ultimately responsible for patient discharges. All discharge efforts were documented in the medical record. The patient could have stayed overnight in the ED.

During an interview on 01/29/24 at 10:05 AM and 01/30/24 at 3:00 PM, Staff C, ED Manager, stated that she expected staff to ensure patients were clear and appropriate for discharge. Patients without rides would "hang out more times than not until daytime and a better plan was established." If the ED was not busy, patients were allowed to stay in the ED rooms. There were 10 ED rooms and space to create three additional hallway bed. "The normal practice was for the patient to stay in the ED." She did not know why Patient #1 was taken to the waiting room. She would not have expected a patient to be in the waiting room hoping for someone to call and check on her. Patients were only placed in the waiting room if they were attempting to call friends/family. When a patient did not have transportation, she expected a call was placed to every family and friend available to the patient, a social work consult and community resources were provided. She expected all efforts made for transportation were documented in the medical record. She expected staff to escalate to management when there was no "realistic" option for transportation. The maintenance department transported patients with a place to go, as a last resort, after hours. She did not expect law enforcement to transport patients. When a patient was in the waiting room after discharge, she expected the nurse to notify the registration clerk and security of the situation. She expected the registration clerk and/or security officer to inform the nurse of any patient needs. It was not an expectation of the support staff to find patient rides or make patient decisions.

During an interview on 01/29/24 at 10:40 AM, and a telephone interview on 01/31/24 at 11:00 AM, Staff J, RN, stated that she was aware the patient was homeless, was kicked out of her family home and was staying with her boyfriend. She did not consult social work, provide community resources or call SMTS. She did not recall if the patient had a list of phone numbers and did not remember calling anyone for the patient. She reported to the waiting room staff the patient was discharged, was waiting for a ride and she was attempting to arrange a ride. The boyfriend had called to check on the patient before she arrived at the ED. She thought he would call again, be informed she was discharged and would pick her up. She did not inform the waiting room staff the patient was homeless and was kicked out of her family home.

During an interview on 01/31/24 at 8:00 AM, Staff S, ED Medical Director, stated that "all people" should have been called for Patient #1's transportation issue. She should have been provided community resources. Options should have been presented to the patient. The physician, nurse and social worker should have been involved in the discussion.

During an interview on 01/31/24 at 2:10 PM, Staff T, ED Physician, stated he was aware the patient was homeless. She was staying with her boyfriend. He expected the patient to be given resources and options. He expected a patient was discharged to a "reasonably safe situation."

During an interview on 01/29/24 at 2:45 PM, Staff L, Security Officer, stated that on 01/08/24 at approximately 4:30 PM, the patient came up to his desk and said, "I want to go home." He then went to speak with the nurse. Staff J, RN, told him she had left a message with a number on a piece of paper in the patient's bag. He was not allowed to make phone calls for patients. At 7:00 PM, he asked Staff R, Registration Clerk, to "please help her get home." The patient gave the clerk a piece of paper with the numbers. There were four to five mental health facility numbers and two other numbers. One of those numbers was her boyfriend and the other was a female. Staff R, called the boyfriend, he answered, and the phone was given to the patient. The patient began to cry and hung up the phone. Staff R asked the patient if he was coming to get her and the patient said "no, he isn't coming to get me," and sat down. He told the patient they would "try to figure something out." One to two hours later Staff W, City Policy Officer (CPO) entered the ED for an unrelated patient. Staff L, asked Staff W, if he could "help give the patient a ride." Staff W spoke with the patient, the patient would not provide an address. Staff N, Emergency Room Technician (ERT), spoke with the patient and was able to confirm the address with the medical record. The address was outside of the city limits, Staff W called Staff V, County Deputy (CD), to transport the patient.

During an interview on 01/30/24 at 6:25 PM, Staff R, Registration Clerk, stated that she came to work on 01/08/24 at 7:00 PM. The patient was in the waiting room, waiting for a ride. The patient handed her a list of numbers and walked away. The numbers were to "facilities" and two other names. She called both "other" numbers; the boyfriend answered. After the patient spoke with the boyfriend she began to cry and said, "he's not coming to get me." The patient did not come back to the desk. Staff W, CPO, came into the ED for an unrelated patient, and he was asked to give the patient a ride. Staff W, spoke with the patient, the patient would not provide an address. Staff N, ERT, confirmed the address with the patient and the medical record.

During an interview on 01/31/24 at 6:15 PM, Staff V, CD, stated that she heard the call through dispatch Patient #1 needed to be transported. She entered the hospital through the ambulance bay, spoke with the other officers and was given a slip of paper with an address. She was not aware the patient was homeless or was kicked out of her family home. She stated the address on Shirley School Road to Patient #1 and she agreed. The patient was concerned the deputy was going to "get into trouble" for taking her home and asked to be let out of the car. The location the patient was dropped off was not the address listed on the paper.

During an interview on 01/29/24 at 2:15 PM, Staff Q, Social Services Director, stated that social work could be called after hours. A social worker could have been called for Patient #1. A maintenance worker could have taken her home during working hours. It was not safe to discharge the patient to the location from which she was kicked out.

During an interview on 02/01/24 at 10:50 AM, Staff U, Emergency Medical Technician, (EMT), stated that she was on the crew that transported Patient #1 to the hospital. The man on the scene told Staff U the patient could not stay with him, and her family kicked her out.