HospitalInspections.org

Based on policy review, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20(l) and §489.24.

The findings included:

The hospital failed to ensure an appropriate medical screening examination was provided within the capability of the hospital's Dedicated Emergency Department (DED) by failing to show evidence of discussion of the risks of refusing the medical screening to 2 of 4 patients who presented to the DED requesting care and left without being seen. (Patients #3, #1)

~cross refer to §489.24(a) & §489.24(c), Appropriate Medical Screening Exam - Tag A2406

Based on policy review, medical record reviews and physician and staff interviews the hospital failed to ensure an appropriate medical screening examination was provided within the capability of the hospital's Dedicated Emergency Department (DED) by failing to show evidence of discussion of the risks of refusing the medical screening to 2 of 4 patients who presented to the DED requesting care and subsequently left without being seen. (Patients #3, #1)

The findings included:

Review of the "EMERGENCY MEDICAL SCREENING" policy, last reviewed 12/06/2019, revealed "...Should a patient refuse a medical screening examination....hospital staff will take all reasonable steps to obtain informed written consent from the patient for refusing the examination....Staff will explain to the patient the hospital's legal obligations, the risks and benefits of refusing the examination....and will exercise every effort to obtain the patient's signature on the Refusal to Stay form.... Should a patient refuse to sign the consent form, a hospital representative will document this refusal on the Refusal to Stay form. ..."

Review of the policy "Leaving the Hospital Against Medical Advice", last reviewed 10/20/2020, revealed " ...I. For patient presenting to the ED and leaving without being seen by a physician or designee, ED staff will complete the form: Refusal to Stay and Obtain a Medical Screening. ..."

1. DED record review, on 09/27/2022, revealed Patient #3, a 26-year-old, arrived to the DED on 07/18/2022 at 1705 as a "Walk In" with a complaint of chest pain. Review of the "Triage Assessment", documented at 1711, revealed "...Chest wall pain that radiates to the back since the AM. Worse with certain movements. Pt (patient) states a hx (history) of pulomonary (sic) embolism (blood clot in lung) and Lupus Ery (Lupus Erythematosus- autoimmune disease). ..." Triage Assessment review revealed the patient's skin was pink, warm and dry and respiratory effort was "Nonlabored". Vital signs were recorded as Temperature (T) 98.6, Pulse (P) 72, Respirations (R) 18, Blood pressure (BP) 117/69 and pulse oximetry 100% on room air. A pain score of 5 (on a scale of 0-10) was documented and Patient #3 was assigned a priority of 3 (on a scale of 1-5 where 1 is most severe). Review of an EKG, dated 07/18/2022 at 1722 revealed " ...Normal sinus rhythm Normal ECG..." Review of "Patient Care Notes" from 1740 revealed "sent blood to lab." Review of lab Chemistry results, time 1738, revealed abnormal results related to Alk Phos (Alkaline Phosphatase) 36 (Reference Range [RR] 45-117), Chloride 108 (RR 98-107) and Anion Gap 8 (6-12), with the other Chemistry results within normal ranges. Review of Lab Chemistry also revealed three Troponins were obtained on 07/18/2022 with results of 5.7 at 1738, 4.9 at 1920 and 5.2 at 2123 (RR 0.0-58.7). Review of Lab Hematology, on 07/18/2022 at 1738, revealed results were within normal ranges. Review of "Patient Care Notes" revealed a note on 07/19/2022 at 0006 which stated " ...(Name) NA (Nursing Assistant), pt (initials) came up to this tech asking about test results when this tech told her this tech could not give test results, pt (initials) became irritated stating 'we've been here for 6....hours, how does no one know what is going on'..." and at 0012 "...When this tech told pt we were working as fast as we could....stated 'get me the....nurse'..." Review of an "ED Cardiovascular Assessment, documented at 0024, revealed notations of midsternal chest pain, nonlabored respiratory effort and regular and skin pink, warm, and dry. A pain score of 8 was documented at 0024 (over 7 hours after the initial pain score of 5). Review of Vital signs (VS) at 0029 (7 hours after the last VS) revealed a pulse rate of 50, respirations of 18, BP of 127/83 and pulse ox of 100%. Another pulse ox of 100% was noted at 0032. Review of "Discharge Information" revealed Patient #3 "Left without being seen" on 07/19/2022 at 0138 (8 hours, 33 minutes after arrival). DED record review did not reveal a provider examined Patient #3, did not provide documentation to indicate if the patient was observed leaving or if the risks of leaving without a medical screening were explained. Further DED record review did not reveal a signed "Refusal to Stay and Obtain a Medical Screening" form.

Telephone interview, on 09/28/2022 at 1115, with NA #1, a Nurse Aide/Unit Secretary, revealed NA #1 typically tried to calmly explain she cannot give test results to patients. Interview revealed NA #1 would let the Triage Nurse know and generally try to have the Triage Nurse go talk with the Patient/ Family. Interview revealed NA #1 did not recall what happened with this patient.

Telephone interview with ED Tech #2, on 09/28/2022 at 1151, revealed she recalled Patient #3. Interview revealed the patient/family had been off and on regularly to the desk. Interview revealed the Tech had stepped away to lunch. Interview revealed the patient/family said they had to be at work the next day. Interview revealed they needed someone who "knew what they were doing." ED Tech #2 stated the family member wanted the test results and the Tech "told her to go to the Triage Nurse." Interview revealed the Triage Nurse talked with her. ED Tech #2 stated she thought there was still a little wait but as soon as she could she thought the triage nurse got (them) to a room. The ED Tech stated she did not recall who the Triage Nurse was and also did not think the Triage Nurse would give results either, that they waited until patients went back.

Telephone interview with RN #3, on 09/28/2022 at 1630, revealed the RN, who triaged the patient, recalled Patient #3. Interview revealed it seemed like musculoskeletal pain, that RN #3 had the patient do range of motion and it elicited pain. Still, RN #3 stated, they would do the full protocol of testing for the patient. Interview revealed RN #3 did not recall Patient #3 asking about lab results. If he had, the RN stated, he would try to have a provider speak with the patient. RN #3 stated he got off duty at 1900. Generally, interview revealed, vital signs for a Level 3 patient should be reassessed every 4 hours. Interview further revealed if a patient decided to leave before being seen there was a form the patient should be asked to sign before they left.

Interview on 09/28/2022 at 1550 with ED Manager #4, revealed they "promote" staff making a note when someone wants to leave without being seen and stated staff tried to document if they could. Follow up interview on 09/29/2022 at 1238 revealed vital signs on Patient #3 should have been checked every 4 hours. ED Manager #4 stated the patient did not leave from the waiting room, he had been pulled back into ED Room 14. Interview revealed that room was across from the nurse station but also directly by a door leading out of the department. Interview revealed Patient #3 could have walked out without being seen by staff.

Interview with MD #5, an ED physician, on 09/29/2022 at 1410 revealed all providers have access to the tracking board. Interview revealed the triage process was designed for the sickest patients to be seen first and if someone intervened on behalf of a patient it could put a provider in a difficult position of taking a less sick person instead of the sicker one. Further interview revealed lab results were available to patients on the patient portal.

2. DED Medical Record review, on 09/28/2022, revealed Patient #1, a 77-year-old arrived to the DED on 07/18/2022 at 1709 for the reason of "weakness". Review of the "ED Triage Assessment", documented at 1716, revealed " ...Stated Complaint and General Appearance Black, tarry stools x (for) 3 days. PT (patient) has a hx (history) of gastric ulcers. Weak since this AM with abd (abdominal) cramping. ..." Triage Assessment review revealed the patient's skin was pink, warm, dry and respirations were not labored. Vital signs were documented as T 98.2, P 75, R 18, BP 147/70, pulse oximetry 98% on room air and a pain scale of 2. Patient #1 was assigned an priority level of 3. Record review revealed labs were obtained at 1732. Lab results outside the reference ranges were noted as RBC (Red Blood Cells) 4.61 (RR 4.69-6.13), Hgb (Hemoglobin) 11.9 (RR 13.5-17.5), Hct (Hematocrit) 38.1 (RR 41.0-53.0), MCH (Mean Corpuscular hemoglobin) 25.8 (RR 26.0-34.0), RDW Coeff of Var (Red Cell Distribution Width coefficient of variation) 15.9 (RR 11.6-14.8), BUN (Blood Urea Nitrogen) 19 (RR 7-18), Creatinine 1.2 (RR 0.67-1.17), Glucose 161 (RR 82-115), Albumin 3.3 (RR 3.4-5). Review of "Discharge" revealed at 2155 (4 hours, 46 minutes after arrival) Patient #1 was noted as "Left without being seen." DED record review did not reveal evidence of any additional vital signs obtained. Record review did not indicate if the patient was called three times, did not reveal evidence whether the staff was aware Patient #1 was leaving or if the risks of leaving were explained. Further DED record review did not reveal a signed "Refusal to Stay and Obtain a Medical Screening" form.

Telephone interview with RN #3, on 09/28/2022 at 1630, revealed RN #3 worked 07/18/2022 and got off duty at 1900. Interview revealed if a patient decided to leave before being seen there was a form the patient should be asked to sign. Interview revealed patients should be called at least three times if staff were if not aware the patient had left. The RN also stated vital signs should be obtained every 4 hours for a priority 3 patient.