HospitalInspections.org

Based on record review, and interview, the Hospital failed to ensure an appropriate medical screening exam was conducted for one Patient (#1) out of a total sample of 30 patients.

Findings include:

Review of the Hospital policy titled "Examination, Treatment, and Transfer of Patients to other Facilities (EMTALA-Emergency Medical Treatment and Labor Act)", revised 1/23/2020, indicated the following:
-The Hospital will, within its capabilities, provide, without discrimination, an appropriate medical screening examination to any individual who is seeking emergency medical care or who is being transferred in an unstable condition.
-Scope - any patient who is seeking emergency medical care.
-All Patients who come to the Hospital seeking emergency medical care shall receive a medical screening evaluation.

Review of the Hospital policy titled "Workplace Safety, Threat Assessment, and Violence Mitigation", approved 1/17/23, indicated the following:
-All workplace violence reports will be taken seriously and will be dealt with appropriately. The Hospital will take all reasonable and appropriate measures to support an environment conducive to the health and safety of employees, patients, and visitors. All real or perceived direct threats to staff from patients, visitors, or fellow employees will be directed to the Hospital Threat Assessment Team for evaluation and recommendation regarding potential interventions to increase staff safety.
-The threat assessment team will focus on interventions for threatened staff which would increase staff safety as well as make recommendations for patient, visitor, or employee interventions.
-All Hospital employees are responsible for immediately notifying a member of management and/or security of any workplace violence they have witnessed, received, or have been told that another person witnessed or received.
-The Threat Assessment Team (TAT) will meet with the concerned staff to assess the staff members level of perceived threat. The TAT will provide an objective assessment of the threat to the staff.
-The TAT is primarily entrusted to provide recommendations to the staff member for their safety.
-If the threat originates with a patient/visitor:
1. Recommendations to the patient's treatment plan
2. increased supervision or security near the patient
3. Suggesting a buddy system for the staff member
4. Recommend changes in the interpersonal interactions with the patient
5. Changing the staffing configuration for the shift or entire admission

Patient #1 arrived via ambulance to the Hospital Emergency Department on 2/25/23 with a chief complaint of diarrhea and diagnoses of hypothyroidism and cerebral disease.

Review of Patient #1's medical record indicated Patient #1 was triaged at the Hospital's Emergency Department on 2/25/23 at 10:19 P.M., the Patient had received intravenous (IV) Zofran (a medication used to treat nausea) and fluids in the ambulance prior to arrival at the Hospital. Registered Nurse (RN) #1 documented that on 2/25/23 at 11:45 P.M., Patient #1 would not return to the waiting room from the Z-pod waiting room and had then went and laid down in the Z-pod (COVID positive patient area). RN #1 documented Patient #1 threw his/her vomit bag at him after being asked to leave the Z-pod area. RN #1 documented he demanded Patient #1 remove him/herself from the area and the Patient demanded to see an "administrator"; the charge was notified and after speaking with the Patient his/her IV was removed and Patient #1 left the premises. RN #2 documented in the Hospital ED LWBS/AMA form that on 2/25/23 at 11:51 P.M., Patient #1 was escorted out of the Hospital by the Police Officer on site and Hospital security. Further review of the medical record failed to indicate any Medical Screening Examination (MSE) was ever conducted for the Patient, nor that the Patient elected to leave the Hospital prior to the conduction of a MSE for the Patient.

Review of a letter to Patient #1 dated 3/3/23 indicated the following:
-We appreciate your phone call on 2/27/23 in which you voiced your concerns about your concerns to the Emergency Department on 2/25/23.
-A thorough review of your concerns has been completed.

Review of the Hospital Collaborative Case Review, dated 3/15/23 indicated the following:
-The incident involving Patient #1 occurred on 2/25/23
-Risk was notified on 2/27/23 of the event involving Patient #1 (2/25/23)
-Patient #1 did not receive a MSE prior to being escorted out of the Hospital by security in a wheelchair.
-Based on the review of this case it does appear that this case meets reporting as an EMTALA violation to the Massachusetts Department of Public Health - failure to perform MSE.
-Violence in triage prior to medical screening education to be rolled out after it is approved by the team on March 31, 2023.

During an interview with the Emergency Department Director of Patient Care Services on 3/21/23 at 11:45 A.M., he said he had reviewed the incident with Patient #1. He said he personally spoke with Patient #1 over the phone, and he/she told him he/she was not seen by the attending physician on 2/25/23 before he/she left the Emergency Department. He said what Patient #1 experienced was not the Hospital's standard of care. He said a draft had been created to re-educate the Emergency Department staff but has not been finalized yet.

During an interview with the Quality Coordinator on 3/22/23 at 10:15 A.M., she said the Patient complaint had been sent to Hospital regarding Patient #1. She said she reviewed Patient #1's record and notified the Director of Emergency Services and they had called the Patient together on 3/13/23. She said the collaborative case review had been held on 3/15/23 and it was decided then the case was an EMTALA violation. She said education related to this event was developed on 3/16/23 but is awaiting finalization.

During an interview with RN #1 on 3/22/23 at 11:50 A.M., he said on 2/25/23 he found the Patient in the Z-pod area of the Emergency Department after he/she did not return to the waiting room. He said he asked him/her to leave the area and return to the waiting room, as there were COVID positive patients in the Z-pod area. He said if Patient #1 refused to leave, he would need to call security. Patient #1 then threw a vomit bag at him. RN #1 said Patient #1 collected his/her items and went to the hall/area adjacent to the Z-pod. RN #1 said he went to the main desk to ask another staff member to talk to Patient #1.

During an interview with RN #2 on 3/22/23 at 3:26 P.M., she said Patient #1 threw a bag at RN #1. She said she went to speak with Patient #1 in the COVID area of the Emergency Department. She said Patient #1's behaviors escalated quickly, and he/she appeared disorganized. RN #2 said she discontinued and removed Patient #1's IV incase the Patient attempted to leave. She said she could not recall if Patient #1 asked to leave. She said the charge nurse on duty met with the Patient after he/she was moved out of the COVID area in a wheelchair.

During an interview with Security Officer #1 on 3/23/23 at 8:31 A.M., he said Patient #1 was asked to leave the COVID area of the Emergency Department by RN #1. He said Patient #1 threw an emesis bag at RN #1, and RN #1 came to the desk and said Patient #1 needs to go he/she was throwing things. He said he accompanied RN #2 to the screening hallway where Patient #1 was along with the Police Officer on detail at the Hospital. He said it was explained to Patient #1 there was zero tolerance for any violence in the Hospital. He said the charge nurse said Patient #1 needed to go. He said Patient #1 said he/she would apologize and said the Hospital should still take care of her.

The Hospital failed to provide evidence of any corrective action implemented after the incident occurred with Patient #1 on 2/25/23 to address a Patient not receiving a MSE when presenting to the Hospital Emergency Department.