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Based on observation, interview and record review, the hospital failed to comply with the provisions of 42 CFR, Section 489.24 when it failed to provide a medical screening examination for two of 57 sampled patients who presented to the ED (Emergency Department) with a potential emergency medical condition (Patient 1 and Patient 2). This resulted in a delay in determining if the patients had an emergency medical condition and required emergency treatment. Patient 1 left the hospital without being seen after waiting six and one half hours for a medical screening examination. Patient 1 had surgery at another hospital and was found to have appendicitis and a large abscess (infection) in the abdomen. Patient 2 came to the hospital's ED with vaginal bleeding and waited greater than four hours for a medical screening examination to determine how badly she was bleeding and/or if she was in labor. See A2406.

Based on interviews, a tour of the hospital and a review of documents supplied by the hospital, the hospital failed to provide an on-call list of physicians by name, to provide back up specialty care and consultation, when required by the ED physician.

Findings:

A tour of the ED was conducted at 0930 hours on 7/6/211. The on-call specialty list provided by the hospital failed to contain the name for the on-call physician providing radiology or nuclear medicine coverage. The on-call specialty list indicated physician coverage for neurology, cardiology, orthopedics, and pediatrics, but failed to list the full telephone number for contact of these specialty physicians. When interviewed at 0930 hours, the ED supervisor agreed that the list failed to contain the full contact information for the on-call physicians.

Based on observation, interview and record review, the hospital failed to provide a medical screening examination and necessary stabilizing treatment, within its licensed capability and capacity for two of 57 sampled patients, who presented with a potential emergency medical condition (Patient 1 and Patient 2). This resulted in a delay in determining if the patients had an emergency medical condition and required emergency treatment. Patient 1 left the hospital without being seen after waiting six and one half hours for a medical screening examination. Patient 1 had surgery at another hospital and was found to have appendicitis and a large abscess (infection) in the abdomen. Patient 2 came to the hospital's ED with vaginal bleeding and waited greater than four hours for a medical screening examination to determine how badly she was bleeding and/or if she was in labor.

Findings:

1. The medical record for Patient 1 was reviewed on 7/6/11 and showed Patient 1 came to the ED of the hospital on 5/16/11 at 1451 hours with a chief complaint of abdominal pain for two days. Patient 1 reported pain of 10/10, partially relieved by pain medication taken at home prior to coming to the hospital. However, when evaluated by the RN (Registered Nurse) in triage at 1558 hours, the triage nurse utilized a "Pain Assessment Worksheet," and documented a pain assessment of 6/10, "moderate pain," and assigned a triage category "ESI 3" (Estimated Severity Index). Triage is a process of rapid assessment of the order in which patients will be taken to an ED bed for treatment. It does not replace the necessity of a trained professional to determine if an emergency medical condition exists.

According to telephone interviews with the complainant on 7/6/11 at 1030 hours and 7/8/11 at 1130 hours, Patient 1 was placed in the ED waiting room after triage. The complainant stated she told the triage nursing staff that the patient had signs and symptoms of appendicitis. The patient did not receive a medical screening examination to determine if an emergency medical condition requiring emergency treatment existed.

The complainant stated at 2025 hours on 5/16/11, six and one half hours after coming to the ED, Patient 1 was summoned to the triage room by NA 1 for repeat vital signs. The complainant accompanied Patient 1 into the room. Patient 1 turned to ask the complainant to "close the door" to the triage room, and then slumped to the floor, unable to get up. The complainant stated NA 1 told the patient "you must get up; you cannot lie on the floor." Patient 1 then stated "please give me a minute." The complainant stated NA 1 recorded the vital signs for Patient 1; however, an RN did not reassess the patient ' s pain and condition. The complainant asked NA 1 to have the patient seen by a physician, but was told by NA 1 to "go see the triage nurse."

The complainant stated that she decided to leave the ED to have the patient seen by her personal physician. Patient 1 was evaluated by the personal physician on 5/17/11. An appendectomy was performed with the finding of "Acute appendicitis and a large peritoneal abscess."

NA 1 was interviewed on 7/7/11 at 1030 hours about Patient 1's visit to the ED on 5/16/11. NA 1 stated she summoned Patient 1 and the complainant to the triage room at 2025 hours. NA 1 stated Patient 1 "slumped to the floor of the triage room." NA 1 stated she told Patient 1 to "get up and sit in the chair, to have his vital signs taken." When interviewed, NA 1 stated that she thought Patient 1 was "acting" so that he would be seen by a physician sooner.

Review of the medical record from another hospital for Patient 1 showed on 5/17/11 he had an appendectomy performed, at which time there was a large abscess found in his abdomen.

2. The medical record for Patient 2 was reviewed on 7/8/11. Patient 2 came to the hospital's ED at 1153 hours on 7/8/11. Patient 2 complained of "heavy vaginal bleeding of 3 days duration." The triage RN identified the Patient as an "ESI 3." She did not have a medical screening examination to determine if an emergency medical condition, including labor, existed. Vital signs were recorded for Patient 2 at 1203 hours and at 1539 hours. There was no further assessment of her bleeding.

When interviewed at 1310 hours and 1545 hours on 7/8/11, Patient 2 stated that she had ongoing vaginal bleeding and was using four perineal pads every hour. Patient 2 stated she felt light headed. She appeared pale. At 1600 hours on 7/8/11, the ED Supervisor and the ED Manager were informed of the status of Patient 2. The ED Supervisor stated that "the vital signs for Patient 2 were stable." The hospital failed to perform a medical screening examination, within its licensed capacity and capability for Patient 2 for at least four hours.