HospitalInspections.org

Based on policy review, record review, ambulance report review, Autopsy report, surveillance video review and facility staff interviews, it was determined the facility failed to ensure that an appropriate Medical Screening Exam (MSE) within the capability of the hospital's emergency department including ancillary services routinely available was provided to determine if a medical condition existed for 1 (#1) of 21 patient who's chief complaint upon presentation to the emergency department (ED) was alcohol ingestion. This failure affected 1 of 21 sampled patients (Patient #1).

The findings include:


Based on clinical record review, surveillance video review and interviews conducted on 02/15/23 and 02/16/23, the facility failed to provide a medical screening exam to a patient, who presented to the Emergency Department (ED) seeking medical care. Despite written documentation of an exam, video surveillance verifies the physician did not provide Medical Screening Examination (MSE) or stabilization treatment. The failure affected 1 of 21 sampled patients (Patient #1) as detailed in citation A 2406.

The facility reported the event to the State agency, as an adverse event, unexpected death. The facility did not report the possible EMTALA violation.

Corrective actions reviewed during the investigation included the following:
1. The ED provider involved in the care of Patient #1 was removed from schedule and subsequently terminated.

2. Education on medical screening exam and assessment/reassessments completed except for those on leave. Providers have 90% completion rate.

3. The nursing education was provided in combination of HealthStream (EMTALA) and huddles (sign in sheet). Currently 65 out of 123 total employees still pending education. All others completed the training on 02/08/23 and 02/09/23.
Education for managers, regarding EMTALA Laws, is 100% completed.

4. ED providers EMTALA training is 100% completed.
ED redesign is completed. It included an area to place patients with higher acuity with monitoring capabilities.

5. The facility has created exam rooms to facilitate medical screening exams for patients in the waiting room.
Rooms for respiratory treatments, electrocardiograms and blood workstations set up in the front to expedite treatment orders.
Observations during the complaint survey verifies the changes have been implemented.

6. The facility modified the staffing, adding a charge nurse for the waiting area; a licensed nurse and advanced paramedic to assist with medication administration, intravenous lines and other treatments.

7. The charge nurses are completing direct observation of all clinicians to ensure first evaluations, first orders, reassessment and documentation are completed. The audits were initiated on 02/10/23 and are ongoing.

8. The (Name of group) Group, who provide the contracted ED providers, will provide training regarding "Unconscious Bias". The date has not been determined.

9. The facility has ongoing review of data analytics to monitor clinician compliance, the report comes out twice a day and is reviewed by local executives and division leaders as well.

10. The facility presented results of the audits completed from 02/01/23 thru 02/14/23. The criteria include timely MSE and order placement, current compliance is at 94%.

11. The nursing staff assessment and reassessment and documentation of vital signs is currently at 80%.

12. The (Name of group) Group is providing additional education on EMTALA, scheduled for 02/16/23 and 02/17/23.

13. The (Name of group) Quality Director is providing one to one training on MSE for every provider and completing performance reviews.

14. The (Name of group) Quality Director will be on site to assess ED changes and patient flow.

15. The ED Medical Director provided education to the providers regarding MSE and performance metrics via email. Providers are reviewing the material and returning email attestation after completion.

Based on policy review, record review, ambulance report review, Autopsy report, surveillance video review and facility staff interviews, it was determined the facility failed to ensure that an appropriate Medical Screening Exam (MSE) within the capability of the hospital's emergency department including ancillary services routinely available was provided to determine if a medical condition existed for 1 (#1) of 21 patient who's chief complaint upon presentation to the emergency department (ED) was alcohol ingestion.

The findings included:


Facility policy, titled, "Florida EMTALA Screening Stabilization" last reviewed 10/24/22, documents:
"Purpose: To establish guidelines for providing appropriate medical screening examinations ("MSE") and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA, 42 U.S.C. S 1395dd, and all Federal regulations and interpretive guidelines promulgated thereunder, as well as section 395.1041, Florida Statutes, and all related administrative rules. The policy stated in part,
"Procedure:
1. When an MSE is Required
A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC exists: ...
3. Extent of the MSE
a. Determine if an EMC exists. The hospital must perform an MSE to determine if an EMC exists ... b. Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital.
c. An on-going process... The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer.
d. Judgment of physician or QMP. The extent of the necessary examination to determine whether an EMC exists is generally within the judgment and discretion of the physician or other QMP performing the examination function according to algorithms or protocols established and approved by the medical staff and governing board.
e. Extent of MSE varies by presenting symptoms. The MSE may vary depending on the individual's signs and symptoms:
i. Depending on the individual's presenting symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures."


Clinical record review conducted on 02/15/23 revealed Patient #1 presented to the facility on 01/24/23 at 8:13 PM, the patient was brought in by Fire Rescue with chief complaint of being intoxicated and incontinent. The ambulance report dated 1/24/23 was reviewed. Review of the ambulance report dated 1/24/23, documentation by the EMS (Emergency Medical Service) personnel revealed that at 7:50PM the patient's vital signs were Blood pressure 134/115 (normal blood pressure "less that 120/80 (CDC.GOV); 74 normal; Respirations 16; SPO2(test use to measure the oxygen level) 97%; Blood glucose 147 (normal 60-100); GCS (assess the level of consciousness) 15 (normal); Temperature: 98.1. Patient #1 level of consciousness was listed as, "alert." Review of the narrative of this report revealed in part,
"Rescue responded ...in reference to an altered conscious ...Pt states she was drinking wine all night and could not hold her urine or bowels any longer. Pt denies LOC (loss of consciousness), Chest Pain, SOB (shortness of Birth), or any complaints at this time." The patient was transported to the hospital without incident.

The triage nurse documented the following: Vital signs at 8:13 PM, blood pressure 104/78, pulse 80, oxygenation 97 percent on room air, respirations 12 and temperature 36.6 degrees Celsius. Patient states she thinks she was drugged. Patient denies any head or neck pain, denies chest pain. The patient was oriented to self and place, confused, skin pale and diaphoretic. Patient had an episode of incontinence prior to arrival to the ED, stool and urine noted to linens and clothing, respirations equal and unlabored.

The ED physician documented a Medical Screening Exam (MSE) was completed at 8:16 PM.
The MSE documented on 01/25/23 at 12:14 AM, indicates the physician examined the patient on 01/24/23 at 8:16 PM. The notes document 63-year-old for evaluation of alcohol intoxication. EMS report that the patient was at a local establishment that is associated with her neighborhood when they were called due to patient being intoxicated. They report that she was being disruptive and had defecated on her seat prompting them to call EMS. EMS state that patient did not have any known falls. On arrival to the ambulance bay she was mildly agitated with staff but was otherwise awake, alert and in no acute distress.
Stated complaint ETOH (Alcohol)
Rapid assessment notes reviewed.
The MSE documents a physical exam. The patient was awake, alert, no acute distress, cooperative, no periorbital redness, airway patent, mucous membranes moist, no respiratory distress, cardiovascular with regular rhythm and abdomen soft with no distention.

Review of the Code Blue record dated 01/24/23 starting at 11:20 PM, documents Patient #1 had no heart rate or rhythm. Resuscitation efforts ended at 11:46 PM.

Reevaluation Notes:
On arrival to the ambulance bay patient awake, no acute distress. No hypotension, bradycardia or hypoxia, brown stool present on clothing without melena. Plan to monitor patient in the ED while attempting to secure safe disposition and placed in front end process per staff. Per multiple staff members patient was awake and interactive. Per medic she reportedly asked for a drink and he states that he gave it to her and returned ten minutes later to recheck vital signs and patient was found to be unresponsive. She was immediately moved to bed 8 and found to be in asystole after multiple rounds of CPR. No cardiac motion observed on bedside ultrasound and time of death was called at 2346. Of note, labs were collected and resulted during active CPR and therefore unreliable.
Despite this patient presenting to the ED with signs and symptoms of altered mental status, confusion, being diaphoretic and pale there was an inappropriate delay between the patient's arrival and the provisions of necessary medical interventions, such as no documentation of written physician orders, no documentation in the medical record to indicate this patient was on a cardiac monitor, no intravenous lines started, no laboratory or diagnostic tests were ordered prior to the patient coding in the ED. As the patient required an appropriate MSE within the capability of the hospital's ED to include ancillary services that are routinely available to determine whether or not an EMC existed for patient #1 on1/24/2023.

The autopsy report for Patient #1 dated 1/25/2023 at 10:45 was reviewed. The section of the report titled "Toxicology Panel" revealed "Hospital blood label patient #1 ...Ethanol level 0.152." (normal reference range in this report was 0.010).

Review of the surveillance video conducted on 02/15/23 at approximately 2:48 PM while accompanied by the Vice President of Quality, Director of Patient Safety and Quality Manager revealed Patient #1 was brought into the facility by fire rescue on 01/24/23 at approximately 8:13 PM. The patient was on a stretcher, the paramedics were observed talking to the staff at the desk and subsequently moved the patient to a recliner in the waiting room. The patient remained in the waiting room until 11:20 PM, when a paramedic found her to be unresponsive. The video indicates the ED physician did not examine the patient despite her documentation. Further review of the surveillance video indicates at 8:27 PM, 8:36 PM, 8;42 PM and 8:56 PM, the nurse and the paramedic had difficulties obtaining vital signs, at one point the nurse brought in another machine to get the vital signs. The staff attempted arms and legs, the patient was awake and talking to the staff. At 9:19 PM, the paramedic talks to the patient. At 9:42 PM, a nurse talks to the patient. At 10:30 PM, the registrar provides the patient with a cup of water.
At 11:19 PM, the paramedic returns and is attempting to talk to the patient, then brings a machine to do vital signs and at 11:20 PM, the patient is taken from the waiting area to the back.

Interview with ED Medical Director, on 02/15/23, at 1:03 PM, revealed the staff reported the event involving Patient #1. The Director then spoke to the physician involved, and was told the patient came in intoxicated; was placed in the waiting room and coded. The next day he called the physician again, just to check on her after the incident, and advised her an investigation was initiated. At the time of the event there were three physicians on duty (two adults and one pediatric); and two midlevel adult providers. The volume was high but not excessive.
Then the next day they reviewed the video surveillance as part of the investigation and learned the physician did not act appropriately, her encounter with the patient was not accurate. The Director was asked what explanation was given as to why the patient did not receive a medical screening exam and replied the physician stated she was waiting for the patient to sober up.
The physician was immediately removed from the schedule and subsequently terminated.

Interview with the Vice President of Quality on 2/15/23 at 1:28 P.M. stated the facility does not have the autopsy results; The family reported to them the autopsy results dissection of the aorta, mass on kidney, and history of alcohol intoxication and hypertension.


Interview with Staff A, a Paramedic, via phone on 02/16/23 at 8:34 AM revealed he worked on 01/24/23 from 6:30 PM to 7 AM. The Paramedic recalls Patient #1 was already in the waiting area when he first saw her. He was working in the back, another patient asked for food and as he was passing by, Patient #1 asked him for water. He did give her cup of water and went on to do vital signs on other patients. Later that evening, he reproaches the patient again, at first, he thought she was sleeping, the patient was not talking to him and was unresponsive, the patient was taken to the back and coded.
The staffing on that evening, was himself at the triage desk, the nurse was medicating patients and there was a mid-shift nurse who left at 11 PM and a medic doing blood draws. They were working short that night due to call outs. The paramedic verbalized assessments are to be completed on arrival and then every hour, it was not a perfect scenario.

Interview with Staff B, Registered Nurse, on 02/16/23 at 9:47 AM via phone, revealed she was the triage nurse on 01/24/23. Patient #1 came in via fire rescue and was sent to the waiting room, on a stretcher. The nurse explained she completed her assessment, the patient was alert, denied pain and was in no distress. The patient remained in the lobby and stated that typically the provider will see the patient and put orders in. The nurse does not recall if she reassessed the patient during her shift and stated she was no longer on duty when the patient coded. The nurse added the staffing was short that evening, her replacement if you can call it a replacement was a medic.

Phone interview with The Vice President of Quality on 02/17/23 at 11:25 AM revealed the surveillance tape provided captures the patient arrival until the time she was found unresponsive and confirmed the physician did not complete a medical screening exam and when interviewed by the medical director, the physician admitted her documentation was not accurate. That is the reason why the medical director immediately suspended the provider and subsequently terminated her contract.

Phone interview with Staff C, Paramedic, on 02/17/23 at 2:54 PM, revealed her recollection of Patient #1. The paramedic stated her shift is 10 A to 10 P. The staff recalls the patient kept saying she was drunk and that she was drugged. The staff was asked to elaborate on what was happening while obtaining the patient's vital signs. The paramedic explained the nurse and herself were having difficulties getting a blood pressure, the machine would not read it, they try her arms and legs. Eventually they were able to get the blood pressure and it was within stable parameters. The paramedic stated she could not get a pulse oximeter reading, and explained the patient was cold and wet, so that may have been the reason. The staff stated she was not on duty when the patient was found unresponsive and that the nurse was the person who inputted the vitals in the electronic medical record.

The facility failed to provide an appropriate medical screening exam to patient #1 on 01/24/2023, who presented to the Emergency Department (ED) seeking medical care. Despite written documentation of an exam, video surveillance verifies the physician did not provide Medical Screening Examination (MSE).