HospitalInspections.org

Based on observation, Hospital #1, Hospital #2 and Hospital #3 Emergency Department (ED) medical record review, Hospital #1's Daily Log Review, review of Specialty Call List for Hospital #1's ED, review of Hospital #1's Medical Staff Bylaws, Hospital #1's physican schedule review, Hospital #1's Staffing Schedule review, document review, staff interview, patient interviews, family interviews, and review of the EMS ambulance report, the facility failed to comply with 489.20(l) by failing to provide a Medical Screening Exam (MSE) and Stabilizing Treatment within its capacity that minimized the health risks of 14 of 28 patients reviewed, Patient #1, #7, #8, #9, #11, #13, #15, #18, #19, #22, #24, #25, #27 and #28.


Findings include:


On 03/01/2017 the State Office received a complaint from the Office of Attorney General (AG) which stated:
"Date of Alleged Event: 01/07/2017
Standard Notes: Reporter (Patient #1's mother) claims victim was transported from the accident scene to hospital. They checked vitals, but did nothing but put him in a room for three hours. Victims father asked for help after three hours, but with no response. Victim chose to leave the hospital to go to a different facility after three hours.
AG Notes: On February 07, 2017 I (AG Investigator) spoke with (Patient #1's mother) who stated her son (Patient #1) was not treated for three hours. (Patient #1's mother) said they left after three hours and went to a small hospital in (another state directly across the river). (Patient #1's mother) said her son was there for trauma after his vehicle had turned over. (Patient #1's mother) said her son's girlfriend was thrown out of the door of the vehicle and was there for trauma as well. (Patient #1's mother) said her husband was told that they were working on getting around to them, due to only having one doctor in the ER....
Note: On February 15, 2017 I (AG Investigator) spoke with ....Risk Manager at (Hospital #1). (Risk Manager) said Patient (#1) came in through their ER after being involved in a car accident and was triaged by the staff... said the nurse checked in on Patient (#1) on three different occasion(s) before (Patient #1's mother) decided to take her son to another facility for treatment. (Risk Manager) said they have 13 beds and there were nineteen patients in the ER on that night with one physician... said each patient was being monitored by nurses during this time..."
The AG referred the complaint to the State Office for investigation.


An unannounced visit was made to Hospital #1 on 03/07/2017 at 9:40 a.m. An entrance conference was held with the Chief Executive Officer (CEO), the nature of the visit was discussed and what paper work would need to be made available to assist with the investigation.


On 03/07/2017 at approximately 11:30 a.m. a tour of the ED was made with the ED Director. Observation revealed 14 ED beds and five (5) Fast Track beds. EMTALA signs were observed in the hallway and the ED physician on-call list was observed and made available.


Review of Hospital #1's ED Daily Log Detail for 01/07/2017 revealed 80 patients were seen during the 24 hour period in the ED. Four (4) of the 80 patients in that time period left without seeing a physician, without receiving a Medical Screening Exam and without receiving any Stabilizing Treatment. Their wait time was between two (2) hours 22 minutes and two (2) hours 53 minutes.


Review of Hospital #1's Specialty Call List for Emergency Department revealed that on 01/07/2017 they had Physicans on-call for: Hospitalist, General Surgeon, OB/GYN, Oncology, Pediatrics, Orthopedics, Cardiology, Nephrology, Neurology, Ear/Nose & Throat. Other specialties include Gastroenterologist, Pulmonologist, and Dermatology.


The facility's Registered Nurse Staffing Schedule was reviewed. Six (6) RNs were on the schedule for the P.M. hours on 01/07/2017.


EMS AMBULANCE REPORT REVIEW:

Review of the EMS ambulance report revealed a request for Immediate Response for an ambulance was made on 01/07/2017 at 8:43 p.m. The ambulance arrived at the scene at 9:01 p.m. The report stated that the patient was the restrained driver in a rollover type Motor Vehicle Collision (MVC). At the time of the collision, the air bags did not deploy. The patient complained of posterior ribcage pain. He rated the pain as eight (8) out of 10 pain scale. Patient (Pt) extracted self from vehicle prior to EMS contact. Pt anxious. Would not consent to spinal immobilization. Pt ambulated to stretcher. Vital signs (V/S) were taken and were within normal limits (WNL). Pt would not allow further interventions.


PATIENT #1 ED RECORD REVIEW HOSPITAL #1

Hospital #1 ED record review for Patient #1 revealed the 22-year-old male arrived at the ED by ambulance on 01/07/2017 at 9:03 p.m. following a MVC.

Review of Hospital #1 ED Nurse Documentation revealed:
"Presenting Complaint: ... Brought into ER (Emergency Room/Emergency Department) by ...EMS with report of having been restrained driver of truck and hit a patch of ice in road and lost control of truck. Reports truck rolled sideways. Denies LOC (loss of conciousness). EMS reports patient was ambulatory at the scene. Patient is c/o (complaining of) lower back pain and lower rib pain on both right and left sides. Accompanied by mother... No IV (intravenous) access. Patient not secured on spine board and does not have a C-collar on.
Acuity Level 3
Triage Assessment: Pain: Complains of pain in lower back and right and left lower ribs currently is 6 out of 10 on a pain scale. Quality of pain is described as aching. Pain began suddenly... is intermittent. Aggravated by increased activity... Appears in no apparent distress. (V/S WNL)
21:03 (9:03 p.m.) Patient placed in Exam Room... Family accompanied patient...
21:20 (9:20 p.m.) Verbal reassurance given...
21:40 (9:40 p.m.) Patient is sitting on side of stretcher talking to mother... Awaiting MD visit. Reminded him to call if he needs assistance.
22:09 (10:09 p.m.) ...no apparent distress, resting quietly. Patient's parents in room... Awaiting MD visit. Reminded him to call if he needs assistance.
22:15 (10:15 p.m.) Patient's mother to ER desk inquiring how much longer before the ER MD will be in to see patient. Mother informed that (ED physician) is in the ER and will be in to see the patient but an exact time is not able to be given. Verbalized her understanding.
22:37 (10:37 p.m.) No apparent distress. resting quietly. Awaiting physician initial evaluation.
23:06 (11:06 p.m.) No apparent distress. resting quietly. Awaiting physician initial evaluation. Patient's parents in room. Asked if they would like coffee or anything a nurse can do. Parents deny needing anything other than for the MD to visit... telling patient and parents that he has encouraged (ED physician) to visit them.
23:35 (11:35 p.m.) No apparent distress. resting quietly. Parents remain in room with patient. Continue awaiting (ED physican) visit.
23:51 (11:51 p.m. - two hours and 48 minutes after arrival) Patient ambulatory from ER accompanied by parents. Father reports they are taking patient to (Hospital #2). Again apologized to patient and parents. Father reports being "too long to wait for a doctor!".
Patient left without being seen, after triage, without provider evaluation."

There was no documented evidence that a Medical Screening Examination (MSE) was provided, that any Stabilizing Treatment was provided, or that an appropriate transfer was made.


PATIENT #1 ED RECORD REVIEW HOSPITAL #2

Review of Patient 1's ED "Encounter Summary" at Hospital #2 revealed:
Arrival date: 01/08/2017 Arrival time: 0023:00 (12:23 a.m.)
Chief Complaint(s): Triage complaints are Motor Vehicle Accident (MVA); Back Pain; Shortness of Breath (SOB) MVA lost control of the car, Roll over, the car/truck stopped with passenger side on ground and he was hanging by the seat belt. Ambulatory at the scene.... Was at (Hospital #1) waited for few hours, he was not seen so he came to (Hospital #2), walked in with his parents, in no distress. C/O chest wall pain and back pain...
Chest X-ray - no acute findings
CT (Computer Tomography): Thoracic Spine without contrast - ...mild compression FX (fracture) of T11 Vertebral body with a small avulsed fractured fragment seen near the anterior aspect of the vertebral body. Also there is a minimal compression fracture of T12.
CT: Cervical Spine without contrast - IMPRESSION: Loss of normal cervical lordosis, secondary to muscle spasm versus patient positioning... no other acute findings.
CT: Brain without contrast MVA, Head injury, small laceration of scalp...
Diagnosis: minimal compression FX T11, T12. MVA Acuity:2.
While in the ED Patient #1 began c/o a headache along with his back pain and was given Dilaudid 1 milligram (mg) and Zofran 1mg IV and Adecel 0.5 milliliter (ml) intramuscular.
01/08/2017 04:04 (4:04 a.m.) Pt (patient) out per ....Ambulance Service in stable condition. (Transfered to Hospital #3)
Reason For Transfer - Transfer is medically indicated - Ortho (Orthopedics)
(Ortho not available at this facility)
Documented evidence revealed Patient # received a MSE, Stabilizing Treatment, and an appropriate transfer was made to Hospital #3.


PATIENT #1 ED RECORD REVIEW HOSPITAL #3

Review of Patient #1's ED record from Hospital #3 revealed he arrived via ambulance on 01/08/2017 at 5:28 a.m. and was triaged as a Level 2. His V/S were WNL. He received blood work and CT scans. Received MSE. Diagnosis given was: Unspecified Fracture T7 - T8 Vertebra, closed fracture and Pain located Perispinal thoracic acute. He was prescribed Norco 5/325 tablet by mouth and referred to a Neurologist. He was discharged from Hospital #3 on 01/08/2017 at 7:01 a.m. with instructions to follow up with the referred Neurologist and his Primary Physician.
* It is noted that the Thoracic Spine CT done at Hospital #2 showed the fractures at T11 and T12.


ADDITIONAL INTERVIEWS

On 03/08/2017 at 9:00 a.m. a telephone call was placed to Patient #1. No one answered. A message with a telephone number was left for him to return the call. No return call was ever received.

During an interview with the Chief Quality Officer on 03/08/17 at 9:45 a.m. all concerns identified during ED record review were discussed and a request was made for any additional information available.


On 03/08/2017 at 10:00 a.m. a telephone interview was held with Patient #1's mother, who had been with Patient #1 at Hospital #1's ED on 01/07/2017. Patient #1's mother stated that there were 25 patients in the ED during the time they were there. The patient and parents were in Hospital #1's ED for approximately three (3) hours and during that time Patient #1 was in excrutiating pain. There was one (1) physician in the ED and he never saw Patient #1. She stated that Patient #1 left and went to Hospital #2, where it was determined that the patient had sustained two (2) fractured vertebrae and a scalp laceration. He was then transferred to Hospital #3 by ambulance for additional tests and further treatment. No additional diagnosis was made. The mother stated that Patient #1 has not been able to work since the 01/07/2017 accident and he was instructed that he would not be able to work for three (3) to six (6) months.


On 03/08/2017 at 11:55 a.m. a telephone interview was held with Hospital #1's ED RN #1. She stated that she routinely works night shift in the ED and has for four (4) years. There is usually one (1) physician in the ED and patients are waiting when he arrives. Their ED physicians are contracted. RN #1 did not remember Patient #1's visit to the ED on 01/07/2017.


On 03/08/2017 at 2:30 p.m. Hospital #1's ED Physician #1 was interviewed over the telephone. Patient #1's complaint and the date he was in the ED were discussed. The physician stated that he did not remember the patient.


On 03/08/2017 at 2:45 p.m. all findings were reviewed during the exit conference with Hospital #1's Chief Nursing Officer, Chief Quality Officer, Compliance Officer, Director of Operations and Chief Executive Officer. No additional information was provided for review.


On 03/20/2017 at 11:00 a.m. another telephone call was placed to Patient #1. No one answered. A voice message with a telephone number was left for him to return the call. No return call was ever received.


ADDITIONAL ED RECORD REVIEWS - HOSPITAL #1

Patient #7: ED record revealed this 2-year-old male patient was carried into the ED by the mother on 12/23/2016 at 7:49 p.m. The mother complained that the patient had been vomiting since 1:30 p.m. without diarrhea or fever. The acuity level was 3. The patient's vital signs (V/S) were taken and were within normal limits (WNL) and the patient was placed in an examination room at 9:51 p.m. The patient was observed at 9:54 p.m., 11:00 p.m., and 12:01 a.m. by an ED nurse. The patient left without being seen by a physician on 12/24/2016 at 1:18 a.m. after a five (5) hour and 28 minute wait. No medications had been administered. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. An unsuccessful attempt was made to contact Patient #7's mother by telephone on 03/17/2017 at 10:20 a.m.


Patient #8: ED record revealed this 58-year-old male patient, arrived at the ED ambulatory on 12/23/16 at 8:24 p.m. with complaints of chronic right hip pain. No documented pain scale. Acuity level was 4. The patient's vital signs were documented at 8:38 p.m. An arm band was placed on the patient at 8:40 p.m. The next observation note was at 11:41 p.m. It stated "Patient Rounding: No answer when name called X 3. Patient has left the ER waiting room." The patient had waited three hours and 14 minutes. No MSE was provided. No Stabilizing Treatment was provided. An unsuccessful attempt was made to contact Patient #8 per telephone on 03/22/2017 at 10:00 a.m.



Patient #9: ED record review revealed this 6-year-old female patient arrived with both parents at the ED on 12/19/2016 at 10:51 p.m. with complaint of abdominal pain. The pain started the night before. The patient's acuity level was 3. The patient complained of pain in left upper quadrant. The pain was rated 10 out of 10 on a pain scale. V/S WNL. Orders were obtained for a urinalysis and urine culture and was collected from the patient for urinalysis and culture at 11:14 p.m. The urinalysis report interpretation was: Urine Urobilinogen was one (1) plus; urine leukocytes were one (1) plus; urine white blood cells were 1-3. At 12:45 a.m. Patient #9 was waiting for a room to become available. The next note at 2:18 a.m. stated the patient was not in the waiting room when called and was not found outside. This was three (3) hours and 27 minutes after being checked in. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. An unsuccessful attempt was made to contact Patient #9's mother by telephone on 03/17/2017 at 10:30 a.m.


Patient #11: ED record review revealed this 53-year-old patient arrived ambulatory at the ED on 12/13/2016 at 9:53 p.m. with the complaint of aching all over for months. The patient also stated "feel like I am gonna fall out sometimes.". The patient's acuity level was 3. Her blood pressure was 174/100 at 10:09 p.m. and was not rechecked. The patient rated pain at five (5) out of 10 on a pain scale. Quality of pain was described as aching. The patient was placed in the waiting room on 12/14/2016 at 12:12 a.m. and complained of pain in back of legs currently is eight (8) out of 10 on a pain scale. The patient left the ED at 1:05 a.m. The patient reported being tired of waiting and no longer wished to wait. The patient left without being seen by ED physician after a three (3) hour and 12 minute wait. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 10:45 a.m. a telephone conversation was held with Patient #11. She stated that she left the ED after 1:00 a.m. on 12/14/2016 because "... it makes no sense. They take too long." She also stated that she went to her primary physician on 12/14/2016 and he diagnosed her with Arthritis.


Patient #13: ED record review revealed this 9-month-old male patient arrived at the ED on 02/09/2017 at 2:33 a.m. carried by mother with complaint of fever since last night. The mother reported giving the patient Tylenol 30 minutes prior to arrival. V/S were WNL. The patient's temperature was 98.6 degrees Fahrenheit (F) at 2:42 a.m. Acuity level was 4. Orders were obtained for: Rapid Strep test; and Influenza A-B, AG, EIA at 2:48 a.m. The specimens were sent to the lab at 2:52 a.m. The test for Influenza was positive. At 3:23 a.m. the parent was informed staff would return to the room in 30 minutes. At 4:59 a.m. the family and patient continued to wait for ED physician initial evaluation. At 5:58 a.m. "Patient left without being seen after triage, without provider evaluation." The family was instructed on treatment of flu and encouraged to return to ER or pediatrician for follow-up. The patient left the ED at 6:01 a.m., three (3) hours and 25 minutes after check-in. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 11:00 a.m. a phone conversation was held with the patient's mother. She stated that they waited almost four (4) hours to see a doctor in the ED on 02/09/2017 and never saw one, so she took her son and left. She visited his primary physician the same day.


Patient #15: ED record review revealed this 18-year-old female patient arrived at the ED ambulatory on 02/08/2016 at 7:54 p.m. The patient complained of pain in the right and left upper quadrants of the abdomen. The patient states that she just found out that she was pregnant and her mother kicked her in the stomach three (3) times because she refused to have an abortion. The patient's V/S were documented. The acuity level was 3. Last menstrual period was 12/20/2016. The patient was placed in a waiting room at 8:05 p.m. Pregnancy was verified at seven (7) weeks and two (2) days. The patient left the ED without being seen at 11:42 p.m., three (3) hours and 47 minutes after check-in. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 11:25 a.m. a telephone conversation was held with the patient's mother. She stated the patient no longer lived with her, she had no new telephone number for her and she did not know if Patient #15 saw another provider on that day or on the next day for her complaint. She stated that she would tell her daughter to return the phone call. No return call was received.


Patient #18: ED record review revealed this 7-month-old male patient was carried into the ED by his parents on 02/06/2017 at 9:37 p.m. The mother stated the infant was coughing, congested, and had a fever since earlier that morning. The patient's acuity level was 4. The patient's temperature was 99.0 degrees Fahrenheit (F) at 9:43 p.m. The patient left the ED on 02/07/2017 at 12:43 a.m., three (3) hours and six (6) minutes after check-in. No reason for leaving was documented. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 11:35 a.m. an attempt was made to contact the patient's mother by telephone. The patient's godfather answered the call, stated he knew nothing about the ED visit, and would have the mother return the call. No return call was received.


Patient #19: ED record review revealed this 8-month-old male patient arrived at the ED by ambulance on 02/06/2017 at 9:40 p.m. with complaint of fever. The patient's acuity level was 4. The patient's temperature was 100.4 degrees F at 9:50 p.m. The next note on 02/07/16 at 12:42 a.m. stated the patient left the ED. This was three (3) hours and two (2) minutes after check-in. The reason the patient left was not documented. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 an unseccussful attempt was made to contact Patient #19's mother by telephone. A voice message was left. No return call was received.


Patient #22: ED record review revealed this 25-year-old female patient ambulated into the ED on 01/16/2017 at 9:45 p.m. The patient complained of frontal headache, bilateral leg swelling, high blood pressure, and difficulty walking. The Acuity level was 3. The patient rated pain at seven (7) out of 10 on pain scale. At 11:01 p.m. the patient was given a warm blanket and lights were dimmed. At 12:00 a.m. the patient was observed sleeping. The patient's blood pressure ranged from 143/97 at 9:08 p.m. to 114/73 at 1:20 a.m. The patient inquired about wait time on 01/17/2017 at 1:22 a.m. At that time the patient was updated on acuity in the ED. The patient verbalized understanding and stated symptoms had improved. The patient chose to leave without being seen. The patient was given verbal discharge instructions to follow with her personal physician and return if symptoms persisted or got worse. No medications were given. The patient left without being seen at 1:20 a.m., four (4) hours and 35 minutes after check-in. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 an unsuccessful attempt was made to contact this patient by telephone. A voice message was left. No return call was received.


Patient #24: ED record review revealed this 18-year-old female patient ambulated into the ED on 01/17/2017 at 11:23 a.m. with complaint of pain all over. The patient's acuity level was 3. The patient complained of: headache, neck, back, and shoulder pain for two (2) days after a MVC. The patient rated pain at 10 out of 10 on a pain scale. The patient's blood pressure was 150/99 at 11:30 a.m. and was not rechecked. On 01/18/2017 at 12:17 a.m. and 12:49 a.m. ED documentation stated, "Awaiting ED physician initial evaluation." At 1:25 p.m. the patient was informed that staff would return (to room) in 30 minutes. The patient left without treatment at 2:29 p.m., after a three (3) hour and six (6) minute wait without seening a physician. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 2:10 p.m. a phone call was placed to the patient. Her phone was no longer a working number. Placed a call to Patient #24's mother at 2:15 p.m.. Her mother said that even though she (Patient #24) was still hurting, she left the ED after waiting about three (3) hours and never saw a doctor. She returned to Hospital #1's ED the next day with continued pain, was diagnosed with a ruptured appendix and had surgery to have appendix removed. On 03/20/2017 Hospital #1 was contacted twice regarding Patient #24's return visit to their ED. The hospital had no documented evidence that this patient returned to their ED on or around 01/17/2017, or had inpatient or outpatient surgery of any kind in that time period. On 03/20/2017 at 1:30 p.m. an interview was held with Patient #24 by telephone. She confirmed that she went back to Hospital #1's ED on 03/18/2017, was told her appendix had ruptured and had surgery to remove her appendix. When asked if she was sure it was Hospital #1 that she went back to she stated, "Yes."


Patient #25: ED record review revealed this 58-year-old female patient ambulated into the ED on 01/16/2017 at 9:07 p.m. with complaints of chest pain. The acuity level was 3. The patient complained of: epigastric pain, chest tightness, diarrhea, nausea and vomiting. The patient complained of pain in the xyphoid area at three (3) out of 10 on a pain scale. At worse was six (6) out of 10. Orders were obtained for: EKG (done at 9:18 p.m.), chest x-ray; Troponin I, Thromboplast, Prothrombin Time; Natriuretic Peptide; ISTAT Troponin; CPK total; CPK MB Fraction; Complete Metabolic Panel; and Complete Blood Cell Count at 9:33 p.m. A cardiac monitor, oxygen, and continuous pulse oxometer monitoring were provided at 10:00 p.m. A chest x-ray impression was documented as WNL. A saline lock was inserted and blood collected for lab tests at 10:02 p.m. At 10:53 p.m. the patient reported all symptoms were resolved, except for some mild chest tightness that she stated was her anxiety. The catheter lock was discontinued, bleeding controlled and a dressing was applied on 01/17/2017 at 12:07 a.m.. The patient's blood pressure decreased from 172/88 at 9:28 p.m. to 106/66 at 12:08 a.m. The patient left without being seen on 01/17/2017 at 12:08 a.m., after a three (3) hour and one (1) minute wait without seeing a physician. There was no documented evidence that a MSE or any other Stabilizing Treatment was provided. On 03/17/2017 at 2:40 p.m. the patient was interviewed via telephone. She stated that the ED was very busy that night, but "was never this bad until they were bought out." She stated that the nurse told her before she left without ever seeing a doctor that her blood work was ok but her EKG was irregular. The next day she called her primary physician and told him of the incident. He requested her EKG from Hospital #1, received it and reviewed it. He scheduled Patient #25 to have a cardiac catheter done due to the irregular EKG.


Patient #27: ED record review revealed this 43-year-old female patient arrived at the ED on 01/07/2017 at 4:04 p.m. The patient complained of abdominal pain that began 2-3 days prior to arrival. The acuity level was 3. The patient reported having a colon resection and hysterectomy on 12/29/2016. The incision was red, no drainage, but pain with bowel movement. At 5:23 p.m. the patient rated her pain nine (9) out of 10 on a pain scale. At 6:58 p.m. the patient was not found in her room. It was reported that the patient left the ED to go to see her doctor after waiting two (2) hours and 53 minutes without seeing a physician. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 3:15 p.m. Patient #27 was interviewed via telephone. She stated that after she waited almost three hours without ever seeing a doctor she left and went to Jackson the next day to see her doctor. "This happens all the time at this hospital. Last year they told me I had a stomach bug and sent me home. I had Stage 4 Colon Cancer."


Patient #28: ED record review revealed this two year old female patient arrived in her mother's arms at the ED on 01/07/2017 at 11:13 p.m. She was triaged with an Acuity Level of 3. Mother stated the child drank about 4 ounces of Benadryl at 2130 (9:30 p.m.), was seen at Hospital #2 earlier and was given charcoal. Hospital #2 was going to send her to Hospital #3 so the mother signed the patient out and came to Hospital #1 for treatment. At 11:48 p.m. Poison Control was notifed. They directed hospital staff to observe, not a toxic dose. On 01/08/2017 at 1:43 a.m. patient left without being seen after a two (2) hour and 30 minute wait. "MD had not been in the room to see patient. Family ready to leave." There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/21/2017 at 3:45 p.m. an unsuccessful attempt was made to contact the patient's mother by telephone. A voice message was left. No return call was received.


Wait time for these 15 patients at Hospital #1's ED, prior to leaving without seeing a physician, without receiving a MSE, and without receiving Stabilizing Treatment, was from two (2) hours 30 minutes to five (5) hours 28 minutes.


POLICY AND PROCEDURE REVIEW

Review of Hospital #1's "EMTALA Medical Screening Stabilizing Policy" (revision date: 9/1/2013) revealed: "Introduction: All individuals presenting on Hospital property requesting emergency medical services, individuals presenting to a Dedicated Emergency Department requesting emergency medical services, and patients arriving/presenting via ambulance requesting medical services shall receive an appropriate Medical Screening Examination and Stabilizing services as required by the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C. Section 1395 and all Federal regulations and interpretative guidelines promulgated thereunder.
Medical Screening/Stabilization - General Requirements: ...when an individual comes,... to the Dedicated Emergency Department of the Hospital and a request is made on the individual's behalf for a medical examination or treatment, the Hospital must provide an appropriate Medical Screening Examination within the capability of the Hospital (including ancillary services routinely available in the Dedicated Emergency Department and emergency services offered at outpatient departments or facilities) to determine whether an Emergency Medical Condition exists...
Medical Screening Examination Requirements... 3. ...Triage is not equivalent to a Medical Screening Examination...


Review of Hospital #1's "Emergency Department Policy Section N" (review date: February 2012) revealed: "Purpose: All patients will receive medical screening by Emergency Department physician. Objectives: Provide initial triage and treatment of all patients. Provide adequate and appropriate licensed staff to meet the needs of the patient census 24 hours a day..."


Review of Hospital #1's "Medical Staff Coverage" policy (reviewed July 2013) revealed: "...Policy: The Emergency Department is staffed with a full time emergency physician, or his temporary physician designee, 24 hours daily, 365 days per year. The physician will be available in the emergency department at all times. He is responsible for providing immediate emergency care on all patients needing such and will also evaluate non-emergency problems in his respective areas of expertise as an extension of service to the private physician when asked to do so. Patients requiring admission to the hospital will be referred to their private physician or the Hospitalist. Admission orders may be written by the Emergency Physician at his discretion.


Review of Hospital #1's "Triage in the Emergency Department" policy (effective 12/31/15) revealed,"... Policy:... 3. Acuity Levels... Level 1 - Requires immediate life-saving intervention; Level 2 - High risk situation...; Level 3 - Requires many resources...; Level 4 - One resource required; Level 5 - No resources required.. 7. Patients presenting with a pregnancy related problem will be medically screened by the Emergency Department Physician or Advanced Practive Nurse... b. OB patients involved in trauma will be treated by Emergency Department Physician per hospital trauma guidelines with consult for OB evaluation..."

Review of the hospital's "Scope of Service - Emergency Department" policy (Reviewed July 2013) revealed: " ...Patient Population: ... Scope and Complexity of Patient Care Needs: All patients that present to NRMC Hospital's premises for a non-scheduled visit and are seeking care shall receive a medical screening exam by an Emergency Department physician that includes providing all necessary testing and on-call services within the capability of NRMC Hospital to reach a diagnosis. Support services including but not limited to clinical laboratory studies and x-rays will be provided to the patient in a timely manner. An on-call list of specialty physicians is maintained to assist in stabilizing patients. All definitive treatment will be given to the patient within the hospital's capabilities ..."


Review of the hospital's "Emergency Services" policy (Reviewed Feb 2012) revealed, "Policy: ...The Emergency Department is classified as a Level IV department ... Procedure: This hospital will provide emergency medical screening and stabilizing treatment, as necessary, to all individuals "coming to the Emergency Department", ..."


Review of the hospital's "Purpose and Objective" policy (Reviewed Feb 2012) revealed, "Purpose: ...All patients will receive a medical screening by the Emergency Department Physician ... Objectives: ...Provide adequate and appropriate licensed staff to meet the needs of the patient census 24 hours a day. Provide treatment to patients within a reasonable period of time ...



CONCLUSION:

EMTALA violations were cited for the facility's failure to ensure Patient #1, #7, #8, #9, #11, #13, #15, #18, #19, #22, #24, #25, #27 and #28 received a Medical Screening Examination from a physician while in their facility and failure to ensure the patients received Stabilizing Treatment.

1. A2400 - comply with 489.24
2. A2406 - provide Medical Screening Exams
3. A2407 - provide Stabilizing Treatment

Based on observation, Hospital #1, Hospital #2 and Hospital #3 Emergency Department (ED) medical record review, Hospital #1's Daily Log Review, review of Specialty Call List for Hospital #1's ED, review of Hospital #1's Medical Staff Bylaws, Hospital #1's physican schedule review, Hospital #1's Staffing Schedule review, document review, staff interview, patient interviews, family interviews, and review of the EMS ambulance report, the facility failed to ensure a Medical Screening Exam (MSE) was provided within the capability of the hospital's Emergency Department for 14 of 28 patients reviewed, Patient #1, #7, #8, #9, #11, #13, #15, #18, #19, #22, #24, #25, #27 and #28.


Findings include:


On 03/01/2017 the State Office received a complaint from the Office of Attorney General (AG) which stated:
"Date of Alleged Event: 01/07/2017
Standard Notes: Reporter (Patient #1's mother) claims victim was transported from the accident scene to hospital. They checked vitals, but did nothing but put him in a room for three hours. Victims father asked for help after three hours, but with no response. Victim chose to leave the hospital to go to a different facility after three hours.
AG Notes: On February 07, 2017 I (AG Investigator) spoke with (Patient #1's mother) who stated her son (Patient #1) was not treated for three hours. (Patient #1's mother) said they left after three hours and went to a small hospital in (another state directly across the river). (Patient #1's mother) said her son was there for trauma after his vehicle had turned over. (Patient #1's mother) said her son's girlfriend was thrown out of the door of the vehicle and was there for trauma as well. (Patient #1's mother) said her husband was told that they were working on getting around to them, due to only having one doctor in the ER....
Note: On February 15, 2017 I (AG Investigator) spoke with ....Risk Manager at (Hospital #1). (Risk Manager) said Patient (#1) came in through their ER after being involved in a car accident and was triaged by the staff... said the nurse checked in on Patient (#1) on three different occasion(s) before (Patient #1's mother) decided to take her son to another facility for treatment. (Risk Manager) said they have 13 beds and there were nineteen patients in the ER on that night with one physician... said each patient was being monitored by nurses during this time..."
The AG referred the complaint to the State Office for investigation.


An unannounced visit was made to Hospital #1 on 03/07/2017 at 9:40 a.m. An entrance conference was held with the Chief Executive Officer (CEO), the nature of the visit was discussed and what paper work would need to be made available to assist with the investigation.


On 03/07/2017 at approximately 11:30 a.m. a tour of the ED was made with the ED Director. Observation revealed 14 ED beds and five (5) Fast Track beds. EMTALA signs were observed in the hallway and the ED physician on-call list was observed and made available.


Review of Hospital #1's ED Daily Log Detail for 01/07/2017 revealed 80 patients were seen during the 24 hour period in the ED. Four (4) of the 80 patients in that time period left without seeing a physician, without receiving a Medical Screening Exam and without receiving any Stabilizing Treatment. Their wait time was between two (2) hours 22 minutes and two (2) hours 53 minutes.


Review of Hospital #1's Specialty Call List for Emergency Department revealed that on 01/07/2017 they had Physicans on-call for: Hospitalist, General Surgeon, OB/GYN, Oncology, Pediatrics, Orthopedics, Cardiology, Nephrology, Neurology, Ear/Nose & Throat. Othere specialties include Gastroenterologist, Pulmonologist, and Dermatology.


The facility's Registered Nurse Staffing Schedule was reviewed. Six (6) RNs were on the schedule for the P.M. hours on 01/07/2017.


EMS AMBULANCE REPORT REVIEW:

Review of the EMS ambulance report revealed a request for Immediate Response for an ambulance was made on 01/07/2017 at 8:43 p.m. The ambulance arrived at the scene at 9:01 p.m. The report stated that the patient was the restrained driver in a rollover type Motor Vehicle Collision (MVC). At the time of the collision, the air bags did not deploy. The patient complained of posterior ribcage pain. He rated the pain as eight (8) out of 10 pain scale. Patient (Pt) extracted self from vehicle prior to EMS contact. Pt anxious. Would not consent to spinal immobilization. Pt ambulated to stretcher. Vital signs (V/S) were taken and were within normal limits (WNL). Pt would not allow further interventions.


PATIENT #1 ED RECORD REVIEW HOSPITAL #1

Hospital #1 ED record review for Patient #1 revealed the 22-year-old male arrived at the ED by ambulance on 01/07/2017 at 9:03 p.m. following a MVC.

Review of Hospital #1 ED Nurse Documentation revealed:
"Presenting Complaint: ... Brought into ER (Emergency Room/Emergency Department) by ...EMS with report of having been restrained driver of truck and hit a patch of ice in road and lost control of truck. Reports truck rolled sideways. Denies LOC (loss of conciousness). EMS reports patient was ambulatory at the scene. Patient is c/o (complaining of) lower back pain and lower rib pain on both right and left sides. Accompanied by mother... No IV (intravenous) access. Patient not secured on spine board and does not have a C-collar on.
Acuity Level 3
Triage Assessment: Pain: Complains of pain in lower back and right and left lower ribs currently is 6 out of 10 on a pain scale. Quality of pain is described as aching. Pain began suddenly... is intermittent. Aggravated by increased activity... Appears in no apparent distress. (V/S WNL)
21:03 (9:03 p.m.) Patient placed in Exam Room... Family accompanied patient...
21:20 (9:20 p.m.) Verbal reassurance given...
21:40 (9:40 p.m.) Patient is sitting on side of stretcher talking to mother... Awaiting MD visit. Reminded him to call if he needs assistance.
22:09 (10:09 p.m.) ...no apparent distress, resting quietly. Patient's parents in room... Awaiting MD visit. Reminded him to call if he needs assistance.
22:15 (10:15 p.m.) Patient's mother to ER desk inquiring how much longer before the ER MD will be in to see patient. Mother informed that (ED physician) is in the ER and will be in to see the patient but an exact time is not able to be given. Verbalized her understanding.
22:37 (10:37 p.m.) No apparent distress. resting quietly. Awaiting physician initial evaluation.
23:06 (11:06 p.m.) No apparent distress. resting quietly. Awaiting physician initial evaluation. Patient's parents in room. Asked if they would like coffee or anything a nurse can do. Parents deny needing anything other than for the MD to visit... telling patient and parents that he has encouraged (ED physician) to visit them.
23:35 (11:35 p.m.) No apparent distress. resting quietly. Parents remain in room with patient. Continue awaiting (ED physican) visit.
23:51 (11:51 p.m. - two hours and 48 minutes after arrival) Patient ambulatory from ER accompanied by parents. Father reports they are taking patient to (Hospital #2). Again apologized to patient and parents. Father reports being "too long to wait for a doctor!".
Patient left without being seen, after triage, without provider evaluation."

There was no documented evidence that a Medical Screening Examination (MSE) was provided, that any Stabilizing Treatment was provided, or that an appropriate transfer was made.


PATIENT #1 ED RECORD REVIEW HOSPITAL #2

Review of Patient 1's ED "Encounter Summary" at Hospital #2 revealed:
Arrival date: 01/08/2017 Arrival time: 0023:00 (12:23 a.m.)
Chief Complaint(s): Triage complaints are Motor Vehicle Accident (MVA); Back Pain; Shortness of Breath (SOB) MVA lost control of the car, Roll over, the car/truck stopped with passenger side on ground and he was hanging by the seat belt. Ambulatory at the scene.... Was at (Hospital #1) waited for few hours, he was not seen so he came to (Hospital #2), walked in with his parents, in no distress. C/O chest wall pain and back pain...
Chest X-ray - no acute findings
CT (Computer Tomography): Thoracic Spine without contrast - ...mild compression FX (fracture) of T11 Vertebral body with a small avulsed fractured fragment seen near the anterior aspect of the vertebral body. Also there is a minimal compression fracture of T12.
CT: Cervical Spine without contrast - IMPRESSION: Loss of normal cervical lordosis, secondary to muscle spasm versus patient positioning... no other acute findings.
CT: Brain without contrast MVA, Head injury, small laceration of scalp...
Diagnosis: minimal compression FX T11, T12. MVA Acuity:2.
While in the ED Patient #1 began c/o a headache along with his back pain and was given Dilaudid 1 milligram (mg) and Zofran 1mg IV and Adecel 0.5 milliliter (ml) intramuscular.
01/08/2017 04:04 (4:04 a.m.) Pt (patient) out per ....Ambulance Service in stable condition. (Transfered to Hospital #3)
Reason For Transfer - Transfer is medically indicated - Ortho (Orthopedics)
(Ortho not available at this facility)
Documented evidence revealed Patient # received a MSE, Stabilizing Treatment, and an appropriate transfer was made to Hospital #3.


PATIENT #1 ED RECORD REVIEW HOSPITAL #3

Review of Patient #1's ED record from Hospital #3 revealed he arrived via ambulance on 01/08/2017 at 5:28 a.m. and was triaged as a Level 2. His V/S were WNL. He received blood work and CT scans. Received MSE. Diagnosis given was: Unspecified Fracture T7 - T8 Vertebra, closed fracture and Pain located Perispinal thoracic acute. He was prescribed Norco 5/325 tablet by mouth and referred to a Neurologist. He was discharged from Hospital #3 on 01/08/2017 at 7:01 a.m. with instructions to follow up with the referred Neurologist and his Primary Physician.
* It is noted that the Thoracic Spine CT done at Hospital #2 showed the fractures at T11 and T12.


ADDITIONAL INTERVIEWS

On 03/08/2017 at 9:00 a.m. a telephone call was placed to Patient #1. No one answered. A message with a telephone number was left for him to return the call. No return call was ever received.

During an interview with the Chief Quality Officer on 03/08/17 at 9:45 a.m. all concerns identified during ED record review were discussed and a request was made for any additional information available.


On 03/08/2017 at 10:00 a.m. a telephone interview was held with Patient #1's mother, who had been with Patient #1 at Hospital #1's ED on 01/07/2017. Patient #1's mother stated that there was 25 patients in the ED during the time they were there. The patient and parents were in Hospital #1's ED for approximately three (3) hours and during that time Patient #1 was in excrutiating pain. There was one (1) physician in the ED and he never saw Patient #1. She stated that Patient #1 left and went to Hospital #2, where it was determined that the patient had sustained two (2) fractured vertebrae and a scalp laceration. He was then transferred to Hospital #3 by ambulance for additional tests and further treatment. No additional diagnosis was made. The mother stated that Patient #1 has not been able to work since the 01/07/2017 accident and he was instructed that he would not be able to work for three (3) to six (6) months.


On 03/08/2017 at 11:55 a.m. a telephone interview was held with Hospital #1's ED RN #1. She stated that she routinely works night shift in the ED and has for four (4) years. There is usually one (1) physician in the ED and patients are waiting when he arrives. Their ED physicians are contract. RN #1 did not remember Patient #1's visit to the ED on 01/07/2017.


On 03/08/2017 at 2:30 p.m. Hospital #1's ED Physician #1 was interviewed over the telephone. Patient #1's complaint and the date he was in the ED were discussed. The physician stated that he did not remember the patient.


On 03/08/2017 at 2:45 p.m. all findings were reviewed during the exit conference with Hospital #1's Chief Nursing Officer, Chief Quality Officer, Compliance Officer, Director of Operations and Chief Executive Officer. No additional information was provided for review.


On 03/20/2017 at 11:00 a.m. another telephone call was placed to Patient #1. No one answered. A voice message with a telephone number was left for him to return the call. No return call was ever received.


ADDITIONAL ED RECORD REVIEWS - HOSPITAL #1

Patient #7: ED record revealed this 2-year-old male patient was carried into the ED by the mother on 12/23/2016 at 7:49 p.m. The mother complained of the patient had been vomiting since 1:30 p.m. without diarrhea or fever. The acuity level was 3. The patient's vital signs (V/S) were taken and were WNL and the patient was placed in an examination room at 9:51 p.m. The patient was observed at 9:54 p.m., 11:00 p.m., and 12:01 a.m. by an ED nurse. The patient left without being seen by a physician on 12/24/2016 at 1:18 a.m. after a five (5) hour and 28 minute wait. No medications had been administered. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. An unsuccessful attempt was made to contact Patient #7's mother by telephone on 03/17/2017 at 10:20 a.m.


Patient #8: ED record revealed this 58-year-old male patient, arrived at the ED ambulatory on 12/23/16 at 8:24 p.m. with complaints of chronic right hip pain. No documented pain scale. Acuity level was 4. The patient's vital signs were documented at 8:38 p.m. An arm band was placed on the patient at 8:40 p.m. The next observation note was at 11:41 p.m. It stated "Patient Rounding: No answer when name called X 3. Patient has left the ER waiting room." The patient had waited three hours and 14 minutes. No MSE was provided. No Stabilizing Treatment was provided. An unsuccessful attempt was made to contact Patient #8 per telephone on 03/22/2017 at 10:00 a.m.



Patient #9: ED record review revealed this 6-year-old female patient arrived with both parents at the ED on 12/19/2016 at 10:51 p.m. with complaint of abdominal pain. The pain started the night before. The patient's acuity level was 3. The patient complained of pain in left upper quadrant. The pain was rated 10 out of 10 on a pain scale. V/S WNL. Orders were obtained for a urinalysis and urine culture and was collected from the patient for urinalysis and culture at 11:14 p.m. The urinalysis report interpretation was: Urine Urobilinogen was one (1) plus; urine leukocytes were one (1) plus; urine white blood cells were 1-3. At 12:45 a.m. Patient #9 was waiting for a room to become available. The next note at 2:18 a.m. stated the patient was not in the waiting room when called and was not found outside. This was three (3) hours and 27 minutes after being checked in. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. An unsuccessful attempt was made to contact Patient #9's mother by telephone on 03/17/2017 at 10:30 a.m.


Patient #11: ED record review revealed this 53-year-old patient arrived ambulatory at the ED on 12/13/2016 at 9:53 p.m. with the complaint of aching all over for months. The patient also stated "feel like I am gonna fall out sometimes.". The patient's acuity level was 3. Her blood pressure was 174/100 at 10:09 p.m. and was not rechecked. The patient rated pain at five (5) out of 10 on a pain scale. Quality of pain was described as aching. The patient was placed in the waiting room on 12/14/2016 at 12:12 a.m. and complained of pain in back of legs currently is eight (8) out of 10 on a pain scale. The patient left the ED at 1:05 a.m. The patient reported being tired of waiting and no longer wished to wait. The patient left without being seen by ED physician after a three (3) hour and 12 minute wait. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 10:45 a.m. a telephone conversation was held with Patient #11. She stated that she left the ED after 1:00 a.m. on 12/14/2016 because "... it makes no sense. They take too long." She also stated that she went to her primary physician on 12/14/2016 and he diagnosed her with Arthritis.


Patient #13: ED record review revealed this 9-month-old male patient arrived at the ED on 02/09/2017 at 2:33 a.m. carried by mother with complaint of fever since last night. The mother reported giving the patient Tylenol 30 minutes prior to arrival. V/S were WNL. The patient's temperature was 98.6 degrees Fahrenheit (F) at 2:42 a.m. Acuity level was 4. Orders were obtained for: Rapid Strep test; and Influenza A-B, AG, EIA at 2:48 a.m. The specimens were sent to the lab at 2:52 a.m. The test for Influenza was positive. At 3:23 a.m. the parent was informed staff would return to the room in 30 minutes. At 4:59 a.m. the family and patient continued to wait for ED physician initial evaluation. At 5:58 a.m. "Patient left without being seen after triage, without provider evaluation." The family was instructed on treatment of flu and encouraged to return to ER or pediatrician for follow-up. The patient left the ED at 6:01 a.m., three (3) hours and 25 minutes after check-in. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 11:00 a.m. a phone conversation was held with the patient's mother. She stated that they waited almost four (4) hours to see a doctor in the ED on 02/09/2017 and never saw one, so she took her son and left. She visited his primary physician the same day.


Patient #15: ED record review revealed this 18-year-old female patient arrived at the ED ambulatory on 02/08/2016 at 7:54 p.m. The patient complained of pain in the right and left upper quadrants of the abdomen. The patient states that she just found out that she was pregnant and her mother kicked her in the stomach three (3) times because she refused to have an abortion. The patient's V/S were documented. The acuity level was 3. Last menstrual period was 12/20/2016. The patient was placed in a waiting room at 8:05 p.m. Pregnancy was verified at seven (7) weeks and two (2) days. The patient left the ED without being seen at 11:42 p.m., three (3) hours and 47 minutes after check-in. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 11:25 a.m. a telephone conversation was held with the patient's mother. She stated the patient no longer lived with her, she had no new telephone number for her and she did not know if Patient #15 saw another provider on that day or on the next day for her complaint. She stated that she would tell her daughter to return the phone call. No return call was received.


Patient #18: ED record review revealed this 7-month-old male patient was carried into the ED by his parents on 02/06/2017 at 9:37 p.m. The mother stated the infant was coughing, congested, and had a fever since earlier that morning. The patient's acuity level was 4. The patient's temperature was 99.0 degrees Fahrenheit (F) at 9:43 p.m. The patient left the ED on 02/07/2017 at 12:43 a.m., three (3) hours and six (6) minutes after check-in. No reason for leaving was documented. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 11:35 a.m. an attempt was made to contact the patient's mother by telephone. The patient's godfather answered the call, stated he knew nothing about the ED visit, and would have the mother return the call. No return call was received.


Patient #19: ED record review revealed this 8-month-old male patient arrived at the ED by ambulance on 02/06/2017 at 9:40 p.m. with complaint of fever. The patient's acuity level was 4. The patient's temperature was 100.4 degrees F at 9:50 p.m. The next note on 02/07/16 at 12:42 a.m. stated the patient left the ED. This was three (3) hours and two (2) minutes after check-in. The reason the patient left was not documented. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 an unseccussful attempt was made to contact Patient #19's mother by telephone. A voice message was left. No return call was received.


Patient #22: ED record review revealed this 25-year-old female patient ambulated into the ED on 01/16/2017 at 9:45 p.m. The patient complained of frontal headache, bilateral leg swelling, high blood pressure, and difficulty walking. The Acuity level was 3. The patient rated pain at seven (7) out of 10 on pain scale. At 11:01 p.m. the patient was given a warm blanket and lights were dimmed. At 12:00 a.m. the patient was observed sleeping. The patient's blood pressure ranged from 143/97 at 9:08 p.m. to 114/73 at 1:20 a.m. The patient inquired about wait time on 01/17/2017 at 1:22 a.m. At that time the patient was updated on acuity in the ED. The patient verbalized understanding and stated symptoms had improved. The patient chose to leave without being seen. The patient was given verbal discharge instructions to follow with her personal physician and return if symptoms persisted or got worse. No medications were given. The patient left without being seen at 1:20 a.m., four (4) hours and 35 minutes after check-in. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 an unsuccessful attempt was made to contact this patient by telephone. A voice message was left. No return call was received.


Patient #24: ED record review revealed this 18-year-old female patient ambulated into the ED on 01/17/2017 at 11:23 a.m. with complaint of pain all over. The patient's acuity level was 3. The patient complained of: headache, neck, back, and shoulder pain for two (2) days after a MVC. The patient rated pain at 10 out of 10 on a pain scale. The patient's blood pressure was 150/99 at 11:30 a.m. and was not rechecked. On 01/18/2017 at 12:17 a.m. and 12:49 a.m. ED documentation stated, "Awaiting ED physician initial evaluation." At 1:25 p.m. the patient was informed that staff would return (to room) in 30 minutes. The patient left without treatment at 2:29 p.m., after a three (3) hour and six (6) minute wait without seening a physician. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 2:10 p.m. a phone call was placed to the patient. Her phone was no longer a working number. Placed a call to Patient #24's mother at 2:15 p.m.. Her mother said that even though she (Patient #24) was still hurting, she left the ED after waiting about three (3) hours and never saw a doctor. She returned to Hospital #1's ED the next day with continued pain, was diagnosed with a ruptured appendix and had surgery to have appendix removed. On 03/20/2017 Hospital #1 was contacted twice regarding Patient #24's return visit to their ED. The hospital had no documented evidence that this patient returned to their ED on or around 01/17/2017, or had inpatient or outpatient surgery of any kind in that time period. On 03/20/2017 at 1:30 p.m. an interview was held with Patient #24 by telephone. She confirmed that she went back to Hospital #1's ED on 03/18/2017, was told her appendix had ruptured and had surgery to remove her appendix. When asked if she was sure it was Hospital #1 that she went back to she stated, "Yes."


Patient #25: ED record review revealed this 58-year-old female patient ambulated into the ED on 01/16/2017 at 9:07 p.m. with complaints of chest pain. The acuity level was 3. The patient complained of: epigastric pain, chest tightness, diarrhea, nausea and vomiting. The patient complained of pain in the xyphoid area at three (3) out of 10 on a pain scale. At worse was six (6) out of 10. Orders were obtained for: EKG (done at 9:18 p.m.), chest x-ray; Troponin I, Thromboplast, Prothrombin Time; Natriuretic Peptide; ISTAT Troponin; CPK total; CPK MB Fraction; Complete Metabolic Panel; and Complete Blood Cell Count at 9:33 p.m. A cardiac monitor, oxygen, and continuous pulse oxometer monitoring were provided at 10:00 p.m. A chest x-ray impression was documented as WNL. A saline lock was inserted and blood collected for lab tests at 10:02 p.m. At 10:53 p.m. the patient reported all symptoms were resolved, except for some mild chest tightness that she stated was her anxiety. The catheter lock was discontinued, bleeding controlled and a dressing was applied on 01/17/2017 at 12:07 a.m.. The patient's blood pressure decreased from 172/88 at 9:28 p.m. to 106/66 at 12:08 a.m. The patient left without being seen on 01/17/2017 at 12:08 a.m., after a three (3) hour and one (1) minute wait without seeing a physician. There was no documented evidence that a MSE or any other Stabilizing Treatment was provided. On 03/17/2017 at 2:40 p.m. the patient was interviewed via telephone. She stated that the ED was very busy that night, but "was never this bad until they were bought out." She stated that the nurse told her before she left without ever seeing a doctor that her blood work was ok but her EKG was irregular. The next day she called her primary physician and told him of the incident. He requested her EKG from Hospital #1, received it and reviewed it. He scheduled Patient #25 to have a cardiac catheter done due to the irregular EKG.


Patient #27: ED record review revealed this 43-year-old female patient arrived at the ED on 01/07/2017 at 4:04 p.m. The patient complained of abdominal pain that began 2-3 days prior to arrival. The acuity level was 3. The patient reported having a colon resection and hysterectomy on 12/29/2016. The incision was red, no drainage, but pain with bowel movement. At 5:23 p.m. the patient rated her pain nine (9) out of 10 on a pain scale. At 6:58 p.m. the patient was not found in her room. It was reported that the patient left the ED to go to see her doctor after waiting two (2) hours and 53 minutes without seeing a physician. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 3:15 p.m. Patient #27 was interviewed via telephone. She stated that after she waited almost three hours without ever seeing a doctor she left and went to Jackson the next day to see her doctor. "This happens all the time at this hospital. Last year they told me I had a stomach bug and sent me home. I had Stage 4 Colon Cancer."


Patient #28: ED record review revealed this two year old female patient arrived in her mother's arms at the ED on 01/07/2017 at 11:13 p.m. She was triaged with an Acuity Level of 3. Mother stated the child drank about 4 ounces of Benadryl at 2130 (9:30 p.m.), was seen at Hospital #2 earlier and was given charcoal. Hospital #2 was going to send her to Hospital #3 so the mother signed the patient out and came to Hospital #1 for treatment. At 11:48 p.m. Poison Control was notifed. They directed hospital staff to observe, not a toxic dose. On 01/08/2017 at 1:43 a.m. patient left without being seen after a two (2) hour and 30 minute wait. "MD had not been in the room to see patient. Family ready to leave." There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/21/2017 at 3:45 p.m. an unsuccessful attempt was made to contact the patient's mother by telephone. A voice message was left. No return call was received.


Wait time for these 15 patients at Hospital #1's ED, prior to leaving without seeing a physician, without a receiving a MSE, and without receiving Stabilizing Treatment, was from two (2) hours 30 minutes to five (5) hours 28 minutes.


POLICY AND PROCEDURE REVIEW

Review of Hospital #1's "EMTALA Medical Screening Stabilizing Policy" (revision date: 9/1/2013) revealed: "Introduction: All individuals presenting on Hospital property requesting emergency medical services, individuals presenting to a Dedicated Emergency Department requesting emergency medical services, and patients arriving/presenting via ambulance requesting medical services shall receive an appropriate Medical Screening Examination and Stabilizing services as required by the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C. Section 1395 and all Federal regulations and interpretative guidelines promulgated thereunder.
Medical Screening/Stabilization - General Requirements: ...when an individual comes,... to the Dedicated Emergency Department of the Hospital and a request is made on the individual's behalf for a medical examination or treatment, the Hospital must provide an appropriate Medical Screening Examination within the capability of the Hospital (including ancillary services routinely available in the Dedicated Emergency Department and emergency services offered at outpatient departments or facilities) to determine whether an Emergency Medical Condition exists...
Medical Screening Examination Requirements... 3. ...Triage is not equivalent to a Medical Screening Examination...


Review of Hospital #1's "Emergency Department Policy Section N" (review date: February 2012) revealed: "Purpose: All patients will receive medical screening by Emergency Department physician. Objectives: Provide initial triage and treatment of all patients. Provide adequate and appropriate licensed staff to meet the needs of the patient census 24 hours a day..."


Review of Hospital #1's "Medical Staff Coverage" policy (reviewed July 2013) revealed: "...Policy: The Emergency Department is staffed with a full time emergency physician, or his temporary physician designee, 24 hours daily, 365 days per year. The physician will be available in the emergency department at all times. He is responsible for providing immediate emergency care on all patients needing such and will also evaluate non-emergency problems in his respective areas of expertise as an extension of service to the private physician when asked to do so. Patients requiring admission to the hospital will be referred to their private physician or the Hospitalist. Admission orders may be written by the Emergency Physician at his discretion.


Review of Hospital #1's "Triage in the Emergency Department" policy (effective 12/31/15) revealed,"... Policy:... 3. Acuity Levels... Level 1 - Requires immediate life-saving intervention; Level 2 - High risk situation...; Level 3 - Requires many resources...; Level 4 - One resource required; Level 5 - No resources required.. 7. Patients presenting with a pregnancy related problem will be medically screened by the Emergency Department Physician or Advanced Practive Nurse... b. OB patients involved in trauma will be treated by Emergency Department Physician per hospital trauma guidelines with consult for OB evaluation..."

Review of the hospital's "Scope of Service - Emergency Department" policy (Reviewed July 2013) revealed: " ...Patient Population: ... Scope and Complexity of Patient Care Needs: All patients that present to NRMC Hospital's premises for a non-scheduled visit and are seeking care shall receive a medical screening exam by an Emergency Department physician that includes providing all necessary testing and on-call services within the capability of NRMC Hospital to reach a diagnosis. Support services including but not limited to clinical laboratory studies and x-rays will be provided to the patient in a timely manner. An on-call list of specialty physicians is maintained to assist in stabilizing patients. All definitive treatment will be given to the patient within the hospital's capabilities ..."


Review of the hospital's "Emergency Services" policy (Reviewed Feb 2012) revealed, "Policy: ...The Emergency Department is classified as a Level IV department ... Procedure: This hospital will provide emergency medical screening and stabilizing treatment, as necessary, to all individuals "coming to the Emergency Department", ..."


Review of the hospital's "Purpose and Objective" policy (Reviewed Feb 2012) revealed, "Purpose: ...All patients will receive a medical screening by the Emergency Department Physician ... Objectives: ...Provide adequate and appropriate licensed staff to meet the needs of the patient census 24 hours a day. Provide treatment to patients within a reasonable period of time ...



CONCLUSION:

EMTALA violations were cited for the facility's failure to ensure Patient #1, #7, #8, #9, #11, #13, #15, #18, #19, #22, #24, #25, #27 and #28 received a Medical Screening Examination from a physician while in their facility and failure to ensure the patients received Stabilizing Treatment.

1. A2400 - comply with 489.24
2. A2406 - provide Medical Screening Exams
3. A2407 - provide Stabilizing Treatment

Based on observation, Hospital #1, Hospital #2 and Hospital #3 Emergency Department (ED) medical record review, Hospital #1's Daily Log Review, review of Specialty Call List for Hospital #1's ED, review of Hospital #1's Medical Staff Bylaws, Hospital #1's physican schedule review, Hospital #1's Staffing Schedule review, document review, staff interview, patient interviews, family interviews, and review of the EMS ambulance report, the facility failed to provide Stabilizing Treatment within its capacity that minimized the health risks of 14 of 28 patients reviewed, Patient #1, #7, #8, #9, #11, #13, #15, #18, #19, #22, #24, #25, #27 and #28.


Findings include:


On 03/01/2017 the State Office received a complaint from the Office of Attorney General (AG) which stated:
"Date of Alleged Event: 01/07/2017
Standard Notes: Reporter (Patient #1's mother) claims victim was transported from the accident scene to hospital. They checked vitals, but did nothing but put him in a room for three hours. Victims father asked for help after three hours, but with no response. Victim chose to leave the hospital to go to a different facility after three hours.
AG Notes: On February 07, 2017 I (AG Investigator) spoke with (Patient #1's mother) who stated her son (Patient #1) was not treated for three hours. (Patient #1's mother) said they left after three hours and went to a small hospital in (another state directly across the river). (Patient #1's mother) said her son was there for trauma after his vehicle had turned over. (Patient #1's mother) said her son's girlfriend was thrown out of the door of the vehicle and was there for trauma as well. (Patient #1's mother) said her husband was told that they were working on getting around to them, due to only having one doctor in the ER....
Note: On February 15, 2017 I (AG Investigator) spoke with ....Risk Manager at (Hospital #1). (Risk Manager) said Patient (#1) came in through their ER after being involved in a car accident and was triaged by the staff... said the nurse checked in on Patient (#1) on three different occasion(s) before (Patient #1's mother) decided to take her son to another facility for treatment. (Risk Manager) said they have 13 beds and there were nineteen patients in the ER on that night with one physician... said each patient was being monitored by nurses during this time..."
The AG referred the complaint to the State Office for investigation.


An unannounced visit was made to Hospital #1 on 03/07/2017 at 9:40 a.m. An entrance conference was held with the Chief Executive Officer (CEO), the nature of the visit was discussed and what paper work would need to be made available to assist with the investigation.


On 03/07/2017 at approximately 11:30 a.m. a tour of the ED was made with the ED Director. Observation revealed 14 ED beds and five (5) Fast Track beds. EMTALA signs were observed in the hallway and the ED physician on-call list was observed and made available.


Review of Hospital #1's ED Daily Log Detail for 01/07/2017 revealed 80 patients were seen during the 24 hour period in the ED. Four (4) of the 80 patients in that time period left without seeing a physician, without receiving a Medical Screening Exam and without receiving any Stabilizing Treatment. Their wait time was between two (2) hours 22 minutes and two (2) hours 53 minutes.


Review of Hospital #1's Specialty Call List for Emergency Department revealed that on 01/07/2017 they had Physicans on-call for: Hospitalist, General Surgeon, OB/GYN, Oncology, Pediatrics, Orthopedics, Cardiology, Nephrology, Neurology, Ear/Nose & Throat. Othere specialties include Gastroenterologist, Pulmonologist, and Dermatology.


The facility's Registered Nurse Staffing Schedule was reviewed. Six (6) RNs were on the schedule for the P.M. hours on 01/07/2017.


EMS AMBULANCE REPORT REVIEW:

Review of the EMS ambulance report revealed a request for Immediate Response for an ambulance was made on 01/07/2017 at 8:43 p.m. The ambulance arrived at the scene at 9:01 p.m. The report stated that the patient was the restrained driver in a rollover type Motor Vehicle Collision (MVC). At the time of the collision, the air bags did not deploy. The patient complained of posterior ribcage pain. He rated the pain as eight (8) out of 10 pain scale. Patient (Pt) extracted self from vehicle prior to EMS contact. Pt anxious. Would not consent to spinal immobilization. Pt ambulated to stretcher. Vital signs (V/S) were taken and were within normal limits (WNL). Pt would not allow further interventions.


PATIENT #1 ED RECORD REVIEW HOSPITAL #1

Hospital #1 ED record review for Patient #1 revealed the 22-year-old male arrived at the ED by ambulance on 01/07/2017 at 9:03 p.m. following a MVC.

Review of Hospital #1 ED Nurse Documentation revealed:
"Presenting Complaint: ... Brought into ER (Emergency Room/Emergency Department) by ...EMS with report of having been restrained driver of truck and hit a patch of ice in road and lost control of truck. Reports truck rolled sideways. Denies LOC (loss of conciousness). EMS reports patient was ambulatory at the scene. Patient is c/o (complaining of) lower back pain and lower rib pain on both right and left sides. Accompanied by mother... No IV (intravenous) access. Patient not secured on spine board and does not have a C-collar on.
Acuity Level 3
Triage Assessment: Pain: Complains of pain in lower back and right and left lower ribs currently is 6 out of 10 on a pain scale. Quality of pain is described as aching. Pain began suddenly... is intermittent. Aggravated by increased activity... Appears in no apparent distress. (V/S WNL)
21:03 (9:03 p.m.) Patient placed in Exam Room... Family accompanied patient...
21:20 (9:20 p.m.) Verbal reassurance given...
21:40 (9:40 p.m.) Patient is sitting on side of stretcher talking to mother... Awaiting MD visit. Reminded him to call if he needs assistance.
22:09 (10:09 p.m.) ...no apparent distress, resting quietly. Patient's parents in room... Awaiting MD visit. Reminded him to call if he needs assistance.
22:15 (10:15 p.m.) Patient's mother to ER desk inquiring how much longer before the ER MD will be in to see patient. Mother informed that (ED physician) is in the ER and will be in to see the patient but an exact time is not able to be given. Verbalized her understanding.
22:37 (10:37 p.m.) No apparent distress. resting quietly. Awaiting physician initial evaluation.
23:06 (11:06 p.m.) No apparent distress. resting quietly. Awaiting physician initial evaluation. Patient's parents in room. Asked if they would like coffee or anything a nurse can do. Parents deny needing anything other than for the MD to visit... telling patient and parents that he has encouraged (ED physician) to visit them.
23:35 (11:35 p.m.) No apparent distress. resting quietly. Parents remain in room with patient. Continue awaiting (ED physican) visit.
23:51 (11:51 p.m. - two hours and 48 minutes after arrival) Patient ambulatory from ER accompanied by parents. Father reports they are taking patient to (Hospital #2). Again apologized to patient and parents. Father reports being "too long to wait for a doctor!".
Patient left without being seen, after triage, without provider evaluation."

There was no documented evidence that a Medical Screening Examination (MSE) was provided, that any Stabilizing Treatment was provided, or that an appropriate transfer was made.


PATIENT #1 ED RECORD REVIEW HOSPITAL #2

Review of Patient 1's ED "Encounter Summary" at Hospital #2 revealed:
Arrival date: 01/08/2017 Arrival time: 0023:00 (12:23 a.m.)
Chief Complaint(s): Triage complaints are Motor Vehicle Accident (MVA); Back Pain; Shortness of Breath (SOB) MVA lost control of the car, Roll over, the car/truck stopped with passenger side on ground and he was hanging by the seat belt. Ambulatory at the scene.... Was at (Hospital #1) waited for few hours, he was not seen so he came to (Hospital #2), walked in with his parents, in no distress. C/O chest wall pain and back pain...
Chest X-ray - no acute findings
CT (Computer Tomography): Thoracic Spine without contrast - ...mild compression FX (fracture) of T11 Vertebral body with a small avulsed fractured fragment seen near the anterior aspect of the vertebral body. Also there is a minimal compression fracture of T12.
CT: Cervical Spine without contrast - IMPRESSION: Loss of normal cervical lordosis, secondary to muscle spasm versus patient positioning... no other acute findings.
CT: Brain without contrast MVA, Head injury, small laceration of scalp...
Diagnosis: minimal compression FX T11, T12. MVA Acuity:2.
While in the ED Patient #1 began c/o a headache along with his back pain and was given Dilaudid 1 milligram (mg) and Zofran 1mg IV and Adecel 0.5 milliliter (ml) intramuscular.
01/08/2017 04:04 (4:04 a.m.) Pt (patient) out per ....Ambulance Service in stable condition. (Transfered to Hospital #3)
Reason For Transfer - Transfer is medically indicated - Ortho (Orthopedics)
(Ortho not available at this facility)
Documented evidence revealed Patient # received a MSE, Stabilizing Treatment, and an appropriate transfer was made to Hospital #3.


PATIENT #1 ED RECORD REVIEW HOSPITAL #3

Review of Patient #1's ED record from Hospital #3 revealed he arrived via ambulance on 01/08/2017 at 5:28 a.m. and was triaged as a Level 2. His V/S were WNL. He received blood work and CT scans. Received MSE. Diagnosis given was: Unspecified Fracture T7 - T8 Vertebra, closed fracture and Pain located Perispinal thoracic acute. He was prescribed Norco 5/325 tablet by mouth and referred to a Neurologist. He was discharged from Hospital #3 on 01/08/2017 at 7:01 a.m. with instructions to follow up with the referred Neurologist and his Primary Physician.
* It is noted that the Thoracic Spine CT done at Hospital #2 showed the fractures at T11 and T12.


ADDITIONAL INTERVIEWS

On 03/08/2017 at 9:00 a.m. a telephone call was placed to Patient #1. No one answered. A message with a telephone number was left for him to return the call. No return call was ever received.

During an interview with the Chief Quality Officer on 03/08/17 at 9:45 a.m. all concerns identified during ED record review were discussed and a request was made for any additional information available.


On 03/08/2017 at 10:00 a.m. a telephone interview was held with Patient #1's mother, who had been with Patient #1 at Hospital #1's ED on 01/07/2017. Patient #1's mother stated that there was 25 patients in the ED during the time they were there. The patient and parents were in Hospital #1's ED for approximately three (3) hours and during that time Patient #1 was in excrutiating pain. There was one (1) physician in the ED and he never saw Patient #1. She stated that Patient #1 left and went to Hospital #2, where it was determined that the patient had sustained two (2) fractured vertebrae and a scalp laceration. He was then transferred to Hospital #3 by ambulance for additional tests and further treatment. No additional diagnosis was made. The mother stated that Patient #1 has not been able to work since the 01/07/2017 accident and he was instructed that he would not be able to work for three (3) to six (6) months.


On 03/08/2017 at 11:55 a.m. a telephone interview was held with Hospital #1's ED RN #1. She stated that she routinely works night shift in the ED and has for four (4) years. There is usually one (1) physician in the ED and patients are waiting when he arrives. Their ED physicians are contract. RN #1 did not remember Patient #1's visit to the ED on 01/07/2017.


On 03/08/2017 at 2:30 p.m. Hospital #1's ED Physician #1 was interviewed over the telephone. Patient #1's complaint and the date he was in the ED were discussed. The physician stated that he did not remember the patient.


On 03/08/2017 at 2:45 p.m. all findings were reviewed during the exit conference with Hospital #1's Chief Nursing Officer, Chief Quality Officer, Compliance Officer, Director of Operations and Chief Executive Officer. No additional information was provided for review.


On 03/20/2017 at 11:00 a.m. another telephone call was placed to Patient #1. No one answered. A voice message with a telephone number was left for him to return the call. No return call was ever received.


ADDITIONAL ED RECORD REVIEWS - HOSPITAL #1

Patient #7: ED record revealed this 2-year-old male patient was carried into the ED by the mother on 12/23/2016 at 7:49 p.m. The mother complained of the patient had been vomiting since 1:30 p.m. without diarrhea or fever. The acuity level was 3. The patient's vital signs (V/S) were taken and were WNL and the patient was placed in an examination room at 9:51 p.m. The patient was observed at 9:54 p.m., 11:00 p.m., and 12:01 a.m. by an ED nurse. The patient left without being seen by a physician on 12/24/2016 at 1:18 a.m. after a five (5) hour and 28 minute wait. No medications had been administered. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. An unsuccessful attempt was made to contact Patient #7's mother by telephone on 03/17/2017 at 10:20 a.m.


Patient #8: ED record revealed this 58-year-old male patient, arrived at the ED ambulatory on 12/23/16 at 8:24 p.m. with complaints of chronic right hip pain. No documented pain scale. Acuity level was 4. The patient's vital signs were documented at 8:38 p.m. An arm band was placed on the patient at 8:40 p.m. The next observation note was at 11:41 p.m. It stated "Patient Rounding: No answer when name called X 3. Patient has left the ER waiting room." The patient had waited three hours and 14 minutes. No MSE was provided. No Stabilizing Treatment was provided. An unsuccessful attempt was made to contact Patient #8 per telephone on 03/22/2017 at 10:00 a.m.



Patient #9: ED record review revealed this 6-year-old female patient arrived with both parents at the ED on 12/19/2016 at 10:51 p.m. with complaint of abdominal pain. The pain started the night before. The patient's acuity level was 3. The patient complained of pain in left upper quadrant. The pain was rated 10 out of 10 on a pain scale. V/S WNL. Orders were obtained for a urinalysis and urine culture and was collected from the patient for urinalysis and culture at 11:14 p.m. The urinalysis report interpretation was: Urine Urobilinogen was one (1) plus; urine leukocytes were one (1) plus; urine white blood cells were 1-3. At 12:45 a.m. Patient #9 was waiting for a room to become available. The next note at 2:18 a.m. stated the patient was not in the waiting room when called and was not found outside. This was three (3) hours and 27 minutes after being checked in. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. An unsuccessful attempt was made to contact Patient #9's mother by telephone on 03/17/2017 at 10:30 a.m.


Patient #11: ED record review revealed this 53-year-old patient arrived ambulatory at the ED on 12/13/2016 at 9:53 p.m. with the complaint of aching all over for months. The patient also stated "feel like I am gonna fall out sometimes.". The patient's acuity level was 3. Her blood pressure was 174/100 at 10:09 p.m. and was not rechecked. The patient rated pain at five (5) out of 10 on a pain scale. Quality of pain was described as aching. The patient was placed in the waiting room on 12/14/2016 at 12:12 a.m. and complained of pain in back of legs currently is eight (8) out of 10 on a pain scale. The patient left the ED at 1:05 a.m. The patient reported being tired of waiting and no longer wished to wait. The patient left without being seen by ED physician after a three (3) hour and 12 minute wait. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 10:45 a.m. a telephone conversation was held with Patient #11. She stated that she left the ED after 1:00 a.m. on 12/14/2016 because "... it makes no sense. They take too long." She also stated that she went to her primary physician on 12/14/2016 and he diagnosed her with Arthritis.


Patient #13: ED record review revealed this 9-month-old male patient arrived at the ED on 02/09/2017 at 2:33 a.m. carried by mother with complaint of fever since last night. The mother reported giving the patient Tylenol 30 minutes prior to arrival. V/S were WNL. The patient's temperature was 98.6 degrees Fahrenheit (F) at 2:42 a.m. Acuity level was 4. Orders were obtained for: Rapid Strep test; and Influenza A-B, AG, EIA at 2:48 a.m. The specimens were sent to the lab at 2:52 a.m. The test for Influenza was positive. At 3:23 a.m. the parent was informed staff would return to the room in 30 minutes. At 4:59 a.m. the family and patient continued to wait for ED physician initial evaluation. At 5:58 a.m. "Patient left without being seen after triage, without provider evaluation." The family was instructed on treatment of flu and encouraged to return to ER or pediatrician for follow-up. The patient left the ED at 6:01 a.m., three (3) hours and 25 minutes after check-in. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 11:00 a.m. a phone conversation was held with the patient's mother. She stated that they waited almost four (4) hours to see a doctor in the ED on 02/09/2017 and never saw one, so she took her son and left. She visited his primary physician the same day.


Patient #15: ED record review revealed this 18-year-old female patient arrived at the ED ambulatory on 02/08/2016 at 7:54 p.m. The patient complained of pain in the right and left upper quadrants of the abdomen. The patient states that she just found out that she was pregnant and her mother kicked her in the stomach three (3) times because she refused to have an abortion. The patient's V/S were documented. The acuity level was 3. Last menstrual period was 12/20/2016. The patient was placed in a waiting room at 8:05 p.m. Pregnancy was verified at seven (7) weeks and two (2) days. The patient left the ED without being seen at 11:42 p.m., three (3) hours and 47 minutes after check-in. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 11:25 a.m. a telephone conversation was held with the patient's mother. She stated the patient no longer lived with her, she had no new telephone number for her and she did not know if Patient #15 saw another provider on that day or on the next day for her complaint. She stated that she would tell her daughter to return the phone call. No return call was received.


Patient #18: ED record review revealed this 7-month-old male patient was carried into the ED by his parents on 02/06/2017 at 9:37 p.m. The mother stated the infant was coughing, congested, and had a fever since earlier that morning. The patient's acuity level was 4. The patient's temperature was 99.0 degrees Fahrenheit (F) at 9:43 p.m. The patient left the ED on 02/07/2017 at 12:43 a.m., three (3) hours and six (6) minutes after check-in. No reason for leaving was documented. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 11:35 a.m. an attempt was made to contact the patient's mother by telephone. The patient's godfather answered the call, stated he knew nothing about the ED visit, and would have the mother return the call. No return call was received.


Patient #19: ED record review revealed this 8-month-old male patient arrived at the ED by ambulance on 02/06/2017 at 9:40 p.m. with complaint of fever. The patient's acuity level was 4. The patient's temperature was 100.4 degrees F at 9:50 p.m. The next note on 02/07/16 at 12:42 a.m. stated the patient left the ED. This was three (3) hours and two (2) minutes after check-in. The reason the patient left was not documented. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 an unseccussful attempt was made to contact Patient #19's mother by telephone. A voice message was left. No return call was received.


Patient #22: ED record review revealed this 25-year-old female patient ambulated into the ED on 01/16/2017 at 9:45 p.m. The patient complained of frontal headache, bilateral leg swelling, high blood pressure, and difficulty walking. The Acuity level was 3. The patient rated pain at seven (7) out of 10 on pain scale. At 11:01 p.m. the patient was given a warm blanket and lights were dimmed. At 12:00 a.m. the patient was observed sleeping. The patient's blood pressure ranged from 143/97 at 9:08 p.m. to 114/73 at 1:20 a.m. The patient inquired about wait time on 01/17/2017 at 1:22 a.m. At that time the patient was updated on acuity in the ED. The patient verbalized understanding and stated symptoms had improved. The patient chose to leave without being seen. The patient was given verbal discharge instructions to follow with her personal physician and return if symptoms persisted or got worse. No medications were given. The patient left without being seen at 1:20 a.m., four (4) hours and 35 minutes after check-in. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 an unsuccessful attempt was made to contact this patient by telephone. A voice message was left. No return call was received.


Patient #24: ED record review revealed this 18-year-old female patient ambulated into the ED on 01/17/2017 at 11:23 a.m. with complaint of pain all over. The patient's acuity level was 3. The patient complained of: headache, neck, back, and shoulder pain for two (2) days after a MVC. The patient rated pain at 10 out of 10 on a pain scale. The patient's blood pressure was 150/99 at 11:30 a.m. and was not rechecked. On 01/18/2017 at 12:17 a.m. and 12:49 a.m. ED documentation stated, "Awaiting ED physician initial evaluation." At 1:25 p.m. the patient was informed that staff would return (to room) in 30 minutes. The patient left without treatment at 2:29 p.m., after a three (3) hour and six (6) minute wait without seening a physician. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 2:10 p.m. a phone call was placed to the patient. Her phone was no longer a working number. Placed a call to Patient #24's mother at 2:15 p.m.. Her mother said that even though she (Patient #24) was still hurting, she left the ED after waiting about three (3) hours and never saw a doctor. She returned to Hospital #1's ED the next day with continued pain, was diagnosed with a ruptured appendix and had surgery to have appendix removed.

On 03/20/2017 Hospital #1 was contacted twice regarding Patient #24's return visit to their ED. The hospital had no documented evidence that this patient returned to their ED on or around 01/17/2017, or had inpatient or outpatient surgery of any kind in that time period. On 03/20/2017 at 1:30 p.m. an interview was held with Patient #24 by telephone. She confirmed that she went back to Hospital #1's ED on 03/18/2017, was told her appendix had ruptured and had surgery to remove her appendix. When asked if she was sure it was Hospital #1 that she went back to she stated, "Yes."


Patient #25: ED record review revealed this 58-year-old female patient ambulated into the ED on 01/16/2017 at 9:07 p.m. with complaints of chest pain. The acuity level was 3. The patient complained of: epigastric pain, chest tightness, diarrhea, nausea and vomiting. The patient complained of pain in the xyphoid area at three (3) out of 10 on a pain scale. At worse was six (6) out of 10. Orders were obtained for: EKG (done at 9:18 p.m.), chest x-ray; Troponin I, Thromboplast, Prothrombin Time; Natriuretic Peptide; ISTAT Troponin; CPK total; CPK MB Fraction; Complete Metabolic Panel; and Complete Blood Cell Count at 9:33 p.m. A cardiac monitor, oxygen, and continuous pulse oxometer monitoring were provided at 10:00 p.m. A chest x-ray impression was documented as WNL. A saline lock was inserted and blood collected for lab tests at 10:02 p.m. At 10:53 p.m. the patient reported all symptoms were resolved, except for some mild chest tightness that she stated was her anxiety. The catheter lock was discontinued, bleeding controlled and a dressing was applied on 01/17/2017 at 12:07 a.m.. The patient's blood pressure decreased from 172/88 at 9:28 p.m. to 106/66 at 12:08 a.m. The patient left without being seen on 01/17/2017 at 12:08 a.m., after a three (3) hour and one (1) minute wait without seeing a physician. There was no documented evidence that a MSE or any other Stabilizing Treatment was provided. On 03/17/2017 at 2:40 p.m. the patient was interviewed via telephone. She stated that the ED was very busy that night, but "was never this bad until they were bought out." She stated that the nurse told her before she left without ever seeing a doctor that her blood work was ok but her EKG was irregular. The next day she called her primary physician and told him of the incident. He requested her EKG from Hospital #1, received it and reviewed it. He scheduled Patient #25 to have a cardiac catheter done due to the irregular EKG.


Patient #27: ED record review revealed this 43-year-old female patient arrived at the ED on 01/07/2017 at 4:04 p.m. The patient complained of abdominal pain that began 2-3 days prior to arrival. The acuity level was 3. The patient reported having a colon resection and hysterectomy on 12/29/2016. The incision was red, no drainage, but pain with bowel movement. At 5:23 p.m. the patient rated her pain nine (9) out of 10 on a pain scale. At 6:58 p.m. the patient was not found in her room. It was reported that the patient left the ED to go to see her doctor after waiting two (2) hours and 53 minutes without seeing a physician. There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/17/2017 at 3:15 p.m. Patient #27 was interviewed via telephone. She stated that after she waited almost three hours without ever seeing a doctor she left and went to Jackson the next day to see her doctor. "This happens all the time at this hospital. Last year they told me I had a stomach bug and sent me home. I had Stage 4 Colon Cancer."


Patient #28: ED record review revealed this two year old female patient arrived in her mother's arms at the ED on 01/07/2017 at 11:13 p.m. She was triaged with an Acuity Level of 3. Mother stated the child drank about 4 ounces of Benadryl at 2130 (9:30 p.m.), was seen at Hospital #2 earlier and was given charcoal. Hospital #2 was going to send her to Hospital #3 so the mother signed the patient out and came to Hospital #1 for treatment. At 11:48 p.m. Poison Control was notifed. They directed hospital staff to observe, not a toxic dose. On 01/08/2017 at 1:43 a.m. patient left without being seen after a two (2) hour and 30 minute wait. "MD had not been in the room to see patient. Family ready to leave." There was no documented evidence that a MSE or any Stabilizing Treatment was provided. On 03/21/2017 at 3:45 p.m. an unsuccessful attempt was made to contact the patient's mother by telephone. A voice message was left. No return call was received.


Wait time for these 14 patients at Hospital #1's ED, prior to leaving without seeing a physician, without a receiving a MSE, and without receiving Stabilizing Treatment, was from two (2) hours 30 minutes to five (5) hours 28 minutes.


POLICY AND PROCEDURE REVIEW

Review of Hospital #1's "EMTALA Medical Screening Stabilizing Policy" (revision date: 9/1/2013) revealed: "Introduction: All individuals presenting on Hospital property requesting emergency medical services, individuals presenting to a Dedicated Emergency Department requesting emergency medical services, and patients arriving/presenting via ambulance requesting medical services shall receive an appropriate Medical Screening Examination and Stabilizing services as required by the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C. Section 1395 and all Federal regulations and interpretative guidelines promulgated thereunder.
Medical Screening/Stabilization - General Requirements: ...when an individual comes,... to the Dedicated Emergency Department of the Hospital and a request is made on the individual's behalf for a medical examination or treatment, the Hospital must provide an appropriate Medical Screening Examination within the capability of the Hospital (including ancillary services routinely available in the Dedicated Emergency Department and emergency services offered at outpatient departments or facilities) to determine whether an Emergency Medical Condition exists...
Medical Screening Examination Requirements... 3. ...Triage is not equivalent to a Medical Screening Examination...


Review of Hospital #1's "Emergency Department Policy Section N" (review date: February 2012) revealed: "Purpose: All patients will receive medical screening by Emergency Department physician. Objectives: Provide initial triage and treatment of all patients. Provide adequate and appropriate licensed staff to meet the needs of the patient census 24 hours a day..."


Review of Hospital #1's "Medical Staff Coverage" policy (reviewed July 2013) revealed: "...Policy: The Emergency Department is staffed with a full time emergency physician, or his temporary physician designee, 24 hours daily, 365 days per year. The physician will be available in the emergency department at all times. He is responsible for providing immediate emergency care on all patients needing such and will also evaluate non-emergency problems in his respective areas of expertise as an extension of service to the private physician when asked to do so. Patients requiring admission to the hospital will be referred to their private physician or the Hospitalist. Admission orders may be written by the Emergency Physician at his discretion.


Review of Hospital #1's "Triage in the Emergency Department" policy (effective 12/31/15) revealed,"... Policy:... 3. Acuity Levels... Level 1 - Requires immediate life-saving intervention; Level 2 - High risk situation...; Level 3 - Requires many resources...; Level 4 - One resource required; Level 5 - No resources required.. 7. Patients presenting with a pregnancy related problem will be medically screened by the Emergency Department Physician or Advanced Practive Nurse... b. OB patients involved in trauma will be treated by Emergency Department Physician per hospital trauma guidelines with consult for OB evaluation..."

Review of the hospital's "Scope of Service - Emergency Department" policy (Reviewed July 2013) revealed: " ...Patient Population: ... Scope and Complexity of Patient Care Needs: All patients that present to NRMC Hospital's premises for a non-scheduled visit and are seeking care shall receive a medical screening exam by an Emergency Department physician that includes providing all necessary testing and on-call services within the capability of NRMC Hospital to reach a diagnosis. Support services including but not limited to clinical laboratory studies and x-rays will be provided to the patient in a timely manner. An on-call list of specialty physicians is maintained to assist in stabilizing patients. All definitive treatment will be given to the patient within the hospital's capabilities ..."


Review of the hospital's "Emergency Services" policy (Reviewed Feb 2012) revealed, "Policy: ...The Emergency Department is classified as a Level IV department ... Procedure: This hospital will provide emergency medical screening and stabilizing treatment, as necessary, to all individuals "coming to the Emergency Department", ..."


Review of the hospital's "Purpose and Objective" policy (Reviewed Feb 2012) revealed, "Purpose: ...All patients will receive a medical screening by the Emergency Department Physician ... Objectives: ...Provide adequate and appropriate licensed staff to meet the needs of the patient census 24 hours a day. Provide treatment to patients within a reasonable period of time ...



CONCLUSION:

EMTALA violations were cited for the facility's failure to ensure Patient #1, #7, #8, #9, #11, #13, #15, #18, #19, #22, #24, #25, #27 and #28 received a Medical Screening Examination from a physician while in their facility and failure to ensure the patients received Stabilizing Treatment,

1. A2400 - comply with 489.24
2. A2406 - provide Medical Screening Exams
3. A2407 - provide Stabilizing Treatment