HospitalInspections.org

Based on review of facility documents and staff interviews (EMP), it was determined that the facility failed to document on its central log an individual who came to the emergency department seeking assistance (PT1).

Findings include:

Review of "Emergency Medical Treatment And Active Labor Act ... Review/Revise Dates: ... March 2009" revealed "IV. Guidelines ... G. Central Log Requirement A central log must be maintained for the hospital's dedicated emergency departments. The central log must include information on those individuals who 'come to the emergency department' ... The hospital has the discretion to maintain the log in a form that best meets the needs of the hospital."

1) Interview with EMP1 on August 31, 2011, at approximately 9:45 AM confirmed that PT1 presented to the Emergency Department (ED) on August 17, 2011, at approximately 12:30 AM. Further interview with EMP1 revealed " ... The [patient] was on the cart in the ED ... The physician talked to the mother and the child ... The physician recommended that the patient go to Westmoreland [Regional Hospital] ... The physician did not actually ever lay hands on the patient ... The mom agreed to take them to Westmoreland ... The [patient] never got registered ... There was no chart ... [the patient] was not logged in.

2) A review of the Emergency Department central log, for the period of August 16, 2011, through August 17, 2011, revealed no documentation that PT1 was entered in to the central log.

Based on review of facility documents and staff interviews (EMP), it was determined that the facility failed to provide a medical screening exam for a patient that presented to the Emergency Department (PT1).

Findings include:

Review of "Emergency Medical Treatment And Active Labor Act ... Review/Revise Dates: ... March 2009" revealed "II. Definitions ... D. Medical Screening Exam (MSE): A medical Screening Exam requires the facility to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. Depending on the patient's presenting symptoms, the medical screening examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing procedures and ancillary studies over a period of time such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans, and/or diagnostic tests and procedures. ... III. Policy Statement It is the policy of Excela Health, Frick Hospital to provide a medical screening examination to all individuals seeking an examination or treatment for a medical condition at our dedicated emergency department ... The medical screening exam will be conducted by a qualified individual(s) to determine if an emergency medical condition exists. ... IV. Guidelines A. Medical Screening Examination (MSE) (i.) A medical screening examination by a a qualified medical person will be offered to determine if an emergency medical condition exists for individuals who present: a. to the hospital's dedicated emergency department ... and request examination or treatment (or such a request made on his/her behalf) for medical condition."

Review of "Rules And Regulations Of The Excela Health Medical Staff ... Revised: 9/16/2010" revealed "I. Admission And Discharge Of Patients ... n. Patients presenting to the Emergency Department - when an individual presents to the emergency department, an appropriate medical screening examination must be provided within the capability of the hospital's emergency department, to determine whether or not an emergency medical condition exists."

1) Interview with EMP1 on August 31, 2011, at approximately 9:45 AM confirmed that PT1 presented to the Emergency Department (ED) on August 17, 2011, at approximately 12:30 AM. Further interview with EMP1 revealed " ... The [patient] was on the cart in the ED ... The physician talked to the mother and the child ... The physician recommended that the patient go to Westmoreland [Regional Hospital] ... The physician did not actually ever lay hands on the patient ... The mom agreed to take them to Westmoreland ... The [patient] never got registered ... There was no chart ... [the patient] was not logged in.

2) Review of an ambulance trip sheet for PT1 revealed "August 16, 2011 ... Arrived to find a [patient] complaining of bleeding from the mouth. Pt's mother stated that '[patient] had tonsillectomy last Thursday. Pt. then coughed and then began to bleed.' ... Loaded pt. and departed enroute to Frick Hospital per [the patient's] mother's request. Arrive at Frick Hospital and the ED Dr. informed us that 'they would not be able to treat the pt. and that we would have to transport the pt. to Westmoreland Regional Hospital.' Loaded pt back into ambulance and transported to Westmoreland Regional Hospital ... Arrived at Frick Hospital ED. Moved pt. inside via stretcher. Upon entering ED, we were informed by ED Dr. that 'they had no ENT (ear, nose, and throat) Dr. and they could not treat our pt.' Dr. then stated that 'we needed to transport pt. to Westmoreland Regional Hospital because the Dr. that performed the pt's surgery would not see our pt. at Frick."

3) Interview with EMP2 on August 31, 2011, at approximately 12:35 PM revealed "At around 12:30 AM I cam out to the nurses station and they said we got a call from Pittsburgh Medical Command about a post-tonsillectomy bleeding ... They came in through the treatment area and pulled up on front of the sink ... The patient was in no distress ... I told them that [other physician] is not on staff and does not come to this hospital and that we did not have an ENT on call that day ... I told them that it would be better for [patient] to go to Westmoreland where [the patient] had the surgery ... The mom said OK and the paramedics and the mom left ... We should have done the paperwork ... We should have done all the proper documentation ... I went and saw [patient]. [Patient] was not bleeding ... I did not do a complete physical exam."