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Based on review of medical records, incident report, chest pain protocol, trespass warning notice, and Sheriff case reports and staff interviews the facility failed to ensure that appropriate medical screening examinations were provided within the capability of the Emergency Department for 2 of 23 sampled patients (# 3 and #23). See findings in Tag A-2406.

Based on review of medical records, incident report, chest pain protocol, trespass warning notice, and Sheriff case reports and staff interviews the facility failed to ensure that appropriate medical screening examinations were provided within the capability of the Emergency Department for 2 of23 sampled patients (# 3 and #23).

Findings include

A review of the clinical record for Patient #3, completed on 5/23/11, revealed the following:
The patient has a previous history of pulmonary fibrosis ( this occurs when lung tissue becomes damaged and scarred.)and hypo plastic right lung (developmental abnormality of the lung... frequently associated with with malformations of the ...musculoskeletal systems). He does not have a primary physician. On 5/12/11, Patient #3 presented to the emergency room at 10:41 a.m., with complaints of back pain. At 11:09 a.m., he was triaged as a "3" with a stated pain level at 10 of 10. He was taken to room #1 after the initial nursing assessment was completed.

"Patient Notes" noted at:
11:20 a.m., states "Pt Ambulating about in exam room without difficulty"
11:25 a.m., states "ARNP (Advanced Registered Nurse Practitioner) _____in to assess"
11:35 a.m., states "Pt ambulatory to ER (Emergency Room) nurses desk with a brisk, steady, upright gait demanding to have information written down for him. ________ (ARNP) informs patient that he would not let her continue with the examination and became hostile with her using many profanities. Pt then turns and says "how do I get out of here?" and starts pacing with a steady, brisk, upright gait. Pt requests for the ER Director name and phone number, card provided with this information. Pt thankful and is let out of the ER, Pt leaves ER with steady, brisk upright gait." Pt left area at 11:40 a.m.

Review of the ARNP assessment dictated 5/12/11 at 11:41 a.m., notes she was not allowed to finish a single question and he would not allow her to discuss with him his situation, was very argumentative. She also writes he is very frustrated because he does not understand what is going on related to his back pain. He refuses further evaluation and management in the emergency room. She then writes we had to call security to ensure that he leave the emergency room in a safe and calm manner. On 5/19/11 at 1:00 p.m., an interview with the Risk Management revealed her conversation with the hospital security found that security was not called or notified as noted in the ARNP assessment. They (Security)did not get involved with the situation until Patient #3 had left the facility when they were given the information needed to file a no trespassing with the sheriff's department against Patient #3.
Review of an incident report written by the Emergency Room Director (ERD). Patient #3 was in the emergency room department on 5/12/11 related to back pain. The Nurse Practitioner (NP) tried to provide education to the patient when he became verbally threatening to her. The ARNP left the room as she felt uncomfortable from a safety aspect. The patient went to the nurses' station wanting his written report but the ARNP explained to him that she was unable to finish the medical screening because the patient became threatening. This conversation was witnessed by several of the emergency room personnel (names unknown). The patient then left and went to administration to talk with the writer (ER Director). The incident report goes on to say after the patient left her office she talked with the ARNP and since the ARNP felt unsafe, she notified security to issue a no trespassing warning that was served by the sheriff's department at the patient ' s home.
Review of the trespassing warning dated 5/12/11 times 1325 (1:25 p.m.) it states ' Do not return or face arrest ' . The complaint was signed by hospital security.
Review of the sheriff case report dated 5/12/11 at 1315 (1:15 p.m.) the officer arrived at the hospital when hospital security informed them they wanted a no trespassing against Patient #3 because he had threaten a nurse and they did not want him to return. The officer also wrote he was advised by Patient #3 that he was treated badly at the hospital and he had filed a complaint with the hospital about his treatment.
On 5/19/11 at 2:30 p.m., after several interviews with the Emergency Room Director (ER Director) and after she was able to read her incident report dated 5/12/11 time stamped 1338 (1:38 p.m.) she stated her incident report is accurate as to how the event unfolded on 5/12/11. Her involvement in the incident with Patient #3 started when he walked into administration looking for her. She stated she talked with him in her office and he explained that he was in the emergency room (ER) and the Nurse Practitioner (NP) would not help him and did not give him his discharge papers and he wanted to file a complaint about the way she treated him in the emergency room. The NP stated that during the interview with Patient #3 she called the ER and they informed her the patient had gotten upset with the staff and was verbally abusive to the NP. She stated she told him since the NP could not finish the exam in the ER there were no discharge papers to give him at this time. She further stated he was upset but left the building and went home. She then went to the ER to gather further information about the incident, talked with administration and decided to issues a no trespassing order against Patient #3. When asked if she had any written document or statements from the ER staff involved with Patient #3 she said " no. " When asked if Patient #3 was verbally abusive to her or anyone in administration, she said " no. " She did say Patient #3 did use profanities when he was talking to her and his voice was high but he was not verbally abusive to her. She also stated security was not involved in the incident until she gave them the information needed to call the sheriff department to issue a no trespassing to Patient #3.
On 5/19/11 at 3:00 p.m., an interview was held with the Administration Assistant (AA) and the Risk Manager. The AA stated she was not involved with Patient #3 on 5/12/11 but she did hear he had called a couple of times. She stated he had called at least 5 times and she had talked with him 3 of those times. He wanted to talk with the Chief Executive Officer of the hospital to explain his side of the story and file a complaint. She stated she had informed the administration and ER Director and was informed to tell Patient #3 he had to talk with the ER Director if he had concerns (which he had already done).
Review of the Grievance Log revealed there were no complaints/grievances listed for Patient #3.
On 5/ 19/11 the surveyor was not able to interviewed the ED charge nurse ___________ because she was out of the country. On 5/19/11 and 5/20/11 the surveyor was unable to interview the ARNP because she was not working on those days and was not able to do a phone interview until Monday 5/23/11.
On 5/20/11 at 2:30 p.m., an interview was conducted with the security guard who was not on scene, at the time of the issues, and wrote the incident report dated 5/12/11. The report related to Patient #3 and information given to him from staff (ED Director). He was actually not on scene until 1325 (1:35 p.m.). His report stated " about 12:15 p.m., Patient #3 swore and became verbal abusive with the NP while she was getting his medical history and he threatened her. She was afraid and left the room. " The patient left the ER at 12:00 p.m. After his visit to the area, the security guard called the sheriff ' s department to issue a no trespassing warrant. He stated he was called by the emergency room charge nurse but was unable to explain why she had not charted that call in Patient ' s #3 medical records. He also stated the first time he heard about the incident was when the ER Director had given him the information needed for the no trespass warning.
On 5/20/11 at 2:50 p.m., an interview with _____________RN an emergency room nurse working on 5/12/11 revealed she did not observe what happen in exam room #1 but she had seen the ARNP at the nursing station and Patient #3 had walked up to the nursing station and was using profanity. She stated there was several emergency room personnel around the station and we all stopped to observe the interaction. She also stated Patient #3 took a step inside the nursing station and the ARNP told him not to do that and he stopped. He appeared to calm down so the staff went about their tasks. She stated no one stepped in to talk with the patient but she thinks the charge nurse did talk to him afterwards.
On 5/20/11 at 3:30 p.m., an interview was conducted with Doctor ________, the emergency room physician who was in charge on 5/12/11 during the incident. He stated he did not know what happen until later on that day when the ARNP told him of the incident. He stated no one had asked him to intervene in the situation or to finish the assessment for the ARNP because Patient #3 was using profanity. When asked if the patient had become violent and threatening, why they did not Baker Act him he stated he would only Baker Act a patient if they were a danger to themselves and he would call the police if they were a danger to the staff or other patients in the emergency room.
On 5/23/11 at about 11:30 a.m., an interview was conducted with the ARNP related to this case. She was asked to recount the events of 5/12/11 and they were fairly close to what is documented above. She was asked what her examination of the patient revealed and she stated, "I never touched the patient. All I did was reach over and tie his gown since they always fall off if not tied." She stated, "he was threatening and I was afraid for myself so I left the room." She stated the room is small and the patient was sitting in a chair against the wall so when she arrived, she sat on the stretcher with very little room between herself and the patient. She stated the patient stood up and she asked him to sit back down. When he did not sit down, she felt threatened as he "towered over her" (Patient is 5 ' 9 " weighing 150lbs) so she backed out of the room and went to the nursing station. She was asked if she went to get someone else to come back to the room with her she said "no," the room was too small for three people. She was asked if she notified the physician she had not conducted a medical screening exam on this patient and she stated "no." She continued by stating the patient was just anxious and scared. "He really was a very nice man, he just wanted answers." When asked to explain further she stated, "He came in with MRI films and he wanted me to look at them and tell him what they said. I explained we do not read films; he would have to wait until he saw his physician to get the results. He was insistent that he needed to know what the plan was for his pain. He started to become loud and his language was inappropriate, I was frightened." She stated she did not make any offers to examine him nor did she offer any remedies for the relief of his pain. She stated he was not here for pain, he wanted his films read. Patient #3 did not receive his medical screening exam. No treatment for the relief of pain was given/offered. The ARNP documentation is inaccurate. She stated she never touched the patient yet dictated a history and physical exam which are present in the clinical record. The ARNP did not advise the physician in charge of any issues until after the patient left the facility. She did not ask him (ED Physician) to complete the exam/screening.
2. Patient #23 did not receive a complete medical screening exam.
Patient #23 arrived at the facility with complaints of chest pain on 5/21/11 at 1447 (2:47 p.m.). At 1455 (2:55 p.m.) an EKG was administered. At 1503 (3:03 p.m.) she was placed in an exam room. Original nursing assessment (at 3:30 p.m.) revealed a history of MI, Cardiomyopathy, and anxiety.
Results from EKG: Normal sinus rhythm with sinus arrhythmia; ST & T wave abnormality, consider lateral ischemia; Prolonged QT; Abnormal ECG; When compared with ECG of 12/11/10; ST now depressed in inferior leads; inverted T waves have replaced nonspecific T wave abnormality in Anterolateral leads; QT has lengthened; Confirmed by Dr._________at 6:56 p.m.
Patient left the facility at 1723 (6:23 p.m.) without any further intervention by staff.
Interview with the ER Director on 5/24/11 at about 2:30 p.m., revealed she did not have any knowledge of this event. After her review of the clinical record, she stated, " your right, we missed this. " When asked what should have happened when a patient arrives with complaints of chest pain, she stated " we have a chest pain protocol the staff is to follow. "
At about 2:45 p.m., on 5/24/11, the ER Director presented a copy of the chest pain protocol which is as follows:
1. Stat EKG - 12 leads
2. Stat CBC with 6 part differential
3. Stat Comprehensive metabolic panel
4. Stat Creatine phosphokinase
5. Stat Lactic Acid Dehydrogenase
6. Stat Lipid Profile
7. Stat Magnesium
8. Stat Phosphorus
9. Therapeutic Protime
10. Stat PTT
11. Stat POC Ed Cardiac Profile
12. Stat Lactic Acid
13. Stat Chest (X-ray) portable

The only portion of the protocol followed was the Stat EKG which showed pronounced changes. There was no contact with a physician to do a medical screening exam. The patient left without being seen by a physician and not having the protocol for chest pain followed, after approximately 3 ? hours (from 2:47 p.m., until 6:23 p.m., when she left.). The facility failed to ensure that their chest pain protocol was followed to ensure that patient #23 received an appropriate medical screening examination on 5/21/2011.