HospitalInspections.org

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that Conemaugh Memorial Medical Center failed to provide stabilization and treatment of emergency medical conditions in two of 16 patients, by failing to reassess vital signs and pain scores, and to provide patients with pain relieving medications. There is also evidence that the current registration processes may unduly discourage individuals from receiving stabilizing treatment.


Findings:

Conemaugh Memorial Medical Center ... PolicyStat ID: 1970090 ... Policy Area: Organizational-Clinical ... Patient Rights policy and procedure dated December 2015. "Statement of Policy: It is the policy of Conemaugh Health System (CHS) to respect the rights of patients during their hospitalization and to recognize that each patient is an individual with unique health care needs. Staff will provide considerate, respectful care, incorporating personal values and belief systems and strive to protect each patient's dignity. ... A Statement of the Patient's Rights ... 9. You have the right to high quality care and professional standards that are always kept and reviewed. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid personal discomfort. ... 25. You have the right to voice questions, concerns, or comments to your health care provider, to the Patient Representative at the hospital or you may contact the Pennsylvania Department of Health, Acute and Ambulatory Care Services, ... ."


Patient handbook entitled "A Guide for Patients & Visitors Conemaugh Memorial Medical Center" revealed, "... Pain Control. An important part of care at Conemaugh Memorial Medical Center is keeping your pain under control. ... Our staff will be asking you about your pain on a routine basis. ... The staff will teach you how to use the 0-10 pain scale to describe your pain. Please do not wait until your pain is above the moderate range (4 and above) and severe before you request relief. It is much harder to ease pain once it becomes severe. If your pain is not tolerable or you are having problems with your pain treatment, please tell your doctor or nurse. We may not be able to take away all of your pain. We will safely treat your pain and work to keep your comfortable. ... Facts About Pain and Medication We will attempt to manage you pain using several different methods. Strong pain medications are not always needed. Pain medications, when given with supervision, are safe and effective. We can treat any side effects that may occur from taking pain medications. ... Our goal is to keep you comfortable and safe. After your pain medication is given, we may need to awaken you to check your pain level and breathing to make sure you are not too sleepy. ... Patient Rights and Responsibilities ... You have the right: ... To treatment of symptoms that may be associated with your illness. To expect prompt response to your report of pain. ... ."


Conemaugh Memorial Medical Center ... PolicyStat ID: 5365331 ... Policy Area: Emergency Department ... DEM Vital Sign Assessment policy and procedure dated September 2018. "... Documentation of Vital Signs/Patient Assessment Protocol ... 6. ESI Level 3 patients who have had a Medical Screening Exam (MSE) by a qualified medical provider should have vital signs documented at a minimum of ever 120 minutes, or per provider order. The last set of vital signs before patient departure should be captured within 30 minutes of leaving the DEM. ... ."


Conemaugh Memorial Medical Center ... PolicyStat ID: 6647837 ... Policy Area: Emergency Department ... DEM Vital Sign Assessment policy and procedure dated July 2019. "... Documentation of Vital Signs/Patient Assessment Protocol ... 4. The following guidelines are based upon the initial Emergency Severity Index (ESI) score and are the minimum requirements for assessment of vital signs . However, vital signs should be performed more frequently if the patient's condition warrants more frequent assessments including changes in condition, provider request, or clinical judgement. ... 3. ESI Level 3 patient who have had a Medical Screening Exam (MSE) by a qualified medical provider should have vital signs monitored and documented at a minimum of every 120 minutes, or per provider order. The last set of vital signs before patient departure should be captured within 30 minutes of leaving the DEM. ... ."


LifePoint Health ... PolicyStat ID: 5139237 ... Policy Area: Clinical Operations-Emergency Department ... CO 008 Assessment/Reassessment policy and procedure dated August 30, 2018. "Scope: This policy applies to all subsidiaries and affiliates ... Purpose: To provide assessment and reassessment guidelines for initial evaluation, continued monitoring, and/or changes in patient acuity levels according to severity of illness or injury. Definitions: Triage--'Triage' is a process for sorting patients based on physiologic and psychologic variables and historical factors to determine the order in which patients will be evaluated by a provider. The process of triage is completed by a qualified RN and utilizes the Emergency Severity Index (ESI) 5 level tool to assign a triage acuity level. When a patient presents to the emergency department (ED), a quick registration and rapid initial assessment to determine ESI level will be completed, and the patient will be placed in the appropriate treatment or waiting area. While the initial triage acuity never changes, patient condition might, and reassessment following acuity assignment is a dynamic process. Rapid Initial Assessment--The process of assigning a triage acuity level as quickly as possible following arrival to the ED. ... Elements of documentation may include (the following list is not meant to be all inclusive and can be modified as necessary in accordance with the patient condition): ... Vital signs and pain evaluation as needed to refine acuity level (vital signs may or may not be necessary to correctly assign a triage level) ... ESI acuity level assignment ... Reassessment--a process of periodic and purposeful re-evaluation based on the patient's chief complaint, acuity, condition, symptoms or treatments/interventions. Vital signs--Usually refers to temperature, pulse rate, respiratory rate and blood pressure. Pulse oximetry may be included if pertinent to the patient's condition. A pain scale should also be included for those patients with pain as a component to their presenting complaint. ... Policy: ... 4. Patients will be reassessed at least hourly prior to initiation of the Medical Screening Exam (MSE) and by facility triage policy once the MSE has been initiated. Document all reassessments in the medical record. ... Procedure: ... 6. After interventions have been applied, reassess the patient for response to the intervention to determined if intended outcomes have been achieved. 7. After medications have been administered , reassess the patient for intended outcomes and adverse reactions. ... ."


"Policy Stat ID: 5022887 ... Life Point Health ... Approved: 8/30/2018 LL.026 EMTALA - Medical Screening and Treatment of Emergency Medical Conditions. Scope: ... Emergency Department ... Purpose: To ensure that individuals coming to an affiliated Hospital's Dedicated Emergency Department seeking assessment or treatment for a medical condition, or coming to Hospital Property requesting (or obviously requiring) treatment for an Emergency Medical condition receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Labor Act ("EMTALA"), 42 U.S.C., Section 1395 and all Federal regulations and interpretive guidelines promulgated thereunder, and, if an Emergency Medical condition is determined to exist, such individuals are offered stabilizing treatment within the Hospital's capabilities and/or are transferred if appropriate, all without regard to the patient's insurance coverage or ability to pay. ... T. To Stabilize means, with respect to an Emergency Medical condition to either provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to occur during the transfer of the individual from a facility ... Policy: ... If an Emergency Medical condition is found to exist, the Hospital will (without regard for the patient's coverage or ability to pay) provide: (a) stabilizing treatment within the capabilities of the Hospital and its staff (including on-call physicians and diagnostic services), and/or (b) an appropriate transfer to another medical facility (if required for the patient's treatment or requested by the patient). ... Procedures: ... The Medical Screening Examination may not be delayed in order to secure the individual's insurance information or payment arrangements. hospitals should request this information only after the Medical Screening Examination has begun. a. Insurance and payment information obtained from the patient shall not be used to communicate with insurance companies or to initiate discussion with the patient regarding copay's, deductibles, or cost of the visit. Should a patient refuse to provide insurance and payment information, no further requests should be made until the Medical Screening Examination is completed. ... c. Hospitals are prohibited from seeking prior authorization for the screening or stabilizing services from the individual's insurer or managed care organization prior to the completion of the Medical Screening Examination and if applicable initiation of stabilizing treatment. Each Hospital should ensure that it uses a reasonable registration process that does not delay screening and does not unduly discourage individuals from remaining for further evaluation. ... 3. Medical Screening Examination ... Depending on the patient's presenting symptoms, the Medical Screening Examination may range from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures. A Medical Screening Examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation documented in the medical record prior to discharge or transfer. ... B. Results of Medical Screening Examination and Next Steps ... If the Medical Screening Examination reveals an Emergency Medical condition, then the Hospital must provide stabilizing treatment within its capacity and capabilities (including on-call physican services and ancillary services) necessary to stabilize the patient or must appropriately transfer the patient to another facility. ... The Hospital may not condition or appear to condition the provision of stabilizing treatment on the patient's ability to pay. A patient should not be asked for payment until the patient has received the Medical Screening Examination and stabilizing treatment has been initiated. ... ."


1. MR23 revealed a 58 year old who presented with several months of bilateral ear pain and one month of headache symptoms. Patient arrived at 16:17 and triage (ESI 3) was completed at 16:23. Patient reported to have an 8 out of 10 pain (16:23) and vital signs were notable for the absence of fever or tachycardia and an elevated blood pressure (16:22 176/77). Patient was seen by a physician assistant at 16:53, who ordered laboratory tests and x-rays of the chest and sinuses. Patient was moved from the Waiting Room into the Emergency Department at 19:51 and assigned to a physician at 19:53. The patient was ordered a normal saline bolus and the patient is documented as refusing the intravenous fluids. At time of discharge the patient's blood pressure was still elevated (18:22 172/77, 20:00 183/90, 20:30 157/88). There is no documentation of a reassessment of pain or administration of pain or other medications.


MR26 revealed a 60 year old who presented with the complaint of total body pain. The patient arrived at 17:55 and completed triage (ESI 3) at 18:07. Triage note described pain all over after taking Imitrex for a migraine headache the night prior. The patient rated the headache as mild but was concerned about the pain over all, vital signs were stable and initial pain score was 8 out of 10 (18:06). The physician assistant evaluated the patient at 18:28 and orders were placed at 18:34. Laboratory tests were within normal limits. CT scan of head and chest x-ray were performed. There is no documentation of a reassessment of pain or administration of pain medications.


2. An interview with EMP17, on May 17, 2019, at 10:35 AM, revealed, "Once we have the information verified, the copay will pop up. I check for accuracy. Sometimes their card is old. I tell them there is an ER copay, and if they pay today, we give a 20 percent discount. If they paid an ER copay and they are then admitted, we put that money towards the admission deductible. Once the doctor sees them, the tracking board gives us a provider time that they were seen. Most of the time, the ER copay is collected at the bedside, patients like the idea of a 20 percent discount. I have had complaints though, one lady said to me that this isn't the time. I tell them I understand and that we can discuss later."


3. A telephone interview was conducted with EMP16, on May 20, 2019, at 11:40 AM. EMP16 stated related to the registration process and copay collection, that they wait until the first provider sees the patient, EMP16 stated that they are never to say it's okay to wait on the copay until admitted. A lot of people are not happy about this process, and stated that they had received a script to follow. It's turned into a competition, there's a goal every month ... ."


4. A telephone interview with EMP7 on May 20, 2019, at 3:30PM revealed, "Registration staff are not allowed in until the patient has been seen by the first provider. The tracking board updates itself. The doctors will look at the board and then take the next patient. Once they assign themselves to a patient, then Registration staff knows they can go in, because the providers would have already been in the room. When advised that copays are being collected as part of the registration process, EMP7 stated, "I didn't know that. That's not how they're supposed to be doing that. I had no idea ... ."