HospitalInspections.org

Based on clinical record review, a review of the hospital's EMTALA policies and procedures, and interview, it was determined that in 1 of 29 (pt. #29) records reviewed for patients who presented to the hospital requesting emergency services, the hospital failed to ensure compliance with 489.24 in that the hospital failed to follow its policy related to refusal of medical screening examination by a patient (pt. #29)leaving without being seen by a physician.

Findings:
1. Please see finding cited at 489.24 (d) (1-3) A2407

Based on policy and procedure review, document review (emergency department log for 3/15/12), and staff interview, the facility ED (emergency department) staff failed to enter a patient who presented to the ED, and left without being seen, into the ED control log at the time of presentation for services, for 1 of 29 patients presenting to the emergency department (pt. #29).

Findings:
1. at 12:35 PM on 4/19/12, review of the policy and procedure "Medical Records" (ED - 411), indicated under section "IV. POLICY STATEMENTS", item H.: "A control register will be kept to adequately identify all persons seeking emergency care. This control register will be continuously maintained by nursing personnel and will include the following information: Identification (name, age, sex, date, time, and means of arrival); nature of the complaint; disposition and time of departure..."

2. review of the ED control log at 10:55 AM on 4/19/12 indicated:
a. a patient (#29) was entered into the control log at the end of the day; the previous entry to pt. #29 was documented as 2230
b. the "time in" for pt. #29 was listed as "1400" and the "time out" noted as "1415"
c. pt. #29 was added to the log more than 8 hours after presenting to the ED for an evaluation

3. Interview with staff member #62, the RN (registered nurse) Vice President of Patient Care Services, at 2:25 PM on 4/19/12 indicated pt. #29 was not placed on the control log chronologically, and was added more than 8 hours after presenting to the ED

Based on clinical record review, policy and procedure review and interview, the facility failed to implement its policy related to the refusal of a medical screening exam by a patient, leaving without being seen (LWBS) by the physician, for 1 of 29 patients (pt. #29) who presented to the ED (emergency department).

Findings:
1. at 12:35 PM on 4/19/12, review of the policy and procedure "Against Medical Advice (AMA), Left Without Being Seen (LWBS), & Elopement" (ED-319), indicated:
a. in section "III. DEFINITIONS", it reads: "...Left without Being Seen (LWBS): Occurs when a patient requests ED treatment and subsequently leaves the facility before being seen by a physician..."
b. in section "IV. POLICY STATEMENTS", it reads: "...B. Left Without Being Seen (LWBS) 1. The ED staff will give the patient information about wait times and encourage them to stay. 2. If the patient still refuses to stay, the staff will attempt to have the patient or responsible party sign a "Refusal of Medical Screening exam" form. 3. The LWBS will be documented on the patient's chart, and an incident report will be completed..."

2. a phone interview with staff member #64, an ED RN, was conducted at 2:30 PM on 4/19/12 and indicated:
a. this RN met the police and handcuffed patient (#29) in the hallway on 3/15/12 and escorted them to room #5 (a room reserved for patients in police custody)
b. this nurse "went to get a T sheet" (form used to triage patients) and when she returned the officer said "I'm going to take [pt] to facility #2--the family says [the pt.] is a known psych patient"
c. in discussing the situation with the ED manager, it was determined that if the police wanted to go to facility #2, they had not signed the patient in, they still had custody of the patient, and the patient was not a harm to themselves or others, so they could proceed with their escort of the patient to facility #2

3. At 12:00 PM on 4/21/12, a phone interview with ED physician # 53 indicated:
a. this physician spoke with the officer who transported pt. #29 and told him the ED was busy and staff would get to the patient as soon as possible.
b. When the physician went to the exam room to see pt. #29, the patient was gone
c. the physician went to the nurse to see where the patient was, and was told the police decided to take the patient to Facility #2 where inpatient psychiatric services were available

4. Interview with staff member #63, Risk Management, at 5:35 PM on 4/19/12 indicated physician #53 reported, during the internal investigation, that one of the police officers spoke with him and decided that waiting for an examination, and completion of the transfer process would take longer than police wished to wait for, and thus police decided to transport the patient to another facility with psychiatric inpatient capabilities

5. There was no documentation to indicate that:
a. the police were encouraged to stay
b. staff attempted to have the patient, or responsible party, sign a "Refusal of Medical Screening" form
c. a patient chart was started with a notation of the patient LWBS
d. an incident report was completed

6. interview with staff member #65, ED RN Coordinator, at 5:35 PM on 4/19/12 indicated
there is no documentation related to patient #29