HospitalInspections.org

Based on review of the facility policies and procedures, Medical Staff Bylaws and Rules and Regulations, Medical Records (MR), 911 dispatch report and audio files and staff interviews it was determined the facility failed to:

1. Ensure an ongoing medical screening examination (MSE) was provided including reassessments of pain and the status of ordered computed tomography (CT) scan.

2. Ensure a patient leaving Against Medical Advice (AMA) was informed of the patient care risks with leaving the facility AMA.

3. Identify and approve individual(s) qualified to perform the MSE for the Emergency Department (ED) in the facility bylaws or rules and regulations.

These deficient practices affected Patient Identifier (PI) # 1, and had the potential to affect all patients served by the facility ED.

Findings include:

Refer to Tags- C2406 and C2407 for findings.

Based on review of the facility policies and procedures, Medical Staff Bylaws and Rules and Regulations, Medical Records (MR), 911 dispatch report and audio files and staff interviews it was determined the facility failed to:

1. Identify and approve individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Department (ED) in the Medical Staff Bylaws and Rules and Regulations.

2. Ensure an ongoing MSE was provided including reassessments of pain and the status of ordered computed tomography (CT) scan.

The deficient practice affected 1 of 3 patients reviewed diagnosed with Acute Appendicitis, including Patient Identifier (PI) # 1, and had the potential to affect all patients served by the facility ED.

Findings include:

Policy: Screening and Transfer Guidelines Emergency Medical Treatment and Labor Act (EMTALA)
Approved: 8/21/2020

Purpose: ...this policy and procedure serves as an outline of the hospital's processes to ensure compliance with the requirements of the EMTALA.

Definitions:

..."Qualified Medical Person" means a physician or an individual deemed competent by the Chief of Emergency Medicine or the Chief of Obstetrics and Gynecology...

Policy:

A. It is the policy of St. Vincent's Blount that if an individual comes to the ED...:

1. The hospital will provide an appropriate MSE within the capability of the hospital's dedicated ED, including ancillary services routinely available to that dedicated ED, to determine whether or not an emergency medical condition exists. The examination will be conducted by an individual(s) determined qualified by the hospital bylaws, rules and regulations....

Procedure:

...B. Medical Screening Examination

...4. The medical screening examination will be performed by a physician or a Qualified Medical Person...

5. The MSE is an ongoing process. The MR will reflect an ongoing assessment of the patient's condition. Monitoring will continue until the individual is stabilized or appropriately admitted or transferred. The MSE will be documented in the MR...

Policy: Admission of Patient to ED...
Effective: 9/15/2012

Purpose: To provide guidelines for the ED admission procedures.

Procedure:

...B. Nurse assigns a triage level based off of Emergency Severity Index (ESI) and enters it on the MR...

...E. ESI Level III: Urgent...

Policy: Patient Reassessment-Emergency Department (ED)
Revised: 8/19/19

Purpose: Establish guidelines for the care of ED patients.

Procedure:

The frequency of nursing assessments is determined by the category that a patient is placed in during the triage assessment process.

Frequencies are determined as follows:

...2. Patients falling into an urgent category should have a problem focused reassessment every hour or as condition warrants....

Policy: Assessment of Patients...
Revised: 11/8/18

Policy: ...The assessment of the care or treatment needs of the patient is ongoing throughout the patient's contact with the organization to ensure continuity of care...

Procedure:

...D. Collaboration among disciplines which is communicated through the MR with medical staff and nursing documentation integrated with the ancillary departments either on line or in the MR.

...Appendix C: Data collection of physiological parameters by nursing.

Data collection...will include, at minimum, the following:

...Pain Assessment...If pain is identified then a comprehensive, age-specific pain assessment will be completed...Ongoing pain reassessment...using pain intensity, will be performed to evaluate the changing nature of pain...


1. The Medical Staff Bylaws and Rules and Regulations were received from Employee Identifier (EI) # 1, Assistant Administrator, Chief Nursing Officer, on 2/2/2021.

Review of the Medical Staff Bylaws and Rules and Regulations on 2/2/2021 revealed no documentation to identify and approve the individual(s) qualified to perform the MSE in the ED, which is required by the regulation.

An interview was conducted with EI # 1 and EI # 3, System Administrative Director, on 2/4/2021 at 11:51 AM who confirmed there was no documentation to identify and approve the individual(s) qualified to perform the MSE in the ED in the Medical Staff Bylaws and Rules and Regulations.

2. PI # 1 presented to Hospital A, St. Vincent's Blount, ED on 1/12/21 at 12:16 PM with a chief complaint of "sent from PCP (Primary Care Physician) for abd (abdomen) pain and possible appendicitis."

Review of the triage documentation dated 1/12/21 at 1:09 PM revealed the following documentation: blood pressure of 161/75, pulse of 100, respirations of 18, temperature 98.6 degrees Fahrenheit and sharp medial lower abdomen pain intermittently at a 5 on a 1-10 numeric pain scale. Review of the pain evaluation, self report documentation revealed "pain level unacceptable, collaborate with provider." PI # 1 was documented as a "3" tracking acuity.

Review of the physician orders dated 1/12/21 at 1:12 PM revealed orders for a CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) and a CT, of the abdomen and pelvis with contrast. Review of the laboratory (lab) testing revealed the following abnormal lab values: WBC (white blood cell) of 13.6, absolute neutrophil count of 8.7, monocyte absolute of 1.4, and a Blood Urea Nitrogen (BUN)/creatinine ratio of 21.

Review of EI # 7, ED physician, assessment dated 1/12/21 at 1:31 PM revealed the following documentation: "...complains of having a 2-day history of fever, chills and abdominal pain with a pulse of 105....history of colon cancer...pain primarily is in the umbilicus area and radiates to the right lower quadrant. In his/her doctor's office he/she had a white count (white blood cell, WBC) of 14.9...

Review of the nursing documentation dated 1/12/21 at 2:15 PM, "pt (patient) states his/her abdomen is hurting, MD (Medical Doctor) aware, pt states he/she does not want pain medication." There was no documentation of pain intensity. Further review of the nursing documentation revealed no documentation another pain assessment was completed through the patient leaving the ED.

Review of the nursing documentation dated 1/12/21 at 3:10 PM, "pt becoming impatient regarding CT wait time. Advised CT machine is under maintenance and they are working to make machine operable as quickly as possible."

Review of the nursing documentation dated 1/12/21 at 4:10 PM, "pt increasingly agitated regarding wait time for CT scan. Advised machine is down and we are doing everything within our power to speed the process."

Review of EI # 4, ED physician, addendum note dated 1/12/21 at 6:57 PM revealed documentation of "patient checked out to me at 1900 (7 PM) pending CT scanning. Unfortunately our CT scan has been down here (in) the ED for some time. He/She has now been waiting here 7 hours. He/She request to be transferred elsewhere. I attempted to contact (two facilities identified, including the receiving facility) transfer is pending at this time. Laboratory studies show a leukocytosis. There is concern initially for appendicitis. Before I was able to initiate transfer patient became very angry and left without discussion of Against Medical Advice (AMA). Patient eloped from the ER (emergency room)."

Review of the nursing documentation dated 1/12/21 at 8:42 PM revealed "pt left AMA..."

Review of the "surgeon presence at...St. Vincent's Blount" and the facility January 2021 Call Schedule revealed the facility did not have a surgeon on call for the facility.

Review of the facility huddle documentation dated 1/11/21 and 1/12/21 revealed documentation of "planned downtime for CT on 1/12/2021 from 12 PM - 2 PM." The facility ED Manager was in attendance at both huddles.

Review of the GE (General Electric) Sys (System) Log printed on 1/12/21 revealed the CT scanner went down at 12:05 PM on 1/12/21.

Review of the facility divert status revealed the facility was placed on CT divert on 1/12/21 from 2:36 PM until 9:34 PM.

The facility failed to ensure an ongoing MSE was completed by not reassessing PI # 1's pain related to the emergent medical condition, attempting to update on the status of the CT scanner to ensure the ordered medical screening was completed or attempting to transfer to another facility for the required CT scan when the facility was not capable of performing the CT scan on 1/12/21 from 1:12 PM until 6:57 PM and was also not capable of performing the surgical intervention if necessary.

911 Dispatch Audio Files and Report dated 1/12/21:

At 8:30 PM, a facility ED nurse called 911 to request the police come to the facility due to PI # 1 leaving with an IV (Intravenous).

At 8:31 PM, the police department are dispatched to the facility.

At 8:32 PM, PI # 1 called 911 to request an ambulance from the facility to another facility due to "I have been laying in the ER for 9 hours waiting for them to treat me and nothing has happened because their CT Scan is gone. I probably have appendicitis. I need an ambulance to pick me up and take me to another hospital please" and having "...severe abdominal pain" During the call, PI # 1 is screaming to someone in the background and when asked by the dispatch staff who PI # 1 was talking to, PI # 1 responded, "the nurses in the ER."

At 8:39 PM, a police officer speaks with dispatch to ask if the ambulance is en route. The dispatch staff replies the ambulance is not in en route. The police officer then request ambulance transport for the patient.

At 8:57 PM, the ambulance arrived but the patient had already left site.

Hospital B, Receiving Facility:

PI # 1 arrived at Hospital B, Receiving Facility ED, on 1/12/21 at 9:41 PM via private vehicle with a chief complaint of "pt states he/she needed a CT scan, was at (hospital A) for 8 hrs (hours), he/she left there AMA and IV (intravenous access) in and came here for CT scan."

Review of the triage documentation dated 1/12/21 at 9:55 PM revealed the following documentation: blood pressure of 182/84, pulse of 107, respirations of 18, temperature 98.6 degrees Fahrenheit and pain a 6 on a 1-10 numeric pain scale.

Review of the ED physician assessment dated 1/12/21 at 10:13 PM revealed documentation of "patient...comes to the hospital for right lower quadrant abdominal pain. Patient developed right lower quadrant suprapubic area abdominal pain 48 hours ago. It has been waxing and waning since then. Is migrated to the right lower quadrant...was seen at (Hospital A) where he/she was noted to have leukocytosis. No CT is able to be done. Patient eloped from the ER (emergency room) and then came here under the understanding that he/she needed a CT of his/her abdomen. Patient reports pain is mild to moderate..." Further review of the ED physician assessment revealed documentation of "...check CT abdomen with contrast...We will give IV fluids, as patient has not been able to eat or drink anything all day and also likely somewhat dehydrated."

A CT of the abdomen and pelvis with contrast was performed on 1/12/21 at 10:46 PM, which revealed acute appendicitis with no perforation or abscess identified. Inflammation extends to the cecal tip.

Review of the ED physician reexamination/reevaluation, there was no documentation of the time and date of the reexamination/reevaluation, revealed documentation of "CT abdomen shows moderate inflammatory changes at the base of the appendix suggestive of acute appendicitis. I did discuss the case with (physician identified) who is on-call for unattached patients. Also discussed with (surgeon identified). He/she (surgeon) does agree to do appendectomy tomorrow." The impression was documented as "Appendicitis" with the plan to "admit: to inpatient unit."

Patient was admitted to Hospital B and underwent a laparoscopic appendectomy on 1/13/21 at 11:08 AM. PI # 1 was discharge home on 1/13/21 at 3:53 PM.

Interviews:

An interview was conducted on 2/4/21 at 8:37 AM with Employee Identifier (EI) # 6, ED Registered Nurse (RN), who was asked the facility procedure for when a patient requires a CT and it is not working. EI # 6 stated, "normally when COVID is not going on and not on diversion, we call (hospital identified) to transfer. Usually as soon as the CT goes down, we go ahead and call..."

An interview was conducted on 2/4/21 at 9:03 AM with EI # 4, ED physician, who was asked the facility procedure for when a patient requires a CT and it is not working. EI # 4 stated, "I have to weigh how long radiology says the CT will be down and how the patient is doing. If it is down minutes, I would wait rather than transfer. Probably, I would wait an hour or two, then get the patient transferred."

An interview was conducted on 2/4/21 at 11:07 AM with EI # 5, ED RN, who was asked the facility procedure for when a patient requires a CT and it is not working. EI # 5 stated, "...I asked during all this and it is to transfer to another facility with a CT operable. In retrospect, seems to be a long time to wait..."

An interview was conducted on 2/4/21 at 3:46 PM with EI # 1, Assistant Administrator, Chief Nursing Officer, who confirmed there was no documentation of a nursing pain assessment following the pain assessment at 2:15 PM on 1/12/21, no documentation the facility staff attempted to update on the status of the CT scanner to ensure the ordered medical screening was completed throughout PI # 1's ED visit or discussion of transferring the patient for needed CT scan from 1/12/21 at 1:12 PM until 6:57 PM.

Based on review of the facility policy and procedure, medical records (MRs), and staff interviews it was determined the facility failed to ensure a patient leaving Against Medical Advice (AMA) was informed of the patient care risks with leaving the facility AMA.

The deficient practice affected 1 of 4 patients reviewed who left AMA, including Patient Identifier (PI) # 1, and had the potential to affect all patients served by the facility ED.

Findings include:

Policy: Patient Elopement/AMA
Revised: 7/17/19

Purpose: Promote hospital-patient dialogue for patient protection when a patient leaves AMA...

Policy: All St. Vincent's Blount personnel are responsible for implementing these procedures.

Procedure:

A. AMA

1. Discourage the patient from leaving the hospital and identify patient care risks anticipated with leaving the hospital AMA.

...5. If the patient will not sign the Release from Responsibility for Discharge, the reason should be documented on the form as "patient refuses to sign form" and witnessed by two (2) RNs (Registered Nurse), properly dated and signed.

1. PI # 1 presented to Hospital A, St. Vincent's Blount, ED on 1/12/21 at 12:16 PM with a chief complaint of "sent from PCP (Primary Care Physician) for abd (abdomen) pain and possible appendicitis."

Review of the physician orders dated 1/12/21 at 1:12 PM revealed orders CT of the abdomen and pelvis with contrast.

Review of the nursing documentation dated 1/12/21 at 3:10 PM, "pt becoming impatient regarding CT wait time. Advised CT machine is under maintenance and they are working to make machine operable as quickly as possible."

Review of the nursing documentation dated 1/12/21 at 4:10 PM, "pt increasingly agitated regarding wait time for CT scan. Advised machine is down and we are doing everything within our power to speed the process."

Review of EI # 4, Hospital A, ED physician, addendum note dated 1/12/21 at 6:57 PM revealed documentation of "patient checked out to me at 1900 (7 PM) pending CT scanning. Unfortunately our CT scan has been down here (in) the ED for some time. He/She has now been waiting here 7 hours. He/She request to be transferred elsewhere. I attempted to contact (two facilities identified, including the receiving facility) transfer is pending at this time. Laboratory studies show a leukocytosis. There is concern initially for appendicitis. Before I was able to initiate transfer patient became very angry and left without discussion of Against Medical Advice (AMA). Patient eloped from the ER (emergency room).

Review of the nursing documentation dated 1/12/21 at 8:33 PM revealed "patient walking out of ED and refusing to let IV (Intravenous line) be removed, informed patient we would have to call police because he/she can't leave with IV in, states he/she doesn't care and walks out.

Review of the nursing documentation dated 1/12/21 at 8:42 PM revealed "pt left AMA. Pt (patient) refused to sign AMA form, pt refused to allow me to remove IV. Police called. Police allowed patient to leave in POV (Privately Owned Vehicle) with IV access." The nursing documentation was signed by 1 RN.

Review of the MR revealed no documentation of the Release from Responsibility for Discharge form, a signature of a second RN, or the facility staff spoke with PI # 1 to informed him/her of the patient care risks of leaving the facility AMA.

Interviews:

An interview was conducted on 2/4/21 at 8:34 AM with Employee Identifier (EI) # 6, ED RN, Team Lead, who described how the patient left the facility AMA. EI # 6 stated, "...The patient became upset and said he/she was leaving...had an IV in his/her arm. I said wait, he/she said I am leaving. I called the police because he/she had an IV and wouldn't let us take it out. It is standard practice for us to call the police. He/She is surrounded by me, (nurse identified), the secretary...in the parking lot. He/She is calling dispatch. (Spouse) is with him/her. The police showed up and said can you just let them take the IV out. He/She said no, I might need it. The police talked with him/her for a while and said if you want to leave, you can get in your car and leave. We went back inside when he/she left... He/She said she was leaving to go to another facility. EI # 5 was then asked did you talk to the patient about the risk of leaving? EI # 6 responded, "when he/she was walking out...her nurse was following. (Nurse identified) was saying no, stop, come back. He/She was upset, and I don't know if (nurse identified) talked to him/her or not..."

An interview was conducted on 2/4/21 at 9:03 AM with Employee Identifier (EI) # 4, ED physician, who described how the patient left the facility AMA. EI # 4 stated, "(Spouse) arrived and he/she left while we were waiting to hear back from (another hospital identified). We gave him/her the option of leaving against medical advice, but (spouse) was here, and he/she decided to leave. He/She wanted to leave AMA. He/She was angry. The nursing staff was trying to get his/her IV out, but he/she refused. The nursing department called the police because there is a policy that the patient can't leave with an IV."

An interview was conducted on 2/4/21 at 11:07 AM with EI # 5, ED RN, who described how the patient left the facility AMA. EI # 5 stated, "He/She is walking out, and I and the secretary follow him/her out asking to take the IV out. It is policy you can't leave with an IV. As we are leaving, someone calls the police. In the parking lot, (spouse) is asking him/her to take the IV out. The Charge nurse meets us outside (EI # 6 identified). When the police show up, they try to get him/her to take the IV out. The police state they can't make him/her take it out. He/She gets in a pick-up truck and leaves..."