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A. Based on document review, medical record review and interview it was revealed the hospital failed to ensure a medical screening exam (MSE) was performed on a patient presenting to the Emergency Department (ED) for treatment for one (1) of twenty-one (21) records reviewed (patient #1). This failure has the potential to discourage patients from possibly seeking life-saving services if the patient was having a medical emergency. This failure could possibly lead to the incapacitation or death of the patient. (See A 2406)

B. Based on document review and interview it was revealed the hospital failed to ensure all patient visits were documented on the ED central log for one (1) of (21) patient visits reviewed (patient #1). This failure has the potential to affect the tracking of care provided to all patients who present to the ED for treatment. (See A 2405)

C. Based on document review, medical record review and interview it was revealed the medical staff did not follow their bylaws, rules and regulations and hospital policies for one (1) of twenty-one (21) records reviewed (patient #1). It was also revealed the ED staff did not follow their hospital policies for one (1) of twenty-one (21) records reviewed (patient #1). This failure has the potential to affect all patients who present to the ED for emergency treatment.

Findings include:

A review of the hospital policy entitled "Ambulance Diversion Policy" last revised 6/21 revealed in part: "Purpose: The purpose of this policy is to properly use the diversion policy as described by the Sate of West Virginia. This policy DOES NOT supersede Wetzel County Hospital's or EMS personnel's obligation to provide care should a patient require emergency stabilization or in the event that a patient desires to be transported to and treated at a specific facility ..."

A review of the hospital policy entitled "Angina (Chest Pain) or Myocardial Infarction Treatment" approved 6/21 revealed in part: "A patient who arrives at the Emergency Department with angina (chest pain) or myocardial infarction will receive the following care: Maintain a patent airway, Stat EKG, place on cardiac monitor and obtain baseline rhythm ..."

A review of the hospital policy entitled "Patient Assessment" last revised 1/20 revealed in part: "All patients presenting to the Emergency Department will be triaged and placed in Level I, II, III, IV or V ..."

A review of the hospital policy entitled "Physical Assessment: Nursing Responsibility" last revised 6/21 revealed in part: "A Registered Nurse will complete a physical assessment of the Emergency Room patient ..."

A review of the hospital policy entitled "Scope of Service in the ED" last revised 6/21 revealed in part: "All patients that present to the Wetzel County Hospital's emergency department and are seeking care shall receive a medical screening exam by an Emergency Department physician. Support services including, but not limited to, clinical laboratory studies and x-rays will be provided to the patient. All necessary definitive treatment will be given to the patient within the hospital's capabilities ..."

A review of the hospital policy entitled "Emergency Department: Purpose and Objectives" approved 6/21 revealed in part: "All patients will receive a Medical Screening Examination by the Emergency Department provider ... Emergency care shall be delivered in accordance with written policy and procedures and standard of care ...Provide initial triage and treatment of all patients ...Provide treatment to patients within a reasonable period of time, depending on the critical nature of the injury or illness ...Provide appropriate discharge instructions and follow-up care ..."

A review of the hospital document entitled "ED Diversion Track & Trend" revealed the hospital had been on diversion from 1/17/22 at 11:58 p.m. to 1/18/22 at 3:04 p.m. for a total of fifteen (15) hours.

An interview with the ED Nurse Manager (NM) on 1/31/22 at 3:15 p.m. revealed the ED NM had been in a meeting with the Assistant Vice President of Nursing when a call was received that a staff member's family member had been turned away from the ED because they were on diversion. Shortly afterwards the ED physician called the ED NM and said they had unintentionally turned away a patient. The ED NM stated they have a twelve (12) bed ED and there were seven (7) or eight (8) patients boarding at that time. They keep one (1) bed for triage and one (1) bed open for a code. The NM stated the family member of the patient had entered through the ambulance bay doors and started telling the nurse what was wrong with the patient. The nurse told the family member they were not seeing patients and they would have to go somewhere else. The NM stated the nurse had just come back from leave that morning and had asked at 8:30 a.m. if anything had changed while they were off related to diversion and the NM had told them nothing had changed. The NM did say all nurses' have been reeducated regarding the diversion policy and they are in the process of setting up a date to reeducate all staff and physicians on the Emergency Medical Treatment and Labor Act (EMTALA).

An interview with the Registered Nurse (RN) on 2/1/22 at 9:15 a.m. revealed they had returned from leave on 1/18/22. They said they were not boarding patients before he/she went on leave. The RN could not remember exactly how many patients were boarding on 1/18/22 but it was more than six (6) and they were on yellow diversion. They stated they had just got back to the desk and the family member came through the "back door" and said the patient was having "chest pain and vomiting." The RN stated they turned around and asked the doctor who was in the office, "I have a patient in the bay with chest pain and vomiting, we only have a code bed. What are we doing with the patients?" He/she stated the physician said we are on diversion, and they could go to another hospital, mentioning the two (2) which were closest. The family heard this and said okay and left.

An interview with the nursing supervisor on 2/1/22 at approximately 10:00 a.m. revealed they were on yellow diversion and that means the resources are limited but they are still taking patients. The nursing supervisor found out the patient had not been seen in the ED on 1/18/22 when the staff member who works at the hospital called and said their family member had been to the ED and was told they were on diversion and would need to go to another hospital. The nursing supervisor immediately spoke with the physician and the RN.

An interview with the ED physician on 2/1/22 at 10:55 p.m. revealed the physician thought the patient was in the field. The ED physician stated, "It did not occur to me we would ask about a patient with chest pain." The ED physician stated, "[The nurse] might have specified the patient was at the door, but I don't think so." The ED physician stated he immediately called the other hospital and apologized and told them they would self-report the event.

An interview with the Director of Operations on 2/2/22 at 10:00 a.m. revealed they did not have a video of the family member or patient at the ED on 1/18/22.

An interview with the ED NM was conducted on 2/2/22 at 10:10 a.m. and they agreed the hospital policies were not followed.

Based on document review and interview it was revealed the hospital failed to ensure all patient visits were documented on the Emergency Department (ED) central log for one (1) of (21) patient visits reviewed (patient #1). This failure has the potential to affect the tracking of care provided to all patients who present to the ED for treatment. (See A 2405)

Findings include:

A review of the facility document entitled "Summary Table by Acuity" dated 1/18/22 with attachment entitled "ED Event Based Report Template" revealed patient #1 had not been entered on the electronic ED log after presenting to the ED on 1/18/22 with chest pain.

An interview with the patient access registration clerk on 2/1/22 at 9:30 a.m. revealed he/she heard a patient's relative tell the nurse there was a patient in the "bay" with chest pain and the patient was told to go to another hospital as they were on diversion.

An interview was conducted with the ED Nurse Manager (NM) on 1/31/22 at 3:15 p.m. and the NM agreed patient #1 had not been entered into the ED central log.

Based on document review, medical record review and interview it was revealed the hospital failed to ensure a medical screening exam (MSE) was performed on a patient presenting to the Emergency Department (ED) for treatment for one (1) of twenty-one (21) records reviewed (patient #1). This failure has the potential to discourage patients from possibly seeking life-saving services if the patient was having a medical emergency. This failure could possibly lead to the incapacitation or death of the patient. (See A 2406)

Findings include:

A review of the hospital policy entitled "Medical Screening" last revised 6/21 revealed in part: "All patients are provided a medical screening examination by an emergency department physician or licensed provider credentialed to work in the Emergency Room ..."

A review of the hospital policy entitled "EMTALA Guidelines" last revised 6/21 revealed in part: "All patients coming to Wetzel County Hospital's Emergency Room seeking care must be accepted and evaluated ...All patients shall receive a medical screening exam that includes providing all necessary testing and services within the capability of the Hospital to reach a diagnosis ..."

A review of the hospital document entitled "Bylaws of the Medical Staff of Wetzel County Hospital" revealed in part: "A Registered Nurse or a Licensed Practical Nurse will see all patients presenting themselves to the emergency room for care and will perform a triage screening examination. He or she will initiate whatever action is necessary to meet the immediate needs of the patient. The Hospital will employ physicians to provide emergency care for all patients. All patients will be seen by the Emergency Room physician ("E.R. Physician") when presenting themselves to the E.R. for treatment..."

A review of the medical record revealed there was no documentation of an ED visit for patient #1 on 1/18/22.

An interview with the nursing supervisor on 2/1/22 at approximately 10:00 a.m. revealed they had received a call from a staff member who stated their family member had come to the ED and been told they would have to go to another hospital because they were on diversion. The nursing supervisor stated they asked the physician if they had turned away a patient with active chest pain and told the physician about the phone call. The nursing supervisor then stated they asked the ED staff if a patient with chest pain had been turned away and the nurse said, "I did, but I asked you." The nursing supervisor stated the physician said, "You never told me the patient was here by personal vehicle." The physician thought the nurse was talking about an Emergency Medical Services (EMS) patient.

An interview with the ED physician on 2/1/22 at 10:55 a.m. revealed they had been in their office which is located behind the nursing desk. They heard a chime over the radio scanner but did not hear what was said. Shortly afterwards the nurse asked the physician if they were seeing/taking chest pain patients while on diversion. The physician "assumed" this was a request from what had been heard on the radio scanner. The physician stated, "I said no unless they are in extremis, they go somewhere else." A little while later the nursing supervisor asked about the patient and that is when the physician realized the patient had been at the ED. The physician said they notified the ED Nurse Manager, and the physician called the other hospital and apologized and told them they would self-report. The physician stated, "[The nurse] might had specified the patient was at the door, but I don't think so, I thought the patient was in the field."

An interview was conducted with the ED physician on 2/1/22 at 10:55 a.m. and they agreed patient #1 had not received a MSE upon presenting to the ED for treatment.