HospitalInspections.org

Based on observation, Hospital #1 and Hospital #2's Emergency Department (ED) record review, ED sign in log review for Hospital #1 and #2, ED log review for Hospital #1 and #2, Employee Schedule review, Medical Executive Committee Meeting minutes review, Medical Bylaws review, EMTALA in-service review, staff interview, patient interview, physician interview, document review, and policy and procedure review, the hospital failed to comply with 489.20 by failing to ensure no delay in examination/treatment and failing to provide a Medical Screening Exam (MSE) and stabilizing treatment within its capacity that minimizes the health risks of five (5) of 22 patients reviewed, Patient #2, #6, #7, #8 and #16.


Findings include:

Cross Refer to A2406 for the facility's failure to ensure Patient #2, #6, #7, #8 and #16 received a Medical Screening Exam when they presented to their ED with Emergency Medical Conditions.


Cross Refer to A2407 for the facility's failure to ensure Patient #2, #6, #7, #8 and #16 received Stabilizing Treatment after presenting to their ED with Emergency Medical Conditions.


On 5/20/16 the State Office received a complaint from the Chief Executive Officer (CEO) of Hospital #2. The Complaint stated in part: " Regretfully, (Hospital #2) finds it necessary to file a complaint against (Hospital #1) related to (Hospital #1's) EMTALA obligations.
... included in this complaint is a case in which one of our employees reported that her daughter-in-law (Patient #7) presented to (Hospital #1) in the evening of May 3, 2016, a 29 year old who was 14 weeks pregnant, actively bleeding to the point of bleeding through her clothes while sitting in the Emergency Department Waiting Room and her sister having to go purchase her clothes at the local Walmart. She sat there for four hours with no medical screening exam before her husband finally decided to put her back in the private vehicle and bring her to (Hospital #2). It was reported that as the husband was loading up his wife, the (Hospital #1) security guard said sorry it has to be this way ...we are just so backed up all the time with (Hospital #2) being on diversion. (Hospital #2) was Not on diversion. The patient came to (Hospital #2) and was seen promptly....
(Hospital #2's) Administration has tried to work with (Hospital #1's) Administration on matters such as this to no avail. We are asking for your review of (Hospital #1's) compliance with EMTALA. We very much appreciate your time and assistance. "



CONCLUSION:
The complaint regarding Patient #7 not being seen by a physician while in Hospital #1's ED was substantiated and EMTALA violations were cited for the facility's failure to ensure this patient received a Medical Screening Exam (MSE) from a physician during the time she was in their facility; failure to ensure the patient received stabilizing treatment; failure to ensure the patient received no delay in treatment and failure to reassess the patient after two (2) hours as per their "Triage Assessment" policy.

Emergency Department Record Review during the course of the survey also revealed that the following patients did not receive a MSE or stabilizing treatment; received a delay in treatment, and were not reassessed every two (2) hours while in the hospital's ED:
Patient #2 - in ED for 8 hours and 44 minutes
Patient #6 - in ED for 2 hours and 37 minutes
Patient #8 - in ED for 3 hours and 17 minutes
Patient #16 - in ED for 53 minutes

Based on observation, Hospital #1 and #2's Emergency Department (ED) record review, ED sign in log review, Employee Schedule review, staff interview, patient interview, and policy review, the hospital failed to ensure the provision of a Medical Screening Exam (MSE) within its capacity that minimizes the health risks for five (5) of 22 patients reviewed, Patient #2, #6, #7, #8 and #16.


Findings include:


On 5/20/16 the State Office received a complaint from the Chief Executive Officer (CEO) of Hospital #2. The Complaint stated in part: " Regretfully, (Hospital #2) finds it necessary to file a complaint against (Hospital #1) related to (Hospital #1's) EMTALA obligations.
... included in this complaint is a case in which one of our employees reported that her daughter-in-law (Patient #7) presented to (Hospital #1) in the evening of May 3, 2016, a 29 year old who was 14 weeks pregnant, actively bleeding to the point of bleeding through her clothes while sitting in the Emergency Department Waiting Room and her sister having to go purchase her clothes at the local Walmart. She sat there for four hours with no medical screening exam before her husband finally decided to put her back in the private vehicle and bring her to (Hospital #2). It was reported that as the husband was loading up his wife, the (Hospital #1) security guard said sorry it has to be this way ...we are just so backed up all the time with (Hospital #2) being on diversion. (Hospital #2) was Not on diversion. The patient came to (Hospital #2) and was seen promptly....
(Hospital #2's) Administration has tried to work with (Hospital #1's) Administration on matters such as this to no avail. We are asking for your review of (Hospital #1's) compliance with EMTALA. We very much appreciate your time and assistance. "


An unannounced visit was made to Hospital #1 on 5/23/16 at 10:00 a.m. The nature of this investigation visit was discussed with the hospital's CEO; the Corporate Compliance for the Administrator and Director of Legal Risk; the Director of the Emergency Department (ED); the Credential Coordinator; and the Director of Accreditation during the entrance conference conducted in the Administration Board Room. A list of what was needed was given and a tour of the ED requested.

A tour of the ED was conducted on 05/23/16 at 10:35 a.m. with the ED Director, the Corporate Compliance for the Administrator and Director of Legal Risk, and the Registered Nurse (RN) Charge Nurse. Four (4) EMTALA signs were observed in the waiting areas. EMTALA signs were also observed located by the triage room and the ambulance entrance. The ED was noted to have a non-urgent clinic which is open from 10:00 a.m. to 10:00 p.m. After patients are triaged, some level three (3), all level four (4) and all level five (5) acuity are sent to the non-urgent side. The ED Director stated that the hospital's policy for the Triage Nurse is to complete a reassessment of the ED patients every two (2) hours.

Document review revealed that Hospital #1 has 29 Critical Care beds, which includes 13 Intensive Care Beds, 12 Critical Care Beds and four (4) Observation Beds. They have 19 Emergency Department beds and 15 beds in their Fast Track Clinic.

The hospital's Medical Executive Committee Meeting Minutes, Medical Bylaws, Quality/Patient Safety Committee Minutes, Performance Improvement Project Documentation and Tracking, EMTALA In-services on all Emergency Department Employees, Emergency Department Log, Emergency Department 'Sign In Log', Emergency Department Physician schedules and Emergency Department Employee Schedules were reviewed.


Interview with President and CEO of Hospital #2 on 05/24/2016 at 9:25 a.m. revealed that he had met with the Administrator of Hospital #1 in the past... " I would just love to see this issue worked out, especially because the two area hospitals are all the people in the surrounding area have and there is such a need for the two hospitals to work together."

On 06/08/2016 at 11:00 a.m. another visit was made to Hospital #1. The nature of the visit was discussed with the Corporate Compliance Officer for the Administrator and Director of Legal Risk, and the Director of Accreditation. A list of items needed were given to them and the surveyors requested to meet with the Medical Director of ED.

On 06/08/16 at 11:25 a.m. an interview with the new Medical Director of ED; the Director of Emergency Service; the Director of ED; the Corporate Compliance for the Administrator and Director of Legal Risk; and the Director of Accreditation revealed:
The Director of Emergency Service stated, "On 11/27/15 at 6:45 a.m. 13 patients had not been seen from the previous shift. In addition a total of 137 patients signed in to be seen and there were a total of 35 admissions for this day. We were two registered nurses (RNs) short on both the morning and evening shifts due to call-ins. This was the Friday after Thanksgiving. I tried calling from the RN PRN (as needed) pool but no one was willing to come in on the holiday. On 12/7/15 there were a total of 94 patients signed in and seen with a total of 24 admissions. There was coverage on this day. On 01/11/16 90 patients signed in and were seen with 24 admissions. On 05/04/20, 98 patients signed in, 4 patients left without being seen and a there was a total of 24 admissions. A Level 1 patient came in during the time Patient #7 was in the ED along with several Level 2 patients."

The Medical Director for the ED stated, "In November 2015, we lost all our Patient Care Representatives who helped in triage, due to budget cuts. The wait times were identified and were sent to the G7 committee." When asked what the G7 committee entailed, he replied, "It's a committee made up of the hospitals Vice Presidents. It is a 7 person committee which has to approve any spending of the facility due to the financial loss this facility has taken in the last year." The Director of Emergency Services stated that she does a chart audit of 30% (percent) every month and she did notice occasional extended wait times. "I came up with an action plan after a patient filed a complaint in February 2016. I have done much research on AHRQ (Agency for Healthcare Research and Quality), have spoken to other hospitals, and I presented a plan to the G7 committee on 05/07/2016 and it was approved. The Pharmacy will now do all medications and four Patient Care Technicians were approved to be hired. The announcements were finalized and the jobs posted on 06/07/2016 and we've already had four applications. The facility has revised their policies to address this issue, however the policies have not been approved as yet." When asked if they were aware if any of the facility staff has ever told the patients their wait time would be a couple of hours, the Director of Emergency Services stated that she does not believe her staff would ever do that. "However, as a courtesy, if the wait is going to be long, I ask the triage nurse, when she does the reassessment, to apologize to the patient and reassure them they will be seen. In addition, I have instructed them several times to never give a wait time. All staff has been trained on this." The ED Director stated, " I would like to add that as of this morning there were eight patients left over for the morning shift to see, 27 scheduled surgeries, 10 patients in the cath lab and their floor census this morning is 180." He also stated that the facility has not been on diversion. During these interviews it was noted that the ED had an Alpha Code called, a Bravo Code called and a Code Brown called. The Brown Code was a gunshot that required extra security for the ED.


HOSPITAL #1 - ED Record Review for PATIENT #7 (COMPLAINT)
Hospital #1's ED record review revealed that Patient #7 left Hospital #1's ED without being seen by a physician. The patient presented to Hospital #1's ED on Tuesday 5/3/16 at 22:23 (10:23 p.m.) with the complaint of heavy bleeding at 21:30 (9:30 p.m.) when she went to the bathroom at home. She stated she was pregnant with a due date of 11/8/16. She denied any abdominal pain. She was documented as a G1P0O0. The patient's triage acuity was a 3. Patient #7 left the ED without being seen by a physician on Wednesday 5/4/16 at 1:09 a.m. She spent a total of two (2) hours and 29 minutes in Hospital #1's ED without being seen by a physician, without receiving a Medical Screening Exam, further assessment, or any stabilizing treatment, thus causing a delay in treatment for this patient. No fetal heart tones were ever assessed. Review of Hospital #1's ED Log for the date and time period Patient #7 was in their ED revealed one (1) Level One (1) Trauma patient presented on 5/3/16 at 21:29 (9:29 p.m.). Review of Hospital #1's employee schedule revealed three (3) ED physicians, nine (9) RNs and one (1) Patient Care Technician (PCT) were working during this date and time.


Interview with Patient #7 on 6/6/16 at 11:10 a.m. confirmed that she presented to Hospital #1's ED on 5/3/16 bleeding vaginally, but with no cramping. She stated that she had to wait 2 ½ hours and got tired so she left and went to Hospital #2. She also stated that the security guard told her on her way out of the ED that he was sorry she had wait. While at Hospital #1 Patient #7 did not see a physician, did not receive a MSE, any further assessments of herself or the fetus and no stabilizing treatment. All of this led to a delay in treatment for this patient.

HOSPITAL #2 ED Record Review for Patient #7
Hospital #2's ED record review revealed that Patient #7 presented to Hospital #2's ED on Wednesday 05/04/2016 at 1:22 a.m. and was triaged at 1:35 a.m. Her triage acuity was a 3. She was seen by the ED physician at 02:36 a.m. Several Lab Tests were performed, including a HCG Qualitative Urine, which was positive. Ultrasound findings stated: Single intrauterine gestational sac is demonstrated containing a single fetus with heart rate of 163 beats per minute. Estimated gestational age of 13 weeks 3 days ... the Primary Diagnosis was documented as 'Pregnant State and First Trimester Bleeding'. The disposition decision was discharge. The patient's condition at discharge was stable. Patient and family were discharged on Wednesday 5/4/16 at 2:52 a.m. to home with instructions.

The Complaint that Patient #7 did not receive a Medical Screening Exam while in Hospital #1's ED was substantiated. This patient also did not receive any further assessment of herself or fetal heart tones of the fetus and no stabilizing treatment, all of which caused a delay in treatment for this patient.



HOSPITAL #1 ED Record Review for PATIENT #2
ED record review revealed that Patient #2 left Hospital #1's ED without being seen by a physician. Patient #2, a 58 year old female, presented to Hospital #1's ED at 10:41 a.m. on 11/27/15 for pain in upper sides, nausea/vomiting and unable to regulate temperature. All symptoms began at 6:00 a.m. The patient was triaged at 11:01 a.m. with acuity of 3. She stated her pain intensity was at level 10. Her documented temperature at that time was 96.9 degrees. Pulse 73, Respiratory Rate 20, Blood Pressure 199/87. She reported she took no medications for her blood pressure. The patient left the ED without being seen by a physician at 7:25 p.m. on 11/27/15. There was no documented evidence the patient was reassessed, received stabilizing treatment or received a MSE during the 8 hours and 44 minutes she was in the ED. This led to a delay in treatment for this patient. Her Discharge Information stated: "Time seen by Provider: (this area was blank) ... Emergency Discharge Date/Time 11/27/16 19:25 (7:25 p.m.). Emergency Discharge Disposition: Left W/O (without) Being Seen In ER ... ED Discharge Type - Eloped AMA ...Left without being seen ... Not in waiting area when called ..."

On 6/6/16 at 3:10 p.m. Patient #2 was interviewed via telephone regarding her 11/27/15 ED visit to Hospital #1. She stated that she was never seen by a doctor, no one ever reassessed her, and she received no stabilizing treatment while in Hospital #1's ED so she left and went over to Hospital #2, where she was seen right away. "I had pains in my sides and I was nauseated and vomiting. I was there (Hospital #1) for over 8 ½ hours. No one checked on me and I never saw a doctor, so I left and went over to (Hospital #2). They saw me right away, gave me some medicine and I went home. I was OK after that."

Patient #2 was in Hospital #1's ED for 8 hours and 44 minutes. The hospital failed to do any further assessment of this patient, failed to provide a Medical Screening Exam or any stabilizing treatment, all which caused a delay in treatment for this patient.

HOSPITAL #2 ED RECORD REVIEW FOR PATIENT #2
Patient #2, a 58 year old female presented to Hospital #2's ED on 11/27/2015 at (24:29)12:29 p.m. The patient was triaged at (13:18) 1:18 p.m. with acuity of 2. She had complaints of pain in her right upper quadrant that started that morning around 7:30 a.m. and also stated that this pain goes into her back and the pain started after she ate some greens yesterday. She was seen by the ED physician at (14:17) 2:17 p.m. Clinician History stated: " Abdominal pain sharp and stabbing ... Quite severe ... localized to right upper quadrant ... complains of marked nausea with vomiting ... having true episodes of vomiting ... nondescript vomitus without blood. " The patient was given Dilaudid 1 mg (miligram) IV (intravenous) push and Zofran 4 mg IV push ... The physician ordered an EKG, lab, Gallbladder ultrasound, x-ray of the abdomen and a CT of the abdomen and pelvis. The examination findings: Slightly distended gallbladder. No other abnormality identified. The disposition decision: Discharge. The patient's condition at discharge was stable. She was discharged to home at (18:25) 6:25 p.m. with instructions and prn (as needed) medication.

There was a noted discrepancy in times between Patient #2's Hospital #1 ED visit and Hospital #2 ED visit.
Her Hospital #1 ED record documents that she was in their hospital on 11/27/15 from 11:01 a.m. to 7:25 p.m.
Her Hospital #2 ED record documents that she was in their hospital on 11/27/15 from 12:30 p.m. to 6:25 p.m.

On 6/8/16 at 11:25 a.m. this time discrepancy was pointed out to Hospital #1's Director of Emergency Services and Director of Accreditation. The Director of Emergency Services stated that she is unsure how this happened and she doesn't believe the wait time was that long. "I feel like the patient would have complained to someone about this extended stay." The Director of Accreditation stated that she believes it could be how the reports are pulled from the system and that the IT team is looking into it.



HOSPITAL #1 ED Record Review for PATIENT #6
ED record review for Patient #6 revealed she left Hospital #1's ED without being seen by a physician. Patient #6 was a 15 year old female who presented to the ED on 12/07/2015 at 12:23 p.m. with complaints of rapid heartbeat and near syncopal episode. She was triaged at 12:48 with acuity of 2. An EKG was performed at 12:55 p.m. which revealed, "Sinus Tachcardia". Patient #6 left without being seen by a physician at 3:00 p.m. There was no documented evidence that a MSE was done or if any further assessment or stabilizing treatment was done during the 2 hours and 37 minutes the patient was in the ED. Her Discharge Information stated: "Time seen by Provider: (this area was blank) ... Emergency Discharge Date/Time 12/07/15 15:00 (3:00 p.m.). Emergency Discharge Disposition: Left W/O Being Seen In ER ... ED Discharge Type - Left without being seen ..."


On 6/7/16 a telephone interview was attempted with Patient #6 and her parents at 9:22 a.m., 9:50 a.m. and at 10:36 a.m. in an attempt to verify the wait time she had at Hospital #1 and ascertain whether she left Hospital #1 and went to Hospital #2 for treatment. The telephone number used was the one found on her ED record. Each call was answered by a recording which stated, "This person is not accepting calls at this time." No other telephone number could be found for this patient/parents. An internet search on whitepages.com was also attempted to find an alternate phone number without success. On 6/8/16 at 10:27 a.m. another attempt was made to find another phone number listed for this patient. The phone number listed on the ED report was off by one (1) number in two (2) places. Both numbers were called. Both numbers had busy signals.

Review of Hospital #2's ED Log revealed that Patient #6 did not present to Hospital #2 to be seen after leaving Hospital #1 without being seen on 12/7/15.


Patient #6 was in Hospital #1's ED for 2 hours and 37 minutes. The hospital failed to do any further assessment of this patient, failed to provide a Medical Screening Exam or stabilizing treatment, all which caused a delay in treatment for this patient.


HOSPITAL #1 ED Record Review for PATIENT #8
ED record review revealed that Patient #8 left Hospital #1's ED without being seen by a physician. Patient #8 was a 3 year 5 month old female who presented to the ED accompanied by her parents on 05/03/16 at 9:23 p.m. with the complaint of not having a bowel movement in weeks. Her mother stated she was seen by a GI Specialist in Jackson previously for this complaint. The parents stated the baby had seven (7) laxatives (Pedialax and one (1) adult laxative) over the last five (5) days with no results. The child states her tummy hurts. The mother stated the child was also on Miralax. Patient #8 was triaged at 9:58 p.m. with acuity of 3, and left without being seen by a physician at 1:15 a.m., 3 hours and 17 minutes later. There was no documented evidence this patient was reassessed, received a MSE or received any stabilizing treatment during the time she was in the ED. Her Discharge Information stated: "Time seen by Provider: (this area was blank) ... Emergency Discharge Date/Time 05/04/16 01:15 (1:15 a.m.). Emergency Discharge Disposition: Left W/O (without) Being Seen In ER ... ED Discharge Type - Left without being seen ... pt (patient) called to room and is not in lobby, pt left..."


On 6/7/16 a telephone interview was attempted with Patient #8's parents at 9:24 a.m., 9:52 a.m. and at 10:37 a.m. in order to verify the wait time she had at Hospital #1 and ascertain whether she left Hospital #1 and went to Hospital #2 for treatment. The telephone number used was the one found on her ED record. Each call was answered by a recording which stated, "This person is not accepting calls at this time." No other telephone number could be found for this patient's parents. An internet search on whitepages.com was also attempted to find an alternate phone number without success. On 6/8/16 at 10:30 a.m. an attempt was made to find another phone number listed for this patient. Another phone number was located for the mother and was called. A recording stated, "The number you dialed is not a working number." The original number was called again and a busy signal was received.

Review of Hospital 2's ED Log revealed that Patient #8 did not present to Hospital #2 to be seen after leaving Hospital #1 without being seen on 5/4/16.

Patient #8 was in Hospital #1's ED for 3 hours and 17 minutes. The hospital failed to do any further assessment of this patient, failed to provide a Medical Screening Exam or stabilizing treatment, all which caused a delay in treatment for this patient.


HOSPITAL #1 ED Record Review forPATIENT #16
ED record review for Patient #16 revealed she left Hospital #1's ED without being seen by a physician. Patient #16, a 29 year old female, presented to the ED on 01/04/16 at 10:30 p.m. complaining of weakness, nausea, headaches and shortness of breath. She was triaged at 10:49 p.m. with acuity of 4. The patient left without being seen at 11:23 p.m. There was no documented evidence that the patient received a MSE or any stabilizing treatment during the 53 minutes she was in the ED.

On 6/7/16 a telephone interview was attempted with Patient #16 at 9:26 a.m., 9:54 a.m. and at 10:39 a.m. in an attempt to verify the wait time she had at Hospital #1 and ascertain whether she left Hospital #1 and went to Hospital #2 for treatment. The telephone number used was the one found on her ED record. Each call was answered by a recording which stated, "The number you are trying to call is unreachable." An internet search on whitepages.com was also attempted to find an alternate phone number without success. No other telephone number could be found for this patient. On 6/8/16 at 10:46 a.m. an attempt was made to find another phone number listed for this patient. No other phone number was located. The orignal phone number was called again. A recording stated, "The number you are trying to call is not reachable."

Patient #16 was in Hospital #1's ED for 53 minutes. The hospital failed to provide a Medical Screening Exam or stabilizing treatment, all which caused a delay in treatment for this patient.

Review of Hospital 2's ED Log revealed that Patient #16 did not present to Hospital #2 to be seen after leaving Hospital #1 without being seen on 1/4/16.



Review of the facility's "Triage Assessment" policy (effective 06/2011; revised and approved 2/2016) revealed, "Affected Departments: Nursing - Emergency Department. Purpose: To promote patient safety by establishing the priority of care based on the physical and psychosocial needs of each patient presenting to the ED for treatment and to facilitate the flow of patients through the ED... Procedure: ...All patients in the waiting room will be reassessed every 2 hours to include a complete set of vital signs and pain assessment. Triage is neither a diagnostic process nor a medical stability screen. A medical screening must be offered to every patient who presents for care..."


Review of the facility's "Emergency Medical Treatment and Labor Act (EMTALA)" policy (Effective 09/1989; Last Revised 04/2016) revealed: "Policy: ...1. If any individual... comes to the emergency department and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital should provide for an appropriate medical screening examination, performed by a qualified medical person, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists.... Definitions:... B. Emergency Medical Condition: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, ...) such that the absence of immediate medical attention could reasonably be expected to result in either: a. Placing the health of an individual (or, with respect of a pregnant woman, the health of the woman or her unborn child) in serious jeopardy. b. Serious impairment to bodily functions. c. Serious dysfunction of any bodily organ or part... Procedure: A. Medical Screening Examination 1. The Hospital shall provide a screening examination for every person who comes to the emergency department and makes a request for examination of an Emergency Medical Condition. The medical screening examination shall be done by a physician or qualified medical person..."


Review of the facility's "Obstetrics Patients Presenting to the Emergency Department" policy (effective: 01/2008; Reviewed/Approved: 09/2015) revealed: "Departments Affected: ...ER, Medical Staff. Purpose: To promote safety by appropriately managing the medical needs of obstetrical patients presenting to the emergency department. Policy: It is the policy of (Hospital) to give a medical screening examination to all obstetrical patients presenting to the emergency department... Procedure: A. Obstetrical patients at less than 20 weeks gestation should receive a medical screening in the Emergency Department. Fetal heart tones should be assessed in patients who are at least twelve (12) weeks gestation, to determine fetal well-being as part of the treatment process..."



CONCLUSION:
The complaint regarding Patient #7 not being seen by a physician while in the ED was substantiated and EMTALA violations were cited for the facility's failure to ensure this patient received a Medical Screening Exam (MSE) from a physician during the time she was in their facility.

Emergency Department Record Review during the survey also revealed that the following patients did not receive a MSE or stabilizing treatment which led to a delay in treatment, and were not reassessed every two (2) hours while in the hospital's ED:
Patient #2 - in ED for 8 hours and 44 minutes
Patient #6 - in ED for 2 hours and 37 minutes
Patient #8 - in ED for 3 hours and 17 minutes
Patient #16 - in ED for 53 minutes

Based on observation, Hospital #1 and #2's Emergency Department (ED) record review, ED sign in log review, Employee Schedule review, staff interview, patient interview, and policy and procedure review, the hospital failed to ensure five (5) of 22 patients reviewed, Patient #2, #6, #7, #8 and #16, received stabilizing treatment while in the ED.


FIndings include:

On 5/20/16 the State Office received a complaint from the Chief Executive Officer (CEO) of Hospital #2. The Complaint stated in part: "Regretfully, (Hospital #2) finds it necessary to file a complaint against (Hospital #1) related to (Hospital #1's) EMTALA obligations.
... included in this complaint is a case in which one of our employees reported that her daughter-in-law (Patient #7) presented to (Hospital #1) in the evening of May 3, 2016, a 29 year old who was 14 weeks pregnant, actively bleeding to the point of bleeding through her clothes while sitting in the Emergency Department Waiting Room and her sister having to go purchase her clothes at the local Walmart. She sat there for four hours with no medical screening exam before her husband finally decided to put her back in the private vehicle and bring her to (Hospital #2). It was reported that as the husband was loading up his wife, the (Hospital #1) security guard said sorry it has to be this way ...we are just so backed up all the time with (Hospital #2) being on diversion. (Hospital #2) was Not on diversion. The patient came to (Hospital #2) and was seen promptly....
(Hospital #2's) Administration has tried to work with (Hospital #1's) Administration on matters such as this to no avail. We are asking for your review of (Hospital #1's) compliance with EMTALA. We very much appreciate your time and assistance."


An unannounced visit was made to Hospital #1 on 5/23/16 at 10:00 a.m. The nature of this investigation visit was discussed with the hospital's CEO; the Corporate Compliance for the Administrator and Director of Legal Risk; the Director of the Emergency Department (ED); the Credential Coordinator; and the Director of Accreditation during the entrance conference conducted in the Administration Board Room. A list of what was needed was given and a tour of the ED requested.

A tour of the ED was conducted on 05/23/16 at 10:35 a.m. with the ED Director, the Corporate Compliance for the Administrator and Director of Legal Risk, and the Registered Nurse (RN) Charge Nurse. Four (4) EMTALA signs were observed in the waiting areas. EMTALA signs were also observed located by the triage room and the ambulance entrance. The ED was noted to have a non-urgent clinic which is open from 10:00 a.m. to 10:00 p.m. After patients are triaged, some level three (3), all level four (4) and all level five (5) acuity are sent to the non-urgent side. The ED Director stated that the hospital's policy for the Triage Nurse is to complete a reassessment of the ED patients every two (2) hours.

Document review revealed that Hospital #1 has 29 Critical Care beds, which includes 13 Intensive Care Beds, 12 Critical Care Beds and four (4) Observation Beds. They have 19 Emergency Department beds and 15 beds in their Fast Track Clinic.

The hospital's Medical Executive Committee Meeting Minutes, Medical Bylaws, Quality/Patient Safety Committee Minutes, Performance Improvement Project Documentation and Tracking, EMTALA In-services on all Emergency Department Employees, Emergency Department Log, Emergency Department 'Sign In Log', Emergency Department Physician schedules and Emergency Department Employee Schedules were reviewed.


Interview with President and CEO of Hospital #2 on 05/24/2016 at 9:25 a.m. revealed that he had met with the Administrator of Hospital #1 in the past... "I would just love to see this issue worked out, especially because the two area hospitals are all the people in the surrounding area have and there is such a need for the two hospitals to work together."

On 06/08/2016 at 11:00 a.m. another visit was made to Hospital #1. The nature of the visit was discussed with the Corporate Compliance for the Administrator and Director of Legal Risk, and the Director of Accreditation. A list of items were given and a request to meet with the Medical Director of ED.

On 06/08/16 at 11:25 a.m. an interview with the new Medical Director of ED; the Director of Emergency Service; the Director of ED; the Corporate Compliance for the Administrator and Director of Legal Risk; and the Director of Accreditation revealed:
The Director of Emergency Service stated, "On 11/27/15 at 6:45 a.m. 13 patients had not been seen from the previous shift. In addition a total of 137 patients signed in to be seen and there were a total of 35 admissions for this day. We were two registered nurses (RNs) short on both the morning and evening shift due to call-ins. This was the Friday after Thanksgiving. I tried calling from the RN PRN (as needed) pool but no one was willing to come in on the holiday. On 12/7/15 there were a total of 94 signed in and seen with a total of 24 admissions. There was coverage on this day. On 01/11/16 90 patients signed in and were seen with 24 admissions. On 05/04/20 98 patients signed in, 4 patients left without being seen and a there was a total of 24 admissions. A Level 1 patient came in during the time Patient #7 was in the ED along with several Level 2 patients. " The Medical Director for ED stated, "In November 2015 we lost all our Patient Care Representatives who helped in triage, due to budget cuts. The wait times were identified and were sent to the G7 committee. " When asked what the G7 committee entailed, he replied, " It ' s a committee made up of the hospitals Vice Presidents. It is a 7 person committee which has to approve any spending of the facility due to the financial loss this facility has taken in the last year. " The Director of Emergency Services stated that she does a chart audit of 30% (percent) every month and she did notice occasional extended wait times. "I came up with an action plan after a patient filed a complaint in February 2016. I have done much research on AHRQ (Agency for Healthcare Research and Quality), have spoken to other hospitals, and I presented a plan to the G7 committed on 05/07/2016 and it was approved. The Pharmacy will now do all medications and four Patient Care Technicians were approved to be hired. The announcements were finalized and the jobs posted on 06/07/2016 and we've already had four applications. The facility has revised their policies to address this issue, however the policies have not been approved as yet. " When asked if they were aware if any of the facility staff has ever told the patients their wait time would be a couple of hours, the Director of Emergency Services stated that she does not believe her staff would ever do that. "However, as a courtesy if the wait is longer I ask the triage nurse, when she does the reassessment, to apologize to the patient and reassure them they will be seen. In addition I have instructed them several times to never give a wait time. All staff has been trained on this." The ED Director stated, "I would like to add that as of this morning there was eight patients left over for the morning shift to see, 27 scheduled surgeries, 10 patients in the cath lab and their floor census this morning is 180." He also stated that the facility has not been on diversion. During these interviews it was noted that the ED had an Alpha Code called, a Bravo Code called and a Code Brown called. The Brown Code was a gunshot that required extra security for the ED.


HOSPITAL #1 - ED Record Review for PATIENT #7 (COMPLAINT)
Hospital #1's ED record review revealed that Patient #7 left Hospital #1's ED without being seen by a physician or receiving stabilizing treatment. The patient presented to Hospital #1's ED on Tuesday 5/3/16 at 22:23 (10:23 p.m.) with the complaint of heavy bleeding at 21:30 (9:30 p.m.) when she went to the bathroom at home. She stated she was pregnant with a due date of 11/8/16. She denied any abdominal pain. She was documented as a G1P0O0. The patient's triage acuity was a 3. Patient #7 left the ED without being seen by a physician on Wednesday 5/4/16 at 1:09 a.m. She spent a total of two (2) hours and 29 minutes in Hospital #1's ED without being seen by a physician, without receiving a Medical Screening Exam, further assessment, or any stabilizing treatment, thus causing a delay in treatment for this patient. No fetal heart tones were ever assessed. Review of Hospital #1's ED Log for the date and time period Patient #7 was in their ED revealed one (1) Level One (1) Trauma patient presented on 5/3/16 at 21:29 (9:29 p.m.). Review of Hospital #1's employee schedule revealed three (3) ED physicians, nine (9) RNs and one (1) Patient Care Technician (PCT) were working during this date and time.


Interview with Patient #7 on 6/6/16 at 11:10 a.m. confirmed that she presented to Hospital #1's ED on 5/3/16 bleeding vaginally, but with no cramping. She stated that she had to wait 2 ½ hours and got tired so she left and went to Hospital #2. She also stated that the security guard told her on her way out of the ED that he was sorry she had wait. While at Hospital #1 Patient #7 did not see a physician, did not receive a MSE, any further assessments of herself or the fetus and no stabilizing treatment. All of this led to a delay in treatment for this patient,

HOSPITAL #2 ED Record Review for Patient #7
Hospital #2's ED record review revealed that Patient #7 presented to Hospital #2's ED on Wednesday 05/04/2016 at 1:22 a.m. and was triaged at 1:35 a.m. Her triage acuity was a 3. She was seen by the ED physician at 02:36 a.m. Several Lab Tests were performed, including a HCG Qualitative Urine, which was positive. Ultrasound findings stated: Single intrauterine gestational sac is demonstrated containing a single fetus with heart rate of 163 beats per minute. Estimated gestational age of 13 weeks 3 days ... the Primary Diagnosis was documented as 'Pregnant State and First Trimester Bleeding'. The disposition decision was discharge. The patient's condition at discharge was stable. Patient and family were discharged on Wednesday 5/4/16 at 2:52 a.m. to home with instructions.

The Complaint that Patient #7 did not receive any stabilizing treatment while in Hospital #1's ED was substantiated. This patient also did not receive a Medical Screening Exam, or any further assessment of herself or fetal heart tones of the fetus, all of which caused a delay in treatment for this patient.



HOSPITAL #1 ED Record Review for PATIENT #2
ED record review revealed that Patient #2 left Hospital #1's ED without being seen by a physician or receiving any stabilizing treatment. Patient #2, a 58 year old female, presented to Hospital #1's ED at 10:41 a.m. on 11/27/15 for pain in upper sides, nausea/vomiting and unable to regulate temperature. All symptoms began at 6:00 a.m. The patient was triaged at 11:01 a.m. with acuity of 3. She stated her pain intensity was at level 10. Her documented temperature at that time was 96.9 degrees. Pulse 73, Respiratory Rate 20, Blood Pressure 199/87. She reported she took no medications for her blood pressure. The patient left the ED without being seen by a physician at 7:25 p.m. on 11/27/15. There was no documented evidence the patient was reassessed, received stabilizing treatment or received a MSE during the 8 hours and 44 minutes she was in the ED. This led to a delay in treatment for this patient. Her Discharge Information stated: "Time seen by Provider: (this area was blank) ... Emergency Discharge Date/Time 11/27/16 19:25 (7:25 p.m.). Emergency Discharge Disposition: Left W/O (without) Being Seen In ER ... ED Discharge Type - Eloped AMA ...Left without being seen ... Not in waiting area when called ..."

On 6/6/16 at 3:10 p.m. Patient #2 was interviewed via telephone regarding her 11/27/15 ED visit to Hospital #1. She stated that she was never seen by a doctor, no one ever reassessed her, and she received no stabilizing treatment while in Hospital #1's ED so she left and went over to Hospital #2, where she was seen right away. "I had pains in my sides and I was nauseated and vomiting. I was there (Hospital #1) for over 8 ½ hours. No one checked on me and I never saw a doctor, so I left and went over to (Hospital #2). They saw me right away, gave me some medicine and I went home. I was OK after that."

Patient #2 was in Hospital #1's ED for 8 hours and 44 minutes. The hospital failed to do any further assessment of this patient, failed to provide a Medical Screening Exam or any stabilizing treatment, all which caused a delay in treatment for this patient.

HOSPITAL #2 ED RECORD REVIEW FOR PATIENT #2
Patient #2, a 58 year old female presented to Hospital #2's ED on 11/27/2015 at (24:29)12:29 p.m. The patient was triaged at (13:18) 1:18 p.m. with acuity of 2. She had complaints of pain in her right upper quadrant that started that a.m. around 7:30 a.m. and also stated that this pain goes into her back and the pain started after she ate some greens yesterday. She was seen by the ED physician at (14:17) 2:17 p.m. Clinician History stated: " Abdominal pain sharp and stabbing ... Quite severe ... localized to right upper quadrant ... complains of marked nausea with vomiting ... having true episodes of vomiting ... nondescript vomitus without blood. " The patient was given Dilaudid 1 mg (miligram) IV (intravenous) push and Zofran 4 mg IV push ... The physician ordered an EKG, lab, Gallbladder ultrasound, x-ray of the abdomen and a CT of the abdomen and pelvis. The examination findings: Slightly distended gallbladder. No other abnormality identified. The disposition decision: Discharge. The patient's condition at discharge was stable. She was discharged to home at (18:25) 6:25 p.m. with instructions and prn (as needed) medication.

There was a noted discrepancy in times between Patient #2's Hospital #1 ED visit and Hospital #2 ED visit.
Her Hospital #1 ED record documents that she was in their hospital on 11/27/15 from 11:01 a.m. to 7:25 p.m.
Her Hospital #2 ED record documents that she was in their hospital on 11/27/15 from 12:30 p.m. to 6:25 p.m.

On 6/8/16 at 11:25 a.m. this time discrepancy was pointed out to Hospital #1's Director of Emergency Services and Director of Accreditation. The Director of Emergency Services stated that she is unsure how this happened and she doesn ' t believe the wait time was that long. "I feel like the patient would have complained to someone about this extended stay." The Director of Accreditation stated that she believes it could be how the reports are pulled from the system and that the IT team is looking into it.



HOSPITAL #1 ED Record Review for PATIENT #6
ED record review for Patient #6 revealed she left Hospital #1's ED without being seen by a physician or receiving stabilizing treatment. Patient #6 was a 15 year old female who presented to the ED on 12/07/2015 at 12:23 p.m. with complaints of rapid heartbeat and near syncopal episode. She was triaged at 12:48 with acuity of 2. An EKG was performed at 12:55 p.m. which revealed, "Sinus Tachcardia". Patient #6 left without being seen by a physician at 3:00 p.m. There was no documented evidence that a MSE was done or of any further assessment or stabilizing treatment was done during the 2 hours and 37 minutes the patient was in the ED. Her Discharge Information stated: "Time seen by Provider: (this area was blank) ... Emergency Discharge Date/Time 12/07/15 15:00 (3:00 p.m.). Emergency Discharge Disposition: Left W/O Being Seen In ER ... ED Discharge Type - Left without being seen ..."


On 6/7/16 a telephone interview was attempted with Patient #6 and her parents at 9:22 a.m., 9:50 a.m. and at 10:36 a.m. in an attempt to verify the wait time she had at Hospital #1 and ascertain whether she left Hospital #1 and went to Hospital #2 for treatment. The telephone number used was the one found on her ED record. Each call was answered by a recording which stated, "This person is not accepting calls at this time." No other telephone number could be found for this patient/parents. An internet search on whitepages.com was also attempted to find an alternate phone number without success. On 6/8/16 at 10:27 a.m. another attempt was made to find another phone number listed for this patient. The phone number listed on the ED report was off by one (1) number in two (2) places. Both numbers were called. Both numbers had busy signals.

Review of Hospital #2 ' s ED Log revealed that Patient #6 did not present to Hospital #2 to be seen after leaving Hospital #1 without being seen on 12/7/15.


Patient #6 was in Hospital #1's ED for 2 hours and 37 minutes. The hospital failed to do any further assessment of this patient, failed to provide a Medical Screening Exam or stabilizing treatment, all which caused a delay in treatment for this patient.


HOSPITAL #1 ED Record Review for PATIENT #8
ED record review revealed that Patient #8 left Hospital #1's ED without being seen by a physician. Patient #8 was a 3 year 5 month old female who presented to the ED accompanied by her parents on 05/03/16 at 9:23 p.m. with the complaint of not having a bowel movement in weeks. Her mother stated she was seen by a GI Specialist in Jackson previously for this complaint. The parents stated the baby had seven (7) laxatives (Pedialax and one (1) adult laxative) over the last five (5) days with no results. The child states her tummy hurts. The mother stated the child was also on Miralax. Patient #8 was triaged at 9:58 p.m. with acuity of 3, and left without being seen by a physician at 1:15 a.m., 3 hours and 17 minutes later. There was no documented evidence this patient was reassassed, received a MSE or received any stabilizing treatment during the time she was in the ED. Her Discharge Information stated: "Time seen by Provider: (this area was blank) ... Emergency Discharge Date/Time 05/04/16 01:15 (1:15 a.m.). Emergency Discharge Disposition: Left W/O (without) Being Seen In ER ... ED Discharge Type - Left without being seen ... pt (patient) called to room and is not in lobby, pt left..."


On 6/7/16 a telephone interview was attempted with Patient #8's parents at 9:24 a.m., 9:52 a.m. and at 10:37 a.m. in an attempt to verify the wait time she had at Hospital #1 and ascertain whether she left Hospital #1 and went to Hospital #2 for treatment. The telephone number used was the one found on her ED record. Each call was answered by a recording which stated, "This person is not accepting calls at this time." No other telephone number could be found for this patient's parents. An internet search on whitepages.com was also attempted to find an alternate phone number without success. On 6/8/16 at 10:30 a.m. an attempt was made to find another phone number listed for this patient. Another phone number was located for the mother and was called. A recording stated, "The number you dialed is not a working number." The original number was called again and a busy signal was received.

Review of Hospital ' s ED Log revealed that Patient #8 did not present to Hospital #2 to be seen after leaving Hospital #1 without being seen on 5/4/16.

Patient #8 was in Hospital #1's ED for 3 hours and 17 minutes. The hospital failed to do any further assessment of this patient, failed to provide a Medical Screening Exam or stabilizing treatment, all which caused a delay in treatment for this patient.


HOSPITAL #1 ED Record Review for PATIENT #16
ED record review for Patient #16 revealed she left Hospital #1's ED without being seen by a physician. Patient #16, a 29 year old female, presented to the ED on 01/04/16 at 10:30 p.m. complaining of weakness, nausea, headaches and shortness of breath. She was triaged at 10:49 p.m. with acuity of 4. The patient left without being seen at 11:23 p.m. There was no documented evidence that the patient received a MSE or any stabilizing treatment during the 53 minutes she was in the ED.

On 6/7/16 a telephone interview was attempted with Patient #16 at 9:26 a.m., 9:54 a.m. and at 10:39 a.m. in an attempt to verify the wait time she had at Hospital #1 and ascertain whether she left Hospital #1 and went to Hospital #2 for treatment. The telephone number used was the one found on her ED record. Each call was answered by a recording which stated, "The number you are trying to call is unreachable." An internet search on whitepages.com was also attempted to find an alternate phone number without success. No other telephone number could be found for this patient. On 6/8/16 at 10:46 a.m. an attempt was made to find another phone number listed for this patient. No other phone number was located. The orignal phone number was called again. A recording stated, "The number you are trying to call is not reachable."

Patient #16 was in Hospital #1's ED for 53 minutes. The hospital failed to provide a Medical Screening Exam or stabilizing treatment, all which caused a delay in treatment for this patient.

Review of Hospital 2's ED Log revealed that Patient #16 did not present to Hospital #2 to be seen after leaving Hospital #1 without being seen on 1/4/16.



Review of the facility's "Triage Assessment" policy (effective 06/2011; revised and approved 2/2016) revealed, "Affected Departments: Nursing - Emergency Department. Purpose: To promote patient safety by establishing the priority of care based on the physical and psychosocial needs of each patient presenting to the ED for treatment and to facilitate the flow of patients through the ED... Procedure: ...All patients in the waiting room will be reassessed every 2 hours to include a complete set of vital signs and pain assessment. Triage is neither a diagnostic process nor a medical stability screen. A medical screening must be offered to every patient who presents for care..."


Review of the facility's "Emergency Medical Treatment and Labor Act (EMTALA)" policy (Effective 09/1989; Last Revised 04/2016) revealed: "Policy: ...1. If any individual... comes to the emergency department and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital should provide for an appropriate medical screening examination, performed by a qualified medical person, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists.... Definitions:... B. Emergency Medical Condition: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, ...) such that the absence of immediate medical attention could reasonably be expected to result in either: a. Placing the health of an individual (or, with respect of a pregnant woman, the health of the woman or her unborn child) in serious jeopardy. b. Serious impairment to bodily functions. c. Serious dysfunction of any bodily organ or part... Procedure: A. Medical Screening Examination 1. The Hospital shall provide a screening examination for every person who comes to the emergency department and makes a request for examination of an Emergency Medical Condition. The medical screening examination shall be done by a physician or qualified medical person..."


Review of the facility's "Obstetrics Patients Presenting to the Emergency Department" policy (effective: 01/2008; Reviewed/Approved: 09/2015) revealed: "Departments Affected: ...ER, Medical Staff. Purpose: To promote safety by appropriately managing the medical needs of obstetrical patients presenting to the emergency department. Policy: It is the policy of (Hospital) to give a medical screening examination to all obstetrical patients presenting to the emergency department... Procedure: A. Obstetrical patients at less than 20 weeks gestation should receive a medical screening in the Emergency Department. Fetal heart tones should be assessed in patients who are at least twelve (12) weeks gestation, to determine fetal well-being as part of the treatment process..."



CONCLUSION:
The complaint regarding Patient #7 not being seen by a physician while in Hospital #1's ED was substantiated and EMTALA violations were cited for the facility's failure to ensure this patient received a Medical Screening Exam (MSE) from a physician during the time she was in their facility, failure to ensure the patient received stabilizing treatment, failure to ensure the patient received no delay in treatment and failure to reassess the patient after two (2) hours as per their "Triage Assessment" policy.

Emergency Department Record Review during the course of the survey also revealed that the following patients did not receive a MSE or stabilizing treatment, received a delay in treatment, and were not reassessed every two (2) hours while in the hospital's ED:
Patient #2 - in ED for 8 hours and 44 minutes
Patient #6 - in ED for 2 hours and 37 minutes
Patient #8 - in ED for 3 hours and 17 minutes
Patient #16 - in ED for 53 minutes