HospitalInspections.org

Based on document review, staff, and patient caretaker interviews, the Emergency Department (ED) staff failed to provide a medical screening examination and failed to enter patients in the ED logbook, in accordance with hospital polices, for 1 of 60 (Patient #31) patients who presented to the ED requesting treatment on July 17, 2013. Surveyors selected 30 cases for review.

Findings include:

1. Review of the facility's EMTALA Policies and procedures, dated 12/12 and the EMTALA Answer Book, 2013 Edition, revealed the following, in part.

"The hospital will provide every patient who comes to the hospital seeking acute medical care with an appropriate medical screening examination to determine whether a patient has an emergency medical condition...if the medical screening reveals that an emergency medical condition exists, the hospital will then provide all such patients with treatment necessary to stabilize this condition...."

"...Comes to the Emergency Department...stated simply, subsection (a) of EMTALA requires that if an individual comes to the emergency department requesting care, the hospital must provide an appropriate screening examination to determine whether the individual suffers from an emergency medical condition...."

"...nursing personnel and the physician will work together in evaluating each individual presenting for emergency care...nursing staff will be aware that all patients regard their health as a priority and interference with good health is considered an emergency to that person..."

"Admission to Emergency Department - obtain all patient demographic information, including correct spelling of name, address, phone number...."

"...All patients who present to the ED are to be entered into the ED Medi-Tech log by the ED unit secretary...."

2. Review of the ED log dated 7/17/13 revealed 29 patients presented requesting treatment before 2 PM, 2 Patients presented requesting treatment between 2 PM and 3 PM, and 29 patients presented requesting treatment after 3 PM. The ED log lacked evidence that showed Patient #31 had presented to the ED requesting treatment on 7/17/13.

3. During an interview on 7/29/13 at 7:23 AM, Caseworker B, from the group home reported that Patient #31 had fallen earlier in the day of 7/17/13. Staff from the group home took the patient to a physician's clinic around 9:00 AM. Staff at the physician's clinic sent the patient to Skiff Medical Center, as an outpatient, for X-Rays of the patient's arm. Following the X-Rays, the patient returned to the group home. A clinic physician called the group home around 2:00 PM informing them Patient #31's right radial bone was broken and needed a cast.

During an interview on 8/1/13 at 11:50 AM, the ED Unit secretary reported she was working on 7/17/13 when a patient, requesting a cast, presented to the ER and she checked the patient in. They (patient and caseworker) mentioned they were at the hospital earlier in the day for an x-ray. I "unchecked" them because the patient was on Medicare and our process, here at the hospital, is to combine visits for x-rays of his arm. I think ED RN A came out and talked with the caseworker that was with the patient and before I could check the patient back into the electronic medical record system, RN A had conversed with the New Care clinic and they told her to send the patient back to the clinic. There was a discussion related to non-availability of an orthopedic doctor here, the orthopedic doctor was on vacation and they would have to go elsewhere to get a cast.

During an interview on 7/30/13 at 10:25 AM, ED RN A reported she remembered Patient #31, a mentally challenged person but could not remember the patient's name. RN A recognized the group home worker sitting with the patient in the waiting room and went out to see what was going on. They had come from the New Care Clinic to our ED requesting a cast for a fractured radius on the arm. I think the Nurse Practitioner at the clinic told him to come to our ER. I explained to the group home worker, that the ARNP (Advanced Practice Nurse Practitioner) told me to send them back to the clinic and she would send them somewhere else. I apologized for the run around. The group home worker understood, he said it was not a problem he wasn't upset.

Based on document review and staff interviews, Emergency Department (ED) staff failed to maintain a central log for 1 of 60 (Patient #31) who presented to the ED requesting treatment on July 17, 2013. Surveyors selected 30 cases for review.

Findings include:

1. Review of the facility's EMTALA Policies and procedures, dated 12/12 revealed the following, in part.

"...Admission to Emergency Department - obtain all patient demographic information, including correct spelling of name, address, phone number...."

"...All patients who present to the ED are to be entered into the ED Medi-Tech log by the ED unit secretary...."

On 7/30/13, at 4:00 PM, the Chief Nursing Officer documented, "Once patient has provided clerk (ED unit secretary) with name, DOB [date of birth] and chief complaint the information is entered into the Medi-Tech system (the electronic medical record system at Skiff Medical Center)."

2. Review of the ED log dated 7/17/13 revealed 29 patients presented requesting treatment before 2 PM, 2 Patients presented requesting treatment between 2 PM and 3 PM, and 29 patients presented requesting treatment after 3 PM. The ED log lacked evidence that showed Patient #31 had presented to the ED requesting treatment on 7/17/13. The facility did not have a medical record for Patient #31.

2. During an interview on 8/1/13 at 11:50 AM, the ED Unit secretary reported she was working on 7/17/13 when a patient, requesting a cast, presented to the ER and she checked the patient in. They (patient and caseworker) mentioned they were at the hospital earlier in the day for an x-ray. I "unchecked" them because the patient was on Medicare and our process, here at the hospital, is to combine the visits for x-rays of his arm. I think ED RN A came out and talked with the caseworker that was with the patient and before I could check the patient back into the electronic medical record system, RN A had conversed with the New Care Clinic and they told her to send the patient back to the clinic.

Based on document review, staff and caretaker interviews, Emergency Department (ED) staff failed to provide a medical screening examination for 1 of 60 (Patient #31) who presented to the ED requesting treatment on July 17, 2013. Surveyors selected 30 cases for review.

Findings include:

1. Review of the facility's EMTALA Policies and procedures, dated 12/12 and the EMTALA Answer Book, 2013 Edition, revealed the following, in part.

"The hospital will provide every patient who comes to the hospital seeking acute medical care with an appropriate medical screening examination to determine whether a patient has an emergency medical condition...if the medical screening reveals that an emergency medical condition exists, the hospital will then provide all such patients with treatment necessary to stabilize this condition...."

"...Comes to the Emergency Department...stated simply, subsection (a) of EMTALA requires that if an individual comes to the emergency department requesting care, the hospital must provide an appropriate screening examination to determine whether the individual suffers from an emergency medical condition...."

"...nursing personnel and the physician will work together in evaluating each individual presenting for emergency care...nursing staff will be aware that all patients regard their health as a priority and interference with good health is considered an emergency to that person..."

2. Review of the ED log dated 7/17/13 revealed 29 patients presented requesting treatment before 2 PM, 2 Patients presented requesting treatment between 2 PM and 3 PM, and 29 patients presented requesting treatment after 3 PM. The ED log lacked evidence that showed Patient #31 had presented to the ED requesting treatment on 7/17/13 or that the patient was triaged or provided a medical screening exam. The facility did not have a medical record for Patient #31.

3. During an interview on 7/29/13 at 7:23 AM, Caseworker B, from the group home reported that Patient #31 had fallen earlier in the day of 7/17/13. Staff from the group home took the patient to a physician's clinic around 9:00 AM. Staff at the physician's clinic sent the patient to Skiff Medical Center, as an outpatient, for X-Rays of the patient's arm. Following the X-Rays, the patient returned to the group home. A clinic physician called the group home around 2:00 PM informing them Patient #31's right radial bone was broken and needed a cast.

Caseworker B stated he accompanied Patient #31 to the Skiff Medical Center ED. They went to the registration window and registered the patient. The registrar asked for the patient ' s name, date of birth, current medications, and why we were there. Caseworker B told the registrar the patient had fallen earlier that day and staff from the group home had taken the patient to the clinic then, shortly after that, took the patient to Skiff Medical Center for x-rays. Now they were at the ED, under the direction of the clinic, to get the patient ' s arm casted.

Caseworker B stated during the interview that the person at the registration desk told them to go to a waiting room right across from the ED registration window. They were in the waiting area for around 20 minutes, when an RN Caseworker B knew (RN A) came out to the waiting room. RN A said they could not put a cast on and we would have to go back to the New Care Clinic.

It just seemed like Skiff ED staff did not want to deal with Patient #31. They did not offer to examine the patient; they just said we do not do casts, the orthopedic surgeon is on vacation and we needed to go back to the clinic. The Caseworker reported being very displeased because, when you are at a hospital, they are supposed to help patients and staff at Skiff ED did not see the patient, no nurse, no doctor, and no staff really. Patient #31 was complaining of pain and guarding the arm, you could tell the patient was in distress.

During an interview on 7/29/13 at 9:10 AM, the group home Administrator reported that staff immediately informed her of Patient #31's fall and injured right arm. The Administrator immediately brought the patient back to the group home and after completing an assessment, staff determined the patient needed to have an x-ray. Group home staff took the patient to the New Care Clinic, and the ARNP (Advanced Practice Nurse Practitioner), at the clinic, told us to take the patient to Skiff Medical Center for an x-ray and she would call us later to report the results. The clinic staff called with the results (broken arm) and directed us to take the patient to Skiff Medical Center for a cast. Purportedly, Skiff Medical Center ED does not apply casts and the ARNP told Caseworker B and Patient #31 to return to the clinic.

The Administrator stated she was incredibly frustrated with the delays that occurred on that day saying, this happened in the morning and by the time the patient received any type of treatment for the fracture it was 5:00 PM. The Administrator said, in her opinion, the impact on [name] was he was in pain unnecessarily.

During an interview on 7/30/13 at 11:30 AM, the Clinic ARNP reported examining Patient #31 and sending the patient, with staff from the group home, to Skiff Medical Center for an x-ray of the arm. The ARNP did remember a phone call from Skiff ED staff telling her they did not cast patients in the ED. The ARNP did not request a physician examine the patient because the ED nurse let her know that Skiff could not cast so she asked the ED RN to send the patient back to the clinic. The ARNP said she was quite baffled they did not see the patient because with a fracture, you want to get it set as soon as possible.

During an interview on 8/1/13 at 11:50 AM, the ED Unit secretary reported she was working on 7/17/13 when a patient, requesting a cast, presented to the ER and she checked the patient in. They (patient and caseworker) mentioned they were at the hospital earlier in the day for an x-ray. I "unchecked" them because the patient was on Medicare and our process, here at the hospital, is to combine visits for x-rays of his arm. RN A had conversed with the New Care Clinic and they told her to send the patient back to the clinic. There was a discussion related to non-availability of an orthopedic doctor here, the orthopedic doctor was on vacation and they would have to go elsewhere to get a cast.

During an interview on 7/30/13 at 10:25 AM, ED RN A reported she remembered Patient #31, a mentally challenged person, but could not remember the patient's name. RN A recognized the caseworker, sitting in the waiting room, and went out to find out why they were at the ED. They (Patient #31 and the caseworker) had come from the New Care Clinic to Skiff Medical Center ED requesting a cast for the patient's fractured arm. RN A called the ARNP at the clinic and told her they do not apply casts in the ED. The ARNP told RN A to send the patient back to the clinic. RN A returned to the waiting room and explained to the caseworker, that the Clinic ARNP told her to send them back to the clinic and the ARNP would send them somewhere else to get a cast. RN A said she apologized to the Caseworker for the run around. The caseworker said he understood, that it was not a problem and he was not upset. When asked if an ED doctor examined Patient #31, RN A replied, no.

During an interview on 7/30/13 at 11:50 PM, The ED Medical Director reported the ED secretary registers all patients presenting to the ED for treatment and a qualified medical professional would always conduct a medical screening exam for any patients presenting to their ED with a broken arm. With arm injuries including fractures, typically they do not cast because there is swelling, they would splint. Casting is never an emergency, splinting is. They do not put casts on, but do put splints on, which has proven to be just as effective as casts because the purpose for the injured extremity is immobilization. The Medical Director confirmed that he and the Skiff ED doctors had the appropriate training to treat orthopedic injuries/fractures and all of the ED doctors were capable of splinting.

During an interview on 7/29/13 at 4:00 PM, ED Interim Nursing Supervisor confirmed, once a patient's name date of birth, etc. is obtained a physician should see the patient.