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Based on document review and staff interviews, the hospital's emergency department (ED) staff failed to follow the hospital's policies when the ED staff failed to provide an adequate medical screening examination for 2 of 41 patients (Patient #9 and Patient #41) that presented to the ED and requested care. Failure to follow the hospital's policies which required the ED staff to provide an adequate medical screening examination within the hospital's capabilities resulted in the hospital's ED staff discharging a patient complaining of abdominal pain without determining the cause of the abdominal pain, and presented to another hospital less than 11 hours later with a diagnosis of acute appendicitis requiring surgery. Failure to follow the hospital's policies regarding providing an adequate medical screening examination also resulted in the hospital's ED staff discharging a pregnant patient complaining of ankle pain after a fall without assessing the well-being of the patient's fetus. The administrative staff identified an average of 21 patients per day who requested emergency medical care at the hospital's dedicated emergency department.


Findings included:

1. Review of the policy "Examination of Emergency Patient and Hospital Transfers", last revised 10/2016, revealed in part, "Policy: ... St. Anthony Regional Hospital will provide medically appropriate care within the hospital's capability. Protocol: The hospital must provide a medical screening examination to anyone who presents to the hospital ... and who requests an examination or treatment to determine whether or not the individual is in an emergency medical condition ... Definitions: ... Medical Screening Examination is to determine whether the individual has an emergency medical condition. The examination includes a history, physical exam, and diagnostic testing within the hospital's capabilities and appropriate to the condition. The screening is on-going until the individual is stabilized or appropriately transferred ..."

2. Review of Patient #9's medical record revealed Patient #9 presented to the hospital's emergency department on 10/6/17 complaining of abdominal pain. The hospital staff discharged Patient #9 prior to performing an adequate medical screening examination to determine if Patient #9 had an unstabilized emergency medical condition. Patient #9 was treated at another hospital where the staff diagnosed her with appendicitis and performed an emergency appendectomy. Please refer to A-2406 for additional information.

3. Review of Patient #41's medical record revealed Patient #41 presented to the hospital's emergency department on 2/12/18 complaining of ankle pain after falling down several stairs. Patient #41 was 32 weeks pregnant at the time of the fall. The hospital staff failed to assess Patient #41's fetal heart rate prior to discharging Patient #41 from the hospital. Please refer to A-2406 for additional information.

Based on document review and staff interviews, the hospital's administrative staff failed to ensure the on-call log contained the names of the physicians available to provide on-call specialty services for 1 of 1 Ear, Nose, and Throat (ENT) physician on-call (ENT Physician G) for the on-call schedules reviewed from 1/1/18 through 5/31/18. Failure to identify the physician available on-call could potentially result in the emergency department physician needing the on-call physician's specialty services and the emergency department physician not knowing the specialty physician was not available to see patients in the emergency department. The hospital's administrative staff identified an average of 21 patients per day who presented to the hospital and requested emergency medical care at the hospital's dedicated emergency department.

Findings included:

1. Review of the emergency department's on-call schedule for 5/23/18 revealed Registered Nurse (RN) H's name listed for ENT Physician G's on-call information. The on-call information did not include ENT Physician G's phone number or other means of contacting ENT Physician G if the emergency department physician required ENT Physician G's assistance.

2. Review of the [St. Anthony's Regional Hospital] Credentialed Staff List, dated 5/2018, revealed RN H's name was not included on the list.

3. Review of the "Call Schedule" for ENT Physician G's clinic from 1/1/18 through 5/31/18 revealed the call schedule listed either RN H's name or Licensed Practical Nurse (LPN) I's name. The schedules did not list ENT Physician G as the contact if the emergency department staff required ENT Physician G's assistance in the emergency room.

4. During an interview on 5/23/18 at 1:40 PM, the Director of Quality verified the on-call schedule for ENT Physician G only listed the nurses for the emergency department staff to contact if they required ENT Physician G's services. The emergency department staff would call the nurse listed on the schedule, who would perform triage, and then notify ENT Physician G about the patient in the emergency department. The schedule did not reflect any days ENT Physician G was not available on-call. The only way the emergency department staff would know if ENT Physician G was unavailable would involve calling the nurse listed on the on-call schedule and then discovering ENT Physician G was not available to provide specialist services to the emergency department physician.

Based on document review and staff interviews, the hospital's emergency department (ED) staff failed to provide an adequate medical screening examination for 2 of 41 patients (Patient #9 and Patient #41) that presented to the ED and requested care from 9/1/2017 through 5/16/2018. Failure of the hospital's ED staff to provide an adequate medical screening examination within the hospital's capabilities resulted in the hospital's ED staff discharging a patient complaining of abdominal pain without determining the cause of the abdominal pain, and who presented to another hospital less than 11 hours later with a diagnosis of acute appendicitis and required surgery. Failure to diagnose acute appendicitis could potentially result in the appendix bursting and spreading infection into the patient's blood stream, potentially causing multiple organ failure and death. Failure to provide an adequate medical screening examination also resulted in the ED staff discharging a pregnant patient complaining of ankle pain after a fall without assessing patient's pregnancy and the well-being of the patient's fetus. Failure to assess the patient's fetus following a fall could potentially result in the hospital staff failing to detect a potentially life threatening condition with the pregnancy that could result in death of the fetus and delivery of a still-born baby. The administrative staff identified an average of 21 patients per day who requested emergency medical care at the hospital's dedicated emergency department.


Findings included:

1. Review of Patient #9's closed medical record revealed Patient #9 presented to the Emergency Department (ED) on 10/6/17 at 2:06 PM complaining of abdominal pain not relieved by Tylenol or Advil. ED Physician D ordered a urinalysis and urine pregnancy test. The urinalysis results did not indicate Patient #9 had an urinary infection. ED Physician D failed to order any further diagnostic testing to determine the cause of Patient #9's abdominal pain. According to the record review, ED Physician D ordered ED Registered Nurse (RN) A to administer pain medication and anti-nausea medication to Patient #9 via injection. ED RN A administered the medication to Patient #9 at 3:12 PM. ED RN A then discharged Patient #9 home at 3:24 PM on 10/6/17 (12 minutes after receiving the injections). ED RN A failed to reassess Patient #9's pain after administering the medication and prior to discharging Patient #9 from the hospital.

Review of Patient #9's medical record from Hospital B (located approximately 60 miles from St. Anthony's Regional Hospital) revealed Patient #9 presented to Hospital B's ED on 10/7/17 at 2:19 AM, complaining of abdominal pain (less than 11 hours after Patient #9 left St. Anthony's Regional Hospital). The ED staff at Hospital B diagnosed Patient #9 with acute appendicitis, and performed emergency surgery to remove Patient #9's appendix.

2. During an interview on 5/23/18 at 9:25 AM, ED RN C stated she preformed the initial nursing assessment for Patient #9's ED visit on 10/6/17. Patient #9 was complaining of abdominal pain rated 8 on a 1-10 pain scale, indicating severe pain. ED RN C documented Patient #9 was hunched over and holding her abdomen to minimize the pain from moving. Patient #9 moved slowly and cautiously to help minimize the abdominal pain. RN C verified the hospital staff failed to perform any laboratory blood tests or any radiology tests to determine the cause of Patient #9's abdominal pain.

3. During an interview on 5/23/18 at 10:15 AM, ED Physician D stated Patient #9 came to the ED complaining of pain located below her belly button. ED Physician D pressed on Patient #9's abdomen in the area where she complained of pain, and did not notice rebound tenderness (relief of pressure when the physician removed his hands from the patient's abdomen, rebound tenderness is a weak sign of appendicitis). ED Physician D could not remember if Patient #9 experienced pain in the lower right side of her abdomen (a strong sign of appendicitis). ED Physician D thought Patient #9's pain was from a recently diagnosed ovarian cyst and urinary tract infection. ED Physician D treated Patient #9's symptoms. However, she later ended up at another ED with appendicitis and required surgery.

4. During an interview on 5/22/18 at 2:10 AM, ED RN A stated she administered pain and anti-nausea medication to Patient #9 on 10/6/17 at 3:12 PM. ED RN A provided Patient #9 with instructions on how to take care of herself at home and discharged Patient #9 to her home at 3:24 PM.

5. During an interview on 5/23/18 at 9:20 AM, the Laboratory Director confirmed the laboratory had the capability and capacity to run simple blood testing such as a complete blood count and complete metabolic profile on 10/6/17 when Patient #9 presented to the hosptial and requested emergency medical care.

6. Review of a document created by the Acting Radiology Director on 5/23/18 revealed the hospital had the ability to perform both a computed tomography (CT) scan (a detailed x-ray scan of the body to allow physicians to diagnose conditions such as appendicitis) and an ultrasound exam (an exam using sound waves to look inside the body) on 10/6/17 when Patient #9 presented to the hospital and requested emergency medical care.

7. Review of Patient #41's medical record revealed Patient #41 presented to the ED at 4:02 AM on 2/12/18. Patient #41 was 32 weeks pregnant (approximately 8 months). Patient #41 complained of left ankle pain after falling down 3 stairs at home. Patient #41 did not strike her head or her abdomen. ED Physician E ordered an x-ray of Patient #41's left ankle. ED Physician E read the x-ray and determined Patient #41 sprained her left ankle. ED Physician E discharged Patient #41 to her home at 5:20 AM on 2/12/18. Patient #41's medical record lacks any documentation indicating the ED staff assessed Patient #41's baby or listened to the baby's heart rate to check on the health of the baby.

8. During an interview on 5/22/18 at 3:50 PM, ED RN F stated she assessed Patient #41 and charted the obstetrical (OB) part of the assessment when Patient #41 presented to the ED on 2/12/18. ED RN F stated thought she listened to Patient #41's baby's heart rate, but she could not find any documentation indicating she listened to Patient #41's baby's heart rate.

9. During an interveiw on 5/23/18 at 8:00 AM, ED Physician E stated she saw Patient #41 for left ankle pain after she fell down a few stairs. ED Physician E stated thought she listened to Patient #41's baby's heart rate, but she could not find any documentation indicating she listened to Patient #41's baby's heart rate.

10. During an interview on 5/23/18 at 11:50 AM, the Medical Director for the Obstetric and Family Medicine Department at the hospital stated she expected a physician, at a minimum, to at least listen to the baby's heart rate in any adult pregnant female who presented to the hospital after a minor fall.