HospitalInspections.org

A Based on review of medical records, policies and procedures, Medical Staff Rules and Regulations, 2 Emergency Services Agreements, Emergency Physicians schedule, staff and physician interviews, and the facility's Average Patient Census at the Top Hour, it was determined that the facility lacked an effective system to ensure that all patients who presented to the Emergency Department received a medical screening examination for 1 of 20 sampled patients (#1). Refer to tag A-2406.

B. Based on reviews of medical record, policy and procedure an d interviews the facility failed to ensure that the hospital provided within the capability and capacity of the staff and facilities available at the hospital stabilizing treatment for 1 of 20 (#1) sampled patients with an identified emergency medical condition. The facility also failed to obtain written informed refusal by not informing patient #1 of the risks and benefits of further medical examination, treatment, or appropriate transfer. Refer to tag A-2407.

A. Based on review of medical records, policies and procedures, Medical Staff Rules and Regulations, 2 Emergency Services Agreements, Emergency Physicians schedule, staff and physician interviews, and the facility's Average Patient Census at the Top Hour, it was determined that the facility lacked an effective system to ensure that all patients who presented to the Emergency Department received a medical screening examination for 1 of 20 sampled patients (#1).

Findings were:

Policies and Procedures:

1.) Review of facility policy entitled Triage, policy number T-10, last revised 11/06, revealed the facility utilized 5 triage levels. Level 1 patients were defined as those who had no pulse, no heart rate, were intubated (tube inserted down the throat to provide ventilation), or were unresponsive. These patients were defined as requiring emergent care. Level 2 patients were those whose condition required immediate care for conditions that were high risk or a threat to life, limb, or vision. Level 3 patients were those who required care as soon as possible and whose condition presented a danger if not treated. Level 4 patients were those who required routine care. Level 5 patients were those whose condition was minor and care could be delayed. This policy required the triage nurse to reassess patients who had to remain in the triage area based on the patient's acuity level and any new or changing patient data. In addition, this policy required all patients who presented to the ED to be triaged by a nurse and to receive a Medical Screening Examination (MSE) by a physician.

2.) Review of the Medical Staff Rules and Regulations, amended 07/10, revealed in Section 4: Emergency Department, 4.1 Coverage, 4.1.5 required the MSE to be performed by qualified medical personnel (QMP). The Medical Staff Rules and Regulations defined QMP as the following: in the ED a physician, a Certified Nurse Practitioner or a Physician's Assistant in consultation with the physician; in Labor and Delivery a physician, a RN, a Physician's Assistant, a Nurse Practitioner, or a Certified Nurse Midwife in consultation with the physician.




Emergency Services Agreement:

1.) Review of the Emergency Services Agreement, effective 12/23/08, revealed that ED practitioners were to staff the ED 24-hours-a-day, 7 days a week. The agreement required the ED providers to provide services in accordance with any and all regulatory and accreditation standards, and all applicable federal and state laws and regulations.

2.) Review of the Emergency Department Services Agreement, effective 06/11/10, revealed the facility had contracted with a new group to provide ED practitioners. The agreement required the ED providers to provide services 24-hours-a-day, 7 days a week. The contract required the practitioners to provide services in accordance with community standards of care, applicable federal, state, and local laws and regulations, and to abide by the facility's policies and procedures as well as the facility's bylaws and rules and regulations of its Medical Staff.

ED physician Schedule:

1.) Review of the ED physician ' s schedule revealed that at the time the patient presented to the ED there were 3 ED physicians on duty between the hours of 3:00 p.m. and 12:00 a.m.
2.) Review of the facility's Average Patient Census at Top of Hour for the day of the patient's presentation revealed the ED was over capacity from 2:00 p.m. until after 11:00 p.m.


Medical Record Review- Patient #1.

Review of Patient #1's medical record and the Emergency Department (ED) central log revealed the patient presented to the ED on 7/26/2010 at 3:45 p.m. The patient was immediately triaged (assessment by a nurse to determine a patient's medical priority of need) by a Registered Nurse (RN) as a level 2 acuity.


Further review of the triage nurse's note revealed the patient's private physician had sent the patient to the facility to have an outpatient vascular (blood vessels) study for complaints of pain in the right lower leg. The nurse noted that the vascular study had revealed a deep vein thrombosis (blood clot) in the patient's right lower leg. The nurse noted that the patient reported having pain in his/her right calf for 5 days. Further review indicated in part, " Pt (patient) told to come to the ER (emergency room) with positive DVT results. " The nurse documented that the patient rated his/her pain as a level 8 on a scale of 1-10 with 1 being mild pain and 10 being severe pain. At 4:48 p.m., the nurse noted that the patient was sent to the waiting room and that the patient was in no apparent distress. In addition, the nurse noted that the patient was on birth control pills.

At 5:45 p.m., blood work was ordered by the ED physician. Review of the laboratory results revealed the patient's blood work was essentially within normal limits. At 6:19 p.m., another ED physician ordered Percocet (pain medication) 325/5 mg (milligrams) 2 tablets to be administered to the patient. At 6:28 p.m., the nurse noted that the patient rated his/her pain as a 7. At 6:31 p.m., the nurse noted that he/she administered the Percocet as ordered by the physician. The nurse noted that the patient was reassessed and remained in the triage waiting room in stable condition. The nurse noted that he/she had explained the wait to the patient.

At 12:06 a.m., the nurse noted that the patient was to be taken to ED room #16. At 12:18 a.m., the nurse noted that the patient was not in the waiting room. On 7/27/2010 at 12:44 a.m., the nurse noted that the patient was unable to wait any longer. There was a copy of the facility's Leaving Against Advice form in the patient's medical record that was signed by someone other than the patient. This person did have the same last name as the patient. There was no documented evidence of the date, time, relationship of the person signing the form, or who witnessed the signature. In addition, there was no documented evidence that the patient had been informed of the risks of leaving the facility without receiving a MSE. Patient #1 was in the ED for approximately 9.5 hours with an identified emergency medical condition, and was not seen by a physician. The facility failed to ensure that their policy was followed regarding patient #1 receiving a medical screening examination with an acuity level of 2, " condition required immediate care for conditions that were high risk or a threat to life, limb " as indicated in the hospital ' s policy.

According to medical record review Patient #1 presented to another hospital on 7/27/2010. Review of the History and Physical dated 7/27/2010 at 04:20 am., revealed the patient ' s chief complaint was Right lower extremity pain for several days. The ED physician documented on Admitting History and Physical dated 7/27/2010 revealed the patient ' s right lower leg was very " tense " on examination, tender and warm. Further documentation by the ED physician indicated in part, " Assessment: New Pulmonary Embolus and DVT. " Review of the Physician ' s Report specified in part, " .. . current diagnosis of a rather large PE (Pulmonary Embolus- .a blockage of an artery in the lungs by fat, air, a blood clot,) ...She/He will definitely be admitted... will put her/him in for telemetry ... spoken with hospitalist staff .. will be treating her/him with Lovenox ( medication- used to prevent blood clots in the legs) and then ...will also likely start Coumadin (medication used to prevent blood clots from forming or growing larger in your blood and blood vessels) .... Final Diagnosis: Pulmonary Embolus. "


Interviews:


During an interview at 11:00 a.m. on 09/09/10 in the Nursing Administrative Conference Room, the Administrative Director of Emergency Services ED (interview #2) stated the facility had changed ED physician groups on 07/23/10 at midnight. The Director stated that this was the first time the facility had changed ED physician groups in the last twenty years. The Director explained that the new group of ED physicians had attended orientation and computer training in the classroom but that this had presented a challenge with the amount of time it actually took the physicians once they went to work in the ED. The Director stated that at the time of the patient's presentation to the ED, the ED had been over capacity. The Director stated that the facility was in the process of placing a practitioner in the triage area with the triage nurse in order to provide a team triage of patients. The Director stated that this process was scheduled to be in place by the end of October 2010.


During an interview at 1:00 p.m. on 09/09/10 in the Nursing Administrative Conference Room, the RN (interview #3) stated that he/she remembered that the patient had been sent to the ED from the outpatient vascular lab to be evaluated and receive treatment for a positive DVT. The RN stated that the ED had been very busy at the time and that the wait time had been exceptionally long due to the new ED physician group. The nurse stated that level 2 acuity patients normally waited about 4 hours.

During a telephone interview at 1:40 p.m. on 09/09/10 in the Nursing Administrative Conference Room, the physician (interview #4) stated that when he/she went to evaluate the patient at around 12:18 a.m. the patient had not been in the room. The physician stated that he/she had not seen the patient.

B. Based on reviews of medical record, policy and procedure an d interviews the facility failed to ensure that the hospital provided within the capability and capacity of the staff and facilities available at the hospital stabilizing treatment for 1 of 20 (#1) sampled patients with an identified emergency medical condition. The facility also failed to obtain written informed refusal by not informing patient #1 of the risks and benefits of further medical examination, treatment, or appropriate transfer.
Findings:
Policies and Procedures:

1.) The facility ' s policy titled " Transfer Activities in Accordance with COBRA legislation " Policy #2134. Revised 4/09 was reviewed. The policy revealed in part, " C. " Stabilized " or to " Stabilize " means: ... b. to provide such medical treatment of the condition as is necessary. "

2.) Review of facility policy entitled Against Medical Advice, policy number A-6, last revised 12/07, defined an AMA as a patient who had been offered a MSE who wished to leave the ED prior to or after treatment had been initiated. The policy required any patient who decided to leave before their treatment was completed to be asked to sign a "Leaving ...Against Medical Advice" form. In addition, the policy revealed that a physician "should speak with the patient so that the patient is advised and aware of the risks and benefits of refusal of further examination and treatment".

Medical Record Review- Patient #1.

Review of Patient #1's medical record and the Emergency Department (ED) central log revealed the patient presented to the ED on 7/26/2010 at 3:45 p.m. The patient was immediately triaged (assessment by a nurse to determine a patient's medical priority of need) by a Registered Nurse (RN) as a level 2 acuity.


Further review of the triage nurse's note revealed the patient's private physician had sent the patient to the facility to have an outpatient vascular (blood vessels) study for complaints of pain in the right lower leg. The nurse noted that the vascular study had revealed a deep vein thrombosis (blood clot) in the patient's right lower leg. The nurse noted that the patient reported having pain in his/her right calf for 5 days. Further review indicated in part, " Pt (patient) told to come to the ER (emergency room) with positive DVT results. " The nurse documented that the patient rated his/her pain as a level 8 on a scale of 1-10 with 1 being mild pain and 10 being severe pain. At 4:48 p.m., the nurse noted that the patient was sent to the waiting room and that the patient was in no apparent distress. In addition, the nurse noted that the patient was on birth control pills.

At 5:45 p.m., blood work was ordered by the ED physician. Review of the laboratory results revealed the patient's blood work was essentially within normal limits. At 6:19 p.m., another ED physician ordered Percocet (pain medication) 325/5 mg (milligrams) 2 tablets to be administered to the patient. At 6:28 p.m., the nurse noted that the patient rated his/her pain as a 7. At 6:31 p.m., the nurse noted that he/she administered the Percocet as ordered by the physician. The nurse noted that the patient was reassessed and remained in the triage waiting room in stable condition. The nurse noted that he/she had explained the wait to the patient.

At 12:06 a.m., the nurse noted that the patient was to be taken to ED room #16. At 12:18 a.m., the nurse noted that the patient was not in the waiting room. On 7/27/2010 at 12:44 a.m., the nurse noted that the patient was unable to wait any longer. There was a copy of the facility's Leaving Against Advice form in the patient's medical record that was signed by someone other than the patient. This person did have the same last name as the patient. There was no documented evidence of the date, time, relationship of the person signing the form, or who witnessed the signature. In addition, there was no documented evidence that the patient had been informed of the risks of leaving the facility without receiving a MSE. The facility failed to provide stabilizing treatment that was within the capability and capacity of the staff and facilities available at the hospital on 7/26/2010 for patient # 1 with an identified emergency medical condition.

According to medical record review Patient #1 presented to another hospital on 7/27/2010. Review of the History and Physical dated 7/27/2010 at 04:20 a.m., revealed the patient ' s chief complaint was Right lower extremity pain for several days. The ED physician documented on Admitting History and Physical dated 7/27/2010 revealed the patient ' s right lower leg was very " tense " on examination, tender and warm. Further documentation by the ED physician indicated in part, " Assessment: New Pulmonary Embolus and DVT. " Review of the Physician ' s Report specified in part, " .. . current diagnosis of a rather large PE (Pulmonary Embolus- .a blockage of an artery in the lungs by fat, air, a blood clot,) ...She/He will definitely be admitted... will put her/him in for telemetry ... spoken with hospitalist staff .. will be treating her/him with Lovenox ( medication- used to prevent blood clots in the legs) and then ...will also likely start Coumadin (medication used to prevent blood clots from forming or growing larger in your blood and blood vessels) .... Final Diagnosis: Pulmonary Embolus. "

Interviews:
During an interview at 10:00 a.m. on 09/09/10 in the ED, the Interim Clinical Manager of the ED (interview #1) stated that physicians or Nurse Practitioners performed the MSE in the ED. The nurse stated that if a patient wanted to leave before completion of the MSE the patient would be advised to stay and complete the MSE. The nurse explained that if the patient continued to want to leave the patient would be asked to sign the AMA form. The Interim Clinical Manager stated that the ED saw between 150 to 170 patients a day and that the ED's peak hours were between 11:00 a.m. and 11:00 p.m.

During an interview at 2:15 p.m. on 09/09/10 in the Nursing Administrative Conference Room, the Registration Clerk (interview #4) stated that when patients present from the vascular lab, a transport person usually accompanied the patient and brought the patient's paperwork. The Clerk stated that sometimes patients with positive deep vein thrombosis were directly admitted from the outpatient vascular lab. The Clerk stated that when patients decided to leave prior to completing the MSE the nurse explained the risk associated with leaving prior to receiving a MSE and would have the patient sign an AMA form.

During an interview at 2:30 p.m. on 09/09/10 in the Nursing Administrative Conference Room, the RN (interview #6) stated that when he/she had a patient to sign an AMA form he/she would sign the form as a witness. The nurse stated that he/she had taken the patient out of the computer but that he/she had not seen the patient. When questioned as to the entry that the patient had left because he/she had not been able to wait any longer, the nurse explained that the computer system forced the staff to have to enter a reason for the patient deciding to leave. The nurse stated that he/she had not had any interaction with the patient.

During an interview at 4:00 on 09/09/10 in the Nursing Administrative Conference Room, the RN (interview #7) stated that he/she did not remember the patient. He/she stated that when a patient signed an AMA the nurse usually explained the benefits of having the MSE. The nurse explained that the technicians recheck vital signs every 2 hours or more frequently on patients waiting in the waiting room.