HospitalInspections.org

Based on the investigation the hospital failed to provide an appropriate medical screening examination (MSE) within the capabilities of the facility for two patients who presented to the ED with a possible emergency medical condition. Patient #1 presented on the hospital grounds, other than the site of the dedicated ED and his girlfriend requested help for patient #1. Secondly, one of the thirty sampled medical records revealed a patient (patient #2) never received a medical screening examination.

Based on documentation and staff interviews the hospital emergency department failed to provide an appropriate medical screening examination to determine if patient #1 had an emergency medical condition as defined by hospital policy. According to the policy, any individual who comes to a hospital facility, which includes the entire hospital campus, driveway, sidewalk, parking lots, clinics and offices within 250 yards of the main hospital building, and who requests examination or treatment of a potential emergency medical condition, will receive a medical screening examination performed by a qualified provider to determine whether or not an emergency medical condition (EMC) exists. If an EMC is determined to exist, the hospital will provide any treatment necessary to stabilize the EMC, within the hospital's capability, or arrange for an appropriate transfer to another facility. In addition to ensure individuals receive appropriate care whether they present to the dedicated Emergency Department (ED) or other areas of the hospital, the facilty developed and Emergency Response Team Policy and Procedure. The policy/procedure established guidelines for the ED personnel who respond to medical incidents occurring in public areas of the hospital, which may involve visitors, patients or employees. The ED response team is comprised of an ED RN and Multifunctional Technician as well as security. Any one can initiate the Emergency Response Team by dialing the emergency #5555.

Patient #1 46 year old male who was driven to Franklin Square Hospital Center by his girlfriend for treatment for alcohol abuse. The patient per his girlfriend, jumped out of the car and dove over a guardrail to a 25 foot drop while the car was moving.

The patient presented on the hospital property at the Women's Pavillion entrance rather than the dedicated Emergency Department (ED). Under 489.24 Special Responsibilities of Medicare hospitals in emergency cases, "comes to the emergency department" is defined as meaning the patient has presented on hospital property, as defined in this section, other than the dedicated emergency department, and requests examination or treatment for what may be an emergency medical condition, or has such request made on his or her behalf. In the abscence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's behavior, that the individual needs emergency examination or treatment. The patient's girlfriend presented to the Women's Pavillion requesting emergency care for patient #1 (her boyfriend) on February 2, 2011 at 9:30 P.M. .

According to the hospital's investigation, the patient's girlfriend had stated she was bringing the patient in for treatment for alcohol. Per the girlfriend, as she drove the car to Franklin Square Hospital Center (FSHC) the patient jumped out of the car while it was moving and jumped head first over a guardrail and landed on the ground below. The girlfriend estimated the drop to be 25 feet. When the girlfriend arrived at FSHC with patient #1, she went to the old Emergency Department (ED). When she realized it was closed, she drove to the Women's Pavillon Labor and Delivery Service (L&D), just feet from the old ED, and requested help because she believed her boyfriend was not breathing. The L&D registrar called Nurse A (L&D Charge Nurse) who responded to the scene and although the patient was breathing, she requested the ED Response Team be called. The registrar called directly to the Emergency Department (ED). Per the registrar, after informing the ED of the situation and request for Emergency Response Team, the ED staff stated they do not respond outside the building or to the parking lots. The registrar informed Nurse A that the Emergency Response Team was not coming. Nurse A notified the nursing supervisor and security.

While waiting for help the girlfriend proceeded to unbuckle patient #1, who proceeded to get out of the car and lay next to the vehicle. The nursing supervisor spoke to Nurse B (ED Charge Nurse) who confirmed that the ED does not respond to the parking lot areas. The supervior returned a call to Nurse A and instructed her to call 911. The security personnel who were on scene, contacted 911. The security noted that the patient was lying face done on the ground outside the passenger side door of a dark blue vehicle. The security staff spoke to patient #1's girlfriend who informed security of the incident where the patient jumped from the car. At approximately 2258 (10:58 P.M.) the Baltimore County EMS and police arrive on scene. The Medics and EMS personnel stabilized patient #1 and transported him to another area hospital at approximately 2319 (11:19 P.M.) due to a potential head trauma since FSHC is not a trauma center.

The investigation included interviews with Nurse A, Nurse B, L&D registrar, the nursing supervisor and security.

The nursing supervisor was interviewed and she stated that after she received the call from Nurse A that the ED staff would not respond to the parking lot, she called the ED and spoke to Nurse B (ED Charge Nurse) who reaffirmed her statement about not reporting to the parking lot areas. The nursing supervior called Nurse B and instructed her to call 911. After the incident, the nursing supervisor was informed by security of the extent and area that the Emergency Response Team covers. The nursing supervisor stated she relied on Nurse B knowledge in the situation. The nursing supervisor reviewed the hospital's Emergency Response Team Policy and Procedure re-educating herself and Nurse B regarding the scope of the policy and determining that the Emergency Response Team must cover all hospital grounds.

On February 3, 2011 at approximately 10:30 A.M., Nurse B was interviewed by the Interim Chair of the ED and Assistant Unit Manager regarding the incident. As the ED Charge Nurse, it was her responsibility to ensure the Response Team was dispatched. According to Nurse B, she was in a patient's room when someone called to her requesting the ED Response Team to the Women's Pavillion parking lot. She stated they do not respond to emergencies outside the building. Later, the night nursing supervisor had a copy of the policy that the ED does respond to the parking lots and FSHC grounds. As a result Nurse B was counseled by the Unit Manager of the ED on February 16, 2011. The hospital's investigation revealed several concerns:
1. There are members of the community surrounding the hospital that still do not know that the ED has moved to the other end of the campus.
2. The nursing staff did not go through the appropriate channel to initiate and emergency code or the Emergency Response Team.
3. The nursing staff including the nursing supervisor were not knowledgeable regarding the hospital policies and procedures for Emergency Response Team and EMTALA.
4. The hospital failed to provide emergency care for patient #1, instead they called 911.

Once the hospital investigated and validated the incident, the hospital has implemented an action plan prior to this investigation and has implemented the following:
1. The hospital has rewritten the Emergency Response Team Policy and Procedure, currently in the draft form, to be effective March 1, 2011. The Policy gives specific information and a map of the areas of the hospital covered by the Emergency Response Team.
2. For weeks after the incident, during daily staff huddles nursing staff were re-educated on the Revised Emergency Response Team and EMTALA. These topics will also be reviewed monthly during staff meetings with physician and the physician assistants.
3. Projected review for all ED staff regarding EMTALA every six months.
4. Review with all staff how to initiate emergency codes via #5555 or the ASCOM phones.
5. The ASCOM phones will be programmed with ED Response Team number.
6. The 2/2/11 incident was shared during the Women's Pavillion Leadership meeting to clarify that the ED Response Team can respond to patients at the Pavillion.
7. Necessary disciplinary action was taken for appropriate staff.
8. Change in the policy to include security to accompany emergency responding team members to the location of the patient, visitor or employee.
9. Re-visit the signage issue to help patients locate the new ED.
10. Percentage of chart audits to determine if requirements for EMTALA are met including for MSE and appropriate transfers. (The February 2011 audits had not been completed during the survey)
11. The Risk Management Committee meeting of 2/15/11 discussed of the importance of simulating emergency situations so staff can practice their responses. Mock codes. This has been referred to the Nurse Educator Council to develop a plan for implementation.

To note even with the above actions, a review of 30 medical records revealed that in 1 (patient #2) out of the 30 patients revealed that the hospital failed to perform a medical screening examination for patient #2 who presented to the emergency department with intractable back pain, and was discharged before a medical screening examination was done.

Patient #2 is a 36-year-old female with degenerative joint disease of the back. Patient #2 has a history of chronic back pain. Other pertinent history includes previous back and gallbladder surgery, gastric sleeve, and right foot drop.

Patient #2 had two other visits to the same emergency department. One recent visit was for cellulitis, and one visit of 7/29/2010 was for pain related to a tear and a bone spur in her lower back. On the 7/29/2010 visit, patient #2 was seen by a Physician's Assistant (PA) who completed a medical screening examination. The PA noted chronic back pain with no new injury. Patient #2 was given oxycodone 5 mg. twice. When she reported it was ineffective, she received dilaudid 2 mg IM. Discharging instruction included "No more narcotics for this complaint from the ER you MUST follow-up LBP (lower back pain) radiculopathy." Patient #2 subsequently enrolled at a pain clinic on 8/10/2010.

On 2/9/2010 patient #2 received two epidurals at the pain clinic, in her lumbar region. On 2/10, patient #2 went to work, but was unable to stay due to severe back pain. Her husband transported her to the hospital where she presented to the ED at 1:53 pm. Patient #2 reports that due to her right foot drop and pain, she was unable to walk, and required a wheelchair for entry into the hospital, as well as assistance for dressing. Patient #2's husband assisted her to prepare for evaluation in the fast track area of the ED, then left to pick up their child.

A PA note of 2/10/2011 at 2:32 pm rated patient #2 pain as 10/10 (with 10 being the worst pain). A nursing note at 3:10 pm states in part, "Patient crying. Informed of wait. Pt. verbalized understanding. ___ PA aware of pt. condition. Will continue to monitor. At 3:30 pm, a note states, ___PA at bedside - pt. yelling and cursing @ PA. Security called and @ bedside."

Interview with the PA by the surveyor on February 23, 2011 revealed that patient #2 was screaming in pain and demanding medication. The PA stated that she twice attempted unsuccessfully to calm patient #2 in order to perform a history. However, patient #2 continued to scream and make some derogatory statements to the PA. The PA states she consulted another PA, who suggested she call security. The PA decided to discharge patient #2 and at 3:40 pm, wrote " Pt seen on 7/29 & told no more narcotics for this complaint (back pain). Went to obtain hx from pt & pt began to scream @ me that she was in pain. I asked pt. to stop screaming so that I can evaluate & help. Pt screamed again stating, "I'm not going to stop F__ scream. I called security to d/c (discharge) pt., was not able to evaluate pt due to demeanor." A provisional diagnosis was made of "1) Chronic back pain, and 2) Aggressive behavior escorted by security." Under HPI (history of present illness), the PA wrote "36 year old female escorted out of ED by security __ belligerent behavior." No physician or administrative staff were consulted prior to discharge.

Patient #2 had to wait for the return of her husband to assist her to get dressed and to wheel her out of the ED. She was taken to another hospital ED where she was evaluated for an emergency medical condition, medicated for pain, and discharged.

In summary, the hospital failed to conduct the required medical screening exam for patient #2 who presented to their emergency department in severe pain.