HospitalInspections.org

Based on policy review, medical record review, hospital data review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

1. The hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 2 of 30 sampled patients (Patient #10 and Patient #30).

~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag A2406

2. The hospital failed to provide stabilizing treatment for 2 of 30 sampled patients (Patient #10 and Patient #30) that presented to the hospital's DED to determine whether or not an emergency medical condition existed.

~ cross refer to 489.24 (d) (3), Stabilizing Treatment - Tag A2407

Based on policy and procedure review, medical record review, hospital data review and staff and physician interviews the hospital failed to ensure an appropriate medical screening examination was provided within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 2 of 30 sampled patients (Patient #10 and Patient #30).

The findings included:

Review of the "EMTALA (Emergency Medical Treatment and Labor Act): Treatment Of Patients With Emergency Medical Conditions" policy, effective 06/11/2019, revealed "...PROCEDURE: A. All individuals presenting to a dedicated emergency department ... for examination or treatment, including minors without a parent and women in labor, shall be given an appropriate medical screening examination to determine if an emergency medical condition exists. The medical screening examination may include laboratory tests, radiology studies, or consultations, as appropriate ... "

A. .Review of the closed DED medical record on 11/9/2021 for Patient #10 revealed a 64-year-old female presented to the DED on 11/3/2021 at 1711 via EMS for a complaint of possible overdose. Review of the Vital Signs at 1725 revealed "Temp: 36.9; Heart Rate: 98; Resp: 20; BP: 146/108; ... SpO2: 97%; O2 Device: None (Room air); ... 0-10 Pain Assessment: 0-10 Pain Scale: 10." Review of the Triage note at 1723 revealed " ... Per EMS report 'possibly drugged yesterday, wants to know with what.' Per pt 'possibly drugged yesterday, and (sic) robbed me. Not sure if it was Fentanyl and I want to know.' ..." Review revealed at 1727 Patient #10 was assigned an ESI acuity of 3. Review of the CBC w/ (with) Differential Resulted at 1802 revealed "Abnormal Result ... MCV 81.0 [Ref Range: 82.0-98.0] ... RDW: 19.9% [Ref Range: 12.0-15.0]; ... Anisocytosis: Moderate [Ref Range: Not Present]." Review of the Comprehensive Metabolic Panel Resulted at 1815 revealed "Abnormal Result ... Potassium 3.3 mmol/L [Ref Range: 3.5-5.1]; Anion Gap: 13 mmol/L [Ref Range: 3-11] ... Total Protein: 8.3 g/dL [Ref Range: 5.7-8.2] ... AST: 124 U/L [Ref Range: <34]; ALT: 78 U/L [Ref Range: 10-49]; Alkaline Phosphatase: 126 U/L [Ref Range: 46-116]." Review of the Urine Drug Screen Resulted at 1905 revealed "Abnormal Result ... Amphetamines Screen, UR: Positive [Ref Range: Negative] ...Cocaine (Metab.) Screen, Urine: Positive [Ref Range: Negative] ... Cannabinoids Screen, Ur: Positive [Ref Range: Negative] ..." Review of the ED Timeline revealed ED AMA Form Printed - English was printed at 2033. Review of the ED Notes at 2039 revealed "Pt decided to leave AMA. Refused to wait any further. Pt wants to go to another hospital that is closer to her home. States "it was a mistake for me to come here. I wanted to go to (Hospital Name) and they brought me here. I want you to call 911 so they can take me there." Made aware I can't make the phone call." Review of the Refusal of Medical Screening, Treatment or Transfer/Statement of Patient Leaving Against Medical Advice signed by Patient #10 on 11/03 (no year documented) and no time documented with RN #9 signature on 11/03/2021 at 2040. Review of the ED Timeline revealed ED Disposition set to AMA at 2043 and Patient discharged. Review revealed there was no MSE note from PIT (provider in triage) provider.

Interview on 11/09/2021 at 1420 with Director #7 revealed the First Provider who sees the patient in the PIT (patient in triage) area is done in real time. Interview revealed the First Provider is the beginning the MSE (medical screening exam).

Telephone interview on 11/09/2021 at 1500 with Physician Assistant (PA) #8 revealed she was the PIT provider on 11/03/2021. Interview revealed a provider is in the triage room during the triage assessment. Interview revealed the provider in PIT will perform their assessment and order tests based on the patient's complaint and assessment. Interview revealed PA #8 usually has a scribe in the PIT with them. Interview revealed if PA #8 has a scribe in PIT there will be a note and if there is not a scribe there will not be a note. Interview revealed on 11/09/2021, there was not a scribe in PIT with PA #8 and PA #8 did not have a note in Patient #10's medical record. Interview revealed PA #8 ordered the test and performed an assessment.

Telephone interview on 11/10/2021 at 0934 with RN #9 revealed she remembered Patient #10. Interview revealed the provider saw her during triage and ordered labs. Interview revealed the registration staff notified RN #9 that someone wanted to leave AMA. Interview revealed RN #9 notified the provider and then spoke with Patient #10 and tried to encourage her to stay to be seen. Interview revealed RN #9 told Patient #10 that she "could potentially die" as they did not know what was going on with her. Interview revealed Patient #10 wanted to leave.

Telephone interview on 11/10/2021 at 1545 with Medical Director #10 revealed the PIT provider starts the MSE. Interview revealed there is a process in place where the PIT provider sees the pt and the provider in the back finishes the MSE. Interview revealed the goal is to have notes on all pts that are seen by a provider.

B. Review of the closed DED medical record on 11/9/2021 for Patient #30 revealed a 84-year-old female presented to DED on 11/3/2021 at 1452 via EMS for a complaint of dizziness. Review of the Vital Signs at 1455 revealed "Temp: 36.6; Heart Rate: 78; Resp: 16; BP: 146/65; ... SpO2: 100%; O2 Device: None (Room air); ... 0-10 Pain Assessment: 0-10 Pain Scale: 0." Review of the Triage note on 11/03/2021 at 1459 revealed "Patient presents to ED by ambulance after an episode of dizziness at home today. EMS reports patient also had episode of shortness of breath followed by vomiting while walking to the ambulance. On arrival to the ED patient complains of dizziness. Denies chest pain/shortness of breath/nausea." Review revealed at 1501 Patient #30 was assigned an ESI acuity of 3. Review of the MAR revealed Patient #30 received sodium chloride 0.9% bolus 500 mL at 1510 and Zofran 4 mg via IV at 1512. Review of the ECG 12 Lead performed at 1523 revealed "NORMAL SINUS RHYTHM, NONSPECIFIC ST ABNORMALITY, ABNORMAL ECG, WHEN COMPARED WITH ECG OF 20-JAN-2020 19:00, NO SIGNIFICANT CHANGE WAS FOUND." Review of the CBC w/Differential Resulted at 1526 revealed "Abnormal Result ... RBC: 3.71 [Ref Range: 3.90-5.03]; HGB: 11.8 [Ref Range: 12.0-15.5] ..." Review of the Troponin I (serial 0-2-6H w/ delta) Resulted at 1601 revealed a normal result. Review of the Comprehensive Metabolic Panel Resulted at 1603 revealed "Abnormal Result ... Potassium: 3.4 ... [Ref Range: 3.5-5.1]; Chloride: 110 ... [Ref Range: 98-107] ... Creatinine: 1.55 ... [Ref Range: 0.55-1.02]; ... Glucose: 216 ... [Ref Range: 70-179] ..." Review of the Magnesium Level Resulted at 1603 revealed a normal result. Review of the TSH Resulted at 1605 revealed a normal result. Review of the Vital Signs at 1652 revealed "Temp: 36.7 degrees Celsius; Heart Rate: 87; BP: 135/59." Review of the ED Timeline revealed the AMA Form was printed at 1657. Review of the ED Quick Updates note at 1723 revealed "Patient wishing to leave AMA. States she understands the risks of leaving before medical treatment has been completed, still wishes to leave. IV removed and fluid stopped." Review of the ED Timeline at 1725 revealed "ED Disposition was set to AMA" and "Patient dismissed." Review revealed there was no MSE note from PIT provider.

Interview on 11/09/2021 at 1420 with Director #7 revealed the First Provider who sees the patient in the PIT (patient in triage) area is done in real time. Interview revealed the First Provider is the beginning the MSE (medical screening exam).

Interview on 11/09/2021 at 1500 with Physician Assistant (PA) #8 revealed she was the PIT provider on 11/03/2021. Interview revealed a provider is in triage room during the triage. Interview revealed the provider in PIT will perform their assessment and order tests based on the patient's complaint and assessment. Interview revealed PA #8 usually has a scribe in the PIT with them. Interview revealed if PA #8 has a scribe in PIT there will be a note and if there is not a scribe there will not be a note. Interview revealed on 11/09/2021, there was not a scribe in PIT with PA #8 and PA #8 did not have a note in Patient #30's medical record.

Interview on 11/10/2021 at 1545 with Medical Director #10 revealed the PIT provider starts the MSE. Interview revealed there is a process in place where the PIT provider sees the pt and the provider in the back finishes the MSE. Interview revealed the goal is to have notes on all pts that are seen by a provider.

The facility failed to ensure that an appropriate medical screening examination was provided for Patient #10 and Patient #30 as stated in their policy and procedure.

Based on policy and procedure review, medical record review, hospital data review and staff and physician interviews the hospital's Dedicated Emergency Department (DED) failed to provide stabilizing treatment within its capability and capacity for 2 of 30 sampled DED patients that were presented to the emergency department for determination of whether or not an emergency medical condition existed for 2 of 30 sampled patients (Patient #10 and Patient #30).

The findings included:

Review of the "EMTALA (Emergency Medical Treatment and Labor Act): Treatment Of Patients With Emergency Medical Conditions" policy, effective 06/11/2019, revealed "...PROCEDURE: A. All individuals presenting to a dedicated emergency department ... for examination or treatment, including minors without a parent and women in labor, shall be given an appropriate medical screening examination to determine if an emergency medical condition exists. The medical screening examination may include laboratory tests, radiology studies, or consultations, as appropriate ... 5. If the qualified medical person determines that an emergency medical condition exists, appropriate treatment shall be offered to stabilize the patient's condition. 6. If the qualified medical person determines within a reasonable medical probability that an emergency medical condition does not exist, that conclusion shall be expressly stated in the patient's medical record, along with notes of the examination and support for the conclusion that an emergency medical examination does not exist ..."

1. .Review of the closed DED medical record on 11/9/2021 for Patient #10 revealed a 64-year-old female presented to DED on 11/3/2021 at 1711 via EMS for a complaint of possible overdose. Review of the Vital Signs at 1725 revealed "Temp: 36.9; Heart Rate: 98; Resp: 20; BP: 146/108; ... SpO2: 97%; O2 Device: None (Room air); ... 0-10 Pain Assessment: 0-10 Pain Scale: 10." Review of the Triage note at 1723 revealed " ... Per EMS report 'possibly drugged yesterday, wants to know with what.' Per pt 'possibly drugged yesterday, and (sic) robbed me. Not sure if it was Fentanyl and I want to know.' ..." Review revealed at 1727 Patient #10 was assigned an ESI acuity of 3. Review of the CBC w/ (with) Differential Resulted at 1802 revealed "Abnormal Result ... MCV 81.0 [Ref Range: 82.0-98.0] ... RDW: 19.9% [Ref Range: 12.0-15.0]; ... Anisocytosis: Moderate [Ref Range: Not Present]." Review of the Comprehensive Metabolic Panel Resulted at 1815 revealed "Abnormal Result ... Potassium 3.3 mmol/L [Ref Range: 3.5-5.1]; Anion Gap: 13 mmol/L [Ref Range: 3-11] ... Total Protein: 8.3 g/dL [Ref Range: 5.7-8.2] ... AST: 124 U/L [Ref Range: <34]; ALT: 78 U/L [Ref Range: 10-49]; Alkaline Phosphatase: 126 U/L [Ref Range: 46-116]." Review of the Urine Drug Screen Resulted at 1905 revealed "Abnormal Result ... Amphetamines Screen, UR: Positive [Ref Range: Negative] ...Cocaine (Metab.) Screen, Urine: Positive [Ref Range: Negative] ... Cannabinoids Screen, Ur: Positive [Ref Range: Negative] ..." Review of the ED Timeline revealed ED AMA Form Printed - English was printed at 2033. Review of the ED Notes at 2039 revealed "Pt decided to leave AMA. Refused to wait any further. Pt wants to go to another hospital that is closer to her home. States "it was a mistake for me to come here. I wanted to go to Duke Raleigh and they brought me here. I want you to call 911 so they can take me there." Made aware I can't make the phone call." Review of the Refusal of Medical Screening, Treatment or Transfer/Statement of Patient Leaving Against Medical Advice signed by Patient #10 on 11/03 (no year documented) and no time documented with RN #9 signature on 11/03/2021 at 2040. Review of the ED Timeline revealed ED Disposition set to AMA at 2043. Patient #10 was not stable prior to being discharged. Review revealed there was no MSE note from PIT (provider in triage) provider and no indication Patient #10's capacity to make decisions for herself had been assessed by the PIT provider this visit.

Interview on 11/09/2021 at 1420 with Director #7 revealed the First Provider who sees the patient in the PIT (patient in triage) area is done in real time. Interview revealed the First Provider is the beginning the MSE (medical screening exam).

Telephone interview on 11/09/2021 at 1500 with Physician Assistant (PA) #8 revealed she was the PIT provider on 11/03/2021. Interview revealed a provider is in the triage room during the triage assessment. Interview revealed the provider in PIT will perform their assessment and order tests based on the patient's complaint and assessment. Interview revealed PA #8 usually has a scribe in the PIT with them. Interview revealed if PA #8 has a scribe in PIT there will be a note and if there is not a scribe there will not be a note. Interview revealed on 11/09/2021, there was not a scribe in PIT with PA #8 and PA #8 did not have a note in Patient #10's medical record. Interview revealed PA #8 ordered the test and performed an assessment.

Telephone interview on 11/10/2021 at 0934 with RN #9 revealed she remembered Patient #10. Interview revealed the provider saw her during triage and ordered labs. Interview revealed the registration staff notified RN #9 that someone wanted to leave AMA. Interview revealed RN #9 notified the provider and then spoke with Patient #10 and tried to encourage her to stay to be seen. Interview revealed RN #9 told Patient #10 that she "could potentially die" as they did not know what was going on with her. Interview revealed Patient #10 wanted to leave.

Telephone interview on 11/10/2021 at 1545 with Medical Director #10 revealed the PIT provider starts the MSE. Interview revealed there is a process in place where the PIT provider sees the pt and the provider in the back finishes the MSE. Interview revealed the goal is to have notes on all pts that are seen by a provider.

2. Review of the closed DED medical record on 11/9/2021 for Patient #30 revealed a 84-year-old female presented to DED on 11/3/2021 at 1452 via EMS for a complaint of dizziness. Review of the Vital Signs at 1455 revealed "Temp: 36.6; Heart Rate: 78; Resp: 16; BP: 146/65; ... SpO2: 100%; O2 Device: None (Room air); ... 0-10 Pain Assessment: 0-10 Pain Scale: 0." Review of the Triage note on 11/03/2021 at 1459 revealed "Patient presents to ED by ambulance after an episode of dizziness at home today. EMS reports patient also had episode of shortness of breath followed by vomiting while walking to the ambulance. On arrival to the ED patient complains of dizziness. Denies chest pain/shortness of breath/nausea." Review revealed at 1501 Patient #30 was assigned an ESI acuity of 3. Review of the MAR revealed Patient #30 received sodium chloride 0.9% bolus 500 mL at 1510 and Zofran 4 mg via IV at 1512. Review of the ECG 12 Lead performed at 1523 revealed "NORMAL SINUS RHYTHM, NONSPECIFIC ST ABNORMALITY, ABNORMAL ECG, WHEN COMPARED WITH ECG OF 20-JAN-2020 19:00, NO SIGNIFICANT CHANGE WAS FOUND." Review of the CBC w/Differential Resulted at 1526 revealed "Abnormal Result ... RBC: 3.71 [Ref Range: 3.90-5.03]; HGB: 11.8 [Ref Range: 12.0-15.5] ..." Review of the Troponin I (serial 0-2-6H w/ delta) Resulted at 1601 revealed a normal result. Review of the Comprehensive Metabolic Panel Resulted at 1603 revealed "Abnormal Result ... Potassium: 3.4 ... [Ref Range: 3.5-5.1]; Chloride: 110 ... [Ref Range: 98-107] ... Creatinine: 1.55 ... [Ref Range: 0.55-1.02]; ... Glucose: 216 ... [Ref Range: 70-179] ..." Review of the Magnesium Level Resulted at 1603 revealed a normal result. Review of the TSH Resulted at 1605 revealed a normal result. Review of the Vital Signs at 1652 revealed "Temp: 36.7 degrees Celsius; Heart Rate: 87; BP: 135/59." Review of the ED Timeline revealed the AMA Form was printed at 1657. Review of the ED Quick Updates note at 1723 revealed "Patient wishing to leave AMA. States she understands the risks of leaving before medical treatment has been completed, still wishes to leave. IV removed and fluid stopped." Review of the ED Timeline at 1725 revealed "ED Disposition was set to AMA" and "Patient dismissed." Review revealed there was no MSE note from PIT provider and no indication Patient #10's capacity to make decisions for herself had been assessed by the PIT provider this visit.
Patient #30 was not stable at the time of her disposition on 11/3/2021.

Interview on 11/09/2021 at 1420 with Director #7 revealed the First Provider who sees the patient in the PIT (patient in triage) area is done in real time. Interview revealed the First Provider is the beginning the MSE (medical screening exam).

Interview on 11/09/2021 at 1500 with Physician Assistant (PA) #8 revealed she was the PIT provider on 11/03/2021. Interview revealed a provider is in triage room during the triage. Interview revealed the provider in PIT will perform their assessment and order tests based on the patient's complaint and assessment. Interview revealed PA #8 usually has a scribe in the PIT with them. Interview revealed if PA #8 has a scribe in PIT there will be a note and if there is not a scribe there will not be a note. Interview revealed on 11/09/2021, there was not a scribe in PIT with PA #8 and PA #8 did not have a note in Patient #30's medical record.

Interview on 11/10/2021 at 1545 with Medical Director #10 revealed the PIT provider starts the MSE. Interview revealed there is a process in place where the PIT provider sees the pt and the provider in the back finishes the MSE. Interview revealed the goal is to have notes on all pts that are seen by a provider.

NC00181487