HospitalInspections.org

Based on document review and interview, the facility failed to ensure that all patients who present to the Emergency Department receive a MSE (Medical Screening Exam) - (see Tag A2406).

Findings include:

1. See findings cited at 42 CFR 489.24(a), Medical Screening Exam A2406.

Based on document review and interview, the hospital failed to ensure an appropriate medical screening examination for an ER/ED (Emergency Room/Emergency Department) patient; for 1 of 20 closed medical records reviewed. (Patient # 10-A).

Findings include:

1. Review of established hospital policy titled: "Triage and Medical Screening Exam", indicated on page 1, under I. POLICY, "guidelines to triage patients and initiate the medical screening examination"; "Patients presenting to the Emergency Department (ED) seeking medical care will be triaged by a Registered Nurse. The medical screening exam (MSE) will be completed by a physician/mid-level provider". Last reviewed 8/2020.

2. Review of established hospital policy titled: "EMTALA (Emergency Medical Treatment and Active Labor Act), indicated on page 1, under POLICY, "It is the policy of" AH # 40 (Acute Care Hospital) "(the Hospital) to provide an appropriate medical screening examination to individuals presenting at .. the Hospital's dedicated emergency department ("DED") requesting examination or treatment of a medical condition ("EMC")". Last reviewed 10/2020.

3. Review of Medical Rules & Regulations, indicated on page 31, under E. Emergency Room, 4. "In accordance with Emergency Medical Treatment and Active Labor Act, (EMTALA or COBRA), and appropriate medical screening examination will be provided to individuals presenting in the DED (dedicated Emergency Department ...), requesting examination or treatment of an emergency medical condition (EMC)"; "A qualified medical person (QMP) shall provide a medical screening in the hospitals DED". Last reviewed 7/2021.

4. Review of closed MR (medical record) for Patient # 10 ( # 10-A), from AH # 40 (acute care hospital), indicated the following:
A. Patient was a 2 year old who presented (brought in by FM # 1 {family member - parent}) to AH # 40's ER/ED (Emergency Room/Emergency Department) at 3:55 pm, on 8/11/2021, for complaint of alleged sexual assault.
B. Nurse note by N # 10 (RN {Registered Nurse} - ER/ED Staff) for patient encounter in triage; reflected "Call received from charge RN and SANE (Sexual Assault Nurse Examiner) in regards to pediatric sexual assault kit, state that kits are collected at AH # 50 (Acute Care Hospital) by appointment. Spoke with FM # 1 and "informed that we can see the patient but specialty nurse for pediatric kit collection are at" AH # 50 by appointment. Informed FM # 1 "we can assist with making appointment". FM # 1 "states I will just take" her/him to AH # 50 "to be seen and walked out". No refusal of care form was signed. FM # 1 left ED with "patient prior to assessment and vitals being taken".

5. Review of closed MR for Patient # 10 ( # 10-B), from AH # 50 (Acute Care Hospital), indicated the following:
A. Patient presented (brought in by FM # 1) to AH # 50's ER/ED, on 8/11/2021 at 4:52 pm, for chief complaint of possible sexual assault - suspected child sexual abuse. Patient was taken to AH # 40, previous to this, and parent was "told" her/him "to come here" (AH # 50) "for evaluation instead".
B. Patient was triaged by nurse staff; acuity = 2. Nurse note reflected FM # 1 wants patient evaluated to be sure that no one has sexually abused the patient. FM # 1 stated "took patient to" AH # 40, "and before they were fully registered someone pulled" her/him "aside and told" her/him "to come here for evaluation instead because they didn't have the proper kit to evaluate the patient". FM # 1 denies the "patient being seen by any medical provider".
C. Patient seen/examined by ER/ED Physician at time of patient presented.
D. Patient then seen by AH # 50's SANE (Sexual assault nurse examiner) at 7:41 pm, with FM # 1 present.
1. SANE nurse note at 9:35 pm, reflected updated ER/ED Physician on patient's status. Discharge instructions were reviewed with FM # 1. Patient ambulatory from department with family (FM # 1 and FM # 2 {parent sibling}).

6. Review of AH # 40's action plan for "MSE", indicated the following:
A. A # 3 (Administrative VP {Vice President} Compliance) received call from AH # 50, in regards to an EMTALA issue - violation.
B. Action plan included: Education, re-education, review of EMTALA log weekly; with review for MSE's performed, chart audits, and reports to ED committee and Leadership Performance Improvement Council meetings.
C. ER/ED Nurse staff re-education on EMTALA was started on 8/12/2021, with approximately 33 staff to have completed thus far. Included N # 10.
D. MD (Doctor Of Medicine) # 20 (ER/ED Medical Director) provided education to ER Medical staff on EMTALA - "Compliance Refresher".
E. Per A # 2 (Director Critical Care); monitor has been put in place for Medical record (ER/ED) audits to start on 9/13/2021; to include "MSE Completed (Y/N) - [yes/no].
F. Audit data - reports to be reported monthly at ED department meetings; next meeting on 10/13/2021 and to LPIC (Leadership Performance Improvement Council); next meeting on 10/5/2021.
G. Any deficiencies to be identified/addressed "in real time" with staff - follow corrective action policy.

7. In interview with administrative staff member A # 3, on 9/7/2021 at approximately 10:22 am, confirmed the following:
A. Received call from AH # 50's administrative staff, in regards EMTALA issue; patient (a minor) who showed up; brought in by parent for screen and treatment at their facility (AH # 50); who had been at AH # 40 first.
B. Made A # 2 and A # 1 (Assistant Vice President - Nursing) aware that AH # 50 had filed a complaint (EMTALA) with ISDH (Indiana State Department of Health) and CMS (Centers for Medicare and Medicaid Services).
C. Have already done their own investigation, review, follow through, staff re-education and plan; monitoring.

8. In interview with administrative staff member A # 1, on 9/7/2021 at approximately 10:23 am, confirmed the following:
A. The triage nurse (N # 10 {Registered Nurse - ER/ED}); triaged the patient, with FM # 1 present; informed FM # 1 that minors/pediatric patients - assault victims go to AH # 50 for assault kit/exam.
B. Patients are seen as an outpatient visit; see pediatric SANE (Sexual assault nurse examiner) nurse there, at AH # 50. After seen here first by MD and/or PA (Physician Assistant) for medical screening exam.
C. The PA arrived to room to see patient (patient # 10 {10-A}) - (pediatric), and found that FM # 1 took the patient and left. FM # 1 did not tell anyone she/he was leaving. No refusal was signed.

9. In interview with administrative staff member A # 2, on 9/7/2021 at approximately 9:59 am, at approximately 10:21 am, at approximately 10:25 am, confirmed the following:
A. Do not have pediatric SANE nurses at AH # 40; have SANE nurses for adult cases.
B. The pediatric patients; sexual assault victims, are triaged, seen by MD or PA, receive MSE and treatment. Then receive further information for referral and follow up as an outpatient through SANE program at AH # 50; have contact; arrangement with SANE nurse there. Most of the pediatric cases; are not usually brought in during the "acute phase".
C. Was informed by A # 3, that AH # 50 had filed an EMTALA complaint on 8/11/2021.
D. Started working on action plan and re-education on 8/12/2021.
E. FM # 1 - to patient # 10; left the ER before patient was seen by MD and/or PA. Patient and FM # 1 were still in triage room; when left; an ED room had not been assigned yet.