HospitalInspections.org

Based on a medical record review, interviews with staff, central log, employee training course, and a review of policies and procedures, it was determined that the facility failed to provide an appropriate medical screening examination for one (1) of 20 sampled patients (P) #1 when P#1 presented to the Emergency Department on 1/3/22 with a complaint of lower back pain. Specifically, P#1 was in the ED for 13 hours and left without being seen. In addition, P#1 did not receive reassessments of vital signs or pain after being triaged.

Findings were:

Cross refer to A-2406, as it relates to the facility's failure to provide P#1 with an appropriate Medical Screening Examination.

Based on a medical record review, interviews with staff, central log, employee training course, and a review of policies and procedures, it was determined that the facility failed to provide an appropriate medical screening examination for one (1) of 20 sampled patients (P) #1 when P#1 presented to the Emergency Department (ED) on 1/3/22 with a complaint of lower back pain.

Findings:

A review of the facility's Central Log revealed that Patient (P) #1 presented to the Emergency Department (ED) and was registered as a patient on 1/3/22 at 10:12 p.m.

A review of P#1's medical record revealed that P#1 was a 28-year-old admitted to the facility's ED on 1/3/2022 at 10:12 p.m. with a chief complaint of Lower Back Pain. P#1 was triaged at 10:14 p.m. by Registered Nurse (RN) DD. P#1 complained that his lower back pain was accompanied by pain that radiated down his left lower leg for the past week but had worsened that day. P#1's vital signs were blood pressure 148/81, pulse 77, respirations 18, pulse oxygenation 99% on room air, and temperature 98.6. P#1 described his pain as 10 out of 10. P#1 was assigned an Emergency Severity Index (ESI) (indicated how sick a patient was) of three. An x-ray of P#1's lumbar spine was ordered on 1/4/2022 at 2:03 a.m. and was completed at 3:09 a.m. The clinical indication noted that P#1 stated he was in severe pain and lying supine and on his left lateral side caused him pain. The x-ray impression noted there was no acute fracture or malalignment of the lumbar spine. A review of a Nurse's Note documented by RN CC stated that P#1 had requested Tylenol #3 (a narcotic medication that relieves pain and induces drowsiness) for pain in P#1's leg and back. The documentation further revealed that P#1 had spoken to the provider at the time, Physician Assistant (PA) AA, concerning his request. A continued review of P#1's medical record revealed an additional Nurse's Note dated 1/4/2022 at 11:31 a.m. by RN BB, which stated that P#1 was called twice but did not respond. P#1's disposition was changed to the Left Without Being Seen (LWBS) at 11:45 a.m.

A review of the facility's employee training course titled "Emergency Medical Treatment and Active Labor Act" (EMTALA) revealed that all Medicare facilities had to provide an MSE to all patients who came to a dedicated emergency department (DED) and requested medical services.
Scope of MSE:
1. Triage was not an acceptable MSE under EMTALA.
2. The MSE must be sufficient to find out whether the patient had an EMC.
3. Finding or excluding an EMC could include:
a. Complete medical history
b. Vital Signs took at regular intervals
c. Physical examination
d. Any necessary laboratory testing and/or imaging studies
Who can perform MSE:
1. Physicians must be on call to perform MSE.
2. Non-physicians who were qualified medical personnel (QMP). The facility must have a written protocol authorizing QMP to perform MSEs.

Stabilizing Care:

Under EMTALA, a Medicare facility must provide stabilizing care to all patients with an EMC if the hospital is able to provide the necessary care.
Patients with an EMC were considered stable when the EMC had been corrected. Any abnormal symptoms had to be normalized through treatment or attributed to a non-emergency medical condition.

A review of the facility's policy titled "Pain Management-EDH, EHH," no number, effective 10/31/2007, revealed that the choice of acetaminophen versus ibuprofen was based upon medications taken prior to arrival to the ED. The nurse would choose the alternate medication if specific medication was given prior to arrival.
An appropriate Pain Scale would be used to determine the level of pain.
a. Adults/Children: Verbal analogue scale (numeric querying based on a 0-10 where 0 was "no pain "and 10 was "the worst pain imaginable " to the patient)
b. Adults/School-Aged Children: Faces Scale (visual analogue scale using face images)
The initiation of appropriate ED Pain Management Protocol (Adult or Pediatric) with order source of "ED Protocol-MD to sign "should be completed.

The patient's pain should be reassessed for effectiveness of medication within 60 minutes. Documentation of the medication administration and response should be completed on the Medication Flowsheet and completion of the Pain Assessment Flowsheet. The patient would be monitored as clinically appropriate to determine effectiveness of the interventions. The ED provider should be notified if a second dose of medication was needed.
Contraindications:
1. Pregnancy
2. Known prior adverse reaction or allergy to protocol medications
3. Head trauma, or altered/decreased Level of Conscientiousness
4. Respiratory distress or depression
5. Severe hepatic or renal disease/transplant
6. No oral pain medication will be given to any patient complaining of abdominal pain; patient will be nothing by mouth (NPO). The physician should be consulted for pain medication order.
7. Recent overdose or dose of Tylenol
8. Narcotic or NSAIDS within the last 6 hours
9. Patient taking other CNS (Central Nervous System) depressants (alcohol, benzodiazepines, barbiturates, antidepressants, recreational drugs)
Protocol:
a. Pain Level 1-3 for an Adult:
Acetaminophen 650 (milligrams) mg PO X1 or Ibuprofen 600mg PO X1
b. Pain Level 4-6 for an Adult:
Hydrocodone-Acetaminophen 5/325mg po x 1 tab (Note: Oxycodone-Acetaminophen 5/325mg po x 1 tab if directed by ED physician or patient allergy to Hydrocodone-Acetaminophen.)
c. Pain Level 7-10 for an Adult:
1. Severe orthopedic injury/fracture and kidney stones should default to this level of intervention.
2. If non-orthopedic injury or trauma, defer to provider for medication order.
3. Assist patient to stretcher as soon as possible; Monitor vital signs/ oxygen saturation.
4. Morphine 4mg IVP (intravenous push) (patients greater than or equal to 14 years of age); administer over 2 minutes to reduce risk of rapid absorption and adverse reaction.
5. Ketorolac 15 mg IVP for suspected kidney stone. If pain not relieved after 30-minutes, may give Morphine Sulfate 2mgs x 1. Notify ED provider if additional pain medication was required.

A review of the facility's policy titled, "EMTALA-Medical Screening, Treatment, and Related Issues," no number, effective 10/20/2016, revealed that any individual who came to the ED requesting care would be offered an appropriate medical screening examination (MSE) to determine if the individual had an Emergency Medical Condition (EMC). If an EMC existed, the facility would provide treatment to stabilize the condition or an appropriate transfer in accordance with the facility's policy on transfers.
Medical Screening Exam (MSE):
1. All individuals who came to the ED would be provided an MSE appropriate to the individual's presenting signs and symptoms, as well as the capability and capacity of the facility.
2. In deciding regarding any MSE and whether an individual had an EMC, the physician or other qualified medical provider (QMP) would consider the assessment of the triage nurse or other medical personnel and/or any information obtained from any other action taken as part of the MSE which may include, but was not limited to, laboratory results or diagnostic tests.
3. The medical record should reflect continued monitoring according to the individual's needs until it was determined whether the individual had an EMC and if he/she did until he/she was stabilized or appropriately transferred.
4. There should be evidence of this ongoing monitoring prior to discharge or transfer.
Refusal of Examination or Treatment:
There were two designations given to a patient when refusing examination and/or treatment:
Left Without Being Seen (LWBS) - Patient left the ED or L&D prior to MSE.
Against Medical Advice (AMA) - Patient left the hospital, ED, or L&D after the MSE was performed.
1. At any time during an ED visit a patient could refuses an MSE and/or treatment or leave the ED before the examination and/or treatment could be completed.
2. The ED personnel would make every attempt to inform the patient of the risks of refusing examination and/or treatment or of leaving before the examination and/or treatment could be completed.
3. The staff's attempt to inform the patient of the risks should be documented in the medical record.
4. If possible, the patient should be asked to wait for the physician or QMP, who could discuss the risks of leaving the facility.
5. If the patient decided to leave prior to the completion of his/her care, all efforts would be made to provide information, resources, and follow-up to assist in ongoing wellness.
4. The circumstances of the patient's refusal or departure would be documented in the medical record, and the hospital; and ED staff would take every reasonable step to complete and have the patient sign a Refusal of Examination/Treatment Form if the patient LWBS or AMA.
5. If the patient refused to sign a Refusal of Examination/Treatment Form or left before one can be prepared prior to the patient's departure, the Form should still be completed and annotated with: (1) the date and time of the request for signature from the patient; and (2) when the patient left. This should be made part of the patient's medical record.

An interview was conducted with triage nurse RN HH in the ED on 1/19/22 at 1:30 p.m. RN HH stated when a patient entered the ED, the patient first registered. The patient would immediately then be triaged. RN HH explained the ESI had five levels, with level one considered the most urgent, such as a heart attack or stroke. These types of patients were top priority, and a bed would be provided immediately. RN HH said that patients with an ESI level three would have two or more studies ordered by the provider, such as laboratory and x-ray. RN HH said such patients could wait until a bed became available. RN HH stated an ESI of three was not a top priority, especially when the ED was receiving a high volume of complicated patients. RN HH continued to say such patients would receive care but could wait while the providers were busy with more severe cases.

A telephone interview was conducted with the ED Nursing Director, RN EE, on 1/19/22 at 3:30 p.m. RN EE stated he remembered P #1 well because he had some interactions with P#1 when he came to work the morning of January 4, 2022. He said the ED census was at maximum capacity and had many low acuity patients. RN EE said after he learned about P#1's behavior during the overnight. RN EE stated he apologized to P#1 for the long wait and tried to explain the triage process to P#1. RN EE said he tried to explain that there were a lot of critical patients that needed more immediate care, and this was the reason for the prolonged wait. RN EE said around 11:00 (approximately), he observed that P #1 was disruptive and intimidating to staff. P#1 became verbally aggressive. RN EE stated that P#1 was so disruptive that P#1 was asked to wait outside and that they would call him when it was his turn. RN EE stated he tried again to explain to P#1 to be patient and that the ED did not see patients in order of arrival but based on critical needs. RN EE said P #1 was standing in the middle of the ED, shouting and being loud and disruptive. RN EE stated that when they face a situation like this, the goal was always to deescalate the situation to ensure everyone's safety. RN EE explained that at no time did a staff member ask P#1 to leave the facility or that P#1 would not be seen. RN EE said P #1 was triaged. A provider placed an order for an x-ray, and the order was completed. RN EE said that around 11:30 a.m., the nurse called for P#1, and they checked outside, but P #1 was nowhere to be found. After several calls, the nurse took P#1 out of the system and marked P#1 as LWBS.

A telephone interview was conducted with Public Safety Officer (SO) II on 1/20/22 at 10:10 a.m. SO II stated he recalled arriving at the ED and saw P #1 standing in front of the triage window, refusing to leave. SO II said that at some point, P#1 moved and stood in the lobby and was very upset. P#1 voiced that his wait had been too long. SO II said he tried to explain the process and how things worked in the ED to P#1. SO II II said P #1 stated he did not want to wait anymore and was leaving. SO II said he encouraged P #1 to stay and told him they would see him after caring for the sickest patients. SO II said P #1 finally agreed to stay and seemed to calm down. Shortly after that, P #1 just disappeared without telling anyone.

A telephone interview was conducted with Physician Assistant (PA) AA on 1/20/22 at 11:10 a.m. PA AA stated P#1 arrived in the ED while he was on break. PA AA said RN DD briefed him when he returned about P #1. RN DD informed him that P#1 was complaining of back pain and that P#1 was agitated because P#1 had not gotten assigned a bed. PA AA said he did a chart review of P #1 and reviewed P#1's triage note. PA AA said P#1's ESI was three. P#1's vital signs were stable, and there were no signs of distress. PA AA said P #1 approached him complaining of back pain and said he needed Tylenol #3. PA AA said he offered P#1 Tylenol (an over-the-counter pain reliever), but P #1 refused and insisted he wanted Tylenol #3. PA AA said they only administered narcotics to patients in a safe environment, not when the patient was in the lobby. PA AA stated they could not administer a narcotic to P#1 until P#1 was in a room for monitoring. P#1 stated he was going home and would return. PA AA said he explained to P#1 that if P#1 left and staff called for him, P#1 would have to start the process over and that it was not a good idea to leave. PA AA said the nurse called P #1 twice, maybe three times, and P#1 did not answer. ED staff removed P#1's name from the system.

A telephone interview was conducted with the Triage Nurse, RN DD, on 1/20/22 at 11:45 a.m. RN DD stated she was working in triage when P #1 arrived. After P#1 was triaged, she directed P#1 to have a seat, but she said P #1 never sat down and said he wanted to remain standing. RN DD said P #1 told her he was going home to get a Percocet (a narcotic medication that relieves pain). RN DD explained that P#1 stood in front of the registration window and refused to move after he was asked several times to allow other patients to check-in. RN DD recalled that P #1 walked back and forth in the ED demanding a room, although she explained to P#1 that they did not have a bed at the time. She stated that she informed P#1 they had a lot of very sick people with respiratory issues in the back and that they roomed patients based on how sick they were. RN DD said she tried to explain the process to P #1. RN DD said they offered Tylenol to P #1 but that he wanted a narcotic. RN DD said she told P#1 they did not do that. RN DD said they administered narcotics to patients only when they could monitor them and not to a patient in the lobby who could leave at any time. RN DD further stated that P#1 had an ESI level of three, and they gave priority to more critical patients.

An interview was conducted with RN BB on 1/20/22 at 12:45 p.m. in the ED. RN BB stated he remembered P #1 because he encountered P#1 when he arrived for his morning shift. RN BB said the waiting time was about twelve to thirteen hours when P #1 arrived in the ED because of the large number of patients. RN BB said when he arrived that morning, P#1 was standing in the middle of the ED lobby close to the entrance door. RN BB asked P#1 to move away from the entrance to allow other patients to come in. RN BB said he tried explaining the triage process to P#1. RN BB told P#1 that they saw patients by acuity, not by order of arrival. RN BB said P #1 got upset and followed him to ED Zone 3. RN BB stated P#1 was upset, verbally aggressive, and followed him around. Someone else intervened due to P#1's behavior. RN BB said P #1 did not tell anyone he was leaving.

A telephone interview was conducted with the complainant on 1/20/22 at 1:24 p.m. The complainant stated that P#1 came to the ED because P#1 wanted to know what was causing the back pain and the problem. The complainant said the night P#1 went to the ED; it was busy. The complainant stated that the facility performed x-rays on P#1, but they did not tell P#1 anything after the x-rays. Since leaving the ED, the complainant said P#1's back was not much better with natural remedies.

Based on a medical record review, interviews with staff, and a review of policies and procedures, it was determined that the facility failed to provide P#1 with an appropriate MSE. P#1 was in the ED for 13 hours and then LWBS. In addition, P#1 did not receive reassessments of vital signs or pain after being triaged.