HospitalInspections.org

Based on review of facility documents, review of facility video surveillance and interview with staff (EMP), it was determined the facility failed to maintain a central log on each individual patient presenting to the Emergency Department (ED) for one of 22 patients seeking care (PT1).

Findings include:

Review of facility's "EMTALA compliance - Emergency Medical Treatment & Active Labor Act, " dated March 2015, revealed " ... Procedure: ... 2. ED Log: - The ED department shall maintain a central log recording the names of patients who present for emergency services. The log shall record the name of each person who presents for emergency services and whether the person refused treatment, was refused treatment by the hospital or whether the patient was transferred, admitted and treated, stabilized and transferred or discharged. ..."

Review of the facility's Emergency Department video surveillance revealed PT1 presented to the facility's ED via EMS (emergency medical services) transport, at the "Emergency Services" entrance on December 7, 2015, at 8:21 PM. Further review of the video surveillance revealed that PT1 left the ED with EMS on December 7, 2015, at 8:35 PM. The video surveillance revealed that EMP2, EMP4, EMP5, and CF1, were aware of PT1's presence in the ED and/or had contact with PT1.

Review of the facility's "ED log" for December 7, 2015, revealed that the patient was not listed on the ED Log to document that the patient arrived to the ED seeking assisstance and to include whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged.

Interview on December 16, 2015, at 9:15 AM, with EMP1 confirmed that the patient's name was not on the ED Log to document that the patient arrived to the ED seeking assistance and to include whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged.

Based on review of facility documents, review of facility video surveillance and interviews with staff (EMP), it was determined that the facility failed to ensure that each patient presenting to the Emergency Department (ED) was provided with an appropriate medical screening examination (MSE) to determine whether or not an emergency medical condition existed for one of 22 patients seeking care (PT1).


Findings include:

Review on December 16, 2015, of facility policy "EMTALA Compliance - Emergency Medical Medical Treatment & Active Labor Act," dated March 2015, revealed " ... 1. Compliance: it is the policy of Roxborough Memorial Hospital to comply with the EMTALA obligations. These policies mandated by Section 1867 of the Social Security Act, as amended, and regulations adopted in 1994 ... Scope of EMTALA ... 4. Application to the hospital: EMTALA is applicable to anyone who presents in any area or department of [facility](including on-campus and off-campus clinics and other departments billed under the Hospital's Medicare provider number) for primary assessment and treatment. The EMTALA requirements are applicable to anyone who is on [facilty's] property, including parking lots, sidewalks and driveways ... Medical Screening Examination: 8.1 Policy: A medical screening examination must be offered to any individual presenting for examination of treatment of a medical condition ... 8.2 Scope: a medical screening examination is the process required to reach, with in reasonable clinical confidence, the point at which it cam be determined whether an emergency medical condition does or does not exist ... ."

Review on December 15, 2015, at 11:30 AM, of the facility's video surveillance recording of the Emergency Department, dated December 7, 2015, timed 8:21 PM revealed EMS (emergency medical service) medics with PT1 on a stretcher entering the Emergency Department (ED) via the ambulance entrance/exit. Further review of the footage revealed that PT1 was moved to a corner of the ED corridor and is parked there for 15 minutes with EMP2 at the patient's stretcher.

The video revealed EMP2 assisting PT1 off the stretcher and into the bathroom. At approximately 8:28 PM the physician on duty, CF1, walks thru the area and speaks with EMP2 for 20 seconds and then exits the area. At 8:36 PM the medics are seen transporting PT1 onto the stretcher and out of the facility's ED through the ambulance entrance/exit.

Interview on December 15, 2015, at 12:20 PM, with EMP4 indicated that the ambulance medics arrived to the facility's ED and requested that the patient not to be registered for an evaluation and treatment. EMP4 indicated that they were unsure if the medics had transferred the patient to the correct ED for evaluation and treatment.

Interview on December 15, 2015, at 12:50 PM, with OTH1 confirmed that they were aware that PT1 was in the ED and confirmed that they did not provide an MSE to the patient. OTH1 indicated that they did not know why the patient was seeking medical treatment.

Interview on December 16, 2015, at 1:45 PM, with EMP2 revealed that the patient was brought to the facility's ED but that the patient did not receive a MSE. EMP2 confirmed that they spoke with the CF1 about the patient and that they were waiting for the medics to confirm if the patient was going to transferred to the "correct ED."

The facility failed to provide an appropriate MSE, to rule out an emergency medical condition, for one patient presenting to the facility's emergency department.