HospitalInspections.org

Based on document review and staff interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.20 and 42 CFR 489.24.

Findings include:

1. The hospital failed to track on a central log everyone who came to the hospital Emergency Department seeking care for an emergency medical condition. See deficiency at A-2405.

2. The hospital failed to ensure patients who did come to the Emergency Department were provided an appropriate medical screening examination within the capability of the hospital's emergency department. See deficiency at A-2406

3. The hospital failed to ensure that all patients presenting to the Emergency Department were provided stabilizing treatment. See deficiency at A-2407.

4. The hospital failed to ensure patients received an appropriate transfer. See deficiency at A-2409.

Based on document review and staff interview, it was determined for 1 of 20 (Pt #1) patients who presented to the Emergency Department (ED), the hospital failed to track on a central log each individual seeking care for an emergency medical condition. This has the potential to affect all patients receiving care in an ER that treats approximately 25 patients a day.

Findings include:

1. On 05/09/2022 at approximately 10:00 AM, an attempt was made by the Acting CEO/Registered Nurse (E #1) and the Emergency (ED) Department Manager (E #7) to locate documentation on Pt #1 in the hospital's electronic medical system. Both individuals were unable to find any documentation that the patient had presented to the emergency department for treatment or was ever an in-patient during the month of April 2022. There was no evidence that the patient was ever registered or placed on the ED tracking log.

2. On 05/09/2022, at approximately 11:00 AM, the Emergency Department (ED) Log was reviewed. The log did not have Pt #1's name on it.

3. On 05/09/2022 at 12:30 PM, an interview with the Acting Chief Executive Officer/Registered Nurse (E #1) was conducted. E #1 confirmed the ED log did not contain Pt #1 name on it and stated, "It should have been on there."

4. On 05/09/2022 at 1:45 PM, a telephone interview with Emergency Department Registered Nurse (E #4) was conducted. E #4 was working in the ED on the night of 04/18/2022. P #1confirmed that Pt #1 was transported by ambulance to the ED, with complaint of chest pain.

5. On 05/09/2022 at 2:50 PM, a telephone interview with Paramedic (E #8) was conducted. E #8 was working in the back of the ambulance, caring for Pt #1 during transport and confirmed that Pt #1 was transported to the transferring hospital.

Based on document review and staff interview, it was determined for 1 of 20 (Pt #1) patients who presented to the Emergency Department (ED), the hospital failed to provide an appropriate medical screening to determine within reasonable clinical confidence whether an emergency medical condition existed. This has the potential to affect all patients receiving care in an ER that treats approximately 25 patients a day.

Finding include:

1. On 05/11/2022 at 3:15 PM, hospital policy "Emergency Medical Treatment and Active Labor Act (EMTALA), 08/13/2021 was reviewed. It reads "4. Medical Screening Examination (MSE): is the process required to determine within reasonable clinical confidence whether an EMC does or does not exist and whether a woman having contractions is in need of immediate medical attention. The MSE is an ongoing process and must be done within the facility's capabilities and the availability of qualified medical personnel.

2. On 04/10/2022, the "Provision of Care Event" (EMTALA) dated 04/20/2022 was reviewed. The factual description of the event is documented as follows: On 04/18/2022 at approximately 8:07 PM, EMS brought Pt #1 to Hospital A's Emergency Department (ED). While enroute to the hospital, paramedic performed an EKG which read as STEMI. Upon arrival to ED, the paramedic showed ED MD (E #6), the EKG. E #6 suggested that Pt #1 should go directly to Hospital B's ED (approximately 25 miles away) for possible cardiac catheterization (insertion of a catheter into a chamber or vessel of the heart). E #6 says the patient was never fully registered on Hospital A's ED tracker and vital signs were stable, so E #6 thought it was appropriate to send patient to Hospital B for higher level of care to not delay an emergent cardiac catheterization. EMS then loaded patient back into the ambulance and went to Hospital B's ED.

3. On 05/09/2022 at approximately 10:00 AM, an attempt was made by the Acting CEO/Registered Nurse (E #1) and the Emergency (ED) Department Manager (E #7) to locate documentation on Pt #1 in the hospital's electronic medical system. Both individuals were unable to find any documentation that the patient had presented to the emergency department for treatment or was ever an in-patient during the month of April 2022. E #1 confirmed there was no documentation that an appropriate medical screening was conducted.

4. On 05/09/2022 at 3:45 PM, a telephone interview with ED Physician (E #6) was conducted. E #6 was working in the ED the day the patient presented. "I was working in the ED when the patient arrived. We received a call shortly before the patient arrived that Pt #1 had altered mental status and low blood pressure. When the patient arrived, she was wheeled in between two rooms on the EMS gurney. One of the paramedics grabbed me and showed me the patient's EKG strip and it appeared to me that she was having a STEMI. The reading on the EKG strip that was presented to me read STEMI. I looked the patient up in our electronic medical record and the patient had an old EKG that I compared it to. The most current EKG indicated a change. The paramedic also confirmed that the EKG strip indicated STEMI. They asked if they should take the patient to Hospital B (receiving hospital). I indicated the patient needed to be transported to a higher level of care that had cardiac catheterization capabilities. I spoke with the ED physician at Hospital B and contacted a cardiovascular service via a web-based application that doctors may use to communicate patient-related information. A return text indicated they were aware of my text message. There were no orders requested by the accepting physician. I did not give any orders for the EMS crew. In hindsight I would have done a better job of documentation of my actions. I should have done a better physical exam and documented it."

Based on document review and staff interview, it was determined for 1 of 20 (Pt #1) patients who presented to the Emergency Department (ED), the hospital failed to provide stabilizing treatment. This has the potential to affect all patients receiving care in an ER that treats approximately 25 patients a day.

Finding include:

1. On 05/11/2022 at 3:15 PM, hospital policy "Emergency Medical Treatment and Active Labor Act (EMTALA), 08/13/2021 was reviewed. It reads "6. Stabilized: means, with respect to an emergency medical condition (EMC), that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility; or the EMC has been resolved.... ."

2. On 04/10/2022, the "Provision of Care Event" (EMTALA) dated 04/20/2022 was reviewed. The factual description of the event is documented as follows: On 04/18/2022 at approximately 8:07 PM, EMS brought Pt #1 to Hospital A's Emergency Department (ED). While enroute to the hospital, paramedic performed an EKG which read as STEMI. Upon arrival to ED, the paramedic showed ED MD (E #6), the EKG. E #6 suggested that Pt #1 should go directly to Hospital B's ED (approximately 25 miles away) for possible cardiac catheterization (insertion of a catheter into a chamber or vessel of the heart). E #6 says the patient was never fully registered on Hospital A's ED tracker and vital signs were stable, so E #6 thought it was appropriate to send patient to Hospital B for higher level of care to not delay an emergent cardiac catheterization. EMS then loaded patient back into the ambulance and went to Hospital B's ED.

3. On 05/09/2022 at approximately 10:00 AM, an attempt was made by the Acting CEO/Registered Nurse (E #1) and the Emergency (ED) Department Manager (E #7) to locate documentation on Pt #1 in the hospital's electronic medical system. Both individuals were unable to find any documentation that the patient had presented to the emergency department for treatment or was ever an in-patient during the month of April 2022. E #1 confirmed there was no documentation that indicated the patient received any stabilizing treatment.

4. On 05/09/2022 at 3:45 PM, a telephone interview with ED Physician (E #6) was conducted. E #6 was working in the ED the day the patient presented. "I was working in the ED when the patient arrived. We received a call shortly before the patient arrived that Pt #1 had altered mental status and low blood pressure. When the patient arrived, she was wheeled in between two rooms on the EMS gurney. One of the paramedics grabbed me and showed me the patient's EKG strip and it appeared to me that she was having a STEMI. The reading on the EKG strip that was presented to me read STEMI. I looked the patient up in our electronic medical record and the patient had an old EKG that I compared it to. The most current EKG indicated a change. The paramedic also confirmed that the EKG strip indicated STEMI. They asked if they should take the patient to Hospital B (receiving hospital). I indicated the patient needed to be transported to a higher level of care that had cardiac catheterization capabilities. I spoke with the ED physician at Hospital B and contacted a cardiovascular service via a web-based application that doctors may use to communicate patient-related information. A return text indicated they were aware of my text message. There were no orders requested by the accepting physician. I did not give any orders for the EMS crew. In hindsight I would have done a better job of documentation of my actions. I should have done a better physical exam and documented it."

5. On 05/11/2022 at 12:45 PM, the medical record of Pt #1, from the receiving hospital was reviewed. Documentation indicated the patient arrived at their ED on 04/18/2022 at 9:29 PM. "The patient was initially received in the emergency department as a STEMI alert by EMS. According to EMS personnel they were dispatched to the long-term care facility in which the patient resides as it was felt by them that the patient had a decrease appetite and an altered mental status. During the initial EMS evaluation an EKG was performed that did demonstrate ST elevation in the inferior leads. Thus, they transferred the patient to our facility for evaluation. Based on EMS report, the Cath Lab was activated. However, on patient arrival, it was revealed that the patient has a ventricular pacemaker, does not have any chest pain, and Pt #1's EKG at our facility is not consistent with an ST elevation myocardial infarction. The patient was examined in the emergency department by an interventional cardiologist and the STEMI alert canceled. The onset of the patient's symptoms is unclear. No clear palliative or provoking factors are identified. Quality is as described above. There is no radiation. The patient denies any pain. When asked why Pt #1 was here, Pt #1 stated "they wanted to take me for a ride. Severity is mild to moderate."

Based on document review and staff interview, it was determined for 1 of 20 (Pt #1) patients who presented to the Emergency Department (ED), the hospital failed to provide an appropriate transfer, which included a request, in writing, indicating the reasons, as well as the risks and benefits of transfer. This has the potential to affect all patients receiving care in an ED that treats approximately 25 patients a day.

Finding include:

1. On 05/11/2022 at 3:15 PM, hospital policy "Transfer to Another Facility" (10/09), was reviewed. It reads "I. POLICY: When a transfer is being considered, it is the physician's responsibility to inform the patient/family of the reasons for the transfer, the benefits, and possible complications."

2. On 05/09/2022 at approximately 10:00 AM, an attempt was made by the Acting CEO/Registered Nurse (E #1) and the Emergency (ED) Department Manager (E #7) to locate documentation on Pt #1 in the hospital's electronic medical system. Both individuals were unable to find any documentation that the patient had presented to the emergency department for treatment or was ever an in-patient during the month of April 2022. E #1 confirmed there was no documentation that the physician informed the patient/family of the reasons for the transfer, the benefits, and possible complications.".

3. On 04/10/2022, the "Provision of Care Event" (EMTALA) dated 04/20/2022 was reviewed. The factual description of the event is documented as follows: On 04/18/2022 at approximately 8:07 PM, EMS brought Pt #1 to Hospital A's Emergency Department (ED). While enroute to the hospital, paramedic performed an EKG which read as STEMI. Upon arrival to ED, the paramedic showed ED MD (E #6), the EKG. E #6 suggested that Pt #1 should go directly to Hospital B's ED (approximately 25 miles away) for possible cardiac catheterization (insertion of a catheter into a chamber or vessel of the heart). E #6 says the patient was never fully registered on Hospital A's ED tracker and vital signs were stable, so E #6 thought it was appropriate to send patient to Hospital B for higher level of care to not delay an emergent cardiac catheterization. EMS then loaded patient back into the ambulance and went to Hospital B's ED.

4. On 05/09/2022 at 3:45 PM, a telephone interview with ED Physician (E #6) was conducted. E #6 was working in the ED the day the patient presented. "I was working in the ED when the patient arrived. We received a call shortly before the patient arrived that Pt #1 had altered mental status and low blood pressure. When the patient arrived, Pt #1 was wheeled in between two rooms on the EMS gurney. EMS staff asked if they should take the patient to Hospital B (receiving hospital). I indicated the patient needed to be transported to a higher level of care that had cardiac catheterization capabilities. I spoke with the ED physician at Hospital B and contacted a cardiovascular service via a web-based application that doctors may use to communicate patient-related information. A return text indicated they were aware of my text message. There were no orders requested by the accepting physician. I did not give any orders for the EMS crew. In hindsight I would have done a better job of documentation of my actions. I should have done a better physical exam and documented it."