HospitalInspections.org

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Based on review of hospital EMTALA (Emergency Medical Treatment and Labor Act) policies; staff/physician and patient interview and record reviews; the facility failed to ensure staff followed their policies to maintain compliance with EMTALA. The facility failed to ensure 1 of 20 patients (Patient 1) received a Medical Screening Exam sufficient to determine whether an emergency medical condition existed. See A-2406.

NOTE: The facility identified the violation prior to the EMTALA investigation on 2/18/2020, provided the staff with EMTALA education on 2/7/2020, including a post test; and has not had any other EMTALA violations in the past 6 months.

Findings are:

A. Review of facility policy titled "Transfer Policy/EMTALA" effective date 11/2015 under section titled "Procedures" states "All patients coming to the ED (Emergency Department) requesting examination and treatment shall receive a Medical Screening Exam (MSE) by a physician, nurse practitioner, or PA-C to determine the existence of an emergency medical condition." "The ED will provide the necessary MSE, stabilizing treatment for the emergency medical condition (EMC) and labor, or shall transfer the patient if the hospital does not have the capability or capacity to provide necessary treatment to stabilize the EMC."

B. Review of Patient 1's 1/4/2020 medical record showed RN A documented a late entry note on 1/15/20 at 6:28 AM indicating Patient 1 arrived to the ED on 1/4/2020 at 7:40 PM complaining of pain under the left breast and the mid upper gastric area. Further documentation showed that patient # 1 phoned the ED at 7:15 PM and about the pain. The patient asked which doctor (Dr) was on for the night. The patient was told Dr X was on call. RN A then explained to Patient 1 the procedure and amount of time it would be to receive treatment or care and that (gender) knows that Dr X will most likely transfer the patient out to (another city) hospital via EMS (ambulance) given the patients medical history. The patient agreed and decided to have (adult child) drive to (another city) rather than to waste time in (this hospital) ER with tests and transport. Patient 1 asked if it was ok to take spouses nitro (nitroglycerin) tablet in the mean time. The RN stated that would not be in the patients best interest and could cause more harm than good. The patient then called (gender) spouse at 8:00 PM to discuss what to do and decided that would leave for hospital in another city.

The second document in the medical record from RN B (dated 1/16/20 at 2:06 AM) revealed documentation by RN B that Patient 1 arrived at the hospital at approximately 7:40 PM, and Patient 1 had called about 20 minutes earlier with complaint of pain in lower chest and upper gastric area. The patient was notified that Dr X was on for the night. Patient 1 had stated that (gender) had taken 2 baby aspirin and wasn't feeling well. The patient shared that (gender) had previously been in ER (with similar complaints in recent past) and had been sent to a hospital in another city via rescue squad and to a cardiologist. The patient was advised we could see the patient or (gender) could go directly to hospital (in another city) since the patient was previously was seen there and (gender) heart doctor was there. Patient 1 then called spouse and asked what to do, at that time the decision was to go to hospital in other city. The patients adult child would drive the patient. The patient was told if further problems and needed immediate assistance prior to arrival at the hospital to phone 9-1-1.

The third document was a "Refusal of Service Form" that was signed on 1/23/2020 by the patient, 19 days after the patients arrival to the hospital on 1/4/20. It stated "Preferred to seek services at a higher level of care 1/4/20."

At no time did the staff follow the facility policy to take the patient into the ER, complete an assessment, set of vital signs, and the staff did not notify the physician. RN A and RN B had a 20 minute conversation with the patient in the hallway outside the ER door before the patient left.

C. A telephone interview with Patient 1 on 2/19/2020 at 3:10 PM revealed the patient went to the ED and wanted to be seen. "I had called in earlier and when I walked in I told them (RN A & RN B) I was having chest pain and needed help. They asked me how sure I was I had chest pain. I didn't see a doctor, the nurse said you won't stay here, you will be transferred to (hospital in another city). They said you may want to go straight to (to hospital in other city). I thought if I die driving to (other city) it was on their hands. My choice that night was to be seen, I have had a heart attack before. I called my (spouse) and left the hospital. My (child) drove me and we stopped by my home, got my Mom and we headed to (one city), but I had an increase in pain so we went into (Hospital C) as it was on the way, and I was scared and needed to be seen." When asked about the document from 1/4/20 the patient signed titled "Refusal of Service", the patient stated, "Later when I was there for something else, they asked me to sign a paper due to I did not get service that day. So I did."

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Based on record review; EMTALA (Emergency Medical Treatment and Labor Act) policy review; receiving hospital record review; patient and staff interview, the facility failed to provide 1 of 20 sampled patients (Patient 1) with a Medical Screening Examination (MSE). Patient 1 presented to the hospital for examination and treatment of a complaint of chest and epigastric pain. The failure to perform a MSE has the potential to cause serious harm and or death from an untreated Emergency Medical Condition (EMC).

Findings are:

A. Review of facility policy titled "Transfer Policy/EMTALA" effective date 11/2015 under section titled "Procedures" states "All patients coming to the ED (Emergency Department) requesting examination and treatment shall receive a Medical Screening Exam (MSE) by a physician, nurse practitioner, or PA-C to determine the existence of an emergency medical condition." "The ED will provide the necessary MSE, stabilizing treatment for the emergency medical condition (EMC) and labor, or shall transfer the patient if the hospital does not have the capability or capacity to provide necessary treatment to stabilize the EMC."

B. Review of Patient 1's 1/4/2020 medical record showed 3 documents, the first document from Registered Nurse (RN A) dated 1/15/20 at 6:28 AM (documented 11 days after the pt visit on 1/4/2020) showed, RN A documented that Patient 1 arrived to the ER at 7:40 PM with the complaint of pain under (gender) left breast and to the mid upper gastric area. The patient had phoned at 7:15 PM about the pain. The patient asked which doctor (Dr) was on for the night. The patient was told Dr X was on call. RN A then explained to Patient 1 the procedure and amount of time it would be to receive treatment or care and that (gender) knows that Dr X will most likely transfer the patient out to a hospital (in another city) via EMS (ambulance) given the patients medical history. The patient agreed and decided to have (adult child) drive to (hospital in other city) rather than to waste time in (this hospital) ER with tests and transport. Patient 1 asked if it was ok to take spouses nitro (nitroglycerin) tablet in the mean time. The RN stated that would not be in the patients best interest and could cause more harm than good. The patient then called (gender) spouse at 8:00 PM to discuss what to do and decided that would leave for another hospital.

The second document in the medical record from RN B dated 1/16/20 at 2:06 AM (documented 12 days after the pt visist on 1/4/2020) showed RN B documented that Patient 1 arrived at the hospital at approximately 7:40 PM, and had called about 20 minutes earlier with complaint of pain in lower chest and upper gastric area. The was notified that Dr X was on for the night. Patient 1 had stated that (gender) had taken 2 baby aspirin and wasn't feeling well. The patient shared that (gender) had previously been in ER (with similar complaints in recent past) and had been sent to a hospital (in another city) via rescue squad and to a cardiologist. The patient was advised we could see the patient or (gender) could go directly to the (hospital in another city) since the patient was previously was seen there and (gender) heart doctor was there. Patient 1 then called spouse and asked what to do, at that time the decision was to continue into (the other city). The patients adult child would drive the patient. The patient was told if further problems and needed immediate assistance prior to arrival at the hospital to phone 9-1-1.

When asked RN A and RN B why the documentation of the 1/4/2020 visit wasn't documented until 12-13 days after the visit, they stated that the Director of Nurses told them it needed to document Patient 1's visit to the hospital even if the patient wasn't seen.

The third document was a "Refusal of Service Form" that was signed on 1/23/2020, 19 days after the patients arrival to the hospital on 1/4/20. It stated "Preferred to seek services at a higher level of care 1/4/20."

At no time did the patient enter the ER and receive an assessment, set of vital signs or have the physician notified of the patient's arrival to the ER. The patient only had a 20 minute conversation with RN A and RN B which occurred in the hallway between the outside ER door entrance and the ER.

C. In an interview at the hospital (on 2/19/20 at 12:10 PM) with Dr X it was revealed that, "I wasn't called on that day about (Patient 1). To my knowledge I was not notified about (gender) being here on 1/4/20."

D. Interview with RN B (on 2/20/20 at 11:45 AM) revealed, that (Patient 1) had called in originally and talked to RN A. About 15-20 minutes later the patient came to the ER door. We (RN A & RN B) went and let the patient into the door and we were standing in the hallway. (Patient 1) was complaining of chest and back pain, stating it started earlier in day. The patient had asked what physician was on call and when found out it was Dr X was "wishy-washy" if wanted to be seen. RN A told the patient if you don't want to see Dr X could go home or go somewhere else. The patient told us (gender) had previous heart issues and had a cardiologist in (another city). The patient than called (gender) spouse for guidance and decided to leave.

E. Interview with RN A on 2/21/20 at 4:45 AM revealed, that (Patient 1) had called in earlier asking for advise due to having left breast and upper epigastric pain. RN A told the patient that advise could not be given and that could come to the hospital if wanted to be seen and having symptoms. RN A stated that the patient arrived 20 minutes later to the ER door. Patient 1 asked immediately who was on call and informed it was Dr X. Asked if (gender) could take spouses Nitro tablets, and was told would not be in the patients best interest and could cause more harm than good if did. Discussed the process if the patient decided to stay that the doctor would be called and with the patients history of cardiac issues, the patient would probably be transferred to (hospital in another city), or could go ahead and just have (adult child) drive the patient to (the hospital in another city) and it would be faster. So called spouse and then left.

F. Review of receiving Hospital "C" (20 miles from this hospital) ED course document dated 1/4/2020 indicated, "2316 (11:16 PM) "patient is wheelchair into room complaining of shortness of breath and retrosternal chest pain. (Gender) is not diaphoretic (sweaty) and vitals ate stable, afebrile (no fever). Patient took aspirin prior to arrival to ED. 2317 (11:17 PM) EKG (electrocardiogram- heart tracing) shows regular sinus rhythm. No evidence of ST elevations, depressions, and arrhythmia's. Ordered extensive laboratory work-up including cardiac enzymes. 2320 (11:20 PM) because of this chest pressure ordered 0.2 mg (milligrams) of nitroglycerin sublingual (heart medicine given under the tongue). 2340 results of chest x-ray negative for pneumothorax (collapsed lung), lung consolidations, enlarged heart and pleural effusion (fluid caught between layers of the outside of lungs). 2345 (11:45 PM) when re examined the patient, was not diaphoretic, denying nausea, vomiting and able to speak in full sentences. However the patient did have some tenderness upon palpation (pressing) on the retrosternal (behind the breastbone) chest cavity. Heart, lungs and abdomen unremarkable. 2400 troponin, CK, CK-MB (blood work to check for heart issues), CMP (blood work to check kidney function and electrolytes) and TSH (thyroid test) were all normal. Throughout this ED course, telemetry show regular sinus rhythm. Patient states after the nitroglycerin SL and IV (intravenous) morphine that the chest pain improved. (Gender) is not diaphoretic, laying in bed comfortably, and talking appropriately with (family). Reviewing history, physical examination along with laboratory work-up and chest x-ray, at this point chest pain is noncardiac origin. (Gender) does report a history of acid reflux and I wonder if a possible GERD (gastroesophageal reflux disease-acid from stomach comes into throat) could be contributing to this chest pain. In addition the tenderness upon palpation of the chest pain consistent with costochondritis (inflammation of the cartilage in the rib cage). Patient should follow up with primary care physician on Monday. Dismissed in stable condition."

F. A telephone interview with Patient 1 (on 2/19/2020 at 3:10 PM) revealed the patient went to the ED and wanted to be seen. "I had called in earlier and when I walked in I told them (RN A & RN B) I was having chest pain and needed help. They asked me how sure I was I had chest pain. I didn't see a doctor, the nurse said you won't stay here, you will be transferred to (hospital in another city). They said you may want to go straight to (hospital in other city). I thought if I die driving to (othere city) it was on their hands. My choice that night was to be seen, I have had a heart attack before. I called my (spouse) and left. My (child) drove me and we stopped by my home, got my Mom and we headed to (the other city), but I had an increase in pain so we went into (Hospital C) as it was on the way, and I was scared and needed to be seen." When asked about the document from 1/4/20 the patient signed titled "Refusal of Service", the patient stated, "Later they asked me to sign a paper due to I did not get service that day. So I did."