HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirement of §489.24 as evidenced by failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. There was no documented evidence that a medical screening examination was provided to Patient #R1 who was pregnant and presented to the hospital for treatment and left the ED after being informed by the staff that the hospital did not deliver babies. This deficient practice was evident for 1of 1 (#R1) random patients reviewed out of a total sample of 20 patients (see findings in A-2406).

Based on record reviews, review of video recording, and staff interviews, the hospital failed to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. There was no documented evidence that a medical screening examination was provided to Patient #R1 who was pregnant and presented to the hospital for treatment and left the ED after being informed by the staff that the hospital did not deliver babies. This deficient practice was evident for 1of 1 (#R1) random patients reviewed out of a total sample of 20 patients.

Findings:

Review of the hospital policy titled, Medical Screening-Emergency Department, Policy Number M-1-01, dated April 2016 revealed in part the following: The hospital shall provide a Medical Screening Examination for every person who comes to the ED making a request for examination and treatment. Further review of the policy revealed: Pregnant patients with a non-pregnancy related condition or who are victims of trauma shall be evaluated in the ED in consultation with the patient's OB/GYN primary care provider, if needed. If it is determined that the individual has an Emergency Medical Condition, hospital shall provide such further medical examination and treatment necessary to stabilize the medical condition within the capability of the hospital, or to arrange for transfer of the individual to another medical facility in accordance with Emergency Medical Treatment & Labor Act (EMTALA) and the procedures set forth in the transfer policy.

Review of the hospital policy titled Triage and reassessment of the ED patient, Policy Number T-2-01 revealed all patients presenting to the ED will be triaged and classified to ensure that patients received appropriate medical intervention, in order of priority based upon acuity utilizing the Emergency Severity Index (ESI) Five Level System.

Review of the hospital policy titled Admission, Discharge and Transfer Guidelines for the Emergency Department, Policy Number M-1-02 revealed all patients presenting for treatment will receive a medical screening examination by a physician or licensed independent practitioner (LIP).

No policy related to the on-call procedures for the emergency department was provided for review during the survey.

During the entrance conference on 08/07/17 at 10:30 a.m., S1CNO stated the hospital did not provide OB services, neurosurgical services, or interventional cardiology services. During the entrance conference the hospital's on-call physician policy related to the ED was requested for review.

Review of the hospital's electronic employee incident report dated 07/12/17 at 2:00 p.m., revealed the following:
"File Owner: Anonymous
Incident Severity: Category A capacity to cause event/error
Just the Facts: Patients husband brought her to the ER where patients husband tried to check her in to be seen for vaginal bleeding while currently 36 weeks pregnant. ER Nurse was very rude to patient and stated "We cannot help you here. We do not deal with babies. If you want to be seen you need to bring her to Hospital "A." Patient continued to plead with ER nurse to help his wife but employee still refused. Eventually patients wife drove off with her in the car. I was only an observer of this incident. I witnessed the patient crying in her car and witnessed the ER nurse refusing a patient of being seen in the [Hospital] ER."

Review of the hospital's investigation and HSS-HO-41 form Hospital Abuse/Neglect Initial Report revealed the following: The incident occurred on 07/11/17 at 2:45 p.m. and was discovered on 07/18/17 at 3:30 p.m. Review of the video surveillance review revealed the following: At 2:44 p.m. a blue car pulled up to the ED dock and a male got out of the driver's door and entered the ED. Less than 3 minutes later, the male exits the ED and walks back to the vehicle with a wheel chair. A nurse (S6RN) follows the male and is seen speaking to the patient and driver for 2 minutes. The male gets back into the vehicle and drives off. The nurse then walks back into the hospital with the wheel chair.
Further review of the form revealed the incident was reported anonymously by a staff member.
Review of the description of the incident revealed the following: S4ED Director was notified of an anonymous incident report about an unidentified patient that needed to be investigated. The incident was entered as an Employee Behavior event. In the details section, it included that an unidentified nurse was being rude to an unidentified pregnant patient and told them that the patient needed to be seen at another hospital. We began an investigation to determine who the subject patient and staff were so that we could then substantiate the claim. The employee was identified and an investigation was immediately commenced. S4ED Director interviewed staff, security, and the nurse that was assigned to triage. Security was notified and the video surveillance was obtained. Upon video review, it was observed that the nurse went out to the ED dock and had a conversation with the patient and husband at the car. Shortly after, the patient left and the triage nurse returned inside. Also on video, S7HIM, an employee was recognized and questioned on what she witnessed. S7HIM stated that she heard the triage nurse ask the patient if they thought they would be able to make it to Hospital "A" because we do not deliver babies. She also stated that she could not hear their responses but the car then left. S6RN was placed on suspension until the investigation was completed. After consulting with HR and leadership the employee returned to work and written documentation of the incident was placed in the employee file and counseling was performed.

Review of the investigation conducted by S4ED Director revealed S6RN was interviewed by S4ED Director on 07/18/17 at 9:00 a.m. The documentation of the interview revealed S6RN was upset they ran off and they shouldn't have left. The documentation revealed S6RN said she told them, "Next time you should consider because of the delay. I didn't want them to leave. I was just telling them for next time." The documentation revealed S6RN stated she could not remember what they looked like and said the guy was anxious.
Review of the interview conducted by S4ED Director and S7HIM revealed the patient's significant other came into the ED looking for a wheel chair. S7HIM indicated she was waiting to check in with S8PA who was helping another patient. S7HIM indicated she got a wheel chair and the nurse soon followed. S7HIM stated, "Lady was pregnant with pains." S7HIM stated the nurse was walking with her and said, "She can't come here. She needs to come to Hospital A." S7HIM said the nurse went out to the car and said, "We don't deliver babies. Do you think you are okay to go to Hospital "A" so that there isn't a delay of care." S7HIM stated she could not hear what the patient said in return. S7HIM stated the nurse was not ugly or rude and stated the patient's husband was very hesitant.

Review of the interview conducted by S3DON with S6RN dated 07/21/17 at 9:00 a.m., revealed in part the following: When asked if she went outside to speak to the patient her immediate response was no. I then advised her that was false information because I had reviewed the videos of that day and I indeed saw her go outside and speak with the alleged patient. She appeared shocked and adamant about not having gone outside. I advised S6RN we would review the video together. When S6RN saw herself on video she became emotional in the sense that it scared her because she did not have recollection of the event. She did not deny that it was in fact her speaking to the patient on the back dock. S6RN was counseled on EMTALA violations and was advised that under no circumstances should we ever suggest a patient going to another facility without a medical screening exam. She verbalized that understanding.


On 08/08/17 at 8:00 a.m., an observation of the recorded video of the ED dock and waiting room on 07/11/17 was conducted with S4ED Director and S5QD. Review of the saved video recording revealed the following:
At 12:45 p.m. a blue car was observed to pull up into the ER dock in front of the ER entrance doors. A male with a red shirt was observed to get out of the driver's side and walk inside the ED entrance. S7HIM was observed standing in the line for the receptionist with her back to the door.
At 12:46 p.m., the male with the red shirt was observed to walk up behind S7HIM. S7HIM and the male were observed to talk to each other. S7HIM then walks toward the ED entrance adjacent to the reception/check in area where Patient Access staff sits. The male with the red shirt follows her and then is seen pacing in the ED waiting area.
At 12:48 p.m., the male in the red shirt was observed to take a wheel chair from someone not visible as they bring it through the ED doors. S7HIM was observed to walk to the ED exit door and S6RN was observed walking behind her. S7HIM stops in the doorway, S6RN walks outside.
At 12:48:39 p.m. the male in the red shirt was observed to push wheel chair to passenger side of the blue car and open the car door. S6RN was observed to approach the open car door, stand on the outside of the open car door and talk to the patient and the male in the red shirt. S7HIM was observed to walk back inside. S6RN continues to talk with patient and male in red shirt.
The male in the red shirt is observed to lean into the car, talking to the passenger. He then pushes the wheel chair away from the car. S7HIM was observed to walk outside and stood near the open door on the passenger side, looking at the car. At this time S6RN was observed looking in the car.
At 12:49 p.m. S6RN pushes the wheel chair away from car. The male in the red shirt closes car door on the passenger side. He enters driver side and backs out of ED Dock. S7HIM was observed to remain standing on ED Dock and watch the car drive away.

In an interview on 08/08/17 at 8:35 a.m., S7HIM stated she was a supervisor in the HIM department and confirmed that she remembered the incident with a pregnant patient at the ED on 07/11/17. She stated she was in the ED that day waiting for a family member. She stated she was waiting in line to speak to the receptionist. She stated this guy was standing behind me, she stated she said, "Sir do you need any help." S7HIM stated she glanced outside and saw his car. She stated the man told her he needed a wheel chair. S7HIM stated she then went to find a wheel chair. S7HIM stated when she walked inside the ER door there was no staff in side and there was no wheel chair in the space they usually were. She stated she saw a nurse coming around the corner and asked her if she had a wheel chair and stated there was a patient needing a wheel chair. S7HIM stated the nurse went to get a wheel chair. S7HIM stated they both walked through the double doors and she told the nurse there was guy outside. S7HIM stated she told the nurse it looks like she was pregnant because she was leaning back. She stated as she and the nurse were passing the receptionist, the nurse said to her "we don't deliver babies". S7HIM stated she did remember seeing the wheel chair at the car door and stated she could see the woman in the front seat and could see a little girl in the back seat behind the woman. Stated she could hear the nurse talking to the patient but could not hear what the patient said. Stated she stayed at the doorway in case she needed to call for help. S7HIM stated she heard the nurse tell the lady we didn't deliver babies here and she asked the lady if she would be ok to go to the nearest facility that delivered babies, she did say Hospital "A". Then the nurse waited, and again said, are you sure. S7HIM stated the nurse was not ugly and did not sound irritated. S7HIM was asked if the man with the patient said anything. S7HIM stated, "He looked at me, I looked at him; it was an uncomfortable moment for me. I don't think he was comfortable taking her somewhere else." S7HIM stated she remembered watching him pull off and watched him go to stop sign and waited to see if he backed up before she went back to her office. When asked how the man looked when he came in, she stated he looked anxious and that was why she asked him if he needed help. S7HIM stated she was uncomfortable because the man looked uncomfortable.

In an interview on 08/08/17 at 9:10 a.m., S6RN confirmed she was working 7:00 a.m. to 7:00 p.m. on 7/11/17 as the triage nurse. S6RN indicated she remembered the clerk said there was a pregnant person and stated she followed a man to the car and the man had the wheel chair. S6RN stated, "Don't know if I mentioned to him we don't deliver babies. I really don't remember everything." S6RN stated she does not remember what she said to the patient or what the patient said to her. S6RN confirmed it bothered her that the patient left and states she remembers feeling that it was not good that they left and went to Hospital "A." S6RN stated she did not know if she encouraged them to go or encouraged them to come in. S6RN stated she was told there was a witness that stated she heard her say "do you think you can make it to Hospital "A." S6RN confirmed she did not know if the patient was in labor. S6RN stated she was informed that a S.O.S. (employee complaint/incident) was written and stated if she did that they should have. S6RN stated, "Obviously I did it all." Stated she remembers the patient, but does not remember the details. S6RN stated, "It floors me that I don't know if I tried to convince them to stay or go." She confirmed she had seen the video and it reveals she was talking with patient and the man but she does not remember what she said or what they said. "I was floored when I saw video." S6RN stated, "When they told me what I did I knew it was an EMTALA."

In an interview on 08/08/17 at 9:56 a.m., S8PA confirmed she was working at the reception desk on 07/11/17 from 5am to 5pm. S8PA confirmed she was aware of the incident on 07/11/17 where an OB patient presented to the ED. S8PA stated a man came in and said "Hey I need a wheel chair and I got someone that is 36 weeks pregnant in the car." S8PA stated she thought the man said the patient had headaches but she was not 100% sure. S8PA stated, "I think S6RN went out with a wheel chair and she was talking with patient." S8PA confirmed she does not know anything else and the patient did not come into the ED. S8PA stated the nurse said they decided to go to another hospital.

In an interview on 08/08/17 at 10:40 a.m. S3DON and S4ED Director were asked if the hospital had implemented any ongoing monitoring related to the above MSE issue. S4ED Director indicated she had done EMTALA training with the staff during orientation and annually and had also done a training last month after the above incident was discovered. Both confirmed that as of now they have not put a monitoring system in place to ensure that this incident doesn't occur again.

In an interview on 08/08/17 at 10:45 a.m., S3DON was asked if a determination of an EMTALA violation was made related to the above incident. S3DON and S4ED Director who was also present stated they all thought it was a violation but it was not written in the report. S3DON confirmed the patient should have been brought inside and received a MSE. Both S3DON and S4ED Director stated, "We all agreed it was an EMTALA violation."

In an interview on 08/08/17 at 10:50 a.m. S5QD stated they went back and forth on if this was an EMTALA violation. S5QD stated, "We know we did not do a medical screening exam." S5QD stated S1COO, S3DON, S4ED Director, and herself were involved in making the determination. S5QA stated since they were not able to interview the patient to determine if the patient decided to go to another hospital or was told by staff to go to another hospital, they don't know what the conversation was.

In an interview on 08/08/17 at 11:00 a.m., S3DON, S4ED Director, and S5QD confirmed they had been unable to find a policy and procedure related to the emergency department's physician on-call procedure. S5QD confirmed there was no policy related to how the hospital would respond to situations in which a particular specialty was not available or the on-call physician cannot respond because of circumstances beyond his control. They confirmed they did not have a policy that addressed on-call physicians permitted to schedule elective surgery during the time they are on-call. S4ED Director stated when a physician in the ED determines an on-call service is needed, the physician calls the operator and asks the operator to contact the physician who is on-call. S3DON indicated the hospital had interns and residents on-call along with staff physicians.