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A. Based on policy review and staff interview, it was determined that the Hospital failed to ensure compliance with A 2402, A 2406 and A2407

Findings include:

1. The Hospital failed to ensure a patient presenting to the ED was provided an appropriate medical screening exam, appropriate posting of signage and and ensure stabilization treatment was provided in the ED.

A. Based on an observational tour of the Emergency Department (ED) and staff interview,it was determined that the Hospital failed to ensure that the Emergency Medical Condition (EMC) signage was posted conspicuously and visible in the ED in Spanish and English for all individuals entering the ED. The Hospital has a 14% Spanish speaking population.

Findings include:

1. On 4/10/12 between 9:15 Am and 9:40 AM, an observational tour was conducted in the ED. The Ambulance and walk-in entrances had an 8 1/2 X 11 inch signage written in English but not in Spanish. The EMC signage was approximately 10 feet from the ED door and surrounded by wheel chairs, making the signage partially visible.

2. The ED Nursing Director confirmed the findings during an interview on 4/11/12 at 10:45 AM.

A. Based on review of the Medical Staff Rules and Regulations, Emergency Department (ED) Log, clinical record, and staff interview, it was determined, that for 1 of 20 clinical records reviewed (Pt. #17), the Hospital failed to ensure a patient presenting to the ED was provided an appropriate medical screening exam.

Findings include:

1. The Medical Staff Rules and Regulations, revised and approved on March 2011, was reviewed on 4/10/12 at 1:00 PM. The Rules and Regulations included (page 26), "13.2-2 Medical Screening Examinations will be preformed by a physician member of the medical staff, or a hospital-employed nurse practitioner working under the supervision of a physician member of the medical staff..."

2. On 4/10/12 between 10:00 AM and 10:30 AM, the ED log for the past 6 months (10/1/11 through 4/9/12) was reviewed. Pt. #17's ED log entry included, "Left Without Being Seen".

3. On 4/10/12 at 2:00 PM the clinical record of Pt. #17 was reviewed. Pt. # 17, a 42 year old female, arrived in the ED on 2/5/12, with a complaint of Suicidal Ideation. The clinical record lacked triage, registration, and patient assessment documentation. The only ED documentation in Pt. #17's record was completed by a Registered Nurse (E #6) who documented that E# 5 ( an outside Psychiatric Consultant Group staff) stated, "no need for Pt. # 17 to be seen. E#5 has already evaluated Pt. #17 and Pt. #17 is denying any suicidal ideation. Pt. #17 went home with resources from E#5. " Pt. #17's record did not include a medical screening examination/assessment by a physician or nurse practitioner.

4. An interview was conducted with the ED Manager on 4/11/12 at 11:25 AM. The Manager stated that the contractual Psychiatric Consultant Group, has a contract with the Hospital and is located in the ED. E #5 saw Pt. #17 and informed the RN (E #6) that Pt. #17 did not require assessment. E #5's documentation is not part of the Hospital clinical record. E #5 is not an individual allowed to perform Medical Screenings for the Hospital. The ED Manager confirmed the findings during the interview.

Based on review of Hospital policies, Ambulance Run Sheet, clinical record review, Medication Administration Record (MAR) review, review of receiving Hospital Medical record of Pt. #1, staff interview and Pt. #1 interview, it was determined that in 1 of 2 (Pt. #1) Emergency Department (ED) records reviewed of patients requesting emergency care, the Hospital failed to ensure treatment and stabilization was provided prior to patient being escorted from the facility.
Findings include:

1. The ambulance run sheet was reviewed and documented that Pt. #1 called the ambulance because she was not feeling well. Per the run sheet, Pt. #1 was lying on her couch, alert and oriented X 3 and in visible pain. Pt. #1 was administered Fentanyl 60mcg at 10:06 AM and 30 mcg of Fentanyl again at 10:13 AM without any relief from pain. The ambulance run sheet indicated that after the 2nd dose of Fentanyl (30 mcg), Pt. #1 stated that it " helped her relaxed but did not diminish the pain. "

2. The clinical record of Pt. #1 was reviewed. Pt. #1 was a 41 year old female that presented to the Hospital ' s ED on 3/26/12 at 10:26 AM via Fire Department ambulance with chief complaint of uncontrolled sickle cell pain in legs, knees, chest and lower back, even after taking Tramadol and Aspirin at home. Pt. #1 was triaged at 10:46 AM with the following vital signs: blood pressure 142/82, pulse 92, respirations 20, temperature 97, oxygen saturation on room air 88% and pain level 9 of 10 (10 is highest level of pain). Pt. #1 was placed on the Emergency Severity Index (ESI) level of 2-Urgent and placed on 3 liters of oxygen by nasal cannula. The clinical record documented that on previous admission, Pt. #1 was allergic to the following medications: cetriaxone, codeine, dilaudid, morphine and vicodin. A Medical Screening Exam (MSE) was performed by Pt. #1 ' s Physician (E #1)/Medical Director of the Emergency Department with a diagnosis of Sickle Cell Disease.

3. The MAR of Pt. #1 documented that on 3/26/12 at 11:00 AM the following IV fluid and medications were administered: 2000 ml of sodium chloride 0.9% at a rate of 500 ml/hr; ondansetron 4 mg IV; Fentanyl 100 mcg IV and diphenhydramine 25 mg IV push. There was no documentation that Pt. # 1 pain was reevaluated after the pain medication was administered or other pain remedy initiated to modify Pt. #1 pain. Documentation also indicated that on 3/26/12 at 11:32 AM, Pt. #1 was crying indicating that her pain level was 9/10 and Pt. #1 ' s doctor (E#1) was notified. At 11:45, AM E#1 was at Pt. #1 bed explaining the reasons for not ordering Demerol. The clinical record documented that E#1 recommended other pain medication: morphine, Dilaudid and Fentanyl which he stated was more effective and safer for her pain, however, Pt.#1 refused

4. On 4/11/12 at 1:00 PM an interview was conducted with E#1. E#1 stated that Pt. #1 came to the hospital with a complaint of joint pain similar to past Sickle Cell pain and the Plan of Care contained a complete work-up including labs and treatment with IV pain medication. E#1 further stated that, " Pt. #1 only wanted Demerol for pain and it is not his practice to give Demerol for Sickle Cell pain because it is problematic with many side effects and risks and he explained this to Pt. #1 who told E#1 that if Demerol would not be given, she would leave and refused to sign the Against Medical Advise (AMA) form " . There was no documentation that Pt. #1 was involved or participated actively in decisions regarding her medical care related to pain management


5. On 4/11/12, a video tape of Pt. #1 ' s leaving the ED was reviewed. The tape included video of the ED hall, entrance and driveway. Pt. #1 was wheeled by Security (E#3) to the ED entrance, assisted by Pt. #1 relative into the car. Patient was assisted from the cot to the wheel chair because, based on the triage fall assessment, she could not self- ambulate and needed assistance on ambulation. Two police cars, 1 fire truck and 1 ambulance arrived and PT. #1 was placed on a backboard and stretcher and placed into the ambulance.

6. The receiving Hospital ' s clinical record where Pt. #1 was taken was reviewed. The ED Admission Summary documented that Pt. #1 presented on 3/26/12 with complaint of " diffuse pain over her entire body for the last 24 hours...she reports whenever you touch her it hurts ...she gets this once a year. " The Treatment and Plan was: " Demerol 75 mg for pain relief, IV fluids, Oxygen and Rocephin for antibiotics after blood and urine cultures were obtained. Urinalysis normal, except for 1+ bacteria. Sickle Cell pain crisis and leukocytosis. The patient will be admitted. " Pt. #1 was discharged from the receiving hospital on 4/2/12 with discharge diagnoses as: sickle cell pain crisis, Macrocytic anemia, Community -acquired pneumonia, anemia, knee pain-no signs of septic arthritis, likely functional asplenic state and diffuse osteosclerosis on X-ray. Patient was offered H. influenza and pneumococcal vaccines which she refused. Pt. #1 also signed the receiving hospital discharge summary sheet.

7. On 5/22/12 at 11:00AM, an interview was conducted with Pt. #1 telephonically. Pt. #1 stated that during the ambulance ride, she was given fentanly IV twice, without any relief. Upon arrival to the ED, she asked the nurse for pain medication. After a while, E#1 came to her door and said, " We get them all the time, and they come here to get a fix. Pt. #1 stated that the doctor, " profile me as a drug seeker. " E#1 then ask her what medications she takes for pain and she stated, " demoral and Toradol. " He told her that he does not give Demerol for Sickle Cell pain and that he would give her something stronger and told the nurse to give her Fentanyl. Pt. #1 further stated, " I told him that Fentanyl was not going to work that I had received Demerol there before and if he wasn ' t going to give it to me, to give me a doctor who would give it. He said that he was in charge and he was not going to do it. I asked him if he could transfer me to another hospital and he said no and told the nurse to discharge me because I was refusing treatment and that ' s when the nurse took the IV out of my arm and told me that I was discharged. They had the Security Guard come into the room and take me off the cot. One of the Security Guards was pulling me out of bed by my legs and telling me to get up, but I couldn ' t walk because my legs were locked up. The other Security Guard had me by my arms as I was still calling 911. They rolled me out to the waiting room; one of the guards was holding me by my shirt in the wheelchair.