HospitalInspections.org

Based on a medical record review, video surveillance review, Incident Report review, policies and procedure review, and interviews with staff, it was determined that the facility failed to provide an medical screening examination appropriate to the individuals' presenting signs and symptoms (severe abdominal pain, depression, urinary urgency and insomnia) that was within the capability of the emergency department to determine whether or not an emergency medical condition existed for one (1) patient (P) (P#1) out of 20 sampled patients. The patient presented to Piedmont Newnan Hospital (Hospital #1) with severe abdominal pain and no medical screening examination was done; the patient went to Hospital #2 was admitted for surgical intervention.

Please refer to findings in Tag- A2406.

Based on a medical record review, video surveillance review, Incident Report review, policies and procedure review, and interviews with staff, it was determined that the facility failed to provide an medical screening examination appropriate to the individuals' presenting signs and symptoms (severe abdominal pain, depression, urinary urgency and insomnia) that was within the capability of the emergency department to determine whether or not an emergency medical condition existed for one (1) patient (P) (P#1) out of 20 sampled patients. The patient presented to Piedmont Newnan Hospital (Hospital #1) with severe abdominal pain and no medical screening examination was done; the patient went to Hospital #2 was admitted for surgical intervention.

Findings:

A medical record review from Facility #1 revealed that Patient (P) #1 was a 66-year-old female with a history of depression, insomnia, and urinary urgency. P#1 presented to the Emergency Department (ED) on 10/11/22 at 12:33 a.m. with a chief complaint of back pain which was updated later to abdominal pain during triage. P#1 was triaged (emergency department nurse assesses the severity of an individual's condition and ensures that critically ill patients are seen first) and vital signs were assessed. P#1 was assigned an acuity level III (Urgent- not life threatening). The pain assessment scale was completed using pain scale 0 to 10 (A tool used to measure, and quantify pain, [4-6 moderate, 7-10 (severe]. P#1 reported a pain scale of 7. P#1 was escorted to hallway bed (HB) number nine at 2:56 a.m. The patient's vital signs were listed as: Temperature:98.6; Heart Rate: 80; Blood Pressure:149/79; oxygen saturation: 97% on room air; and Respirations:18.

A review of the standard orders at 12:39 a.m. revealed nursing: NPO (nothing by mouth), laboratory blood work and urinalysis, IV (intravenous)-insert, peripheral IV-INT (intermittent needle therapy- infusion of a volume of fluid/medication over a set period).

Review of Patient #1's laboratory report was reviewed. The following laboratory results listed as abnormal: CBC auto differential (complete blood count- blood test measures number of types of cells in your blood, including white blood cells (WBC): WBC- elevated-12.0 ( Hospital Reference Range 4.0 to 10*3/uL); RBC (Red Blood Cell)-Low 4.07 (Hospital Reference Range: 4.20- 5.40*6/uL); Comprehensive metabolic panel CMP- (measures sodium, potassium, glucose and how well the kidney and livre are working): Sodium- Low -131 (Hospital Reference Range-137-145mmol/L); Glucose: 125 (Hospital Reference Range-70-100 mg/dl); Anion Gap (measures the blood acid -base balance) 9-Low (Hospital Reference Range 10-20); Uranalysis complete with reflex culture (test examines urine samples , including urinary tract infections, kidney and liver disorders and diabetes)- Urine Clarity - Hazy- Abnormal,(Hospital Reference Range- Clear) and Ketones (blood is to acidic)- Trace Abnormal (Hospital Reference Range- Negative). There was no documentation in the medical record to indicate the ED physician was informed of the abnormal laboratory results.

A review of an 'ED Note' at 4:48 a.m., written by Registered Nurse (RN) CC, revealed that P#1 and P#1's husband had used the call light several times to ask for pain medication. P#1 was aware that she was waiting to see a physician to get medication orders. P#1 requested to see a doctor immediately. The ED Note revealed that RN CC spoke to the ED physician. Continued review revealed that P#1 was yelling and cussing at RN CC, stating that she was leaving. P#1's husband asked to speak to the charge nurse, who was aware of the request.

A review of an 'ED Note" at 4:56 a.m., written by RN CC, revealed that P#1's IV was removed at P#1's request. P#1 said, "do not speak to me" and that RN CC needed to tell the ED doctors that the number one cause of hospital lawsuits was a delay in care.

A further review of the medical record revealed that the ED disposition was changed to Left Without Being Seen (LWBS) at 4:58 a.m.

A review of an 'ED Note 'at 5:03 a.m., written by RN CC, revealed that the charge nurse spoke to P#1 and P#1's husband.

Continued review of the medical record failed to reveal a reassessment of P#1's vital signs or pain after being in the hospital's ED for 4.5 hours.

A medical record from Facility #2 revealed that P #1 presented to ED on 10/11/22 at 9:49 a.m. with a chief complaint of right lower quadrant (RLQ) abdominal pain for two days with nausea. P#1 denied vomiting or diarrhea. P#1 had signs and symptoms as well as radiographic (imaging) findings consistent with acute appendicitis (condition in which appendix becomes inflamed). P#1 was taken to the operating room (OR) for laparoscopic appendectomy (an invasive surgery to remove the appendix through several small incisions). P#1 was found to have gangrenous (death of body tissue due to lack of blood flow or serious bacterial infection) perforated (pierced with hole or holes) appendicitis. P#1 was discharged in stable condition on 10/14/22 with a discharge diagnosis of acute appendicitis.


A review of Facility#1's video surveillance" dated 10/11/22 revealed the following:
"State Video #1" dated 10/11/22:
12:32 a.m.- P#1 was observed entering the facility's Emergency Department (ED)
12:33 a.m.- P#1 was observed speaking with registration staff at the desk
12:36 a.m.- P#1 was observed being escorted to the bathroom by ED staff with a specimen cup in hand
12:38 a.m.- P#1 was observed returning to the waiting area

"State Video #2" dated 10/11/22:
12:38 a.m.- P#1 was observed walking through the waiting area
12:41 a.m.- P#1 was observed walking back through the waiting area

"State Video #3" dated 10/11/22
12:41 a.m.- P#1 was observed walking towards the front entrance of ED
12:42 a.m. - P#1 was observed standing against the wall
12:44 a.m. - P#1 was observed walking into the bathroom
At 12:45 a.m.- P#1 was observed walking to the waiting area and then sitting down
At 12:47 a.m.- P#1 was observed speaking to registration staff and returned to her seat in the waiting area

"State Video #4" dated 10/11/22:
12:57 a.m.- P#1 was observed sitting down in the waiting area

"State Video #5" dated 10/11/22:
1:17 a.m.- P#1 was observed being escorted by staff out of the waiting area
1:27 a.m.- P#1 was observed walking back into the waiting area

"State Video #7" dated 10/11/22:
2:59 a.m.- P#1 is observed being escorted by staff through the ED to hallway bed #9

"State Video #8" dated 10/11/22:
2:59 a.m.- P#1 was observed in the ED, escorted by staff to hallway bed (HB) #9
3:52 a.m.- RN CC entered the medication room. RN CC exited the medication room with items in hand. RN CC entered the enclosed curtain at HB #9 with P#1.
3:53 a.m.- RN CC exited the enclosed curtain at HB #9 with P#1 with the same items in hand and walked to the nurse's desk. RN CC picked up a black portable phone and placed a call.
3:54 a.m.- RN CC walked over to speak with MD II, then walked back to the nurse's desk
4:45 a.m.- RN CC was observed behind the privacy curtain at HB #9, speaking with P#1.
4:46 a.m.- RN CC was observed returning to the nurse's desk
4:52 a.m.- P#1's husband was observed exiting the privacy curtain at HB #9 and walking to nurse's desk to speak with RN CC
4:53 a.m.- RN CC was observed leaving the nursing desk and walking into medication room after scanning an ID badge to unlock the door
4:54 a.m.- RN CC was observed entering the privacy curtain at HB #9 with P#1
4:55 a.m.- RN CC was observed exiting the privacy curtain at HB #9 with P#1 and returning to the nurse's desk
4:58 a.m. - P#1 exited the privacy curtain and walked to the nurse's desk to speak with RN CC
At 5:02 a.m.- P#1 received papers from RN HH and exited the ED

A review of the Incident Report dated 10/27/22 regarding P#1's incident in the ED on 10/11/22 revealed the Director of Quality was notified by a third party, on P#1's behalf. A continued review revealed MD MM reviewed P#1's chart and the circumstances surrounding the incident. MD MM stated the medical record was reviewed and based on the chief complaint and normal vital signs on the busiest night of the week, P#1 was triaged appropriately.

A review of the facility's policy titled, "Admission to the Emergency Department", policy # 7725775, last revised 3/2/20, revealed the purpose of the policy was to access, evaluate, diagnose, and treat the perceived, actual, potential, or physical problems of all patients who presented requesting care. The policy revealed that all patients who presented to emergency services would be seen by a provider. Any patient who requested treatment would receive an appropriate MSE. The patient would be provided treatment to stabilize the medical condition. Any patient who reported they were choosing to leave prior to the provider examination would be considered "Leaving Without Being Seen" (LWBS). Licensed staff would inform the patient of the risk of leaving without being seen. Any patient that left prior to provider examination would be dispositioned as LWBS.

A review of the facility's policy titled, "Patient Assessment/Reassessment and Vital Signs," policy #9213064, last revised 2/19/21, revealed the purpose was to provide guidelines for the assessment and vital signs of the ED patients during their stay in the department. The policy revealed that reassessment and repeated vital signs should be based on patient acuity and condition. Patients should be rounded on at least hourly. Assessments and reassessments should be individualized to the condition of the patient.

A review of the facility's policy titled, "Transfer Activities in Accordance with EMTALA Requirements," policy # 11101630, last revised 1/27/22, revealed the purpose was to establish guidance for providing appropriate medical screening examinations, stabilizing treatment, and appropriate transfer of patients in accordance with the Emergency Medical Treatment and Labor Act (EMTALA), and all regulations promulgated thereunder. It was the policy of the facility to abide by the requirements set forth in EMTALA regulations for patients presenting to the hospital seeking emergency treatment by:
1. Providing an appropriate medical screening examination (MSE)
2. Providing necessary stabilizing treatment for emergency medical conditions (EMC)
3. Obtaining or attempting to obtain written refusal of examination or treatment when/if the patient refuses such action
Definition:
1. EMC- A medical condition manifesting itself by acute symptoms of sufficient severity (including, but not limited to, severe pain) such that the absence of immediate medical attention could reasonably be expected to result in either:
a. Placing the health of the individual in serious jeopardy
b. or serious impairment of bodily functions


A review of the facility's policy titled "Leaving Against Medical Advice," policy #11646189, last revised 4/27/22, revealed the purpose was to establish guidance and provide a procedure to be followed when a patient elected to leave without notifying staff or elected discharge against medical advice.
1. Leaving Against Medical Advice: The patient's nurse should have the patient read and sign the form titled "Leaving Hospital Against Advice," as posted with this policy. If the patient refuses to sign such statement, the form should be completed with the patient's name and the date witnessed by staff. Staff should write "signature refused" on the form and make a notation in the medical record.
2. Leaving the Emergency Department Without Being Seen: If a patient wished to leave from triage prior to receiving a medical screening, the triage/treatment area nurse would notify the charge nurse and make an attempt to encourage the patient to stay and be seen. The patient would be advised of the risks involved in leaving without having a medical screening performed. If a record had been made, the nurse would document the conversation in the medical record.


An interview was conducted with Chief Nursing Officer (CNO) AA on 11/2/22 at 3:05 p.m. in the large conference room. CNO AA stated she has worked at the facility for nearly 20 years and has been the CNO for four years. She continued to say that she became familiar with P#1 after P#1 filed a complaint with a third-party company regarding her treatment in the ED on 10/11/22. CNO AA stated that once she learned about P#1's negative experience in the ED, she met with members of management, including the Director of the ED, the Director of Quality, and the Chief Medical Officer, to discuss P#1's experience. CNO AA confirmed that she reviewed the video surveillance from the ED on the day P#1 was present and stated she expected RN CC to complete an assessment when P#1 was brought back to hallway bed (HB) number nine. CNO AA continued to explain that she could not explain why RN CC did not complete an assessment, notify the ED physician more than once or escalate any delays to the charge nurse. She continued to explain that RN CC was a new nurse in the facility and had recently completed training. RN CC said that all employees were trained during orientation to "Stop, Think, Act, and Review" when faced with difficult decisions or situations and RN CC did not follow this protocol. CNO AA stated that she did not speak directly with RN CC regarding P#1; therefore, she could not verify why there was no assessment completed.

An interview was conducted with ED Medical Director (MD) MM on 11/2/22 at 3:30 p.m. in the large conference room. MD MM confirmed that he was made aware of P#1 after P#1 filed a complaint with a third-party company. He stated that after reviewing the incident report regarding P#1, he met with CNO, Director of the ED, Director of Quality, and the Coordinator of Patient Relations to discuss where they, as a facility, dropped the ball in caring for P#1 when she came to the ED for treatment. He continued to say that he reviewed P#1's chart, and P#1 was triaged correctly at a level III based on her complaints and symptoms when she presented to the ED. MD MM said he later spoke with P#1 over the phone to follow up with her regarding her health and to express his sincere apology for her unfortunate experience in the ED. MD MM explained that when he spoke to P#1, he apologized for not having her pain addressed immediately. He continued to say the ED physician on duty at the time was extremely overwhelmed and did not refuse to see P#1 but could not take focus off more critical patients who needed to be seen. MD MM stated that in the future, anyone who presented to the ED in pain would have their pain addressed immediately. Furthermore, the facility would ensure that anyone having their pain addressed was seen without delay.

During a telephone interview with RN CC on 11/3/22 at 10:00 p.m., she confirmed that she did recall P#1 during her ED visit in early October 2022. RN CC stated that she has been an RN for seven years and had worked at this facility for approximately three months. RN CC explained that the first time she saw P#1 was when the charge nurse walked P#1 from the front to the HB, which happened to be the HB she was assigned. She continued to explain that she walked over to ask P#1 what had brought her to the ED. RN CC stated that the first thing P#1 told her was that she was an OB/GYN and already knew that she had pancreatitis (inflammation of the pancreas) and needed pain medication. RN CC said that P#1 told her not to touch her because she was in pain and needed medication. RN CC continued to say that she went to consult MD II regarding P#1. She advised MD II that P#1 was in extreme pain and that P#1's pain scale was 10 out of 10. She asked MD II if there was anything she could give P#1 to ease her pain until she could be seen. RN CC stated that MD II advised her that she would continue working through her current patient list and get to P#1 as soon as possible. RN CC said she told P#1 that MD II would be in to see her as soon as MD II could. She continued to explain to P#1 that she was not authorized to dispense pain medication until the provider placed an order. She stated that P#1 asked how much longer it would take. RN CC said that she told P#1 that she did not know how long it would be. RN CC stated she went to MD II a few times to check on the status of MD II, seeing P#1, and MD II seemed overwhelmed and could not give a time. RN CC stated that she did not escalate a delay issue concerning P#1 to the charge nurse until P#1 was ready to walk out of the ED. RN CC explained that P#1 came to the nurse's desk to let her know that she had decided that she would no longer wait for MD II. The IV, which had already been placed in P#1's hand, was removed at that time. She continued to explain that P#1 requested a copy of her laboratory results. The charge nurse printed off P#1's results and gave them to P#1. P#1 then walked out of the ED with her husband.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that on 10/11/2022 patient #1 received an appropriate medical screening examination as per her request when she presented to the hospital' s ED. Additionally, there was no documentation in the medical record to indicate that 10/11/22 at 5:02 A.M., when she left the ED that she was informed by a licensed staff of the risks of leaving without being seen as stated in the facility's policy and procedure. As a result, P#1 left Facility #1 and hours later was seen at Facility #2, where P#1 was admitted and diagnosed with acute appendicitis, which required surgical intervention.