HospitalInspections.org

Based on a review of clinical records, facility documentation and interviews with staff, the facility failed to provide an appropriate medical screening examination timely, and failed to appropriately address the presenting symptoms of a cardiac patient within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists.

Findings were:

A review of the clinical record revealed that patient #1 presented to the emergency department of UMC on 6-18-19 at 6:22 pm ambulatory and via private vehicle. The patient was triaged at 6:27 pm and assigned an ESI II.

Online reference at https://www.ahrq.gov/professionals/systems/hospital/esi/index.html (Agency for Healthcare Research and Quality) defines the ESI:
"The Emergency Severity Index (ESI) is a five-level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs."

The triage note states "Pt presents to EC [emergency center] for c/o CP [complaint of chest pain] that started while he was out spraying his yard. Wife does report that patient was seen 2 days ago after a motorcycle accident but was cleared. Taking plavix for CAD and stent placement." Patient #1 rated his pain as a 3 on a 0-10 pain scale. He described it as "aching, dull" and stated that the pain was in his chest. He stated that it was relieved with medications, repositioning and rest. He stated a medical history that included coronary artery disease and hyperlipidemia. He denied any allergies. Due to the patient's presenting symptoms, the emergency center's chest pain protocol was instituted and the following interventions were performed:

The emergency center's chest pain protocol was instituted and the following interventions were performed:
* 6:32 pm - EKG that stated "sinus rhythm, minimal voltage criteria for LVH, consider normal variant borderline ECG" (no signature present to indicate that the EKG was reviewed by an emergency room provider; results were reviewed by staff #9 on 6-19-18 at 9:06 am, approximately 10 hours after the patient left)

* 6:58 pm - chest x-ray that stated "no acute pulmonary changes"

* 7:07 pm - lab work to include a CBC, CMP and Troponin T (high sensitivity); the Troponin T HS results indicated a value of 13.1 ng/l with a target reference range of <=6 ng/l.

* 8:00 pm - EKG that stated "sinus rhythm, normal ECG" (reviewed and signed by staff #8 (a physician assistant) at 8:06 pm and over-read by staff #9 on 6-19-18 at 9:07 am, approximately 10 hours after the patient left)

Nurses notes state, in part:
* 7:29 pm - "Pt's [patient #1] wife approached triage desk stating '[patient #1] is laying on the floor now because he is in so much pain. [Patient's own cardiologist] told us we would go straight back.' Explained to wife that we could re-check his vitals and his EKG. Explained we did not have an available room right at the moment and that his EKG did not show anything major, thus why he is still waiting for a room. Wife rolls her eyes and walks away."

* 10:44 pm - "Pt approached triage desk asking for IV to be taken out. Pt states 'I've been here since 5 [o'clock] and y'all aren't doing anything.' Pt was asked if he would like to speak to a physician prior to leaving. Pt states 'I would have like(sic) to a long time ago.' CN [charge nurse] called for AMA [against medical advice]. Pt placed in triage room 3. See vitals updates, EKGs, radiology and labs."

* 10:46 pm - "[Staff #7] speaking w/pt in triage room 3 at this time."

* 10:50 pm - "Pt refused to sign AMA. Pt(sic) wife states 'do me a favor and tell [patient's own cardiologist] that we will not come back to this hospital again.' Explained to wife that I do not have his number to relay this message. Wife states 'yes you can'. Pt's IV dc'd. Left AMA w/no acute distress noted. Pt ambulatory."

The patient's vital signs (to include blood pressure, pulse, oxygen saturation and respiratory rate) were documented at the following times:
* 6:27 pm
* 7:53 pm
No other documentation of vital signs was found in the medical record for patient #1. In an interview with staff #6, staff #6 was asked if he could locate documentation of any other vital sign assessments in the record and he was unable to do so. When asked why vital signs had not been assessed at the frequency dictated by facility policy, staff #6 stated that it had been his understanding that the patient and his wife had been verbally abusive and that was the reason why the vital signs had not been assessed at the frequency dictated by facility policy. When asked to locate documentation of the patient's alleged behavior in the record, staff #6 was unable to do so.

Glasgow coma scale assessments were documented at the following times:
* 6:27 pm
* 7:00 pm
* 8:00 pm
* 9:00 pm
* 10:00 pm

At 10:43 pm, an "AMA discharge note" was entered into the medical record by staff #7. It read as follows:
"Patient's competence: non-intoxicated
Patient comprehension: The patient vocalized appropriate understanding of the risks and alternatives.
Patient's rationale for leaving: wait is too long and he is feeling better
Leaving against medical advice; discharge risk discussed: specifically discussed: worsening condition, posible(sic) loss of life, with the patient's family members.
Patient/Family understands that the patient may change their decision and may return: yes.
Alternative treatment plans discussed: with the patient
Follow up treatment plan discussed: with the patient
Hospital emergency department AMA form discussed: with the patient.
Hospital emergency department AMA form signed: the patient refused to sign
Performed by: self.
Witnessed by: RN
Notes: Patient is well appearing with reasonable normal vital signs. Labs unremarkable. Patient wishes to leave. He has capacity to make his own medical decisons(sic) and understands the risks of the decision to leave prior to thorough medical evaluation inlcuding(sic) worsening condition, morbidity and mortality. All questions answered to the best of my ability at time of encounter. No formal physical exam appropriate in the setting in which I met the patient. Patient's spouse verbally abusive and visibly upset over being asked to wait in the lobby for this long."

Two of the eighteen other patients reviewed arrived within 30 minutes after patient #1 arrived and were placed in exam rooms for their care. A summary of their visits is as follows:
* Patient #2, a 57-year-old male, arrived by ambulance with abdominal pain and was taken directly to an exam room at 6:33 pm, despite being assigned an ESI III (of lesser severity than an ESI II). Patient #2 was treated and discharged at 11:30 pm.

* Patient #3, a 30-year-old male, arrived by ambulance with heart palpitations, chest pain and difficulty breathing and was seen in an exam room at 6:47 pm. He was assigned an ESI II. He was treated and discharged at 8:32 pm.

The clinical record provided no documentation that patient #1 was ever placed in an exam room or that a medical screening exam was performed.

A review of the Emergency Department Policy & Procedure Manual revealed the following policies:

"937.0 Electrocardiogram Interpretation" states, in part:
No patient on whom an EKG is done in the Emergency Center is to be released until the electrocardiogram is read by the Emergency Center physician or a faculty physician."

"955.0 Patient Rounds" states, in part:
"All patients in an EC treatment area will have vital signs performed and documented every 2 hours or more often as clinical condition warrants."

"TC-10.0 EMTALA (attachment titled "20 Commandments of EMTALA") states, in part:
" ...
2. Thou Shall: Provide a medical screening examination, beyond triage, to all patients regardless of acuity who present in the hospital and/or 'provider-based' locations (including movement to the main hospital EC as necessary to complete the medical screening exam)."

A review of the facility Bylaws, Rules & Regulations for the Medical Staff revealed the following (page 30):
"V. Emergency Services
...
D. Patients treated in the Emergency Center must be seen by an attending physician or mid-level provider, to include Physician Assistants and Nurse Practitioners, prior to transfer, discharge, consult or referral to the patient's primary care physician or medical home. Attending physicians and mid-level providers are considered to be qualified medical providers and may perform medical screening exams.
E. No patients will be transferred or discharged from the Emergency Center without being attended by a member of the Professional and/or House Staff and until they are stabilized."