HospitalInspections.org

Based on observation and interview, the facility failed to conspicuously post EMTALA (Emergency Medical Treatment and Labor Act) signage specifying the rights of individuals.

This lack of EMTALA signage may prevent a patient from fully understanding their rights.

Findings included:

During a tour of the facility's ED (Emergency Department) on 1/2/20 between 10:40AM and 12:00PM, no EMTALA signage was found at the ambulance entrance or the two (2) ambulance bays.

During interview of Staff F (Clinical Informatics Specialist) and Staff G (Assistant Nurse Manager) at the time of observation, both Staff F and G confirmed the EMTALA signage was missing.

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Based on document review and interview, in 3 (three) of 16 (sixteen) On-Call Physician Lists reviewed, the facility did not consistently identify the individual physician assigned for On-Call duty.

This failure to identify the individual physician assigned may result in a delay of evaluation and treatment by an On-Call Physician.


Findings included:

The facility's Gastroenterology On-Call Physician List dated 9/5/19 to 1/30/20 listed the service's group name, "Brookhaven Gastroenterology Associates," instead of the name of the individual physician assigned to on-call duty.

The facility's Pulmonary On-Call Physician List dated 9/5/19 to 12/30/19 frequently listed the services's group name, "Suffolk Chest Physicians," instead of the individual physician names.

The same inconsistent identification of named physicians was also identified on the Neurosurgery On-Call Physician List dated 9/5/19 to 1/29/20, where the services's group name, "Brain and Spine Surgery" was frequently listed.

Per interview of Staff C (Chief Medical Office) on 1/3/20 at 11:15AM, Staff C confirmed these findings.
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Based on medical record (MR) review, document review and interview, in 1 (one) of 20 (twenty) MRs reviewed, the facility failed to provide a Medical Screening Examination (MSE) to identify and possibly treat an Emergency Medical Condition (EMC).

This failure to provide a MSE placed patients at risk for adverse outcomes.

Findings included:

Review of the facility's policy and procedure (P&P) titled, "Triage - Initial Patient Assessment," dated 5/17/18 stated, "A qualified licensed practitioner (QLP) will provide all patients presenting to the Emergency Department with an appropriate Medical Screening Examination. The purpose of the initial triage assessment is to ensure immediate access to care for patients...Triage is not equivalent to the Medical Screening Examination...An ESI [Emergency Severity Index] Level 2 patient is in a High-Risk situation. A patient assigned an ESI Level 2 is considered Urgent and will be evaluated by the ED physician as soon as possible. The Triage responsibilities include...Finger stick [blood sugar check] for diabetic, alcoholic, and patients with acute change in mental status..."

Review of the facility P&P titled, "Emergency Medical and Treatment Act (EMTALA) Compliance," dated 5/21/18 stated, "...any individual who comes to the Emergency Department requesting examination and treatment shall be provided with an appropriate medical screening examination ...this is a process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an individual has an emergency medical condition. A medical screening examination is not an isolated event, but a process that begins but does not end with triage. An emergency medical condition is/are manifesting symptoms which, in the absence of immediate medical attention, is likely to cause serious jeopardy to the health of the individual ...The ED triage does not constitute a medical screening exam."

Review of Patient #1's MR identified the following: This 54 year old was brought in to the Emergency Department (ED) by ambulance on 6/9/19 at 1:14AM.

The Ambulance Pre-Hospital Care Report dated 6/9/19 stated, "The patient was found at 12:45AM sitting up on his sofa in his home complaining of not being able to breathe. The patient stated he is a Diabetic and not feeling well for a couple of days...he has been sick with throwing up and being very thirsty. He admits to drinking alcohol earlier today." The Ambulance Care Report identified a physical assessment that included a review of systems, vital signs and a blood glucose (blood sugar) level result of 327 [normal range for fasting is less 100 and for non-fasting less 130]. An intravenous (IV) line and oxygen were started and the patient was placed on a cardiac monitor in the ambulance. Vital signs were reassessed three times while in the ambulance and Patient #1 remained stable. The patient was delivered to the hospital at 1:14AM.

The Triage Nursing Note dated 6/9/19 at 1:33AM identified that Patient #1 presented to the ED at 1:25AM and was assigned a Triage ESI Level of 2 [urgent need for medical resources]. At 1:33AM, Patient #1's pulse rate was 84 [normal range 60-100], Respirations were 24 [normal range 12-20], Blood pressure was 123/98 [normal range 90/50 - 110/80] and his Oxygen Saturation was 100% (normal range 96-100%). The Triage Nursing note stated, "The patient was receiving 15 liters of oxygen per minute [maximum dose] in the ambulance...Chief Complaint: 54-year-old male patient brought in by ambulance for shortness of breath. As per the patient, he has been short of breath since yesterday. On triage the patient appears short of breath and insisting that he 'needs water before I die. I'm diabetic and I need water.' Patient smells of alcohol and is belligerent on triage."

Although the Ambulance Report identified Patient #1 as a Diabetic with a blood sugar level of 327, and the patient self-reported his Diabetic history during Triage, a blood sugar level was not assessed in Triage, as per facility policy.

Additionally, once Patient #1 was moved from the Triage area to the Main ED at 1:35AM, and the Triage Nurse signed out of Patient #1's electronic medical record (EMR) at 1:39AM, there was no documented evidence that a subsequent nursing physical assessment was performed, or that Patient #1 was monitored while in the main Treatment Area. Further, there was no documented evidence that a MSE by qualified medical personnel was performed, or medical treatments and interventions ordered and administered. There was no documented evidence that Patient #1 was offered or refused medical care/treatment. There was no documented evidence of any physical assessments, treatment or monitoring of Patient #1 from 1:39AM through 3:47AM (2 hours and 6 minutes). At 3:47AM, the primary nurse opened the EMR when Patient #1 was found unresponsive by a housekeeper.

A Nursing Note dated 6/9/19 at 6:10AM stated that Patient #1 was "found unresponsive on a stretcher by staff at 3:55AM." Cardio-pulmonary resuscitation (CPR) was started and the patient was assessed by a physician.

A Physician Note dated 6/9/19 at 4:29AM stated, "...patient is in cardiac arrest. History obtained via Triage Nurse came in presenting with shortness of breath since yesterday. There was suspicion of alcohol use and the patient was saying he was thirsty. While he was waiting to be seen [by a physician], the patient decompensated, stopped breathing and went into cardiac arrest. Cardiac arrest code was called, the patient was intubated, and cardiac monitor applied. The patient was in asystole and no return to spontaneous circulation was achieved. At 4:25AM, resuscitative efforts were terminated, and the patient was pronounced dead."

A Written Statement dated 6/10/19 authored by the ED Housekeeper who found the patient unresponsive stated the following: "I was cleaning and as I go down the hallways, I usually ask the patients is everything okay? I noticed a patient who was in distress earlier, now appeared as if sleeping. I went to ask the patient if he was alright and he was cold to the touch. I quickly notified a nurse and went to the Doctor's Box to notify them that we had a code. The patient earlier was sitting in a stretcher and was yelling and super agitated, that he could not breathe. I noticed now that he was quiet, and his color did not look normal and I knew something was wrong."

During interview of Staff D (Triage RN/Registered Nurse) on 1/2/20 at 3:05PM, Staff D stated that on 6/9/19, she was working towards the end of her shift. Staff D stated that she was working overtime hours and she was on hour 14 of a 16-hour shift. The ED was busy that Sunday night and they were working short with only 8 (eight) RNs instead of the typical 12 (twelve). Patient #1 was brought in by ambulance and Staff D received a quick report from the ambulance crew. Staff D stated, "The family had called EMS [Emergency Medical Services] because he was short of breath and he was intoxicated." When asked what did she do to address Patient #1's presenting problems of high blood sugar and polydipsia [abnormally great thirst as a symptom of disease, such as diabetes], Staff D stated, "I didn't' think he was in a diabetic crisis...I was focused on his breathing, not his Diabetes...I thought the thirst was because of the alcohol...we do have a glucometer in Triage but with everything else and the need to off load the Triage area, I didn't do a blood sugar check on him. The aide transported the patient to the hallway for his primary nurse to assume care...there was no verbal handoff to the nurse in that primary area."

During interview of Staff B (RN/Nursing Director ED Services) on 1/2/20 at 3:15PM, Staff B confirmed the Triage Assessment was not comprehensive or complete as per facility policy, and no MSE was performed on Patient #1 after he left the Triage Area.

Staff B also revealed that the primary nurse in the main Treatment Area did not assess the condition of the patient whose history included Diabetes and whose initial symptoms included shortness of breath, extreme thirst (polydipsia) and an untreated, elevated blood sugar level, because the primary nurse "did not look up at the bed tracking board to see his assignment, and there was no formal handoff when the patient was placed in the main Treatment Area of the ED" by the Aide.

During interview of Staff E (ED Attending Physician/Assistant Medical Director) on 1/3/20 at 1:00PM, Staff E stated, "What happened here was unacceptable...a patient was there for over two hours and no physician had ownership, which was a problem...also, the nurses didn't know who to communicate with...what should have happened for this presenting patient was a very good physical exam...plenty of intravenous hydration...stat blood workup and an immediate CT Scan of the head...that did not happen and it was unacceptable...now, to prevent this from ever happening again we have a Charge Nurse who, after the patient is Triaged, assigns a Physician or Physician's Assistant to the patient...the Medical Director sent out an email to us all [ED Providers] back in June and he brought it up in our monthly Emergency Department meetings in June and July about the front end process changes...we are also looking at the quality metrics from 'Door to Bed to Providers'."

The facility failed to provide a comprehensive Triage assessment, a MSE by a qualified medical staff person, and potential stabilizing treatment.

The facility was aware of the problem and had implemented the following corrective measures at the time of the investigation:
1. Email communication to ED staff dated 6/11/19 identifying "A major process change in the way patients are seen in the ED;"
2. ED Staff Meeting Minutes and Sign-In Sheets dated 7/31/19 and 8/4/19 that included an explanation of the "New ED Bed Assignment Process;"
3. ED Physician Staff Meeting Agenda and Sign-In Sheets dated 6/26/19 that included an explanation of the "ED Direct to Bed Process;"
4. A Quality Metrics Table dated 2018 to Present that identified monthly ED Metrics, such as Door to Bed, Bed to Provider, Provider to Disposition time durations, used to audit and monitor the new ED Bed Assignment Process.