HospitalInspections.org

Based on observation and staff interview, it was determined that the facility failed to conspicuously post signage specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment of emergency medical conditions and women in labor or information indicating whether or not the hospital participates in the Medicaid program.

Findings include:

1. A tour of the Emergency Department (ED) conducted on 10/19/17 at 1004, revealed that there were no EMTALA signs posted in the following areas:

a. Hospital Main Entrance/Lobby

b. ED Pediatric Waiting Area

c. ED Family Room

d. Internal Waiting Rooms #1-#3

e. (Observation Unit) ACC 5 Bay 53

f. Labor & Delivery (L&D) Triage Rooms #1-#4

2. Observation of Adult ED waiting area, revealed one (1) sign was posted in an area that was not visible where all patients are seated.

3. Observation of Internal Triage Room #3 revealed an EMTALA sign obstructed by a tall cabinet. The sign was not conspicuously posted, making visualization difficult.

4. The above findings were confirmed by Staff #3, Staff #4 and Staff #15.

Based on review of Emergency Department (ED) on-call lists and staff interviews, it was determined that the facility failed to ensure that a physician on call list, that identifies the name of an individual physician on call for a specialty, is maintained.

Findings include:

1. On 10/23/17, review of the Orthopedic Surgery on-call schedule for October 2017 indicated the following:

a. The name of a physician group and not an individual physician was listed as on call for the following dates: 10/3/17, 10/4/17, 10/5/17, 10/6/17, 10/7/17, 10/8/17, 10/9/17, 10/10/17, 10/12/17, 10/17/17, 10/18/17, 10/19/17, 10/20/17, 10/21/17, 10/22/17, 10/23/17, 10/24/17, 10/25/17, 10/26/17, 10/27/17, 10/28/17, 10/29/17, and 10/30/17.

2. On 10/23/17, review of the Pediatric Physician on-call schedule for May 2017 indicated the following:

a. From May 1, 2017 to May 31, 2017, under the name of the physician on-call for adols (adolescents) it states, "see attached sheet."

b. There was no evidence of an additional sheet listing the name(s) of the physician on-call for adolescents during the month of May, 2017.

3. Staff #1 and Staff #27 confirmed the above findings.

37432

Based on review of medical records, staff interviews, and review of facility documents, it was determined that the facility failed to ensure all Emergency Department (ED) patients received an appropriate medical screening exam (MSE), which includes appropriate classification from the triage nurse based on the Emergency Severity Index (ESI).

Findings include:

Reference #1: Facility policy Triage Protocol states, "... Patient triage determines the order in which the patient is medically screened by the ED physician. ... Procedure: ... 3. When ED beds are not available, the Triage Nurse(s) assess patients, assign acuity levels, and provide minor first aid as needed. Acuity levels are based on the Emergency Severity Index (ESI) 5 level triage tool that uses resources and acuity to categorize patients. ... ."

Reference #2: Emergency Severity Index (ESI) Algorithm states, "... B. ... Severe pain/distress is determined by clinical observation and/or patient rating of greater than or equal to 7 on 0-10 pain scale. ... Box B: Severe pain/distress? - ESI level rating 2 ... Box D: Danger zone vitals? ... 3-8y/ HR >140/ RR >30/ SaO2 <92% - ESI level rating 2 ... ."

1. Review of Medical Record #1 on 10/21/17 indicated the following:

a. The patient arrived to the ED on 6/19/16 at 1955 with complaints of abdominal pain rated nine (9) out of ten (10) on the numeric pain scale. The patient stated she had a Caesarean section a couple of weeks prior to arriving at the ED.

b. The patient was triaged at 2004 and assigned an ESI level of three (3). The ESI triage algorithm indicated an ESI level of two (2) is assigned for severe pain greater than seven (7) on the numeric pain scale.

c. The patient was first called to come into the treatment area on 6/20/17 at 0123, five (5) hours and twenty-eight (28) minutes after arriving to the ED.

d. ED documentation indicated the patient left without treatment (LWT) on 6/20/17 at 0248. There was no evidence that the patient received a medical screening exam (MSE).

2. Review of Medical Record #2 on 10/21/17 indicated the following:

a. The patient arrived to the ED on 6/19/16 at 2107 with complaints of pain to his/her nose and right arm, eight (8) out of ten (10) on the numeric pain scale. The patient stated he/she fell down steps and hit his/her face on the concrete steps.

b. The patient was triaged at 2148 and assigned an ESI level of three (3). The ESI triage algorithm indicated an ESI level of two (2) is assigned for severe pain greater than seven (7) on the numeric pain scale.

c. The patient was first called to come into the treatment area on 6/20/17 at 0421, seven (7) hours and fourteen (14) minutes after arriving to the ED.

d. ED documentation indicated the patient LWT on 6/20/17 at 0456. There was no evidence the patient received a MSE.

3. Review of Medical Record #3 on 10/21/17 indicated the following:

a. The patient arrived to the ED on 6/19/16 at 2205 with complaints of a headache rated seven (7) out of ten (10) on the numeric pain scale. The patient stated his/her carbon monoxide monitor went off and the fire department found carbon monoxide present in the home.

b. The patient was triaged at 2252 and assigned an ESI level of three (3). The ESI algorithm indicated an ESI level of two (2) is assigned for severe pain greater than seven (7) on the numeric pain scale.

c. On 6/20/16 at 0036, the patient was called to the treatment area for the first time. The patient did not respond.

d. On 6/20/16 at 0042, the patient states he/she is going to leave and come back in the morning because of the wait time.

e. ED documentation indicated the patient LWT on 6/20/16 at 0127. There was no evidence the patient received a MSE.



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4. Review of Medical Record #7 on 10/20/17 revealed the following:

a. Patient #7 arrived at the ED on 5/16/17 with complaints of fever and vomiting and was assigned an ESI level 5.

b. Patient #7 falls within the age range of 3-8 years of age.

c. Triage vital signs indicated Pulse 144, Resp 20, Temp 100.2 (TE).

d. According to the facility's ESI algorithm, the appropriate ESI level was 2.

5. Review of Medical Record #16 on 10/20/17 revealed the following:

a. Patient #16 arrived at the ED on 5/31/17 with complaints of vaginal pain, abscess and was seventeen (17) weeks pregnant.

b. Triage was completed at 2108. There was no documented evidence of a pain assessment upon triage. The patient was assigned an ESI level 3.

c. At 2249, Patient #16 rates her pain level 7 out of 10 in buttocks and abdomen.

d. According to the facility's ESI algorithm, severe pain (pain greater than or equal to 7) required an ESI 2 classification.

6. Staff #1, Staff #20 and Staff #27 confirmed the above findings.

7. The medical record of Patient #13 indicated that the patient's chief complaint in triage included vaginal itching and pain. There was no pain level assigned to the patient by the triage nurse. The patient was assigned an ESI 3 classification. Since there was no pain scale for the patient, it could not be determined whether the patient should have been classified as ESI 2.

8. The medical record of Patient #17 indicated that the patient's pain level during triage was "10" on a scale of 1-10. The patient was assigned an ESI level 3. According to the facility's ESI algorithm, severe pain (pain greater than or equal to 7) required an ESI 2 classification.

9. The medical record of Patient #18 indicated that the patient's pain level during triage was "10" on a scale of 1-10. The patient was assigned an ESI level 3. According to the facility's ESI algorithm, severe pain (pain greater than or equal to 7) required an ESI 2 classification.

10. The medical record of Patient #25 indicated that the patient was brought to the ED on 10/19/17 by ambulance accompanied by police. The triage nurse documented: "Presenting complaint: Patient states: He took a handful of Buproprion pills because his girlfriend broke up with him [sic] EMS states: Patient took a bunch of pills to try to kill himself. ....." The patient was assigned a triage classification of ESI 3. According to the facility's ESI algorithm, the patient was in a high risk situation and should have been classified as an ESI 2.

Based on review of medical records, staff interviews, and review of facility policies and procedures, it was determined that the facility failed to provide stabilizing treatment, within the capabilities of the facility, for all patients who present to the Emergency Department (ED).

Findings include:

Reference #1: Facility policy "Triage Protocol" states, "... 4. A Pivot Nurse is assigned to the waiting area to support the triage process and provide ongoing reassessments of patients pending bed assignments in the ED. 5. The Triage nurse or other on-duty nurses may initiate... initial medications based on protocol to expedite patient care. ... Adult Medication Protocol: Tylenol 650 mg po (by mouth) once for temp (temperature) greater than 101 F or complaints of pain or Motrin 600 mg po once for temp greater than 101 F or complaints of pain."

Reference #2: Facility policy "Pain Assessment and Reassessment" states, "... Pain management is accomplished through assessment, administration of appropriate treatment, and reassessment/evaluation of treatment. ... Pain Assessment and Reassessment... Emergency Department: The RN will assess the patient's level of pain during the initial assessment, and, thereafter, a minimum of every 4 hours, or more often pursuant to specialty area guidelines... ."

Reference #3: Facility policy titled "Constant Observation for the Suicidal Patient" stated: ".....
PURPOSE:
Identifies personnel responsibilities during the constant observation of a suicidal patient, thereby protecting the patient from potential harm and elopement until a Physician/Psychiatric screening/consult evaluation has been completed and the need for continued observation established.
POLICY:
Patients deemed to be at high risk for suicidal behavior(s) and/or elopement are placed on constant observation until a physician/psychiatric screening/psychiatric consult has been completed and the need to continue the observation is established.
1. The Registered Nurse facilitates the physician and psychiatric screening/consult of the patient.
2. A Registered Nurse, PCA, Psychiatric Screener, Security Officer, Transport Personnel, may provide the constant observation.
.....
PROCEDURE:
1. Constant observation may be initiated by the registered nurse.
2. The patient's room is inspected for items and environmental hazards which can be used to inflict self harm, documentation in the medical record reflects their removal.
3. The patient is changed into a hospital gown, clothing is removed including undergarments. Clothing and valuables are then removed from the room and secured in an area not accessible to the patient.
.....
5. The observer remains with the patient at all times. The patient is escorted to the bathroom and diagnostic area(s) by the observer. The observer is relieved by another employee for breaks/meals, etc.
.....
8. Constant observation is discontinued with the following circumstances:
- patient agrees to voluntary admission
- patient is no longer suicidal
- patient is to be discharged
- Time of transfer to another facility
- An order is received from a LIP (Licensed Independent Practitioner) discontinuing the constant observation.
....."

1. Review of Medical Record #1 on 10/21/17 indicated the following:

a. The patient arrived to the ED on 6/19/16 at 1955 with complaints of abdominal pain rated nine (9) out of ten (10) on the numeric pain scale. The patient indicated she had a Caesarean section a couple of weeks prior to arriving to the ED.

b. ED documentation indicated the patient left without treatment (LWT) on 6/20/16 at 0248.

c. There was no evidence in the medical record that Tylenol or Motrin were initiated for pain management during the patient's wait in the ED, as indicated in the triage policy.

d. There was no evidence in the medical record that the patient's pain was reassessed after four (4) hours.

2. Review of Medical Record #2 on 10/21/17 indicated the following:

a. The patient arrived to the ED on 6/19/16 at 2107 PM with complaints to his/her nose and right arm rated eight (8) out of ten (10) on the numeric pain scale. The patient indicated he/she fell down steps and hit his/her face on concrete steps.

b. ED documentation indicated that the patient LWT on 6/20/16 at 0421.

c. There was no evidence in the medical record that Tylenol or Motrin were initiated for pain management during the patient's wait in the ED, as indicated in the triage policy.

d. There was no evidence in the medical record that the patient's pain was reassessed after four (4) hours.

3. Review of Medical Record #3 on 10/21/17 indicated the following:

a. The patient arrived to the ED on 6/19/16 at 2205 with complaints of a headache rated seven (7) out of ten (10) on the numeric pain scale. The patient indicated the carbon monoxide detector went off in his/her home, and the fire department detected elevated CO2 levels in the home.

b. ED documentation indicated that the patient LWT on 6/20/16 at 0127.

c. There was no evidence in the medical record that Tylenol or Motrin were initiated for pain management during the patient's wait in the ED, as indicated in the triage policy.



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4. Review of Medical Record #16 on 10/20/17 revealed the following:

a. Patient #16 arrived at the ED on 5/31/17 with complaints of vaginal pain, abscess and is seventeen (17) weeks pregnant.

b. Triage was completed at 2108.

c. At 2249, Patient #16 rates pain level 7 out of 10 in buttocks and abdomen.

d. The initial triage assessment lacked evidence of a pain assessment.

5. Review of Medical Record #20 on 10/20/17 revealed the following:

a. Patient #20 arrived at the ED on 7/1/17 at 1446 with complaints of back and chest pain.

b. Triage was completed at 1452.

c. At 1503, Patient #20 rates pain level 9 out of 10 in left clavicle, anterior aspect of left upper chest and mid sternal area.

d. The initial triage assessment lacked evidence of a pain assessment.

6. Staff #1, Staff #20 and Staff #27 confirmed the above findings.

7. Review of the medical record of Patient #8 revealed:

a. The patient was brought to the ED by ambulance and arrived at 1136 on 5/16/17. The triage nurse documented that the patient was found on a strangers steps in a different town. He/she also documented that the patient smelled of alcohol and had a seizure. The patient was assigned an ESI Acuity Level 1.

b. The medical record documented that the Medical Screening Exam was completed at 1128. The ROS (Review of Systems) section of physician documentation stated: "..... Psych: Positive for suicidal ideation, hallucinations. ....."
The HPI (History of Present Illness) section of physician documentation stated: "..... Patient reports he drinks alcohol daily and he drank a lot yesterday. Patient also reports he is experiencing suicidal ideation and hallucinations. ....."

c. The patients blood was drawn for a blood alcohol concentration and it was determined to be 406.

(i) The patient was not placed on constant observation status by either the registered nurse or the physician.

(ii) The patient was placed on a stretcher in the hallway instead of in a room with an observer.

(iii) A psychiatric consult or screening was neither ordered or done.

(iv) The patient was documented as having eloped from the ED with a saline lock still inserted.









13237

Based on medical record review, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure a transfer form is completed for all patients transferred out of the Emergency Department (ED).

Findings include:

Reference: Facility policy BH (Behavioral Health) - Transfer of Patients to Other Institutions from [Facility Name] states, "... Procedure ... 3. A transfer form is to be completed. The ER physician will complete the physician's portion; the nurse will complete the portion relevant to nursing; ... The name of the receiving physician accepting the transferred patient will appear on the form as well. 4. The original is kept in the ED record and a copy is sent with the patient to the receiving hospital. ... ."

1. Review of Medical Record #19 on 10/20/17 indicated the following:

a. The patient presented to the ED on 7/1/17 at 12:58 PM with complaints of suicidal ideation. The triage assessment indicated the patient's child stated the patient was "acting strange" and needed a psychiatric evaluation.

b. On 7/1/17 at 2:16 PM, the patient received a psychiatric assessment by the Psychiatric Social Worker, with a recommendation to admit the patient to an inpatient psychiatric facility.

c. The patient was transferred to an inpatient psychiatric facility on 7/2/17 at 2:33 AM. There was no evidence of a transfer form in the patient's medical record.

d. Upon interview, Staff #20 indicated that a transfer form for Patient #19 was not necessary because he/she was a committed patient.

2. Staff #1 and Staff #27 confirmed the above findings.