HospitalInspections.org

Based on a tour of the facility, observations and interviews, the hospital failed to post signs in treatment areas of the Emergency Department (ED), that identify a patient's rights with respect to examination and treatment of emergency medical conditions and women in labor. The findings include:

a. A tour of the ED was conducted on 6/19/14 with Director #1 and Nurse Manager #1. A sign which identified a patient's rights under the Emergency Medical Treatment and Labor Act (EMTALA) was posted in a hallway of the ED but was not posted in a conspicuous place or places likely to be noticed by all individuals entering the emergency department which would include the ED entrance, admitting area, waiting room, and treatment area. Review of the sign location and interview with Director #1 and Nurse Manager #1 on 6/25/14 at 9:34 AM noted that the sign was not posted in a place where patients would readily notice it.

Based on medical record reviews, review of facility documentation, and interviews, the hospital's Emergency Department (ED) failed to provide the necessary medical screening for one of five female patients who were pregnant (Patient #1) and who verbalized signs and symptoms of a medical emergency. The finding includes:


a. Patient #1 was 23.5 weeks pregnant and presented to the ED on 5/13/14 and was registered with the Financial Counselor at 11:15 AM. The patient registration information identified that the patient was pregnant and complained of leg and hand swelling. ED nursing documentation by RN #1 indicated that the Patient and/or family (Person #1) notified staff that they were leaving at 11:59 AM as they were able to make an appointment elsewhere. The note further identified that Patient #1 and Person #1 were advised to stay and return if symptoms worsened. Patient #1 was in the ED for 45 minutes, did not receive a medical screening exam and disposition was documented as left before triage (LBT) on 5/13/14 at 12:01 PM.

The ED log and/or staffing schedule dated 5/13/14 at 12:00 AM to 9:00 AM identified that 3 to 15 patients arrived to the ED every hour, 27 patients arrived between 9:00 AM and 10:00 AM, 20 patients arrived between 10:00 AM and 11:00 AM and/or there were two triage nurses during this time period. The ED log and/or staffing schedule dated 5/13/14 from 11:00 AM to 12:00 PM identified that 29 additional patients came to the ED and a third nurse was in place at 11 AM to take over as First Nurse. Review of staffing and interview with Director #1 on 6/19/14 at 11:50 AM indicated that the ED was staffed with the usual staffing on 5/13/14 at 11:15 AM to include a First Nurse and two additional triage nurses. Director #1 identified that the role of the First Nurse was to speak with a patient when he/she arrived in the ED and do a quick visual assessment and interview. The First Nurse then informs the Financial Counselor what to enter as the patient's initial complaint. The patient would be triaged later by one of the other two triage nurses. Director #1 noted that approximately 25 or 26 patients come to the ED every hour and the role of the First Nurse was to track beds/movement and observe the patients in the waiting room.

Interview with the ED Nurse Manager on 6/24/14 at 1:30 PM identified that the ED staff included a Clinical Nurse Leader whose role included to reassign staff as needed. Interview with RN #1 on 6/24/14 at 9:05 AM noted that he/she did not recall Patient #1, would speak to the patient first and inform the Financial counselor what to enter into the electronic record as the patient's reason for coming to the ED. RN #1 indicated that if Patient #1 had complained of a headache (H/A) he/she would have checked the patient's blood pressure because that would be a sign of preeclampsia. RN #1 further identified that in review of the ED patient log for 5/13/14, the ED was very busy that day.

Interview with the Financial Counselor on 6/24/15 at 9:54 AM noted that he/she did not recall Patient #1 and if he/she was informed that a patient's symptoms had worsened, he/she would direct them to the nurse.

Interview with Patient #1 on 6/19/14 at 9:40 AM identified that he/she first spoke with the receptionist (Financial Counselor) and told the receptionist that she was 6 months pregnant, had a H/A, was dizzy and had swollen hands and feet. The receptionist took her insurance card, and repeated the patient's complaints of pregnancy with swollen hands and feet (without including the H/A), and asked Patient #1 to have a seat.

Interview with Person #1 on 6/19/14 at 9:20 AM indicated that after almost an hour, he/she informed the receptionist (Financial Counselor) that Patient #1's H/A was worsening and asked how much longer it would take for Patient #1 to be seen. The receptionist stated that it could take 1 to 2 hours to be seen. Person #1 and Patient #1 informed staff that they had made an appointment elsewhere and were leaving.

Interview with Director #1 on 6/24/14 at 1:38 PM noted that although the hospital monitors ED patients' length of stay, the hospital did not monitor reception to triage time. Although hospital staff had three opportunities to assess Patient #1 (upon entry at 11:15 AM, when informed that Patient #1's H/A had worsened at 11:59 AM and when informed that Patient #1 was leaving 12:01 PM), an assessment of Patient #1's blood pressure and/or assessment by a qualified medical person was not provided.

The hospital triage policy identified that all patients who arrive to the ED will be greeted by an RN (First Nurse) who performs an initial rapid triage to determine the level of acuity and need for subsequent treatment. In the case of Patient #1, there was no level of acuity assigned. The policy further indicated that if no interventions are needed, the patient would proceed to the triage desk for a brief triage assessment that would determine the priority of care and include a full set of vital signs. In the case of Patient #1, the patient was directed to the waiting room instead of the triage nurse per policy. The hospital triage system protocol failed to identify that a patient could be asked to wait in the ED waiting room prior to being fully triaged.

The hospital medical staff bylaws identified that any individual who comes to the ED will be provided an appropriate medical screening exam by a qualified medical person to include a licensed physician, physician assistant, or nurse practitioner.


ED records from Hospital #2 identified that Patient #1 was directly admitted to the labor and delivery department on 5/13/14 at 12:23 PM with a diagnoses of preeclampsia and a life- threatening pregnancy complication "HELLP" (hemolysis of red blood cells, elevated liver enzymes and low platelet count). Patient #1 required a cesarean section on 5/15/14 and delivered the baby at a gestational age of 24 weeks.