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Based on medical record review, policy review and staff interviews, the facility failed to provide an appropriate medical screening examination for one (1) of twenty (20) patients (#7) who presented to the emergency room with complaints of back pain and diarrhea. Refer to findings in Tag 2406.

Based on medical record review, policy review and staff interviews, the facility failed to provide an appropriate medical screening examination for one (1) of twenty (20) patients (#7) who presented to the emergency room with complaints of back pain and diarrhea.

Findings include:

Review of patient medical record #7 revealed the 57 year old patient arrived at the facility's emergency department on 3/17/15 at 4:30 PM with chief complaint of detox.
The medical record did not contain evidence of a signed Consent for Treatment form.

The patient was triaged on 3/17/15 at 4:38 PM, and assigned an emergency severity index (ESI) level 2 (emergent). Triage vitals signs were: 99-74-17 176/103 95% oxygen saturation.
Review of triage notes revealed the patient ambulated to triage; wanted something for pain, but wanted detox from Oxycodone (medication used to treat pain). The patient had a history of back problems, and stated he/she was going to shoot himself/herself if not given something for pain.

Physician #5 performed a history and physical on the patient on 3/17/15 at 5:24 PM, noting the patient's history of L5-S1 fusion in 1999; currently with severe back pain, bilateral leg pain, and watery stools for 5 days; depression, not suicidal/homicidal. Musculoskeletal examination: no tenderness, no swelling, deformity.

Orders included psychiatric consultation, seclusion for up to 4 hrs for escalating irrational behavior, and laboratory studies which included complete blood count with differential, Chemistry 8, blood alcohol, urinalysis, and urine drug screen. Lab results were positive for Benzodiazepine (Medication -a tranquilizer used to treat anxiety) and Oxycodone (only).

Nursing notes on 3/17/15 at 5:49 PM documented the patient was alert and oriented to person, place and situation, in no apparent distress, somewhat combative, aggressive with wife since short on pain meds. Patient stated he/she had a history of back problems and was currently taking medication through the pain clinic. Patient stated he/she was short approximately 2 weeks worth of medication, and is now out and hurting. The patient denied suicidal ideations, but had experienced them in the past. Has guns in the house, and could shoot self if he/she wanted to, but denied ideations at the time.

The initial documentation of pain on 3/17/15 at 7:00 PM revealed the patient's pain was 8/10 to his/her upper and lower back, chronic. The patient was walking around the room in steady gait; hospital police assisted patient to the rest room; spouse sitting in hallway out side the patient's room.
The medical record did not contain evidence of any further pain assessments.
The medical record contained evidence that the patient had been monitored every fifteen minutes while in seclusion.
The medical record did not contain evidence that any medications or treatments had been administered to address the patient's complaint of severe pain.

3/17/15 Nursing Notes revealed that at 10:17 PM, the patient was slamming the stretcher against the room door; the stretcher was removed, and the mattress was placed on the floor; hospital police at bedside.

A Tele-physician psychiatric examination was requested on 3/17/15. The request form documented the reason for the consult was: psych eval- patient has history of chronic back pain, states "I can't handle the pain and I'm mad." The examination was performed on 3/17/15 at 10:51 PM by MD #4. The physician noted the patient had a history of chronic back pain, ran out of pain medication 2 weeks ago. The patient told his/her spouse that he/she could not deal with the pain anymore, and threatened to harm self if he/she could not get pain medication. A psych consult was requested for this reason. The examination documented the patient was alert, oriented, well groomed, irritable, angry, speech normal, organized thought process, normal thought content, good judgement and insight, no hallucinations, decreased sleep, symptoms of depression. Adamantly denies plan or intent to harm self or others, and regrets statements, contracts for safety and does not pose a danger to self or others. Cleared for psych discharge. Diagnosis: adjustment disorder, chronic back pain, prostate problems, coping with medical issues.

The medical record did not contain evidence that the patient's vital signs had not been reassessed following triage or prior to discharging the patient.
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The patient was discharged to home on 3/18/15 at 12:23 AM in improved condition, ambulatory. His/her final diagnosis was depression, suicidal risks. The medical record documented that the patient received discharge instructions, however, the form was marked as "pt unable to sign".

11/18/15 at 10:30 AM interview with the RN Clinical Infomatics Specialist revealed that the ER did not have a policy or protocol for treatment of pain or diarrhea.

11/19/15 at 9:30 a.m. interview with MD #3: After reviewing the electronic medical record, the MD stated that heshe did not recall the patient well, but that the patient did not specifically mention having diarrhea. He/she explained that the issue was the patient was possibly taking more medicine than prescribed. The MD went on stating that the big concern was the patient had chronic pain, and had made significant threats of harming himself and that's why a psychiatric consult was ordered. MD #3 stated that chronic pain should be handled by the patient's own physician, not in the emergency room. He/she could not recall if the patient received treatment for his/her chronic pain in the ER. The MD continued on stating that regarding diarrhea- if a patient is not acutely ill, such as having a fever, etc. it is a self-limiting illness, which does not usually require treatment or a stool culture. MD #3 explained that the patient's electrolytes were normal, and there were no signs of dehydration, therefore no fluid was necessary. The MD continued to state that when he/she received the patient at 6:00 PM, the patient was waiting for a psychiatric consult. After the consult, MD #3 stated that he/she printed discharge instructions on depression and adjustment disorder, which was the diagnosis by the consulting psychiatrist, and also referred the patient to a Behavioral Health Center with instructions to call first thing in the morning. After printing the instructions he/she put them on the chart and did not know if the patient received them or not. MD #3 explained that withdrawal symptoms vary, especially if someone is taking multiple drugs.
The MD stated that he was aware that the patient's blood pressure was elevated, but, that according to accepted references, the ER should not treat acute hypertension in the emergency room unless there is associated organ damage.

11/19/15 at 10:08 a.m. interview with RN #6: The RN stated that he/she works the 7:00 AM to 7:00 PM shift, and has worked in this ER as an RN for 6 years. After review of the electronic record medical record, the RN stated that he/she recalled the patient reported that he/she had stood up from the couch at home, stating he/she could not stand the pain anymore, so came to the ER. The RN's understanding was that the patient had come to the ER for detox. The nurse stated that he/she thought he/she was assigned to the patient, and that the first time he/she saw the patient was at 5:49 PM, but did not recall how the patient looked, his/her behavior, or any threats made. The RN did not recall who took the patient's vital signs, or the results. The RN explained that if the patient is not critical, vital signs should be taken every 4 hours. If the patient is critical, vital signs should be taken every 30 to 60 minutes and on discharge. Additionally, if vital signs are abnormal, or if the patient is experiencing a high level of pain, the results should be charted and reported to the physician. There was no documentation in the medical record to indicate that Patient#7's elevated blood press and complaint of severe pain was reported to the ED physician.

11/19/15 at 11:39 AM interview with MD #5: After reviewing the electronic medical record, the physician stated that he/she worked 10 a.m. to 6 p.m. that day, and only had the patient for about an hour. The MD did not recall the patient, but based on the medical record, the patient came to the emergency room for detox and had stated that he/she was suicidal, had severe back pain from a prior operation in 1999. The patient had stated that he/she lost his prescription for Oxycodone and had diarrhea. The physician's understanding was that the patient's main concern was that he/she wanted detox, was depressed, and had suicidal ideations associated with his/her medical condition. The MD stated that he/she ordered a psychiatric consult due to the patients statements, adding, if someone threatens their self, we take it seriously. The MD did not think he/she ordered any pain medicine for the patient, explaining that it is hard to balance treatment for a patient demanding medication and wanting detox at the same time. The physician stated that he/she did not feel that narcotic medication would have been appropriate because the patient would need something strong due to his history, and, the patient wanted to get off narcotics. The MD stated that he/she did not recall being made aware of the patient's blood pressure being elevated, but that the patient's blood pressure could have been elevated due to pain and/or agitation. MD #5 stated that the patient's blood pressure should have been taken again, several times, adding that if it went higher, he/she would have evaluated the patient to decide if treatment was necessary or not due to it being a secondary issue. The MD stated that the patient's diarrhea may have been from decreasing the pain medications. The patient's electrolytes were normal, if he/she was experiencing serious diarrhea, his/her potassium would have been low and electrolytes would have been off (which they were not), and added that he/she would not be concerned about diarrhea in this setting. The patient had no abdominal tenderness or limitations on examination, and the examination was mostly unremarkable.
The Doctor was unsure if he/she was made aware of the patient's aggressive behavior or not, and had ordered seclusion due to the patient's statements, not his actions. MD #5 continued explaining that if he/she had been told the patient was violent or aggressive, he/she may have ordered restraints and a sedative or anti psychotic medication, such as Geodon or Haldol (both antipsychotics) . The physician stated that he/she transitioned the patient to another doctor at 6:00 PM.

Review of facility policy titled EMTALA- Transfer Policy, effective date 12/2010, last revised 11/2010, last reviewed 7/18/2013, revealed that the hospital must provide an individual who comes to the emergency department a medical screening examination to determine whether an emergency medical condition exists. A hospital may not delay provision of an appropriate medical screening examination of further medical examination/treatment in order to inquire about the individual's method of payment or insurance status. Where an emergency medical condition exists, the hospital must either provide treatment until the patient is stabilized, or if it does not have that capability must transfer the patient to another facility.

Based on medical record review, policy review and staff interviews, the facility failed to provide an appropriate medical screening examination for one (1) of twenty (20) patients (#7) who presented to the emergency room with complaints of back pain and diarrhea.

Findings include:

Review of patient medical record #7 revealed the 57 year old patient arrived at the facility's emergency department on 3/17/15 at 4:30 PM with chief complaint of detox.
The medical record did not contain evidence of a signed Consent for Treatment form.

The patient was triaged on 3/17/15 at 4:38 PM, and assigned an emergency severity index (ESI) level 2 (emergent). Triage vitals signs were: 99-74-17 176/103 95% oxygen saturation.
Review of triage notes revealed the patient ambulated to triage; wanted something for pain, but wanted detox from Oxycodone (medication used to treat pain). The patient had a history of back problems, and stated he/she was going to shoot himself/herself if not given something for pain.

Physician #5 performed a history and physical on the patient on 3/17/15 at 5:24 PM, noting the patient's history of L5-S1 fusion in 1999; currently with severe back pain, bilateral leg pain, and watery stools for 5 days; depression, not suicidal/homicidal. Musculoskeletal examination: no tenderness, no swelling, deformity.

Orders included psychiatric consultation, seclusion for up to 4 hrs for escalating irrational behavior, and laboratory studies which included complete blood count with differential, Chemistry 8, blood alcohol, urinalysis, and urine drug screen. Lab results were positive for Benzodiazepine (Medication -a tranquilizer used to treat anxiety) and Oxycodone (only).

Nursing notes on 3/17/15 at 5:49 PM documented the patient was alert and oriented to person, place and situation, in no apparent distress, somewhat combative, aggressive with wife since short on pain meds. Patient stated he/she had a history of back problems and was currently taking medication through the pain clinic. Patient stated he/she was short approximately 2 weeks worth of medication, and is now out and hurting. The patient denied suicidal ideations, but had experienced them in the past. Has guns in the house, and could shoot self if he/she wanted to, but denied ideations at the time.

The initial documentation of pain on 3/17/15 at 7:00 PM revealed the patient's pain was 8/10 to his/her upper and lower back, chronic. The patient was walking around the room in steady gait; hospital police assisted patient to the rest room; spouse sitting in hallway out side the patient's room.
The medical record did not contain evidence of any further pain assessments.
The medical record contained evidence that the patient had been monitored every fifteen minutes while in seclusion.
The medical record did not contain evidence that any medications or treatments had been administered to address the patient's complaint of severe pain.

3/17/15 Nursing Notes revealed that at 10:17 PM, the patient was slamming the stretcher against the room door; the stretcher was removed, and the mattress was placed on the floor; hospital police at bedside.

A Tele-physician psychiatric examination was requested on 3/17/15. The request form documented the reason for the consult was: psych eval- patient has history of chronic back pain, states "I can't handle the pain and I'm mad." The examination was performed on 3/17/15 at 10:51 PM by MD #4. The physician noted the patient had a history of chronic back pain, ran out of pain medication 2 weeks ago. The patient told his/her spouse that he/she could not deal with the pain anymore, and threatened to harm self if he/she could not get pain medication. A psych consult was requested for this reason. The examination documented the patient was alert, oriented, well groomed, irritable, angry, speech normal, organized thought process, normal thought content, good judgement and insight, no hallucinations, decreased sleep, symptoms of depression. Adamantly denies plan or intent to harm self or others, and regrets statements, contracts for safety and does not pose a danger to self or others. Cleared for psych discharge. Diagnosis: adjustment disorder, chronic back pain, prostate problems, coping with medical issues.

The medical record did not contain evidence that the patient's vital signs had not been reassessed following triage or prior to discharging the patient.
.
The patient was discharged to home on 3/18/15 at 12:23 AM in improved condition, ambulatory. His/her final diagnosis was depression, suicidal risks. The medical record documented that the patient received discharge instructions, however, the form was marked as "pt unable to sign".

11/18/15 at 10:30 AM interview with the RN Clinical Infomatics Specialist revealed that the ER did not have a policy or protocol for treatment of pain or diarrhea.

11/19/15 at 9:30 a.m. interview with MD #3: After reviewing the electronic medical record, the MD stated that heshe did not recall the patient well, but that the patient did not specifically mention having diarrhea. He/she explained that the issue was the patient was possibly taking more medicine than prescribed. The MD went on stating that the big concern was the patient had chronic pain, and had made significant threats of harming himself and that's why a psychiatric consult was ordered. MD #3 stated that chronic pain should be handled by the patient's own physician, not in the emergency room. He/she could not recall if the patient received treatment for his/her chronic pain in the ER. The MD continued on stating that regarding diarrhea- if a patient is not acutely ill, such as having a fever, etc. it is a self-limiting illness, which does not usually require treatment or a stool culture. MD #3 explained that the patient's electrolytes were normal, and there were no signs of dehydration, therefore no fluid was necessary. The MD continued to state that when he/she received the patient at 6:00 PM, the patient was waiting for a psychiatric consult. After the consult, MD #3 stated that he/she printed discharge instructions on depression and adjustment disorder, which was the diagnosis by the consulting psychiatrist, and also referred the patient to a Behavioral Health Center with instructions to call first thing in the morning. After printing the instructions he/she put them on the chart and did not know if the patient received them or not. MD #3 explained that withdrawal symptoms vary, especially if someone is taking multiple drugs.
The MD stated that he was aware that the patient's blood pressure was elevated, but, that according to accepted references, the ER should not treat acute hypertension in the emergency room unless there is associated organ damage.

11/19/15 at 10:08 a.m. interview with RN #6: The RN stated that he/she works the 7:00 AM to 7:00 PM shift, and has worked in this ER as an RN for 6 years. After review of the electronic record medical record, the RN stated that he/she recalled the patient reported that he/she had stood up from the couch at home, stating he/she could not stand the pain anymore, so came to the ER. The RN's understanding was that the patient had come to the ER for detox. The nurse stated that he/she thought he/she was assigned to the patient, and that the first time he/she saw the patient was at 5:49 PM, but did not recall how the patient looked, his/her behavior, or any threats made. The RN did not recall who took the patient's vital signs, or the results. The RN explained that if the patient is not critical, vital signs should be taken every 4 hours. If the patient is critical, vital signs should be taken every 30 to 60 minutes and on discharge. Additionally, if vital signs are abnormal, or if the patient is experiencing a high level of pain, the results should be charted and reported to the physician. There was no documentation in the medical record to indicate that Patient#7's elevated blood press and complaint of severe pain was reported to the ED physician.

11/19/15 at 11:39 AM interview with MD #5: After reviewing the electronic medical record, the physician stated that he/she worked 10