The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PORTNEUF MEDICAL CENTER 777 HOSPITAL WAY POCATELLO, ID 83201 Nov. 12, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. The hospital failed to ensure MSE's were provided to 3 of 24 patients (#1, #2, #5) whose records were reviewed. This resulted in the inability of the hospital to ensure patients with potential emergency medical conditions were cared for in a safe and effective manner. Findings include:

The policy " EMTALA Plan " , dated 2/01, and revised 4/11, included the following definitions:

" Appropriate Medical Screening Examination (MSE): The Medical Screening Examination includes, but is not limited to: vital signs, oral history, physical examination of affected or potentially affected systems, consideration of known chronic conditions, tests or services routinely available to the Center as needed to determine presence of an emergency medical condition, consultation as needed with other Medical Staff, continued monitoring of patient's condition and documentation of the above in the medical record, along with documentation of any final patient disposition."

This policy was not followed. Refer to C2406 as it relates to the failure of the hospital to provide appropriate MSEs to patients.

The hospital failed to implement policies to ensure compliance with the requirements at 42 CFR Part 489.24.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interviews and review of medical records, it was determined the hospital failed to ensure complete MSE's were provided to 3 of 24 ED patients (#1, #2, and #24) whose records were reviewed. This resulted in patients with emergency medical conditions that were not diagnosed . Findings include:

Patient #1's medical record documented a [AGE] year old female who arrived by ambulance to the ED on 10/24/14 at 3:44 AM.

A "NURSING ASSESSMENT," dated 10/24/14 at 3:47 AM, included Patient #1 "...states she is addicted to cutting and went too deep tonight to left forearm, pt states she has been cutting self for 12 years, pt states she does not want to be here, pt denies SI just cutting on self, pt states she did not want to come but EMS brought her in, pt states she wants to leave. pt has wrap to left forearm, pt able to move arm and fingers, pressure wrap applied by EMS in place, pt states she called EMS." A description of the wound to her forearm was not documented in the record. The nurse documented, on 10/24/14 at 4:05 AM, that Patient #1 eloped before the physician had seen her. The record did not indicate whether Patient #1 appeared sober or not.

Patient #1's psychiatric history by an RN, dated 10/24/14 at 3:51 AM, stated " Cutter, History of suicide attempts, History of depression, History of suicidal ideation, Previous ED psychiatric evaluations. Borderline personality disorder. SOCIAL HISTORY:...Patient states 'I drink until I pass out'...Patient drinks socially, every week, Alcohol history notes: Patient states 'I drink until I black out and pass out. I drink every day to feel ok,' Patient currently uses drugs, abuses marijuana, abuses opiate."

A physician note in Patient #1's record, dated 10/24/14 at 4:04 AM, stated the patient reported she was not suicidal and did not want to be in the hospital. The note then said Patient #1 eloped out of the ER prior to the physician's assessment. Also at 4:04 AM, the physician documented "Disposition type: Incomplete Care, Disposition: Elopement, Disposition Transport: Private Vehicle, Condition: Stable. " It was not clear how the physician determined Patient #1 was stable since he did not examine her. The physician documented Patient #1's diagnosis at 4:04 AM as "Self-Inflicted Laceration. "

Patient #1 returned to the ED on the afternoon of 10/24/14 at approximately 2:16 PM. A nursing assessment at 2:35 PM on 10/24/14 documented Patient #1 "...was seen here last night for L forearm self-inflicted wound. She became anxious before it was repaired and left. Pt arrives today and requests repair of wound but does not want Social worker called. Pt has large wound across her L inside upper forearm that is oozing blood." Measurements of the wound were not documented. The nurse then documented "Psychiatric/social assessment: findings include affect normal. " The assessment also noted security personnel were at Patient #1's bedside. Patient #1 was discharged from the ED at 3:31 PM on 10/24/14.

Physician notes for this visit were not documented until the following day, on 10/25/14 at 9:56 AM. The physician wrote Patient #1's chief complaint was "...presents for evaluation of laceration to arm, on the left, through dermis" and stated the laceration was from a "self-inflicted knife wound." On 10/25/14 at 10:00 AM, the physician wrote Patient #1 had a 4 centimeter laceration through the dermis on her left forearm. He wrote her psychiatric examination was normal, including her judgment and insight. He stated she was not suicidal. The record documented the wound was repaired with staples. An assessment of the likelihood that Patient #1 would continue to cut herself was not documented.

Another medical record documented Patient #1 returned to the ED on 10/27/14 at approximately 12:31 AM, 57 hours later. A PA documented, on 10/27/14 at 1:03 AM, that Patient #1 presented to the ED for evaluation of lacerations to her face and chest. It stated the wounds were self-inflicted using a razor blade. The note stated the wounds were associated with alcohol use. A physical examination by the PA was documented at 1:02 AM on 10/27/14. It stated lacerations were present on Patient #1's left upper chest and superior shoulder through the dermis. It stated she had normal muscle and tendon function. It stated a laceration was also present on the right side of Patient #1's face. "DOCTOR NOTES" by the PA, dated 3/27/14 at 1:03 AM, stated Patient #1 denied being suicidal and refused a social work consult. It stated her chest lacerations were repaired with staples. It stated Patient #1 refused repair of the lacerations on her face.

A description of the facial wounds was not documented. A note titled "LACERATION REPAIR" by the PA, dated 10/27/14 at 1:05 AM, stated there were multiple repairs. The note stated a laceration with a total length of 30 centimeters (11.8 inches) was repaired with greater than 10 staples. Measurements and further description on the lacerations were not clearly documented in the record.

A nursing assessment for Patient #1, dated 10/27/14 at 12:45 AM, stated "Psychiatric/social assessment findings include affect, alcohol on breath, crying, depressed, Notes: Drinking at bar, left with a guy that later left her, states 'felt like a loser,' denies wanting to harm herself but she has an addiction to cutting to relief the pain, states is in counseling but has no one to turn to on the weekend."

The physician documented, at 1:01 AM on 10/27/14, Patient #1's diagnosis was "self-mutilation, multiple lacerations." The record documented Patient #1 was discharged home at 1:13 AM on 10/27/14. An assessment of Patient #1's psychiatric status was not documented. An assessment of the likelihood that Patient #1 would continue to harm herself was not documented.

Patient #1 returned to the ED on 10/27/14 at 4:55 AM 3 hours and 42 minutes after her discharge.

A nursing assessment, dated 10/27/14 at 4:55 AM, stated Patient #1 was anxious and intoxicated. It stated she had "left earlier after self-cutting, [went home and] felt confused et scared, everything is the matter et I just want to live a normal life again, doesn't feel safe but denies is suicidal, lacerations [times] 2 to left leg."

A behavioral health assessment by a social worker was conducted for Patient #1. The note, dated 10/27/14 at 7:52 AM, stated she was brought to the ED by police. The note stated she had an extensive history of cutting. The note stated she had severe scarring on her abdomen, arms, and legs from cutting. The note stated she had 7 ED visits since 9/06/14 for self-inflicted injuries. The note stated the physician told the social worker conducting the assessment that the cuts by her neck were near a major artery. The note stated Patient #1 had been pulling out some of the sutures and reopening her wounds. When asked why Patient #1 had reopened the wound on her arm, she said she wanted people to see how deep it was. The social worker recommended Patient #1 should be admitted to the behavioral health unit as an inpatient. Patient #1 was placed on a physician hold on 10/27/14 at 8:25 AM.

Patient #1's medical record documented she was held in the ED until a bed became available on the behavioral unit. She was admitted to the inpatient unit at 12:28 PM on 10/27/14. She remained on the behavioral unit until her discharge home on 11/04/14.

Pictures of Patient #1's wounds were taken on the behavioral unit on 10/27/14 at 8:50 PM. She had 4 lacerations approximately 2.5 inches long on her left thigh. Three of these wounds had been stapled. She had 3 lacerations on her left upper arm, the longest approximately 3 inches long. Two of these wounds had been stapled. She had 2 lacerations on her left forearm approximately 2 inches long. Both wounds were stapled. She had lacerations on her right thigh in the shape of a 6 that was 1.25 inches by 2.5 inches. The width of the cut was 0.25 inches. She had 4 lacerations on her left upper shoulder and neck the longest of which was over 5 inches. All 4 lacerations were stapled. She had 3 lacerations on her right face by her eye, the longest of which was over 1.25 inches. She had a laceration on her left elbow over 2 inches long and 3/8 inch wide. It had been stapled but Patient #1 had removed the staples at some point. It was raw and open. Finally, she had a series of 9 crisscrossed lacerations on her left lower leg. The longest was approximately 5 inches.

A PA, who was on duty when Patient #1 (MDS) dated [DATE] at 12:34 AM, was interviewed on 11/06/14 beginning at 3:00 PM. He stated he had seen Patient #1 a couple of times in the past. He stated he had also been on duty when Patient #1 came in on 10/24/14 and she had eloped out of the back door.

The PA stated that, on the first 10/27/14 visit, Patient #1 had 4 lacerations to her shoulder and neck, the longest of which was 10 centimeters long (4 inches). He stated he had stapled 2 of the lacerations. He stated the physician had to help with the stapling in order to get the edges of the lacerations to line up. He stated he asked Patient #1 why she cut herself. He stated she was very guarded. He stated he was very worried about her because of the lacerations. He stated this was the worst he had ever seen her. He stated he told Patient #1 she did not need to be suicidal to kill herself. He stated Patient #1 told him she did not appreciate "all you people" talking about her and whispering behind her back. He stated Patient #1 told him she knew what she was doing and she told him she knew where the major blood vessels were. He stated he was glad when Patient #1 was finally admitted later on 10/27/14. He stated he assessed Patient #1 with the physician. He stated they discussed doing a psychiatric evaluation but Patient #1 was blunt about not wanting to stay. He stated Patient #1 told him she was going to call her counselor. He stated they did not place Patient #1 on an involuntary hold. He stated Patient #1 said she was not suicidal and had a counselor. He stated Patient #1 told him she cut herself to release the pain. He stated Patient #1 called a taxi and left the hospital.

The physician, who was on duty when Patient #1 (MDS) dated [DATE] at 12:34 AM, was interviewed on 11/06/14 beginning at 4:50 PM. He stated Patient #1 had a long history of cutting and she had been seen several times for that. He stated he was aware Patient #1 had been to the ED on Friday, 10/24/14, and he stated Patient #1 had removed the staples that had been placed on that day and reopened her wound. He stated Patient #1 had cuts on her left shoulder and on her right face at her temple. He stated he evaluated Patient #1 with the PA. He stated he had sewn up numerous cuts for Patient #1 in the past. He stated her affect was pretty dramatic but she denied suicidal thoughts. He stated she was not intoxicated. He stated Patient #1 cut herself as a way to release pain and stress. He stated he thought Patient #1 lived alone. He stated he thought about a psychiatric assessment but he decided not to order one. He stated Patient #1 had several parallel lacerations on her left shoulder and more superficial cuts on her right temple. He stated he did not think Patient #1 had lacerations on her legs. He stated he thought he looked at her legs but did not document this. He reviewed Patient #1's medical record and stated he did not document her psychiatric status. He stated he recommended the facial lacerations be repaired but said Patient #1 refused to allow staff to repair those lacerations. He stated the facial lacerations were not well approximated (there was separation of the wound edges) but were not gaping. He stated after Patient #1 left the ED she became distraught and called the ED nurse. He stated the nurse told Patient #1 to come back to the ED. He stated he was not aware of the call at the time Patient #1 contacted the nurse. He stated when he found out about the call later, he notified police and asked them to do a welfare check on Patient #1. He stated the police then went to Patient #1's home and brought her back to the ED.

The hospital did not provide an appropriate MSE to Patient #1. Even though she had seriously cut herself within the last 3 days and the nurse documented she had been drinking alcohol, staff did not evaluate her psychiatric status and did not evaluate the likelihood that she would continue to cut herself, potentially causing serious harm to her health and safety.





2. The American Heart Association website, accessed on 11/21/14, defined the following blood pressure categories:

Normal - less than 120/80
Pre-hypertension - Systolic 120-139 or diastolic 80-89
Hypertension Stage 1 - Systolic 140-159 or diastolic 90-99
Hypertension Stage 2 - Systolic greater than 160 or diastolic greater than 100
Hypertensive Crisis - Systolic greater than 180 or diastolic greater than 110

Patient #2 was a [AGE] year old male who (MDS) dated [DATE] at 3:16 AM, with a complaint of chest pain.

Patient #2's initial blood pressure, taken at 3:21 AM, was 182/116. His blood pressure remained elevated while he was in the ED, as follows:

4:27 AM 166/104
4:36 AM 166/105
4:54 AM 175/112
5:05 AM 179/112

Patient #2's diastolic blood pressures at 4:54 AM and 5:05 AM were above the level defined as hypertensive crisis.

A section of the record, titled "HISTORY OF PRESENT ILLNESS" was time stamped at 3:49 AM, and electronically signed by a PA. It stated, "Patient to ED with [significant other] and family for evaluation of acute onset substernal chest pain that began about 1 hour ago while at home at rest. Not associated with palpitations, N/V, HA, mental status changes, abd pain. Patient has not had similar symptoms in the past. Earlier in the evening patient was out with friends, dancing, drinking ETOH; had approx. 6 beverages. Initially denies illicit drug use. Hx of HTN, but noncompliant with medication, he is not sure what previous med was. No recent illness, injuries, travel. Patient admits to me when family is out of room that approx. 2 hours ago he smoke #1 methamphetamine cigarette. [sic] He has not used this in the past, he feels ashamed." Additionally, it stated "Symptoms are localized, most severe in substernal area, pain radiates, Radiation to the neck...Pain is dull in nature, described as aching...Sudden onset of symptoms, 1, hours prior to arrival. [sic] Symptoms are improving, are constant."

A section of the record, titled "PAST MEDICAL HISTORY", was time stamped at 3:24 AM, and electronically signed by an RN. It stated, "Past medical history includes history of hypertension."

A section of the record, titled "PHYSICAL EXAM" was time stamped at 3:53 AM, and electronically signed by the PA. It included, "Vital Signs Reviewed, Patient afebrile, Pulse normal, Blood pressure, hypertensive, Respiratory rate normal".

Patient #2's ED record included an ECG with a time stamp indicating it was completed at 3:21 AM. The section titled "Diagnosis" stated "Sinus rhythm, Anteroseptal infarct - age undetermined, Summary: Abnormal ECG". His record included a second ECG with a time stamp indicating it was completed at 4:51 AM. The section titled "Diagnosis" stated "Sinus rhythm, Anteroseptal infarct as previously, No significant change, Summary: Abnormal ECG, Compared with 3/30/2014 3:21 AM". Each of the ECG reports stated they were confirmed by a physician. However, they did not state the date and time of the confirmation. Additionally, Patient #2's ED record did not include documentation by ED staff related to the ECG results.

A section of Patient #2's record titled "DOCTOR NOTES" was time stamped at 4:48 AM, and electronically signed by the PA. It stated "Chest Pain resolving while in ED and VS improving. Labwork thus far negative. As noted above after parents left room patient admitted to smoking methamphetamines 1 hour prior to pain beginning. This is likely etiology of pain, but also consider esophagitis from ETOH use. By the end of encounter CP improved, but mild ST present. Plan to dc home with supportive care, CP NOS education and PCP f/u Monday." The note did not include a reference to Patient #2's elevated blood pressure.

A section of the record titled "ATTENDING" was time stamped at 5:12 AM, and electronically signed by the physician. It stated "The documented history was done by the PA/resident, The documented physical exam was done by the PA/Resident, Chief Complaint: HX reviewed with PA as noted. Pt. noted appearing sl. Anxious but comfortable on gurney. ED workup noted, case discussed. Agree with d/c and Rx as planned. I have personally seen and examined this patient. I have fully participated in the care of this patient. I have reviewed all pertinent clinical information, including history, physical exam and plan." The documentation completed by the physician did not include a reference to Patient #2's elevated blood pressure.

A section of the record titled "INSTRUCTIONS" was time stamped at 4:58 AM, and electronically signed by the PA. Under "DISCHARGE" it stated, "CHEST PAIN (NONSPECIFIC), HYPERTENSION. Under "SPECIAL" it stated, "Return home, rest and push fluids. Avoid drug or alcohol use. Followup with [Primary Care Physician] on Monday for recheck and to restart your high blood pressure medication. If untreated, high blood pressure can lead to heart attack, stroke, death. Please return to ER if you feel you are worsening, changing or if any concerns."

Patient #2's elevated blood pressure was not treated in the ED.

A section of Patient #2's record titled "DISPOSITION" was time stamped at 5:07 AM, and electronically signed by the RN. It stated, "Private vehicle, Condition: Stable, Patient left the department." Patient #2's condition on discharge was not documented by the PA or the physician.

An additional registration form indicated Patient #2 returned to the ED later that day. The registration form documented an emergency department admitted and time of 3/30/14 at 7:49 PM, with chief complaint of code blue and admitting diagnosis of cardiac arrest. A "RECORD OF DEATH" stated Patient #2 died on [DATE] at 8:02 PM.

The PA who provided care to Patient #2 during his ED visit on 3/30/14 at 7:49 PM was interviewed on 11/06/14 at 5:35 PM. He stated he remembered the patient.

The PA was asked about the involvement of the ED physician in Patient #2's care, including reviewing vital signs and ECGs. He stated he believed the physician poked his head in and saw the patient. Additionally, he stated the PA's do not read ECGs and that they are read by the MD in the ED, then reviewed by a cardiologist for confirmation. He stated the physician who confirmed the ECG results was a cardiologist and he would not have read the ECG until a couple days after it was done. He reviewed the record and stated he could not see where the ED physician signed to indicate he read the ECG.

The PA stated the patient's complaint was chest pain, but upon examination he felt that it was epigastric pain. He stated he would typically order a chest x-ray for chest pain, but did not order one because the pain was epigastric.

The PA stated when he discharged Patient #2 he had not seen the vital signs taken at 5:05 AM, including the blood pressure of BP 179/112.

The attending physician for Patient #2's ED visit on 3/30/14 at 7:49 PM, was interviewed on 11/06/14 at 2:00 PM. He stated he was not concerned with Patient #2's blood pressure levels while he was in the ED. He stated he did not think he was having a hypertensive crisis.

The physician confirmed there was no documentation in Patient #2's record related to a review of his ECG results while he was in the ED.

Patient #2's medical screening exam was not comprehensive to determine whether an emergency medical condition existed.

3. Patient #5's medical record documented a [AGE] year old female who (MDS) dated [DATE] at 5:11 AM. Her presenting complaint was neck pain. The section of Patient #5's medical record titled "Patient Data," dated 8/29/14 at 5:15 AM, rated her neck pain at 8 out of 10.

The section of Patient #5's medical record titled "DISPOSITION," written by Physician A and dated 8/29/14 at 7:38 AM, stated she was discharged home by private vehicle in stable condition. The note directly beneath "DISPOSITION" was written by the RN. It stated Patient #5 left the ED at 8:36 AM.

An untitled EMS record by ambulance personnel, dated 8/29/14 at 5:55 AM, stated Patient #5 had fallen and paramedics arrived to find her on the floor near her bed. The EMS record stated Patient #5 appeared to have an altered mental status and slurred speech. The EMS record stated Patient #5 had a history of a bowel infection and urinary tract infection. The EMS record stated Patient #5 was on home dialysis but did not state what type of dialysis she received. The EMS record stated Patient #5's son reported she had not lost consciousness.

Physician A documented Patient #5's diagnosis, disposition, discharge instructions, and noted the patient was signed out by Physician B. Physician B documented Patient #5's history of present illness, review of systems, and physical examination.

Patient #5's "MEDICAL HISTORY," dated 8/29/14 at 5:21 AM, stated she had a history of diabetes and hypertension and stated she was on dialysis but did not mention which kind. It stated she did not have a history of cardiac disease.

The American Heart Association website, accessed on 11/21/14, defines the following blood pressure categories:

Normal - less than 120/80
Pre-hypertension - Systolic 120-139 or diastolic 80-89
Hypertension Stage 1 - Systolic 140-159 or diastolic 90-99
Hypertension Stage 2 - Systolic greater than 160 or diastolic greater than 100
Hypertensive Crisis - Systolic greater than 180 or diastolic greater than 110

Four sets of vital signs were documented for Patient #5 including 4 blood pressures. The pressures were 205/98 at 5:15 AM, 205/98 at 5:21 AM, 206/100 at 6:21 AM, and 218/99 at 7:31 AM. No blood pressures were documented between 7:31 AM and 8:36 AM when she was discharged .

All 4 of Patient #5's systolic blood pressures were above the level defined as hypertensive crisis.

The review of systems was documented by Physician B. Nothing unusual was documented at the cardiovascular or neurological sections. Under "Physical Exam," dated 8/29/14 at 6:21 AM, Physician B wrote "Blood pressure, hypertensive ..." No other mention of Patient #5's blood pressure was documented by a physician.

X-rays of Patient #5's shoulder and cervical spine were negative for fracture.

The medical record stated Patient #5 was medicated for pain at 5:53 AM on 8/29/14.

A "DISCHARGE INSTRUCTIONS RECEIPT" for Patient #5, dated 8/29/14 but not timed, stated her diagnosis was cervical strain. It stated Patient #5 was given instructions for a soft tissue neck injury and a bowel infection. Patient #5's blood pressure was not mentioned in the discharge instructions.

A second medical record documented Patient #5 returned to the ED on 8/29/14 at 2:51 PM. The history of present illness, dated 8/29/14 at 4:25 PM, stated Patient #5 had been found by her family around 1:00 PM. Her diagnosis was stroke. She was admitted to an inpatient bed for treatment.

Physician B was interviewed on 11/12/14 beginning at 7:00 AM. He confirmed he was on duty on 8/29/14 at 5:11 AM when Patient #5 presented to the ED but he said he did not remember her. He reviewed Patient #5's medical record. He stated he did not know why Patient #5 fell . He stated his documentation did not address Patient #5's elevated blood pressure. He stated a blood pressure number alone did not tell the practitioner anything. He stated he probably assumed Patient #5 was in pain and this accounted for her elevated blood pressure. He reviewed Patient #5's inpatient admission and stated an MRI did show she had suffered a stroke.

The hospital did not provide an appropriate MSE to Patient #5. Hospital staff did not investigate her elevated blood pressures and did not take her blood pressure within 1 hour of discharge.