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|METROSOUTH MEDICAL CENTER||12935 S GREGORY BLUE ISLAND, IL 60406||Feb. 10, 2016|
|VIOLATION: COMPLIANCE WITH 489.24||Tag No: A2400|
|Based on document review and interview, it was determined that the Hospital failed to ensure compliance with A 2406. This potentially affected all patients presenting to the Emergency Department (ED) with emergency medical conditions.
1. The Hospital failed to ensure the patient received a medical screening exam, (A-2406).
|VIOLATION: MEDICAL SCREENING EXAM||Tag No: A2406|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on document review and interview, it was determined for 1 of 6 patients (Pt #1) who presented to the Hospital's ED between 10:10 pm on 1/28/16 and 2:27 am on 1/29/16, the Hospital failed to ensure a medical screening exam (MSE) was completed based on highest acuity.
1. The Hospital's policy entitled, "Triage Assessment of Patients by Emergency Severity Index (ESI) Policy" (revised 2/12/15) was reviewed on 2/8/16 at approximately 2:00 pm and required, "...To determine patient acuity; To identify severity of illness or injury; To ensure patients with highest acuity are seen first..."
2. The clinical record for Pt #1 was reviewed on 2/8/16 at approximately 11:00 am. Pt #1 was a [AGE] year old male who presented to the Hospital's emergency department (ED) via ambulance on 1/28/16 at 10:10 pm with a complaint of abdominal pain. The ED nurse's (E #1) triage note dated and timed 1/28/16 at 10:15 pm included, " ...pt states L [left] lower abd [abdomen] cramping started 1 hour ago, complains of N/V [nausea/vomiting] ...Numeric Rating at Rest: 10=Worst possible pain ... " Pt #1' s triage vital signs were documented as follows: heart rate-79, blood pressure-138/74, respirations-15, and temperature-98.3. Based on triage assessment, E #1 assigned an acuity level (ESI) of 3 - urgent to Pt #1. Pt #1's clinical record included an ED clinical summary completed by the ED charge nurse (E #2) which included, " ...ED Departure Time: 01/29/2016 02:27:00 [2:27am-more than 4 hours after triage). The clinical record lacked documentation of the location of Pt #1 following triage. The ED log indicated Pt #1 left after triage, and lacked a medical screening exam (MSE).
3. The ED log was reviewed from 01/28/16 to 01/29/16. During Pt #1 ' s time in the waiting area after triage at 10:15 pm through departure on 01/29/16 at 2:27 am, 7 patients arrived, received treatment, and were discharged . Five of the seven patients were assigned a lower acuity level of 4 (less urgent) and included the following: [AGE] year old male via ambulance with back pain (ESI-4); [AGE] year old male with nausea/vomiting (ESI-4); [AGE] year old male with rash (ESI-4); [AGE] year old male with left ear impacted cerumen, emotional stress reaction (ESI-4); [AGE] year old male with left ankle injury (ESI-4).
4. On 02/08/16 at approximately 1:40 pm, the triage notes for these 7 patients were reviewed on the computer with the ED Manager (E #4). When this surveyor asked why patients with a lower acuity ESI received MSEs before those with a higher acuity ESI, E #4 stated that the patients are seen based on their presenting symptoms, as well as the anticipated length of stay. Therefore, the patient with severe back pain might not have been unable to sit in an upright position in the waiting room. A patient with active vomiting would not be appropriate to put in the waiting area. Patients with conditions that can be treated in a shorter amount of time might be seen and discharged before a patient with a longer anticipated length of stay would be brought back to a room.
5. On 2/9/16 at approximately 11:00 am, an interview was conducted with the ED Medical Director (MD #1). MD #1 stated patients are seen in order of severity based on airway, vital signs, and presenting symptoms.