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UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW 2450 RIVERSIDE AVENUE MINNEAPOLIS, MN 55454 Sept. 22, 2014
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on interview and document review, the hospital failed to maintain a central emergency department (ED) log which accurately tracked the care of patients who presented to the ED, for 1 of 20 patients reviewed (P20), who presented to the ED for evaluation of an emergency medical condition (EMC).
Findings include:

The hospital's ED log did not indicate that P20 presented to the ED, seeking emergency medical treatment on 09/07/14. There was no documented evidence that P20 came to the ED on 09/07/14.

Nurse (H)/RN was interviewed on 09/23/14 at 7:30 a.m. Nurse (H)/RN stated he was the ED Charge nurse on 09/07/14 for the 11:00 p.m. - 7:30 a.m. shift. Sometime prior to 11:30 p.m. on 09/07/14 (exact time not recalled), Nurse/(H) received a call from Security that a patient had arrived to the ED waiting area. Nurse/(H) went to the ED waiting area to check on the patient. The patient was intoxicated. Two friends accompanied the patient and indicated the patient needed to be seen for dehydration. The patient's friends asked for a detox bed. Nurse/(H) told the patient's friends there were no detox beds available, but the patient could be seen in an ED exam room. The patient's friends told Nurse/(H) they were going someplace else and abruptly left the hospital. Nurse/(H) stated he did not enter the patient's visit on the ED log because he didn't get the patient's name, before the patient and friends suddenly left the ED. Nurse/(H) did not have the patient sign a declination form indicating that the patient had declined the MSE that was offered, because Nurse/(H) did not have a declination form with him when he went to the ED waiting area to check on the patient.

The hospital's policy Emergency Medical Services (EMTALA), revised September 2012, indicated "EMTALA requires a hospital to maintain a central log on each individual who comes to its emergency department or other areas on hospital property seeking emergency medical care."

The hospital's policy Central Log for Emergency and Labor & Delivery Departments, revised 09/10/12, indicated that both departments would "maintain a complete and accurate daily log of all individuals who come to the emergency departments ...individuals who are not arrived in the electronic record who have presented to the emergency department seeking assistance will be documented directly on the log."

The hospital ' s policy Standards of Nursing Care in the Emergency Department, revised 08/01/14, indicated that "patients who choose to leave prior to having a Medical Screening Examination will be asked to sign a Declination of MSE form indicating reason for leaving."
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interview and document review, the hospital failed to provide a medical screening examination (MSE) for 1 of 20 patients (P20), who presented to the emergency department (ED) for evaluation of an emergency medical condition (EMC).
Findings include:

Nurse (H)/RN was interviewed on 09/23/14 at 7:30 a.m. Nurse (H)/RN stated he was the ED Charge nurse on 09/07/14 for the 11:00 p.m. - 7:30 a.m. shift. Sometime prior to 11:30 p.m. on 09/07/14 (exact time not recalled), Nurse/(H) received a call from Security that a patient had arrived to the ED waiting area. Nurse/(H) went to the ED waiting area to check on the patient. The patient was intoxicated. Two friends accompanied the patient. One of the patient's friends told Nurse/(H) that the patient had a history of alcoholism, had relapsed, and had consumed no food or fluid intake for 72 hours, other than alcohol. The friend stated the patient was dehydrated from alcohol consumption and needed to be seen. The friend expressed concern about the patient's relapse and asked for a detox bed. Nurse/(H) told the patient's friends that the hospital's detox beds were full, but the patient could be seen in an ED exam room. The friend stated they did not want to take the patient home with them. The friend asked if there was someplace else they could go. Nurse/(H) told the friend they could check with Community Outreach, which was open on weekdays. The friend told Nurse/(H) they were going someplace else and the patient and friends abruptly left the hospital.

The patient's Friend/(L) was interviewed on 09/26/14 at 8:15 a.m. Friend/(L) stated s/he accompanied P20 to the ED on 09/07/14. Another friend of P20's was also present. The two friends took P20 to the ED because P20 is chemically dependent on alcohol. P20 had not eaten or drank anything other than alcohol for three days. The two friends were concerned about P20's well-being. When they arrived at the hospital, there were no other patients in the ED waiting room. Within a minute, a nurse and security guard came into the waiting room and the nurse asked P20 why P20 needed to be seen. P20 was too intoxicated to answer. The other friend told the nurse about P20's chemical dependency to alcohol with a drinking relapse that had lasted three days. The other friend explained that P20 needed to detox and be re-hydrated. The nurse explained that the hospital had no detox beds available. The other friend asked the nurse if someplace else could treat P20. The nurse suggested Community Outreach, which was only open during daytime hours on weekdays. The other friend asked if there was anywhere else they could go right now. The nurse said the only option he was aware of was the emergency departments. Friend/(L) told the nurse that P20 needed to be seen for dehydration. The nurse offered P20 an exam in one of the ED exam rooms. Friend/(L) declined and told the nurse they were going someplace else. Friend/(L) stated the nurse wasn't very friendly and acted like P20 didn't belong there. The two friends left the hospital and took P20 to the ED at St. Joseph's Hospital.
Attempts to reach P20 for an interview were unsuccessful.

Physician/(G)/ED Medical Director was interviewed on 09/22/14 at 10:55 a.m. Physician/(G) stated he interviewed Nurse/(H) regarding P20's visit to the ED on 09/07/14. Although Nurse/(H) offered P20 a MSE, Nurse/(H) also made statements to P20 about the unavailability of detox beds, which is the role of physicians, not nurses. In addition, Nurse/(H) didn't have P20 sign a declination form, which is the hospital's protocol when a patient declines care in the ED. Physician/(G) stated that Nurse/(H) "behaved poorly" on 09/07/14.

ED Director (EDD)/(F) was interviewed on 09/22/14 at 8:45 a.m. EDD/(F) stated she became aware of a possible EMTALA violation by ED staff after St. Joseph's Hospital notified the University of MN Medical Center of a concern regarding a patient being denied care in the ED on the evening of 09/07/14. EDD/(F) stated she investigated the matter and learned that Nurse (H)/RN was the nurse who had encountered P20 in the hospital's ED waiting area on the evening of 09/07/14.
The recipient hospital's medical record indicated that P20 presented to the recipient hospital's ED on 09/08/14 at 12:04 a.m. for evaluation of alcohol intoxication. The patient's friends informed ED staff at the recipient hospital that P20 had a history of substance and alcohol abuse, with both inpatient and outpatient treatment. P20's friends told ED staff at the recipient hospital that this was P20's second relapse in 18 months and P20 had been consuming only alcohol for three days. P20 was examined in an ED exam room. P20's alcohol breath test was 0.290. P20's affect was blunt. P20's speech was slurred and delayed. P20 reported that s/he had no medical problems and normally took Zoloft daily, but had not taken any Zoloft for several days. P20 was given oral Ativan, Ibuprofen, and oral fluids and food. Crisis was consulted but P20 declined any assistance with chemical dependency. P20's friends would not take P20 home. No detox beds were available. P20 remained in the ED overnight until s/he was clinically sober. P20's alcohol breath test at 10:40 a.m. on 09/0914 was 0.033. P20 was discharged to home at 11:25 a.m. on 09/08/14.

The hospital's policy Emergency Medical Services (EMTALA), revised September 2012, indicated that a "MSE means physical assessment of an individual, within the capability of the hospital, sufficient to determine if an EMC exists...the MSE is the process required to reach with reasonable clinical confidence the point at which it can be determined whether an EMC does or does not exist...the MSE must be performed by individuals designated by the hospital's Board...Fairview currently designates ED physicians and OB nurses as Qualified Medical Providers...it is a violation for any Hospital to fail to perform a MSE on any patient coming into any Hospital or to fail to provide appropriate treatment for any individual that has an EMC."
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interview and document review, the hospital failed to ensure compliance with requirements at 42 CFR 489.24, as evidenced by the deficient practice cited at 42 CFR 489.24 (a) and (c).