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UNIVERSITY OF NEW MEXICO HOSPITAL 2211 LOMAS BOULEVARD NE ALBUQUERQUE, NM 87106 April 26, 2012
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, document review, and medical record review, the hospital failed to determine if an emergency medical condition existed for 20 of 20 (#1-20) sampled patients. As a result, the hospital could not ensure that each of the patient's needs would be monitored and met until the patient was stabilized or transferred. The findings are:

A. Review of the medical record of Patient #1 revealed that the patient had presented at the Emergency Department on 04/05/12 at 15:00 (3:00 pm), stating that she was experiencing upper abdominal pain, increasing abdominal distention, pelvic pain, constant diarrhea, and had vomited in the morning. The record indicated that a registered nurse completed a triage of the patient at 15:37 (3:37 pm), identifying the patient's "tracking acuity" as "C" and her "tracking group" as "E-D."

B. Further review of the medical record of Patient #1 revealed that she was first seen by a physician on 04/06/12 at 07:00. A physician Progress Note, written on 04/06/12 at 14:00 (2:00 pm), states, "Pt [patient] initially seen at 07:00 in flow briefly then 08:00 following rounds to complete exam. During encounter pt explicitly denied SI [suicidal ideation] or plans. While waiting for RUQ US [right upper quadrant ultra sound] pt evidently took 2/3 of a 180 pill 40 mg propranolol [antianginal beta blocker] Rx. This was per the mother who reported it to me. I immediately called PC [Poison Control] to ask about the appropriateness of lavage. They agreed that it should be initiated. Pt initially refused lavage but in 5 min agreed. Pt was immediately transferred to rsus [resuscitation] where she was cooperative with placement of the lavage tube." The medical record showed that the patient coded and "became pulseles [sic]" and "unresponsive to multiple attempts at ressusciatation [sic]." An "Adult Cardiopulmonary Resuscitation Record," dated 04/06/12, indicated that the code ended on 04/06/12 at 1349 (1:49 pm), "mother at bedside."

C. In interview on 04/17/12 at 8:50 am, the Chair of the Department of Emergency Medicine, the Associate Dean for Clinical Affairs at the School of Medicine, and the Chief Nursing Officer stated that the medical screening exam (MSE) is "started" by the triage nurse and continues until a physician sees the patient and "completes" the MSE. They stated that the hospital uses a modified Emergency Severity Index (ESI) to classify the acuity level of a patient's condition, with A as the most acute and E as the lowest level of acuity.

D. Review of a form entitled "Medical Screening Exam" revealed three categories (classifications) in a vertical column, identified by number as "1," "2," and "3." At the top of the vertical column, under the word "Category," the words "circle one" appears in small print in parentheses. The "Criteria" for Category 1 is "Triage category B. Vital signs abnormal or condition suggesting emergent condition." The Criteria for Category 2 is "Triage category C or LOWER. Potentially emergent condition that should be evaluated in the ED." The Criteria for Category 3 is "Medically stable with NO obvious emergent condition." An open box in the lower right hand corner of the form contains the words "Patient Label."

E. In interview on 04/24/12 at 4:30 pm, the Executive Director of Emergency Services, Associate Dean for Clinical Affairs, and Director of Emergency Services reiterated that the triage nurse "starts" the MSE. When the RN surveyor responded that the EMTALA requirements do not contain a provision for an individual to be qualified to "start" the MSE, but another individual (a physician) to complete the MSE, the Associate Dean for Clinical Affairs stated that the Emergency Department triage nurses are qualified in the hospital bylaws to conduct the MSE.

F. Review of the hospital policy entitled "Hospital Board of Trustees-Medical Screening Examinations," with an effective date of 01/29/10, revealed that the "following individuals shall be allowed to perform MSE's: physicians (to include house officers); nurse practitioners; physician's assistants; and registered nurses trained to perform MSE's and acting within the scope of the New Mexico Nursing Practice Act."

G. Review of the medical records of patients #1-20 revealed no documented evidence in any of records that a qualified medical person -- nurse, physician, or other clinician identified as qualified by the hospital -- determined that the patient either had an emergency medical condition or did not. None of the records contained the "Medical Screening Exam" form, either as a blank form or as a completed one.

H. On 04/26/12 at 10:00 am, the Chair of the Department of Emergency Medicine submitted to the State Agency a document that he titled "Clarification of Medical Screening Exam in the case of EMTALA investigation - Patient [#1]. The document states, in part, the following: "The patient (MDS) dated [DATE] at 1500 [3:00 pm] with a primary chief complaint of abdominal pain which was chronic in nature. She was immediately triaged by a nurse at the Pivot Station, assigned a triage category of "C", and normal vital signs were documented on the Pivot Sheet. At 1537 [3:37 pm] the medical screening exam was initiated in the Sub-Triage Care Area by the same nurse that conducted her triage at the Pivot Station. ... This nurse is a qualified medical provider to conduct medical screening exams within the scope of her New Mexico licensure per [hospital] policy. As part of this process, she ordered the following laboratory studies at 1546 [3:46 pm]: CBC, chemistry 7, urinalysis, liver function tests, and lipase. These studies were ordered under the Nurse-Initiated-Provider guidelines established by the Medical Director for the Emergency Department. The results of these labs were reviewed by the same nurse at 20:02 [8:02 pm]. ... The nurse determined that this patient did not have an emergent medical condition. The patient subsequently received resident and attending physician evaluations which concurred with the determination that the patient did not have an emergent medical condition."

I. Review of a document entitled "CHART ACCESS FOR A SPECIFIC PATIENT" revealed that an Emergency Department nurse accessed the chart of Patient #1 on 04/05/12 at 20:02 (8:02 pm). The documented indicated that on that date and time the nurse used a computer keyboard tab to access Patient #1's chart for the purpose of a doing a "Results Review." The document was not in evidence in the medical record of Patient #1.

J. In interview on 04/26/12 at 11:00 am, the Chair of the Department of Emergency Medicine, when asked if the medical record of Patient #1 contained documented evidence of the determination that Patient #1 did not have an emergency medical condition, replied that it did not contain such evidence. He stated that none of the medical records of patients treated in the Emergency Department include a written, explicit indication that a qualified medical person has determined whether the patient has an emergency medical condition. He added that the medical records themselves also do not identify the date and time of such a determination.