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|NORTHWEST HOSPITAL CENTER||5401 OLD COURT ROAD RANDALLSTOWN, MD 21133||Sept. 25, 2019|
|VIOLATION: MEDICAL SCREENING EXAM||Tag No: A2406|
|Based on a review of 26 closed medical records, sampled from a 10-day period in September 2019, staff interviews and policies and procedures, it was determined that the hospital's emergency department (ED) did not provide appropriate medical screening exams and had inappropriate delays in treatments, labs, and imaging in 10 of the 26 records reviewed. A sample of 3 patients are listed below.
The hospital used a Provider in Triage (PIT) during the peak hours of every day. The PIT may be on-site or remote (tele-PIT) and accessed by a video link. According to the Medical Director (MD) of the ED, in an interview on 9/24/19 at 2 PM, the provider on-site may be a mid-level (PA-C or CRNP) or physician and the provider for tele-PIT is a mid-level. The tele-PIT has the capability to look at the patient and ask questions but cannot do a physical examination. According to the MD, the tele-PIT is to use a RN to perform a physical examination if one is needed, and also has the option of calling an on-site provider from the main ED to consult on the patient.
When asked, the hospital has no policy defining the use and limitations of the tele-PIT providers. The hospital did provide PIT guidelines which did not clearly delineate the difference between on-site PIT and tele-PIT.
During observations in the Emergency Department on 9/24/19 at 9:30 am, it was noted that a patient was brought over to the TelePIT screen for assessment. During this examination, the provider was able to verbally interact with the patient, however a physical examination was not able to be performed. No other staff members, RN or MD, were present during the examination, therefore the physical portion of the assessment was not completed.
An interview was conducted with the Medical Director of the Emergency Department (ED) on 9/24/2019 at 2:00 PM. The director stated it was within the capability of the tele-PIT to order labs and imaging, however that process has been curtailed due to over utilization.
The following are examples of delayed MSEs:
1) Patient #1 (P1) was a 60+ year old patient who was transported to the Emergency Department (ED) via Emergency Medical Services (EMS) with complaints of chest pain and shortness of breath. The patient was evaluated by the tele-PIT provider. The patient was not physically evaluated by the ED physician for over 6 hours from arrival to the ED. When the on-site physician saw the patient, labs were ordered STAT (immediately) but were not completed for an additional 2 hours.
2) Patient #4 (P4) was a 70+ year old patient who was transported to the ED by EMS with complaints of severe abdominal pain and distention (swelling), slurred speech and shortness of breath. The patient's medical history was significant for an aneurysm, cardiac issues, and renal failure. The ED physician did not assess the patient until 5+ hours after arrival and it wasn't until that time that the Urgent Stroke Protocol was activated. This caused a delay in the collection of pertinent bloodwork and a CT scan to rule out a potential stroke. The patient was found to be in fluid overload. Documentation in the records indicates numerous phone calls to the Internal Medicine (IM) physician to admit the patient, however, staff couldn't reach the IM for admission orders for 3 hours.
3) Patient #5 (P5) was a 65+ year old patient who was transported to the ED by EMS with complaints of chest pain. Per the medical record, P5 had a history of cardiac issues. The patient was seen by the PIT, however the ED physician did not evaluate the patient for over 7 hours from the time of arrival. An EKG was ordered STAT by the PIT, however it was not completed for almost 2 hours after the order was placed. Furthermore, vital signs were taken in triage on arrival, but not repeated for almost 6 hours.
The chief complaints for most of these patients were potentially life threatening. Without a timely Medical Screening Exam (MSE), there was no way to identify whether someone's presenting symptoms represented a true medical emergency. Based on documentation, it was unclear, given the physical and procedural limitations on the tele-PIT providers, if that system suffices for a MSE.