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SHANDS LAKE SHORE REGIONAL MEDICAL CENTER 368 NE FRANKLIN ST LAKE CITY, FL 32055 June 12, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of the medical record, Security Incident report review, interviews and policy and procedure review the facility failed to ensure that an individual who comes to the emergency department (ED) be provided an appropriate medical screening examination within the capability of the of the hospital's ED including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition existed for 1 (#1) of 21 sampled patients.
This failure affected 1 of 23 sampled patients. Refer to findings in Tag A- 2406.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on the emergency department central log review, Security Incident report, review, policy and procedure review, and staff interviews it was determined the facility failed to maintain a central log on each individual who comes to the emergency department seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted , and treated, stabilized and treated or discharged for 1 (#1) of 21 sampled patients

Findings:

During an interview on 06/12/2019 at 10:09 AM, the Risk Manager stated he had been called by Patient #1, stating that on the weekend she had been turned away from entering the ED in the early morning of 05/26/2019 due to a lock-down. It was explained to the security guard she had an emergency, but was turned away. Patient #1, should have been allowed to enter the Emergency Department (ED) and be seen in the ED.

Review of the Security Incident revealed, reported in the early morning of 05/26/2019 from 4:43 a.m. to 5:33 a.m., a person had been turned away from the ED at the time of the lockdown.

During interviews on 06/12/2019 beginning at 11:20 AM through 12:15 PM with Staff A, Staff B, Staff C and Staff D, RNs it was stated that even if we have a lockdown we will have the patient sign in and will go out to the lobby and check them. We will bring the patient back into the ED to be triaged and have the ED physicians do a medical evaluation. We usually will not let anyone leave the ED until there is an all clear.

During an interview on 06/12/2019 at 2:36 PM, the Director of Facility Operation/Security stated a person did call the Risk Manager on the Monday after the weekend to state that she had been turned away from the ED after presenting to the ED for an allergic reaction. The Security Incident Report was reviewed with the Director of Facility operations and revealed, "Dated on 05/26/ showed at 4:43 AM received a call from admissions that we were to go on lock-down. Lock-down ended at 5:33 AM. Law enforcement had found suspect, cause of lock-down due to patient being stabbed." The Director of Facility Operation stated, "The expectation is that any patient should not be turned away from the ED even during a lock-down."

During a telephone interview on 06/12/19 at 2:50 PM Staff E, Security Guard stated she works for the contracted security firm as one of the security guards. She was the security guard on duty during the lock down on 05/26/2019. Staff E stated, "I did not know that it is against the law to turn people away when they come to the emergency room . We had a patient in the hospital who had been stabbed. The stabber was a female as told to me by the police. When this female person came to approach the hospital, I stopped her. She looked a little bit off at that time. I suspected she was the one who stabbed the male patient." Staff E stated this woman told her that she was having a bad allergic reaction and wanted to go to the Emergency Department (ED). I was told by the ED Nurses not to let anyone in. When asked to describe the female seeking emergency medical attention, Staff E stated that her face was very swollen, and her lips were swollen. I thought she was the perpetrator. When asked if she tried to call a nurse or someone to see and examine the patient; Staff E replied; "I should have done that, call the nurse, but I did not, now I know. I did not know that it is a law, no one had told me". When asked if she is aware of the facility's lock down policy, she stated; I did not know that it is a law to turn people away when they come to the ED." When asked why she did not call law enforcement, she did not answer. When asked if she had not allowed entry to other patients she stated, "No."

Review of the emergency central log for the date of 05/26/2019 revealed the name for Patient #1 was not documented on the log. The facility failed to ensure that their Policy and procedure was followed as evidenced by failing to enter patient #1's name on the facility's Emergency Department(ED) Central Log on 5/26/2019 when she presented to the ED seeking assistance for a medical condition.

Review of the facility's policy and procedure titled "EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening Stabilization Policy "A facility that is not on diversion status may not refuse or fail to accept an admission. If a patient arrives on campus, the facility must provide an MSE (Medical Screening Examination). Individuals coming to the ED must be provided an MSE.

Review of the facility's policy and procedure titled "Emergency Medical Treatment and Patient Transfer Policy" Central log means that the facility maintains all individuals who present to the facility seeking emergency medical assistance and the disposition of such individuals. The purpose of the central log is to track the care provided to everyone who comes to the facility seeking care for an EMC (Emergency Medical Condition). The EMTALA obligates the facility to provide medical screening, treatment and transfer for EMC. The facility must apply, in a non-discriminatory manner and regardless of ability to pay, a screening process that is reasonably calculated to determine whether an EMC exists.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on review of the medical record, Security incident report review, interviews and policy and procedure review the facility failed to ensure that an individual who comes to the emergency department be provided an appropriate medical screening examination within the capability of the of the hospital's ED including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition existed for 1 (#1) of 21 sampled patients.

Findings:

Review of the Security Incident revealed, reported in the early morning of 05/26/2019 from 4:43 a.m. to 5:33 a.m., a person had been turned away from the ED at the time of the lockdown.

During an interview on 06/12/2019 at 10:09 AM, the Risk Manager stated he had been called by Patient #1, stating that on the weekend she had been turned away from entering the ED in the early morning of 05/26/2019 due to a lock-down. It was explained to the security guard she had an emergency, but was turned away. This person, Patient #1, should have been allowed to enter the ED and be seen in the ED.

During an interview on 06/12/2019 at 12:05 PM, Staff F, LPN (Licensed Practical Nurse) stated, I have been in the ED for many years. If told we are on lockdown; yes it is something to know, but it really doesn't change much except for not letting patients/family leave for safety.

During an interview on 06/12/2019 at 10:40 AM, the Director of the ED an RN, (Registered Nurse) stated, that even if we have a lockdown in the ED or main hospital, patients can still walk into the ED lobby and sign in to be evaluated. Even in a lockdown the assigned RN for triage will do rounds if there are patients in the waiting room. Staff has at times gone out to the parking lot, but never off the facility premises and with security or police. Again, the ED lobby is never locked, and patients can still walk in and be medically screened even during a lockdown. My staff should never tell anyone including security that no one is to come into the ED during lockdown. All staff gets training in EMTALA (Emergency Medical Treatment and Labor Act) annually and at orientation.

During an interview on 06/12/2019 at 2:36 PM, the Director of Facility Operation/Security stated a person did call the Risk Manager on the Monday after the weekend to state that she had been turned away from the ED after presenting to the ED for an allergic reaction. The Security Incident Report was reviewed with the Director of Facility operations and revealed, "Dated on 05/26/ showed at 4:43 AM received a call from admissions that we were to go on lock-down. Lock-down ended at 5:33 AM. Law enforcement had found suspect, cause of lock-down due to patient being stabbed." The Director of Facility Operation stated, "The expectation is that any patient should not be turned away from the ED even during a lock-down."

During a telephone interview on 06/12/19 at 2:50 PM Staff E, Security Guard stated she works for the contracted security firm as one of the security guards. She was the security guard on duty during the lock down on 05/26/2019. Staff E stated, "I did not know that it is against the law to turn people away when they come to the emergency room . We had a patient in the hospital who had been stabbed. The stabber was a female as told to me by the police. When this female person came to approach the hospital, I stopped her. She looked a little bit off at that time. I suspected she was the one who stabbed the male patient." Staff E stated this woman told her that she was having a bad allergic reaction and wanted to go to the Emergency Department (ED). I was told by the ED Nurses not to let anyone in. When asked to describe the female seeking emergency medical attention, Staff E stated that her face was very swollen, and her lips were swollen. I thought she was the perpetrator. When asked if she tried to call a nurse or someone to see and examine the patient; Staff E replied; "I should have done that, call the nurse, but I did not, now I know. I did not know that it is a law, no one had told me". When asked if she is aware of the facility's lock down policy, she stated; I did not know that it is a law to turn people away when they come to the ED." When asked why she did not call law enforcement, she did not answer. When asked if she had not allowed entry to other patients she stated, "No."

During an interview on 06/12/2019 at 2:50 PM the DSI Security Officer Staff on duty currently stated, he has worked at the facility for around four years, but works for DSI Security. The Security Officer states knowing not to ever stop anyone going into the ED even in lockdown. He further stated, EMTALA training is given annually and more if needed.

The medical record from facility #2 for patient #1 was reviewed. The medical record showed that patient #1 walked into the ED lobby on 05/26/19 at 5:26 A.M., and signed in. The patient's chief complaint is severe lip swelling on left side of face impacting mouth, lips and tongue. The patient's vital signs at 5:27 A.M. was listed as: Blood Pressure: 134/80; Pulse: 94; Temperature: 36.9; Respirations-19; and oxygen saturation on room air was 99%.
At 5:28 A.M. the patient was taken to a room immediately and her ESI (Emergency Severity index- for patients identified with life threatening conditions are taken directly to a room and immediate physician's intervention is requested. Usually to do with high risk situations (time sensitive diagnosis) level was 2- Emergent. At. 5:29 AM, physician in to see patient, intravenous fluids given. Review of the emergency department medication administration record for Hospital B for Patient #1 revealed Diphenhydramine HCL (anti histamine- used to relieve symptoms of allergy 50 mg. (milligrams) IV (intravenously) times two doses for a total of 100 mg. Epinephrine 0.3 mg (medication used in emergencies to treat very serious reactions) subcutaneous times two doses, Epinephrine 0.5 ml inhalation times two doses. Dexamethasone Sodium Phosphate (steroid used to treat severe allergic reactions and reduces inflammation) 10 mg IV. Methylprednisolone (used to treat severe allergic reactions) 125 mg IV. Additionally, Potassium 20 meq in 100 ml of normal saline was administered for a Potassium level of 2.9 which was low.

A review of the section of the medical record titled History and Physical -showed in part, Presentation: Chief Complaint Allergic reaction. Additional Context - Severe lip swelling left sided, started at midnight, took 25 of Beady. Review of Systems Skin: Swelling (left lips/perioral/tongue). Basic Physical Exam - Moderate to severe swelling of the left upper and lower lip, mild apparent left ligular (part of tongue) swelling ...no noted breathing or current airway compromise..." Further review of the record revealed that at 8:47 AM, the patient was admitted to Facility# 2 to an in -patient room with a diagnosis of Angioedema of lips (dermal subcutaneous or submucosal swelling that is acute, painless and of short duration. It may involve the face, neck, lips, larynx. Can be heredity or from food/drug allergy. Treatment usually consists of subcutaneous injections of epinephrine, intubation or a tracheotomy to prevent respiratory obstruction). The facility failed to ensure that their policy and procedure were followed as evidenced by failing to provide an appropriate medical screening examination for patient #1 on 5/26/2019 who presented to the hospital campus for a medical evaluation in order to determine whether or not an emergency medical condition existed .Review of the facility's policy and procedure titled "EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening Stabilization Policy "A facility that is not on diversion status may not refuse or fail to accept an admission. If a patient arrives on campus, the facility must provide an MSE (Medical Screening Exam). Individuals coming to the ED must be provided an MSE.

Review of the facility's policy and procedure titled "Emergency Medical treatment and Patient Transfer Policy" The EMTALA obligates the facility to provide medical screening, treatment and transfer of EMC (Emergency Medical Condition). The facility must apply, in a non-discriminatory manner and regardless of ability to pay, a screening process that is reasonably calculated to determine whether an EMC exists.