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ST MARY'S MEDICAL CENTER 901 45TH ST WEST PALM BEACH, FL 33407 Jan. 28, 2020
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of medical records, video surveillance review, policy and procedure review, and staff interviews, it was determined the facility failed to ensure that an appropriate medical screening examination was provided as required, that was within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for one (Patient #1) of 20 sampled patients.

The findings included:

Refer to findings at A2406.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on observation, clinical record review, video surveillance review, Grievance Log, policy and procedure review, and staff interviews, it was determined the facility failed to ensure each individual who comes to the emergency department (ED) / hospital seeking assistance was included on the central log in the ED, for 1 of 20 sampled patients (Patient #1), as evidenced by lack of evidence on the ED log the patient had presented to the ED for assistance.

The findings included:

Facility policy titled Emergency Treatment and Labor Act, last approved 08/2019 documents, "The purpose of this policy is to set forth policies and procedures for hospital's use in complying with the requirements of the Emergency Medical treatment and Labor Act (EMTALA).
Definitions:
Comes to the emergency room , for purposes of this policy, an individual is deemed to have come to the emergency department if the individual meets at least one of the following requirements. Presents at a dedicated emergency department, and requests examination of treatment for a medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition.
Presents on Hospital property, other than a dedicated emergency department, and requests examination or treatment for what may be an emergency medical condition, or as such a request made on his or her behalf. In the absence of such a request be or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs emergency examination or treatment ....
Central Log ... The Hospital must maintain a central log of individuals who come to the emergency department and include in such log individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted , stabilized, and/or were discharged . The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE (medical screening evaluation) ..."

Observation of the facility Emergency Department (ED) entrance conducted on 01/27/20 at 9:30 AM revealed upon entering the building, there is a reception desk located in the middle of the hallway, and there are two doors: one to the right for the adult emergency room lobby and one to the left for the pediatric emergency room lobby. All patients and visitors have to stop at this desk to obtain a pass to enter the ED and the main hospital.

Interview with the Greeter, who sits at the desk located by the entrance to the ED, conducted on 01/27/20 at 9:43 AM, revealed her duties are to give visitors and patients an identification pass prior to entering the facility. She said if a patient presents with a medical emergency, she directs them to the adult or pediatric emergency room or calls for assistance.

Review of the Grievance Log revealed an entry related to Patient #1, dated 01/21/20. The grievance documents Patient #1 is a neurologist and his spouse was out of town so he drove himself to the emergency department with stroke like symptoms. When he arrived, he states that he was disoriented and slurring his words, so he asked to see Dr. M.... He stated that three staff members did not intervene so he showed his business cards and Dr M...'s business card to them, he felt that a medical person should have assessed him. He attributes his devastating diagnosis to delaying his care because he felt the three people did not recognize the symptoms. He drove himself back home and then returned later in the afternoon to the ED.

Review of the surveillance video conducted on 01/27/20 at approximately 10:45 AM revealed on 12/24/19 at 7:36 AM, Patient #1 presented to the facility through the emergency department entrance and approached the reception desk, and there were three staff members at the desk. The patient was observed interacting with the staff and leaving the facility at 7:46 AM. The surveillance video has no audio capability.

Review of the ED Central Log, dated 12/24/19, failed to capture Patient #1's first visit to the ED on 12/24/19 at 7:36 AM. The registry indicates the patient arrived on 12/24/19 at 2:29 PM via car with chief complaint of potential stroke.

Interview conducted with Staff H, the Greeter, identified by the surveillance video, on 01/27/20 at 10:54 AM, revealed that Staff H recalls Patient #1 walked in through the emergency room entrance and asked for doctor M... The patient handled her his business card. It was not clear what he wanted; he was mumbling something, it was odd. The patient stood there for a while, and she could not understand him but tried to assist him. The greeter confirmed that at no point did she contact clinical staff from the emergency department to assist the patient. The greeter stated, "I did not put two and two together", the patient was a physician, looking for another physician. "I do know the signs of a stroke and also know that every person may have different symptoms". The patient did not talk very much, he looked kind of normal, he was calm, but I could not understand him. Then she said, she thought maybe he was waiting for something or someone. There were two other staff members in the area, a security guard and a lift coach. The greeter reiterated "I honestly know the signs of a stroke" and felt she probably should have called someone from the emergency department but the fact that the patient was a physician looking for another physician threw her off.

Interview with Staff I, the Security Guard, conducted on 01/27/20 at 11:09 AM, revealed the greeter and he had discussed the incident related to Patient #1. The patient was of Indian descent and came in through the emergency department entrance, he came in walking normal, asking for Dr. M... He recalls the patient did not talk much, but it was difficult to understand him. The patient was weird, he stood around for a while and was asked if he wanted to go to the emergency department and he said no and walked out.

Interview conducted with Staff J, the Lift Coach, on 01/27/20 at 2:06 PM, revealed her recollection of Patient #1 was that he was pretty quiet, did not say much, looked like he had a language barrier, and it was difficult to understand him. Staff J stated she was not sure if he spoke English or what, don't remember specifics of the conversation with the greeter, but knows that she was trying to help him, but the patient did not say much.

The ED central log provided no evidence the facility documented Patient #1, as presenting to the hospital for examination and treatment, as required to stabilize the medical condition during his first visit to the ED on 12/24/19 at 7:36 AM. The staff involved described the patient as odd, weird, mumbling speech and with language barrier but at no point was a clinical staff summoned to assist Patient #1.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on observation, clinical record review, video surveillance review, policy and procedure review, and staff interviews, it was determined the facility failed to ensure that an appropriate medical screening examination was provided as required, that was within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for one 1 of 20 sampled patients, (Patient #1).

The findings included:

Facility policy titled Emergency Treatment and Labor Act, last approved 08/2019 documents "The purpose of this policy is to set forth policies and procedures for hospital's use in complying with the requirements of the Emergency Medical treatment and Labor Act (EMTALA).
Definitions:
Comes to the emergency room , for purposes of this policy, an individual is deemed to have come to the emergency department if the individual meets at least one of the following requirements. Presents at a dedicated emergency department, and requests examination of treatment for a medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition.
Medical Screening Examination or MSE means the screening process required to determine with reasonable clinical confidence whether an emergency condition does or does not exist.
To stabilize means: with respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer or discharge of the individual from the hospital.

Policy:
If an individual comes to the Emergency Department as defined above: The hospital will provide an appropriate medical screening examination within the capability of the hospital or dedicated emergency department, including ancillary services routinely available, to determine whether or not an emergency medical condition exists.
The hospital will not base the provision of emergency services and care upon an individual's race, ethnicity, religion, national origin, culture, language, age, sex, preexisting medical condition, physical or mental disability, insurance status ..., except to the extent that a circumstance is relevant to the provision of appropriate medical care.
The hospital will either provide an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to stabilize the emergency medical condition or arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below, while providing stabilizing treatment according to the hospital's capability.

Triage and Registration:
Triage, as soon as practical after arrival, individuals who come to the emergency department as defined above should be triaged in order to determine the order in which they will receive a medical screening examination. Triage is not a medical screening examination, as it does not determine the presence or absence of an emergency medical condition, but rather, simply determines the order in which individuals will receive a medical screening examination.

Registration: Qualified medical personnel are not precluded from contacting the individual's physician at any time to seek advice regarding medical history and needs that may be relevant to the medical treatment and screening of the individual, as long as this consultation does not inappropriately delay services required.

Medical Screening Examination:
The hospital shall provide a medical screening examination to any individual who comes to the Emergency Department as defined above.
The medical screening examination is the examination of the patient by the Qualified Medical Person required to determine within reasonable clinical confidence whether an emergency medical condition does or does not exist. The examination should be tailored to the patient's complaint and depending on the presenting symptoms.
Monitoring must continue until the individual is stabilized or appropriately admitted or transferred. The medical screening examination, and ongoing patient assessment, must be documented in the medical record."


Observation of the facility Emergency Department (ED) entrance conducted on 01/27/20 at 9:30 AM revealed upon entering the building, there is a reception desk located in the middle of the hallway, and there are two doors: one to the right for the adult emergency room lobby and one to the left for the pediatric emergency room lobby. All patients and visitors have to stop at this desk to obtain a pass to enter the ED and the main hospital.

Interview with the Greeter, who sits at the desk located by the entrance to the ED, conducted on 01/27/20 at 9:43 AM, revealed her duties are to give visitors and patients an identification pass prior to entering the facility. She said if a patient presents with a medical emergency, she directs them to the adult or pediatric emergency room or calls for assistance.

Review of the Grievance Log revealed an entry related to Patient #1, dated 01/21/20. The grievance documents Patient #1 is a neurologist and his spouse was out of town so he drove himself to the emergency department with stroke like symptoms. When he arrived, he states that he was disoriented and slurring his words, so he asked to see Dr. M.... He stated that three staff members did not intervene so he showed his business cards and Dr M...'s business card to them, he felt that a medical person should have assessed him. He attributes his devastating diagnosis to delaying his care because he felt the three people did not recognize the symptoms. He drove himself back home and then returned later in the afternoon to the ED.

Review of the surveillance video conducted on 01/27/20 at approximately 10:45 AM revealed on 12/24/19 at 7:36 AM, Patient #1 presented to the facility through the emergency department entrance and approached the reception desk, and there were three staff members at the desk. The patient was observed interacting with the staff and leaving the facility at 7:46 AM. The surveillance video has no audio capability.

Review of the ED Central Log, dated 12/24/19, failed to capture Patient #1's first visit to the ED on 12/24/19 at 7:36 AM. The registry indicates the patient arrived on 12/24/19 at 2:29 PM via car with chief complaint of potential stroke.

Interview conducted with Staff H, the Greeter, identified by the surveillance video, on 01/27/20 at 10:54 AM, revealed that Staff H recalls Patient #1 walked in through the emergency room entrance and asked for doctor M... The patient handled her his business card. It was not clear what he wanted; he was mumbling something, it was odd. The patient stood there for a while, and she could not understand him but tried to assist him. The greeter confirmed that at no point did she contact clinical staff from the emergency department to assist the patient. The greeter stated, "I did not put two and two together", the patient was a physician, looking for another physician. "I do know the signs of a stroke and also know that every person may have different symptoms". The patient did not talk very much, he looked kind of normal, he was calm, but I could not understand him. Then she said, she thought maybe he was waiting for something or someone. There were two other staff members in the area, a security guard and a lift coach. The greeter reiterated "I honestly know the signs of a stroke" and felt she probably should have called someone from the emergency department but the fact that the patient was a physician looking for another physician threw her off.

Interview with Staff I, the Security Guard, conducted on 01/27/20 at 11:09 AM, revealed the greeter and he had discussed the incident related to Patient #1. The patient was of Indian descent and came in through the emergency department entrance, he came in walking normal, asking for Dr. M... He recalls the patient did not talk much, but it was difficult to understand him. The patient was weird, he stood around for a while and was asked if he wanted to go to the emergency department and he said no and walked out.

Interview conducted with Staff J, the Lift Coach, on 01/27/20 at 2:06 PM, revealed her recollection of Patient #1 was that he was pretty quiet, did not say much, looked like he had a language barrier, and it was difficult to understand him. Staff J stated she was not sure if he spoke English or what, don't remember specifics of the conversation with the greeter, but knows that she was trying to help him, but the patient did not say much.

Interview with the Director of the ED and the Director of Patient Safety on 01/28/20 at 10:34 AM revealed the Director was aware of the incident involving Patient #1, and that the guest relations staff interacted with the patient and it did not involve the ED staff, so she is not aware of details of the circumstances around it, the investigation was completed by the Guest Services Manager. The Director was asked what her thoughts were, regarding the current patient flow to get into the ED, and confirmed the guest service area is an additional step for patients needing to go in the ED. The patients go to the guest service desk and get a patient pass, no registration occurs at that time. Then, patients have to go in the ED area for registration and triage.
The Director of Patient Safety explained since the grievance related to Patient #1, the facility is reviewing how patients come in the ED and identified the extra step of having to stop at that guest desk is not delaying care but is an added step, not necessary. The facility is discussing the process to add ropes to direct patients directly into the ED, so visitors and patients will be separated. The director said the leadership team talked about it again yesterday and are fine tuning the details of the process, working on the logistics.

Further review of the record indicates Patient #1 returned to Emergency Department (ED) on 12/24/20 at 2:29 PM with chief complaint of Potential Stroke, difficulty speaking with history of Cerebrovascular Accident (CVA) with previous left side facial droop. The CT (Computed Tomography) of the head documented evolving left MCA (Middle Cerebral Artery) infarct, Acute Infarct of the left caudate head not well seen, no intracranial hemorrhage. The ED physician consulted the stroke team, neurointerventional and neurology; and diagnosed the patient with stroke symptoms. Patient #1 was subsequently admitted .

The records provided for review during the investigation failed to reveal evidence the facility provided Patient #1, an appropriate medical screening examination within the capabilities of the staff and facilities available at the hospital, for his medical condition during his first visit to the ED on 12/24/19 at 7:36 AM., at no point was a clinical staff summoned to assist Patient #1 to determine whether or not an EMC existed.