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Based on review of Medical Staff Bylaws and Rules and Regulations, hospital EMTALA (Emergency Medical Treatment and Labor Act) policy and procedure, medical records and interview, it was determined Vaughn Regional Medical Center Parkway Campus failed to:

1. Identify and approve individual(s) qualified to perform the medical screening examination (MSE) in the facility medical staff bylaws or rules and regulations. This had the potential to affect all patients presenting to the emergency department (ED).

2. Document that risks of leaving and the benefits of staying to complete the medical screening exam and receive stabilizing treatment were explained to one of four patients that left the hospital emergency department ED against medical advice (AMA). This deficient practice affected Patient Identifier # 5 and had the potential to affect all patients leaving AMA.

Refer to A2406 and A2407 for findings.

Based on medical record (MR) review, Medical Staff Bylaws and Rules and Regulations, hospital procedure and interview, it was determined the hospital failed to provide a medical screening exam (MSE) by qualified medical personnel (QMP) for patients presenting to the emergency department (ED).

This deficient practice affected five (5) of 21 MR's reviewed, including Patient Identifier (PI) # 19, PI # 14, PI # 3, PI # 1, and PI # 4, and had the potential to affect all patients presenting to the ED seeking a MSE for evaluation of an emergency medical condition (EMC).

Findings include:

Hospital Policy: Emergency Medical Treatment and Labor Act (EMTALA) - Screening, Stabilizing, and Transferring Procedures for Patients with Emergency Conditions, 02-780-0064
Policy Number: 1154531
Last Revised: 11/2013
Approved: 04/2022

Procedure:

Part I: Screening Procedures

Whenever an individual comes to the hospital ED requesting an examination or treatment, a physician or other QMP, as determined and stated in writing by the hospital board of trustees, must screen the individual to determine whether an emergency condition exists.

Hospital Rules and Regulations:

Article VI: Emergency Medical Screening, Treatment, Transfer, and On-Call Roster Policy

Screening, Treatment and Transfer

6.1 (a) Screening:

...(3) All patients shall be examined by QMP, which shall be defined as a physician trained in emergency medicine, or in the case of a woman in labor, a registered nurse trained in obstetric nursing pursuant to hospital policy...who may determine true, false or no labor but may not make a medical diagnosis.

1. PI # 19 presented to the ED via private car on 6/19/24 at 3:57 PM with a chief complaint of right hip pain.

Review of the MR revealed PI # 19 received a MSE at 4:04 PM by a certified registered nurse practitioner (CRNP) and not a physician as required in the hospital Rules and Regulations.

An interview was conducted on 9/12/24 at 1:58 PM with Employee Identifier (EI) # 2, ED Medical Director and Chief Medical Officer, who confirmed the hospital Rules and Regulations/Bylaws failed to include mid-level practitioners (CRNPs and Physician Assistants) as QMP.

2. PI # 14 presented to the ED via private car on 7/15/24 at 9:03 PM with a chief complaint of a cut on the right hand.

Review of the MR revealed PI # 14 received a MSE at 9:06 PM by a CRNP.

An interview was conducted on 9/12/24 at 1:58 PM with EI # 2 who confirmed the hospital Rules and Regulations/Bylaws failed to include mid-level practitioners as QMP.

3. PI # 3 presented to the ED via private car on 8/23/24 at 2:48 PM with a chief complaint of pain in the right arm, nausea and vomiting.

Review of the MR revealed PI # 3 received a MSE at 2:51 PM by a Physician Assistant (PA).

An interview was conducted on 9/12/24 at 1:58 PM with EI # 2 who confirmed the hospital Rules and Regulations/Bylaws failed to include mid-level practitioners as QMP.

4. PI # 1 presented to the ED via private car on 8/23/24 at 10:54 PM with a chief complaint of chest pain and spitting up blood.

Review of the MR revealed PI # 1 received a MSE at 11:07 PM by a PA.

An interview was conducted on 9/12/24 at 1:58 PM with EI # 2 who confirmed the hospital Rules and Regulations/Bylaws failed to include mid-level practitioners as QMP.

5. PI # 4 presented to the ED via private car on 9/10/24 at 8:56 AM with a chief complaint of chest pain and nausea.

Review of the MR revealed PI # 4 received a MSE at 8:56 AM by a CRNP.

An interview was conducted on 9/12/24 at 1:58 PM with EI # 2 who confirmed the hospital Rules and Regulations/Bylaws failed to include mid-level practitioners as QMP.

Based on medical record (MR) review, hospital policy and staff interview, it was determined the hospital failed to document the specific medical risks and benefits of leaving the hospital emergency department (ED) before completing the medical screening exam (MSE) and receiving stabilizing treatment.

This deficient practice affected one of four patients reviewed who left AMA (against medical advice), including Patient Identifier (PI) # 5, and had the potential to affect all patients leaving the hospital ED AMA.

Findings include:

Hospital Policy: Patient Leaving AMA
Policy Number: 03-780-0007
Approved Date: 05/2024

Purpose:

Establish criteria for documentation of patients leaving AMA.

Policy:

All patients indicating the desire to leave AMA shall sign an AMA form.

- The Registered Nurse and/or physician shall discuss, with the patient and/or family, the potential complications that may occur if the patient leaves prior to the physician discharging the patient.
- The AMA form shall state the possible consequences.
... - Document the patient's desire to leave AMA, conversations on potential complications and patient's condition prior to leaving the ED.

1. PI # 5 presented to the ED via emergency medical service on 8/24/24 at 1:04 AM with a chief complaint of Motor Vehicle Crash, Chest Pain and Body Ache.

Review of PI # 5's MR revealed PI # 5 received a MSE by the ED physician at 2:12 AM, and then left AMA after ordered labs were collected.

Review of the AMA form revealed PI # 5 signed the form at 2:42 AM. "Other" was checked under both Medical Risks and Medical Benefits. There was no description of the specific medical risks of leaving AMA nor the benefits of staying to complete the MSE and receiving stabilizing treatment documented on the AMA form.

An interview was conducted on 9/12/24 at 4:06 PM with Employee Identifier # 1, ED Director, who confirmed the specific risks and benefits before leaving AMA were not documented.