HospitalInspections.org

Based on observation and interview, the facility failed to post conspicuously the required signage (per section 1867 of the Social Security Act) specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC) and women in labor and whether or not the hospital participated in the Medicaid program under a State plan (under Title XIX). The hospital failed to :

*Post required signage at the back entrance to the Emergency Room (ER);

*Post signage in a manner that was noticeable and visible to individuals waiting for ER examination and treatment (front lobby entrance to ER ).

Findings include:

TX 00284296

Ambulance/Back ER Entrance:

Observation on 04-20-18 between 10 a.m. and 11:00 a.m. with ER Registered Nurse (RN) # 8 revealed an ambulance entrance in the back of the hospital. On the exterior brick wall was a large red sign affixed to the building that said: "EMERGENCY."

Interview with RN # 8 at the time of observation she stated this was one of two (2) entrances to the hospital ER. She went on to say that after hours, the front doors to the hospital were locked and signage directed patients to this back entrance for emergency treatment.

Further observation at this same time failed to reveal the required signage concerning EMC, women in labor, and hospital participation in Medicaid program.


Front lobby ER Entrance:

Observation on 04-20-18 at 11:30 a.m in the front hospital lobby revealed a registration desk. The door to the ER was located to the left of the registration desk.

On a large wall to the left of the registration desk were multiple framed documents. One of the framed documents contained the required verbiage concerning EMC, women in labor, and hospital participation in Medicaid program.

The sign measured 10 x 12 inches and the font size was small. The sign was located approximately 15 feet from the registration desk. At the time of observation surveyor and the Chief Nursing Officer (CNO) # 2 were unable to read the words on the sign.

Interview on 04-23-18 at 1:10 p.m. with Chief Executive Officer (CEO)# 1 she reported she was unaware of the "visible from 20 feet of vantage point" requirement.

Record review of Medicare Provider Agreement [Code of Federal Regulations (CFR) 42 CFR 489.20(q) ] "requires a hospital to post conspicuously a sign(s) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor and to indicate whether or not the hospital participates in the Medicaid program. The letters within the signs must be clearly readable at a distance of 20 feet or the expected vantage point of the emergency departments clients..".

Based on interview and record review, the facility (Hospital A) failed to provide a medical screening examination (MSE) to Patient # 1 who presented to the facility on 04-08-18.


Findings include:


TX # 00284296


Record review of complaint narrative TX 00284296 revealed allegation that Patient # 1 had been taken to the Emergency Room (ER) at Hospital A on 04-08-18. The patient had knee surgery at Hospital A two days prior. Patient # 1 was experiencing knee pain and swelling; and was unable to ambulate. "The ER Nurse at Hospital A directed the patient and his father to Hospital B across the street. There was no exam done on 15-year-old Patient # 1".

Hospital A:


Chief Executive Officer (CEO) interview:


During an interview on 04/20/18 at 10:07 with facility CEO # 1, she stated she received a call from the ER nursing supervisor from Hospital B on 04-09-18 who informed her about a possible Emergency Medical Treatment & Active Labor Act (EMTALA) violation from the night before. CEO said she informed the ER Medical Director and the facility Chief Nursing Officer (CNO) and they immediately began an investigation and staff EMTALA training.


CEO said Patient # 1 should have received a medical screening exam at their hospital.


Chief Nursing Officer (CNO) interview:


During an interview on 04/20/18 at 10:07 with facility CNO # 2 , she reported the investigation showed the father of Patient # 1 had called the facility on 04-08-18 and said his son had fallen on his knee. The son just had knee surgery here 2 days prior. The ER Nurse advised them to come to the ER for an x-ray. After the telephone call, the ER Nurse on duty perceived there were no crutches or splints available for Patient # 1. When the ER nurse was unable to contact Patient # 1's father by telephone, she met them out front and directed them to a different hospital. Patient # 1 was not registered, triaged, or medically screened.


CNO # 2 stated although the nurse was trying to be helpful, "the patient should've been brought back to our ER, screened, and treated".


ER Physician interview:


During a telephone interview on 04/20/18 at 1:00 p.m. with ER Physician #10 he stated he was the ER physician on duty on 04-08-18. He said he was unaware a possible EMTALA incident had occurred until the facility informed him. Physician # 10 said on 04-08-18 he was told by ER Nurse # 11 a patient was coming to the ER but he never saw the patient. He went on to say " ...when I came down to ask if the patient came in, the front [desk staff] told me the patient went to a different ER".


ER Physician # 10 further stated he was not aware of any issues with unavailability of orthopedic supplies that day. He denied advising ER Nurse # 11 to telephone patient's father to suggest they consider going elsewhere.


ER Nurse interview:


During a telephone interview on 4/20/18 at 2:55 pm with ER Nurse # 11 , she said she was on duty on 04-08-18. On this day, she received a telephone call from the father of Patient # 1. Patient # 1 had knee surgery at the facility two days prior and had just fallen and injured his surgical knee. The father asked if he should bring his son there or to another hospital. ER Nurse # 11 told the father they could choose where to go but told him he could bring his son to her facility for an x-ray. ER Nurse # 11 said the father chose this option and said he was on his way.


ER Nurse # 11 stated she then notified the ER doctor the patient was on his way to the facility. ER Nurse # 11 was unable to locate any orthopedic supplies such as splints, braces or crutches.


ER Nurse # 11 said she informed ER Physician # 10 about the lack of orthopedic supplies. When she told the doctor about the lack of proper supplies, ER Physician # 10 advised she call the father and advise them its best to go to another facility.


ER Nurse # 11 was unable to contact the father of Patient # 1 by telephone. She met the father and Patient # 1 out in front of the facility as they arrived in their car. When she informed them of the lack of necessary supplies, the father asked where should they go? ER Nurse # 11 said she told him of the 2 closest hospitals; the father chose Hospital B and drove off.


Record review of facility ER admission log for 2018 year to date (YTD) failed to reveal Patient # 1's name as being registered and medically screened.


Record review of facility "Medical Staff Rules & Regulations", undated, read: " ...11. Emergency Room. The Emergency Room services shall meet all regulatory requirements. An Emergency physician shall be in the hospital for rendering emergency care twenty-four (24) hours per day, seven (7) days a week. Members of the Medical staff shall accept responsibility for emergency services care in accordance with emergency services policies and procedures ..."


Record review of facility policy titled "Emergency Room Scope of Service", dated August 18, 2016, read: "...Policy Statement ...Any patient that requires care (regardless of where they are located on hospital premises) will receive initial evaluation and care ...A Medical Screening Exam (MSE) will be completed for all patients presenting for treatment prior to asking for financial information ...Any patient who requests services or care at this facility shall not be transferred form the facility for economic or other non-medical reasons before emergency services are provided. Emergency Departments Services: A. General services include: 1. Medical Screening Exam ..."


Record review of facility policy titled "Emergency Department Basic Care Standards & Documentation," dated August 18,2016, read: "Procedure: 1. All persons presenting to the ED will be recorded in the Emergency Log. The log shall consist of date, time, patient's first and last name, address, age, ED nurse and ED physician on duty, nature of injury, classification and disposition patient at discharge, 2. Patients shall receive a Medical Screening Exam (MSE) ..."


Hospital B


ER Physician:


During a telephone interview on 04/23/18 at 8:00 A.M. with ER Physician # 15 at Hospital B, he stated he was the ER physician on duty on 04-08-18 when Patient # 1 and his father presented to the ER.


ER Physician # 15 went on to say that Patient # 1 was a 15-year-old male who had surgery 2 days prior at Hospital A, which was about 2 blocks down the street.


"On this date (Sunday) Patient # 1's left knee was very swollen and painful. He had fallen. The father said he called Hospital A and was told to bring his son in. When they got there, the doctor told him to go across the street (to our hospital), as 'we don't have the necessary ortho supplies'."


ER Physician # 15 said he was concerned for an anterior cruciate ligament (ACL) injury, "so we x-rayed and stabilized and got an ortho consult." He went on to say on 04-08-18 he called Hospital A and spoke with both the ER physician & the ER Nurse on duty. He said he was told conflicting information.


ER Physician # 15 stated at the very least the boy should have had his pulses checked and vital signs taken. He went on to say the ER at Hospital A was a slow ER but they have x-ray, ortho, and full ER capabilities.


Medical Record: Patient # 1:


Record review of Patient # 1's ER record, dated 04-08-18 from Hospital B revealed the following:


Patient # 1 arrived on 04-08-18 at 8:26 p.m. with chief complaint of "fall injury post-surgical (sic)".


ER Physician exam, dated 04-08-18 (time 21:51): read: "The patient presents with pain, that is acute ...the problem was resulted from falling .... The patient is not able to bear weight ...patient had left meniscus tear repaired 2 days ago ...patient states he accidentally fell onto left knee when bent...complains of pain and swelling to left knee... Father states prior to coming here, they called the ER at (Hospital A) and was informed to go to their Emergency Department (ED). Father states they went there and presented to the ED (Hospital A) and was told to come here to 'hospital across the street'. I discussed with ED Physician and nurse at Hospital A's emergency department. Both were aware patient was there, wasn't given medical screening exam, no vital signs, patient was told to come here..."


Further review of the medical record for Patient # 1 revealed treatment included x-rays, ibuprophen, as well as the provision of a knee immobilizer and crutches. In addition, an orthopedic consult was obtained.