HospitalInspections.org

Based on a review of documentation and interviews, the facility failed to provide an appropriate medical screening examination within the capability of the emergency department.

Findings were:

Facility Based Policy and Procedure entitled "Transfer of Patients To Another Hospital" stated in part,
"When a patient arrives at the hospital, they must be evaluated by a physician ...
ALL patients presenting to the Emergency Department will be considered as needing emergency services and have the right to a screening examination to determine whether or not an emergency medical condition exists ...
No delay will be made in providing an appropriate screening exam as required in this section or stabilizing treatment of a patient with an unstable medical condition, in order to inquire about the individual's method of payment or insurance status..."

Facility Based Policy and Procedure entitled "Patient Assessment" stated in part, "A physician with Emergency Department privileges is responsible for determining the degree of assessment and subsequent care or treatment provided to any patient who comes in or is brought to the Emergency Department.
A Registered Nurse will assess the patient's need for nursing care in the Emergency Department ...
3. Perform physical assessment appropriate to the illness or injury.
? Include the vital signs."

A review of the facility Emergency Department Log included an entry that Patient #1 was registered at 0050 on 07/28/13.

The only documentation present in the medical record for Patient #1's visit to the Emergency Department on 07/28/13 was an Emergency Room Report and demographic sheet (which indicated blood sugars and insulin administered to the patient). No triage form was completed for this patient. No vital signs were assessed and/or documented.

The emergency room report for Patient #1 on 07/28/13 entered by the physician stated the following, "This 22-year-old-man was brought to the ER early on the morning of 07/28/13 by his family for agitation and high blood sugar. He had been agitated and they checked his blood sugar and found it to be greater than 300. They called EMS who checked his blood sugar and found it be closer to 400. He was brought into the ER into the waiting room; however, he was very agitated, combative, and unwilling to actually come into the ER. I observed him in the waiting room and he was very sweaty and combative, and holding onto a chair. He was refusing to come into the emergency room; however, I was concerned about sedating him as this would provide a difficulty in assessing his clinical status; it would not be clear if any change in his mental state was secondary to the medication or to acute change in his medical condition. Additionally with his combative nature and his size; he is a very large gentleman, approximately 300-pounds, I was concerned for the medical staff 's safety. Therefore I wrote an outpatient order for 10 units of insulin with the hope that we could lower his insulin and this would make him feel better, thereby calming him down and enabling us to bring him into the ER for workup. After approximately 1 hours his blood sugar was rechecked and was found to be closed to 300, which was somewhat improved; however, the patient was still very agitated and unwilling to come into the ER. I wrote a repeat order for another 10 units of insulin; after 1 more hour we rechecked his blood sugar and it was slightly above 200. The patient was doing better, however, per family request they asked if he could be discharged and they could just take care of him at home and follow up in the clinic. Although I was somewhat concerned given his very elevated blood sugars, I acquiesced to this without him ever being formally brought into the ER. Strict warnings were given regarding patient condition; worsening condition; altered level of consciousness; volume depletion. The patient was allowed to go home with his family."

In an interview on 09/11/13, staff member #1, the ED physician, confirmed that full examination of the patient was not performed due to the patient's exhibited agitation. "I saw him (Patient #1) through the window and did not lay hands on him...I visually assessed him (Patient #1) from the emergency room into the waiting area. I saw he (Patient #1) was out in waiting room with family. [Facility employee] was trying to bring him back, and due to agitation was unable to bring him back. That was the extent of my direct interaction with the patient."

In an interview on 09/11/13, staff member #2, the ED nurse, also confirmed that the physician did not perform a complete examination of Patient #1 on 07/28/13. "He (physician) visually assessed him (Patient #1) from inside the ED into waiting room...Waiting room has glass window to clerk's desk. From that vantage point you can see 90% of the waiting room. You can see from nurse's desk all the way into the waiting room."

The above findings were confirmed in interviews with staff members #1 and #2 on 09/11/13.