HospitalInspections.org

Based on review of personnel files (PF) and interview with staff (EMP), it was determined the facility failed to ensure education was provided to facility staff regarding the Emergency Medical Treatment and Active Labor Act (EMTALA) for two of two personnel files reviewed (PF7 and PF8).

Findings include:

A request was made on March 12, 2014, for the facility's policy/procedure on EMTALA training for the Emergency Department (ED) registration clerks. No policy/procedure was provided.

Review on March 12, 2014, of PF7 and PF8 revealed no documentation of EMTALA training for these individuals.

Interview with PF7 on March 12, 2014, at approximately 1:15 PM during an observation tour of the ED revealed PF7 was unable to define or voice an understanding of EMTALA. PF7 was unable to recall if EMTALA training was discussed or offered during orientation or during the ED's yearly inservice reviews.

Interview with PF8 on March 12, 2014, at approximately 1:30 PM during the observation tour of the ED revealed PF8 was unable to define or voice understanding of EMTALA. PF8 was unable to recall if EMTALA training was discussed or offered during orientation or during the ED's yearly inservice reviews.

Interview with EMP2 on March 12, 2014 at approximately 1:45 PM confirmed the registration clerks just came under the ED purview. EMP2 assumed the nurse manager position on March 1, 2014. The registration clerks were previously under the Finance Department. EMP2 did not think the registration clerks were educated on EMTALA. EMP2 confirmed the registration clerks were now under the ED's purview.

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to provide a proper medical screening examination within the capability of the hospital's Emergency Department to determine whether or not an emergency medical condition existed for two of 25 medical records reviewed (MR1 and MR4).

Findings include:

Review on March 12, 2014, of the facility policy "Triage," dated reviewed February 2010, revealed "1 Purpose: A comprehensive triage is the process of assessing patients quickly to decide the urgency of their condition, the priority for therapeutic interventions, and the location in the department where these interventions should occur. It is also an area which is able to facilitate patient flow through the emergency department, as well as, provide information and support to families, patients and visitors. ... V. Patient Acuity: A. Five-Level Acuity System Level 1 Red, Acuity Critical, Treatment [and] Assessment Immediately ... Level 2 Blue, Acuity Unstable Condition, Treatment [and] Assessment Next Available Room Sample Conditions (but not limited to) ... Urinary retention and Severe emotional distress. ... Level 3 Green, Acuity Potentially Stable, Treatment [and] Assessment Able to Wait Short Amount of Time ... Level 4, Acuity Stable Condition, Treatment [and] Assessment Can Wait Reasonable Amount of Time ... Level 5 Black, Acuity Routine, Treatment [and] Assessment Unspecified Amount of Time. ... VIII. Nursing Process. ... B. Vital signs (VS) will be done on patients if required for categorization or if time permits. Otherwise vital signs are the responsibility of the primary nurse. Any patient presenting to the ED who is a level I or II will be taken immediately to an appropriate area. It is the primary nurse's responsibility to do a full assessment including vital signs. C. Pain Scale 1. Should be attempted on all patients. It is used in conjunction with the presenting complaint, to assign patients with similar complaints, to different triage level. Pain scales are not absolute, but do allow the patient to communicate the intensity of a problem from their perspective. The more intense the pain (9-10/10) the more the care provider should be concerned about the need to identify or exclude serious illness and attempt to offer empathy or interventions that will diminish unnecessary pain and suffering. Because pain perception is very individual and may be influenced by age and cultural differences, it would be unwise to exclude serious problems when pain is not described as severe. ... 2. The consistent use of pain scales is an extremely important component of the triage scale. This also allows for conformation of improvement that both provider and patient can understand. Continued severe pain should lead to reconsideration of the diagnosis and treatment. ..."

Review on March 12, 2014, of the facility policy "Procedure for Transfer of a Patient to another Facility (Acute Care, SNF, Rehab, Psych)," dated reviewed February 2010, revealed "I. Policy: The decision to transfer a patient from the Blue Mountain Health System to another facility will be made by the physician in collaboration with the patient, family, receiving facility and receiving physician. II. Purpose: To provide guidelines for staff when transferring patients to another facility when a specific level of care is required by the patient. III. Equipment: Medical Necessity Form EMTALA Patient Transfer Form Personal belongings Clinical Records Transfer Summary."

[Pain level rating: Zero represents no pain and 10 the worst possible pain.]

1) Review of MR1 on March 12, 2014, revealed this 85-year-old patient was transported to Palmerton Hospital's Emergency Department (ED) on February 12, 2014, by a family member. MR1 was triaged at 18:58 by EMP4 with the following information: "Chief complaint: Urinary retention and Foley problem. Pain level now: 10/10." The patient's history revealed "pt [patient] had scope last Thursday, seen here Friday for unable to urinate, given bladder spasm pill on monday, removed cath [catheter] at 0900 today, unable to void since, c/o [complaint] abd [abdominal] pain)." The patient was triaged and assigned an Acuity of Level 4.

Interventions were listed as "ID band on patient. To waiting room." There was no documentation the patient's pain of 10/10 was addressed or reassessed.

Nursing progress notes documented the family member was concerned MR1 could have a heart attack due to the degree of pain, anxiety and discomfort. EMP4 documented they informed the family urinary retention will not cause a heart attack. The family requested the patient be brought back and given a foley. EMP4 documented at 19:22 "supervisor called and notified." EMP4 documented at 19:33 "(received call from 911, pt's [patient's] family calling from wr [waiting room] requesting ambulance for pt to be seen, palmerton police on site investigating situation, discussed with police family causing scene and situation in ed, ambulance can be heard outside.) EMP4 documented at 19:43 "(pt left facility via ambulance)."

Continued review of MR1 revealed documentation at 19:43 on February 12, 2014, which noted the patient's disposition/discharge as unchanged. There was no documentation of a reassessment being performed. There was no documentation MR1 was seen by the ED physician. There was no documentation MR1 was medically screened. There was no documentation the facilty's policy and procedure on Procedure for Transfer of a Patient to another Facility was followed.

Review of the medical record for MR1 from receiving hospital on March 12, 2014, revealed the patient arrived at the other acute care facility via ambulance on February 12, 2014, at 20:22. Acuity: Level 2. The Chief Complaint was listed as urinary retention. Pain level now of 10/10. The nursing physical assessment at 20:25 documented abdominal distention and tenderness. Patient was catheterized for 550 ml. of clear amber urine at 20:26. The nursing progress note at 20:53 noted pain level was 0/10. The patient's status was improved; the patient states feels better. At 21:37 discharge instructions were provided to the patient, and the patient was discharged, accompanied by family via private vehicle driven by family member.

Review on March 12, 2014, of the EMS report narrative from February 12, 2014, for MR1 revealed the Palmerton ambulance was dispatched to Palmerton Hospital's ED. Upon arrival at scene the patient was found sitting in the front seat of a car parked outside of the emergency room. The patient was conscious, awake, alert and oriented and was complaining of severe bladder pain. The patient was moved from the car to the ambulance by stretcher for transport to another facility.

Interview with OTH1 on March 12, 2014 at approximately 13:30 confirmed the ED was very busy on February 12, 2104 with a high volume of acute patients. OTH1 stated "I do not like to see elderly patients suffer and if the patient was properly triaged as a Level 2 instead of a Level 4 this would have brought this patient to my attention. The triage nurse did not make me aware of the patient's pain level or discomfort. I was made aware of this patient only minutes prior to the patient's transfer to another facility."

Interview with EMP6 on March 12, 2014 at approximately 13:00 confirmed the ED was very busy on February 12, 2014. EMP6 noted the patient's family member was upset because the patient was not being catheterized to relieve the pain and discomfort. The family member was cutting in front of other patients being registered demanding that EMP6 put a catheter in the patient. EMP6 explained to the family member that EMP6 was not a medical person. The family member stated the patient was sweating and shivering. EMP6 obtained a blanket and pillow for the patient and notified the triage RN (EMP4). EMP6 also notified the Nurse Supervisor (EMP5). EMP6 noted EMP5 stated EMP5 could not come to the ED for every problem.

2) Review of MR4 on March 12, 2014 revealed the patient presented to the ED at 15:10 on January 6, 2014. Acuity: Level 4. Chief complaint was listed as lumbar pain with radiation to left hip, left buttock and down left leg. Pain level now was listed as 10/10. Interventions included ID band on patient. To waiting room." Documentation of Patient Discharge/Disposition at 18:01 revealed the Patient left the ED without being seen by a physician. Patient notified ED staff that they were leaving due to long waiting time (three hours). ED physician notified of patient departure.

Based on review of facility policies, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure an appropriate medical screening was provided prior to obtaining all insurance information for one of six medical records of patients who left without being seen (MR2).

Findings include:

Review of the facility's policy "Emergency Medical Treatment and Labor Act (EMTALA) Guidelines," dated approved June 2009, revealed " ...III Procedure: 1. Any person presenting anywhere on Hospital property and who requests emergency services or who would appear to a prudent lay person observer to be in need of medical attention shall be evaluated by the dedicated emergency department (DED) to determine if an emergency condition exists. ... 3. There shall be no delay in providing an MSE (medical screening exam) or stabilizing treatment for an emergency medical condition in order to inquire about the person's method of payment or insurance status. Reasonable registration processes may be followed, including asking whether the person is insured, provided that these do not delay screening or treatment or unduly discourage persons from remaining for further examination or treatment."

Review on March 13, 2014, of MR2 revealed the patient presented to the emergency department on February 14, 2014, at 15:30 following an ATV (all terrain vehicle) accident with complaints of neck and back pain. The medical record contained copies of the patient's insurance cards and a full registration. Continued review revealed no documentation that a triage was completed. Documentation noted staff discovered the patient eloped at 16:25.

Interview with EMP7 on March 13, 2014, at 1:00 PM confirmed it is the facility's process to do a quick registration when the patient presents to the Emergency Department. The quick registration includes the patient's name, date of birth, and they may ask for the insurance provider's name. EMP7 confirmed MR2 contained a complete registration, as all insurance cards were copied and contained in the medical record. EMP7 confirmed the complete registration should not have been completed until the triage was completed. EMP7 confirmed MR2 left without being seen and no triage was performed.