HospitalInspections.org

Based on the hospital's Emergency Medical Treatment and Labor Act (EMTALA) policy, medical record review, the hospital's Dedicated Emergency Department (DED) log and interview, the hospital failed to ensure all patients presenting to the hospital's DED received an appropriate medical screening examination (MSE) to determine if an emergency medical condition existed for 1 of 20 (Patient #12) sampled patients presenting to the hospital's DED.

Refer to the findings in deficiencies A 2406.

Based on policy review, medical record review, document review and interview, the hospital (Hospital #1) failed to ensure all patients presenting to the Dedicated Emergency Department (DED) seeking medical attention received an appropriate Medical Screening Examination (MSE) to determine if an emergency medical condition (EMC) existed for 1 of 20 (Patient #12) sampled pediatric patients presenting to the DED.

The findings included:

1. Review of the facility "EMTALA [Emergency Medical Treatment And Labor Act] -Medical Screening Examinations [MSE]" policy revealed, "...The MSE will be performed without delay...In no event will the provision of the MSE and stabilizing treatment be based upon...preexisting medical condition...
Any individual presenting to the ED [Emergency Department]...and requesting emergency care will receive a MSE within the capabilities of the Hospital's ED to determine whether or not an Emergency Medical Condition exists...The MSE must be the same for all individuals presenting to the ED with the same condition...
If the patient or the patient's Legally Responsible Representative refuses the MSE after being fully informed of the Risks and Benefits related to such refusal, ED personnel will utilize the Refusal of Examination and Treatment for Emergency Medical Condition form and attempt to obtain written acknowledgement of the patient's refusal..."

Review of the facility "EMTALA, Definitions and Terminology" policy revealed, "...19. 'Stable for Transfer' means that after providing a Medical Screening Examination...the Hospital may facilitate a transfer to another facility...20. 'Transfer' means the movement of an individual outside the Hospital's facilities...to a higher level of care and transfers requested by the individual..."

Review of the facility "EMTALA, Patients Who Leave the Hospital Against Medical Advice or Without Being Seen by a Physician" policy revealed, "...Procedure...
Leaving DED Prior to Triage...the risks and benefits associated with leaving prior to receiving a medical screening examination ("MSE") must be discussed with the individual...
Leaving DED after Triage but before an MSE...Discuss with the individual the risks and benefits involved in leaving prior to the MSE and document this in the medical record...
Leaving DED after the MSE...Discuss with the individual the risks and benefits and document this in the medical record..."

2. Hospital #3's medical record review revealed Patient #12 was hospitalized at the hospital from 4/26/18 - 4/27/18 with diagnoses that included Febrile Seizure-simple, Left Acute Otitis Media and Viral Upper Respiratory Infection.

Hospital #3's Discharge Summary revealed on 4/25/2018 Patient #12 had a fever at home of 102 degrees and was diagnosed with Left Otitis Media. On 4/26/18 the patient was at home with a grandparent when he went limp, eyes rolled back in his head, was unresponsive and breathing slower than usual. Patient #12 was taken to a local DED and then transferred to Hospital #3, a children's hospital. The patient improved and was discharged home on 4/27/18 to the care of his parents and pediatrician.

3. Hospital #1's medical record review revealed Patient #12, a 12 month old, presented to the hospital's DED on 10/11/18 at 11:14 PM with his parents. The record documented the patient's triage was complete at 11:25 PM. The record also documented the patient left against medical advice (AMA) at 11:20 PM (sic).

At 11:19 PM DED Physician #1 documented the following regarding Patient #12:
"History of Present Illness...parents state that child has been having some recurrence seizures...reported seizures in the past which she [he] has been sent to [name of Hospital #3]...Over the past 3 days the child has had some upper respiratory symptoms but also had shots there is no reported fever...On arrival there is no seizure activity..[.] The occurrence was single episode..."

The DED Physician documented under the section titled Differential Diagnosis, " Grand mal seizure, seizure, new onset, focal seizure, febrile seizure...."

There was no documentation DED Physician #1 had performed a medical screening examination (MSE) to determine a diagnosis. There was no documentation the patient's temperature had been checked.

The physician documented the parents told him Patient #12 was having a recurrence of his seizures again, and asked what will be the end result. Physician #1 documented he informed the parents there was a limited evaluation that could be performed at Hospital #1 and it "would be best to [transfer to] Children's Hospital [Hospital #3]"

The DED physician documented, "...I also told him [father] a [I] be happy to do an evaluation here and transfer them [to children's hospital approximately 2 hours away]"

The DED physician documented, " the parents said no there is no point in that will [we'll] just go on ourselves..."

Review of the Nursing documentation revealed Registered Nurse (RN) #1 documented on 10/11/18 at 11:28 PM, "Parents brought patient in to be seen for seizures. Physician entered room with nurse and after speaking with physician walked out of hospital and stated they are taking their child to [name of children's hospital]..." RN #1 documented the parents left with the child Against Medical Advice (AMA).

Review of the "Refusal of Medical Screening Examination And/Or Treatment In The Emergency Department" form was blank and only signed by RN #1 at 2320 (11:20 PM). There was no documentation the risks and/or benefits were discussed with the child's parents in accordance with the facility policy. There was no documentation the child's parents signed the form.

4. Review of Hospital #2's medical records revealed Patient #12 presented to Hospital #2's DED on 10/11/18 at 11:49 PM via private vehicle with his parents. The 12 month old was treated for an elevated temperature of 102 degrees, Acute Suppurative Otitis Media of the Left Ear and Simple Febrile Seizure. The patient was discharged home on 10/12/18 at 2:30 AM in stable condition.

5. In an interview on 10/29/18 at 3:25 PM in Hospital #1's board room, Physician #1 stated, "I knew a patient arrived and I try to go with the nurse to get the story as soon as possible. [Name of RN #1] entered the room and started asking questions. I came in shortly after. The Dad stopped talking and said 'Oh, it's you.' He [Dad] said he's having another seizure. So I asked where we are at this point regarding [Name Hospital #3]. The dad was angry and said they [children's hospital] didn't do anything unless they see it [seizure]. Then we talked and they decided to leave. I told them I probably needed to send [transfer] him to [Hospital #3] and it would probably take a couple hours. They just decided to leave."

In an interview on 10/30/18 at 7:40 AM in Hospital #1's board room, RN #1 stated, "I brought them [parents and Patient #12] back, [Name of Physician #1] was not far behind. I told him I had a baby with a seizure. The mom asked, 'Are you going to give him anything?' [Name of Physician #1] said, 'Not for the seizures.' He [Physician #1] told them [parents] he would send them to [Name of Children's hospital]. They [parents] asked how long it was going to take. [Physician #1] told them it could be an hour or take several hours and I confirmed...[Name of Physician #1] said with him [Patient #12] having seizures he needs to go to [Name of Children's hospital], we're not equipped to handle that. We told them we were going to do the work up and then send them to [name of Children's Hospital]. They [parents] wanted to know if they were going to [Name of Children's Hospital] one way or the other and [Name of Physician #1] said 'Yes.' As soon as they saw [Name of Physician #1] their attitude changed and demeanor changed."