HospitalInspections.org

Based on record review, interview with facility staff and review of policy and procedures, the hospital failed to ensure compliance with EMTALA Regulations 489.20 and 489.24 in one of twenty (Pt. #1) patients reviewed, that the facility failed to provide a medical screening examination, and failed to ensure that all patients presenting to the emergency department are entered into the central log.

See findings:

1) Facility failed to document patients who presented to the Emergency Department on the central log. See C-2405.

2) Facility failed to provide a medical screening exam to patients who present to the Emergency Department. See C-2406.

Based on record review, policy and procedure review, and interviews with facility staff by surveyor
#13469, in one of twenty MR (medical records) reviewed (#1), the facility failed to ensure that all patients presenting to the hospital seeking medical treatment be included in the central log. Failure to maintain an accurate visit log does not allow the hospital to track cares provided to each person who comes to the hospital seeking medical treatment.

Findings include;
Per policy review on 12/7/10 in the AM, the policy "Log Book" last review date 1/2010, directs the following: "Policy: All persons presenting to the ER (Emergency Room) are automatically logged into an ER Activity Report within the EMR (electronic medical record) system, upon registration. Because the EMR is a new system, all patients also continue to be entered in the paper log book."

Per MR review, on 12/6/10 at 12:00 PM, patient #1 presented to the hospital ED (emergency department) around 2:30 AM on 11/22/10 complaining of on-going abdominal pain.

Per review, on the morning of 12/7/10 of both the EMR log and paper log of patients presenting to the ED, there was no evidence found that patient #1 was entered into either log following her visit to the ED seeking medical treatment at around 2:30 AM on 11/22/10.

Per interview, with both Administrator (A) and Nursing Supervisor (D) on 12/7/10 in the AM, both (A) and (D) confirmed that patient #1 was not entered into either the EMR log or the paper log following her visit to the ED on the night of 11/22/10.

Based on review of medical staff rules and regulations, review of policy and procedures, interviews with facility staff, and medical record review by surveyor #13469, in 1 of 20 MR (medical records) reviewed
(#1), the hospital ED (emergency department) staff failed to provide a MSE (medical screening exam) for patient #1 who presented to the ED on 11/22/10. Failure to provide a MSE resulted in the hospitals inability to determine whether or not an emergency medical condition existed that needed immediate treatment for patient #1 on the night of 11/22/10.

Findings include:
Per review of the medical staff rules and regulations, on the AM of 12/7/10, dated 1/2/09 (last revision date 9/1/09), the rules direct the following: "EMTALA compliance: 1. Every patient who presents to the Emergency Room shall have a medical screening exam completed by a credentialed member of the medical staff."

Per review of the ED policy titled EMTALA, the policy directs the following: "Scope: Providers and Nursing Staff will be aware of EMTALA regulations and are responsible for carrying out the established EMTALA policies." "Purpose: To assure that emergency care is provided for patients regardless of their health condition or their ability to pay for their care." "Procedure: 1 General: All Patients presenting to the Emergency Room will receive an Emergency Medical Screening Examination by a credentialed provider of the medical staff."

Per MR review, on 12/6/10 12:00 PM, ED MD (medical doctor) (B) note dated 11/21/10 indicates that patient #1 presented to the hospital ED at 3:38 PM on 11/21/10 complaining of increasing abdominal pain, nausea and vomiting. She was unable to keep her medicines down. She was recently diagnosed with kidney stones on 11/5/10 and underwent a right ureteroscopy with retrograde pyelogram and stone extraction on 11/10/10 and discharged from the hospital on 11/13/10. She was seen on 11/15/10 and 11/18/10 in the ED with right flank pain and was treated for those symptoms.

At the 11/21/10 visit to the ED a MSE was done by MD (B) and it was determined that patient #1 was status post right renal lithiasis extraction, stent placement and removal, and had a urinary tract infection. Per MD (B) notes, she was treated with IV (intravenous) fluids, Zofran to control nausea, Dilaudid for pain relief, the antibiotic Levaquin IV, and was told to follow up with her primary care provider as needed. She was discharged to the care of her grandmother in improved condition at 9:30 PM on 11/21/10.

Per review of nursing notes dated 11/22/10 at 2:45 AM, RN (E) documented that patient #1 returned to the ED after being discharged at 9:30 PM on 11/21/10. Patient #1 indicates that she is still having abdominal pain. Per RN (E) note, she called MD (B) who was on-call for the ED at the time patient #1 arrived on 11/22/10. Per RN (E) note, MD (B) told her that "she will not give the patient anymore pain medication due to patient receiving a large amount of pain medication already. The MD also told RN (E) that the patient needs to be seen by the MD who performed her surgery for kidney stones and her primary MD who are located in another town." RN (E) informed patient #1 what MD (B) had said. "Patient #1 responded by saying she does not see a regular doctor anywhere. RN (E) then informed patient #1 that she should be seen in another town's ED for any further abdominal pain tonight." Patient #1 became upset and left the ED.

Per interview, with RN (E) at 8:30 AM on 12/7/10, (E) said she called MD (B) and informed him that patient #1 was back in the ED complaining of continued abdominal pain and was requesting pain medication. Per RN (E), MD (B) told her he would not be accessing patient #1 Port or giving her anymore pain medication tonight. Per RN (E), MD (B) said she could watch patient #1 in the ED or patient #1 could go to another town and another ED if she wanted to.

Per interview, with MD (B) on 12/7/10 at 12:55 PM, MD (B) said she got a call from RN (E) the night of 11/22/10 indicating that patient #1 had returned to the ED complaining of abdominal pain. Per MD (B) she told RN (E) that she would not be giving the patient any more pain medication - Dilaudid, and that the patient could be observed in the ED if she wanted. Per MD (B), she did come into the hospital, but patient #1 had already left.

Per interview, with Administrator (A) on 12/6/10 at 11:15 AM, patient #1 presented to the hospital ED for the second time around 2:30 AM on 11/22/10 complaining of continued abdominal pain. Per Administrator (A), after the RN spoke with MD (B) she informed the patient that MD (B) would not be giving her anymore pain medication. As a result, patient #1 left the ED. Per Administrator (A), RN (E) never took the patient into the ED, did not do a triage or nursing assessment, and MD (B) did not do a MSE per hospital policy and procedure.

Patient #1 subsequently sought treatment at another hospital at 3:47 AM on 11/22/10.