HospitalInspections.org

Based on facility policy/protocol review, medical record review, staff and medical staff interviews the facility failed to follow their EMTALA policy and Initial Patient Care (IPC) Protocols in the ED for 1 (P8) of 20 sampled emergency department (ED) patients. This failed practice has the potential to cause negative outcomes for all patients who present to the ED for treatment. According to facility provided data the facilities ED saw an average of 5,803 patients per month for the past 6 months.

See citation A2406 and A2407, that also resulted in A2400 to not be met.

Based on facility policy/protocol review, medical record review, staff and medical staff interviews the facility failed to follow the chest pain protocol in triage, and failed to room a patient to be seen with a chief complaint of chest pain within 3 hours of presentation to conduct an medical screening exam (MSE) to rule out an emergency medical condition (EMC) for 1 (P8) of 1 left without being seen after triage ED sampled patients. This failed practice has the potential to cause harm or death to patients who present to the emergency department (ED) with an EMC. According to facility provided data the ED saw an average of 5,803 patients per month for the past 6 months.

See citation A2400 and A2406, that also resulted in A2407 to not be met.

Findings include:

A. Review of facility policy, "Examination, Treatment, and Transfer of Individuals who come to the Emergency Department (EMTALA)," approved 3/2023 revealed:

1. A Medical Screening Exam (MSE) is defined as, "the process required to determine with reasonable clinical confidence whether an EMC does or does not exist. Screening is to be conducted by physicians to determine whether an EMC exists.

2. An Emergency Medical Condition (EMC) is defined as, "a medical condition manifesting itself by acute symptoms of sufficient severity."

Review of facility policy, "Triage," approved 2/2023 revealed criteria for a designated triage nurse is a Registered Nurse (RN) must have the approval of director or designee and completed Emergency Severity Index (ESI) training and competency. Appropriate reassessments will be documented on the medical record.

Review of facility policy, "Initial Patient Care (IPC) Protocols in the ED," approved 6/2023 revealed IPC protocols are pre-approved physician orders for commonly seen symptoms in the ED. The RN will use the symptom-based IPC protocols as written and will not substitute, eliminate, or extend treatment beyond what is specified in the IPC protocol. The use of an IPC protocol is not a substitute for physician involvement and will never alter/delay interaction between the physician and the patient.


B. Review of P8's medical record revealed, P8 presented to the acute care hospital ED on 10/16/2024 at 2:55 PM via car, with a chief complaint of chest pain, the facility IPC ED chest pain protocol was initiated by the triage Registered Nurse (RN) at 2:59 PM.

P8's medical record lacked evidence of the facility following the IPC ED chest pain protocol orders, confirmed with RN-A on 12/10/2024 at 2:48PM as evidenced by:
-No documentation of Aspirin given.
-No documentation of an intravenous IV being placed
-No documentation of continuous telemetry (monitor the heart to rule out an emergency).
-No documentation of a repeat an EKG every 5 minutes (12 leads are placed on the patient's chest to take a picture of the heart to rule out an emergency, requires a physician to decide).
-No documentation of P8's triage 232/148 blood pressure being communicated to a physician.
-No documentation of the IPC ED chest pain protocol order being discontinued by a physician prior to P8 being placed in the lobby on wait room status at 3:28PM.
-No documentation of P8's blood pressure being rechecked before P8 was called to be roomed at 6:10 PM [3 hours after P8 presented to the ED with a chief complaint of chest pain.]

C. During an interview on 12/11/2024 at 10:24AM, Physician-A confirmed that P8's medical record lacked evidence of triage nurse and physician communication regarding P8's 232/148 blood pressure. Physician-A confirmed P8's medical record lacked evidence of P8 being seen for a chief complaint of chest pain by a QMP to rule out an EMC on 10/16/2024 before the patient was discovered to have LWBS (the patient left the facility without being seen by a qualified medical professional) after triage at 6:10 PM with a presentation time of 2:55PM. [3 hours and 21 minutes later]. Physician-A confirmed P8's medical record lacked evidence of the nurse following the IPC ED chest pain protocol, and no IPC ED chest pain protocol discontinue order by a physician prior to P8 being placed in the lobby on wait room status at 3:28PM.

Based on EMTALA policy review, medical record review, staff and medical staff interviews the facility failed to rule out an emergency medical condition (EMC) within 3 hours of patient presentation with a chief complaint of chest pain for 1 (P8) of 1 sampled left without being seen (LWBS) (the patient left the facility without being seen by a qualified medical professional) after triage emergency department (ED) patients. This failed practice has the potential to cause a delay in stabilizing treatment to all patients who present to the ED with an EMC. According to facility provided data the ED saw an average of 5,803 patients per month for the past 6 months.

See citation A2400 and A2406, that also resulted in A2407 to not be met.

Findings include:

A. Review of facility policy, "Examination, Treatment, and Transfer of Individuals who come to the Emergency Department (EMTALA)," approved 3/2023 revealed:

1. A Medical Screening Exam (MSE) is defined as, "the process required to determine with reasonable clinical confidence whether an EMC does or does not exist. Screening is to be conducted by physicians to determine whether an EMC exists.

2. An Emergency Medical Condition (EMC) is defined as, "a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain)."

3. If an EMC is determined to exist, the hospital will provide the individual ...any necessary stabilizing treatment within the capabilities of the staff and the facilities available at the hospital."

B. Review of P8's medical record revealed, P8 presented to the acute care hospital ED on 10/16/2024 at 2:55 PM via car, with a chief complaint of chest pain. P8's medical record lacked evidence of a qualified medical professional (QMP) ruling out an EMC prior to being placed in the lobby on waiting to room status for 3 hours and 21 minutes, confirmed by Physician-A on 12/11/2024 at 10:24AM.

C. During an interview on 12/11/2024 at 10:24AM, Physician-A confirmed that P8's medical record lacked evidence of triage nurse and physician communication regarding P8's 232/148 blood pressure. Physician-A confirmed P8's medical record lacked evidence of P8 being seen for a chief complaint of chest pain by a QMP to rule out an EMC on 10/16/2024 before the patient was discovered to have LWBS (the patient left the facility without being seen by a QMP) after triage at 6:10 PM with a presentation time of 2:55PM.