HospitalInspections.org

Based upon record review and interview, the facility failed to ensure Medical Staff Bylaws, Rules, and Regulations and Emergency Department policies and procedures were adopted, implemented, and enforced to ensure compliance with EMTALA (Emergency Medical Treatment and Labor Act) requirements.

Review of the Medical Staff Bylaws, Rules, and Regulations, Article X, Number 42, revealed the following: The following disciplines are authorized to function as Qualified Medical Personnel (QMP) and initiate medical screening examinations or perform Nursing examinations.
Emergency Department: 1) Advanced Nurse Practitioner; 2) Physician Assistant;
3) Registered Nurse; 4) Paramedic
Labor and Delivery: 1) Advanced Nurse Practitioner; 2) Registered
Behavioral Health: 1)Advanced Nurse Practitioner; 2) Registered Nurse; 3) Licensed Social Worker; 4) Licensed Professional Counselor
Other Off Campus Sites: 1) Registered Nurse; 2) Paramedic; 3) Physical Therapist;
4) Occupational Therapist

This was the only mention of Emergency Department Services found in the Medical Staff Bylaws, Rules and Regulations. The bylaws, rules and regulations did not contain any other provisions for compliance with EMTALA (Emergency Medical Treatment and Labor Act) requirements.

Review of the Emergency Department Policies and Procedures Manual, last approved in January, 2000, revealed no policies to ensure compliance with EMTALA Requirements. There was no policy related to the exclusionary criteria for medical screening exams used by the Medical Staff or how to use the exclusionary criteria. Further review of the policies revealed a policy titled "Triage" which was last review/revised in January, 2000. The triage policy revealed the following: "The purpose of triage is a process of assessment and assignment of urgency ratings to patients in the emergency room according to emergent, urgent, and non-urgent classifications performed by the emergency department staff."

Review of 28 medical records and the emergency room log revealed the triage nurses were using a scale titled "Emergency Severity Index" that rates the patient on a scale 1-5 with 1 being emergent and 5 being non-urgent. There was no policy found related to the Emergency Severity Index or information on how to apply the scale during patient triage.

An interview was conducted with the Quality Manager on 10/27/11 at 3:00 pm in the conference room. The Quality Manager confirmed that the Medical Staff Bylaws, Rules, and Regulations did contain the information about who could conduct a medical screening examination but there was no other rules to reflect the requirements for EMTALA. The Quality Manager also confirmed the Emergency Department Policies and Procedures Manual was last approved in January, 2000, and had no policies related to triage, medical screening examination, qualified medical personnel, or compliance with EMTALA requirements.

Based upon record review and interview, the facility failed to ensure 1 of 28 (#3) patients reviewed received an appropriate medical screening examination in the Emergency Department. The facility also failed to ensure policies and procedures were developed and enforced to ensure compliance with EMTALA requirements.

Review of patient # 3 medical record revealed patient presented to facility emergency department on 10/21/11 at 1:51 pm. The triage record was timed 2:07 pm and revealed chief complaint as "chronic pain to left side of body-assault in February". Patient rated his pain 8 of 10 on the Wong Pain Scale with 0 being no pain and 10 being the worst pain you ever had. The patient ' s blood pressure was 170/110. Patient reported no home meds. The record revealed patient needed assistance to walk and that patient was a smoker. Review of the emergency physician's record revealed patient was seen by the physician at 3:20 pm. The physician (#4) record revealed the patient's chief complaint was "Chronic Pain" with onset/duration "7 months". The physician's record documented past history of hypertension and family history of hypertension and diabetes. The record revealed the review of systems and physical examination was all within normal limits. No labs were done and no progress notes were written. The physician had placed a check mark that the nursing assessment and vital signs were reviewed; however the physician did not document evaluation of the elevated blood pressure, the cause of the pain, or the severity of the pain scale. The physician documented the clinical impression as "Chronic Pain for 7 months". The physician placed a check mark in the box by the statement "emergency medical condition does not exist and immediate medical attention not necessary, no immediate serious, impairment or dysfunction of body or organs is reasonably expected". Further documentation of the medical record revealed the statement "Patient left after medically screened".

An interview was conducted with the Medical Director of the Emergency Department, Staff #4, on 10/27/2011 at 3:30. The Medical Director reported how he had developed
an exclusionary criteria to determine if a patient can be "medically screened out". The Medical Director further reported that when the nurse triages a person according to the "Emergency Severity Index" (ESI) and their score is a (5), the patient most likely can be Medically Screened. The Medical Director was given the medical record of Patient #3 to review and he reported that the patient did not meet the exclusionary criteria and had an ESI of 5. The Director further reported the patient had Chronic Pain for 7 months and that is not an emergency condition. The Director was then asked to review the RN Triage Record that revealed patient had pain on the left side of his body, elevated blood pressure of 171/110, pain scale of 8 out of 10, and the report of no home medications. The Director then reviewed his documentation again and stated "I just missed it, I made a mistake." When asked if he considered the elevated blood pressure and the severity of the pain scale an emergent condition that required further treatment and stabilization, the Medical Director stated "Yes".

A telephone interview was conducted with Patient # 3 on 11/1/11. The patient reported he told the nurse that he had pain on the left side of his body as a result of a physical assault that occurred in February, 2011. The patient reported that the nurse checked vital signs and asked about the level of pain. The nurse also asked if patient was taking any medications. The patient was then instructed to return to the waiting area until he was called to see the physician. The patient reported when he went back to see the physician, the physician came into the room and was looking at some papers and then checked off some things on the paper and then left out of the room. The patient reported the physician did not talk with him or do an assessment. The patient reported the physician left the room and a lady came in and asked him if he had insurance and when told no, the lady asked if he could pay $220.00. The patient again responded "no" and the lady told him he was discharged and free to go home. Patient reported they did nothing for me, did not give any discharge instructions, referrals, or prescriptions.

An interview was conducted with Staff #5 at 3:00 pm in the conference room. Staff #5 reported that when a patient arrives to the facility they sign in giving their chief complaint then taken to the triage area and assessed by the nurse. The patient is then either placed in an exam room or asked to return to the waiting area. The patient is placed in an exam room as soon as available and then is medically screened by the physician. If the physician determines the patient does not have an emergent medical condition, the physician leaves the room and tells the patient someone will be in to talk with them. At that point, the registration/admission clerk enters the exam room and tells the patient the doctor determined they did not have an emergent condition and the facility would be happy to treat them, but if they had no insurance they would have to pay for the visit. Staff #5 reported the clerk does give the patient a list of community resources where care can be received but nursing does not go back to the room.

Review of the Emergency Department Policies and Procedures Manual, last approved in January, 2000, revealed no policies to ensure compliance with EMTALA Requirements. There was no policy related to the exclusionary criteria for medical screening exams used by the Medical Staff or how to use the exclusionary criteria. Further review of the policies revealed a policy titled "Triage" which was last review/revised in January, 2000. The triage policy revealed the following: The purpose of triage is a process of assessment and assignment of urgency ratings to patients in the emergency room according to emergent, urgent, and non-urgent classifications performed by the emergency department staff.

Review of 28 medical records and the emergency room log revealed the triage nurses were using a scale titled "Emergency Severity Index" that rates the patient on a scale 1-5 with 1 being emergent and 5 being non-urgent. There was no policy found related to the Emergency Severity Index or information on how to apply the scale during patient triage.