HospitalInspections.org

Based on facility policy review, review of Emergency Department (ED) staffing schedules, review of employee time punches, review of a facility document, review of the ED central log, medical record review, and interviews, the facility failed to provide an appropriate medical screening exam (MSE) and failed to provide stabilizing treatment for 1 ED patient (Patient #2) with abdominal pain of 30 ED patients reviewed.

The findings include:

Please refer to A-2406 for failure to provide MSE.

Please refer to A-2407 for failure to provide stabilizing treatment.

Based on review of facility policy, review of Emergency Department (ED) staffing schedules, review of employee time punches, review of a facility untitled document (ED Advisory tracking spreadsheet), review of the ED Central Log, medical record review, and interview, the facility failed to provide an appropriate medical screening examination (MSE) for 1 patient (Patient #2) of 30 patients medical records reviewed who presented to the ED with complaint of abdominal pain.

The findings include:

Review of the facility's policy titled "Emergency Medical Treatment and Patient Transfers" revised 3/2018 showed "...When an individual comes to the Emergency Department of the hospital...an appropriate medical screening examination, within the capabilities of the emergency department (including ancillary services routinely available to the emergency department), shall be provided to determine whether an emergency medical condition exists..."

Review of the facility's policy titled "TRIAGE" revised 5/2019 showed "...Patients presenting to the ED will be cared for according to a triage system utilizing an assessment by the ED personnel. This will be accomplished by using the Triage documentation on the ED record. The process will occur prior to seeing the ED provider...A brief history concerning medical problems, allergies and patient's chief complaint will be obtained..."

Review of the facility's policy titled "VITAL SIGNS" revised 5/2019 showed "...A complete set of vital signs will be taken on every patient age 6 years and older on admission..."

Review of the facility's policy titled "SCOPE OF SERVICES" revised 8/2019 showed services provided by the facility included "...Emergency Department...Staffed 24 hours a day, 7 days a week, 365 days a year (24/7/365) with a physician and a minimum of 2 licensed personnel (minimum of 1 registered nurse per shift)..."

Review of the facility's policy titled "Patient Diversion" revised 2/2020 showed "...When necessary because of a lack of capacity, capability to treat additional patients or equipment failure, diversion status may be initiated...Diversion...will be avoided if possible...Individual departments must continuously evaluate resources and patient demand and implement strategies for providing continued full-service to the community and minimizing diversion..."

Review of an ED staffing schedule dated 4/3/2020 showed no Registered Nurse (RN) was scheduled to work in the ED from 7:00 PM until 8:00 PM.

Review of the ED employees' time punches dated 4/3/2020 showed no RN was working in the ED from 7:00 PM until 8:50 PM (1 hour 50 minutes).

Review of a facility untitled document (ED Advisory tracking spreadsheet) dated 4/3/2020 showed the ED was on advisory (notification to Emergency Medical Services that the facility was not accepting patients) from 7:00 PM to 8:50 PM due to lack of a RN working in the ED.

Review of the ED Central Log dated 4/3/2020 at 7:00 PM showed 1 patient (Patient #2) presented to the ED for treatment during the time period of 7:00 PM until 8:50 PM.

Patient #2's medical record review revealed that the patient presented to the ED on 4/3/2020 at 7:06 PM with a complaint of abdominal pain.

Review of an ED Physician's note dated 4/3/2020 at 7:06 PM showed Patient #2 complained of Abdominal Pain. Further review no documentation the physician obtained a medical history on Patient #2. ED Physician #1 performed a physical examination of the patient at 7:20 PM and noted the patient had mild, but worsening abdominal pain, nausea, abdominal distension, and dysuria (painful or difficult urination).

Medical record review showed no documentation a Nurse assessed or triaged Patient #2. Further review showed no documentation the patient's vital signs were obtained while she was in the ED and there was no documentation the patient received any interventions for pain, while in the ED. Continued review revealed no documentation diagnostic studies (laboratory studies or radiologic studies) were done to determine the cause of the patient's abdominal pain.

Patient #2 was discharged from the ED on 4/3/2020 at 7:27 PM (7 minutes after the patient was seen by the ED physician) with diagnosis of "...Stone in kidney..." The patient was given a prescription for pain medication and told to return to the ED the next morning if there was no improvement in her condition.

Patient #2 presented to the ED again on 4/4/2020 at 8:09 AM (12 hours 42 minutes after discharge from the ED on 4/3/2020) with a complaint of Lower Back Pain Radiating to Both Sides of the Abdomen.

Review of a Nurse's triage assessment dated 4/4/2020 at 8:09 AM revealed the patient was triaged as a level 3 (urgent) patient. The patient's vital signs were documented as temperature 98 degrees, respirations 20, pulse 99, blood pressure 116/85, and the patient rated her pain level as a 9 (on a scale from 1-10, with 10 being the worse pain). The patient's pain was described as worsening.

Review of an ED Physician's note dated 4/4/2020 revealed Patient #2 described her abdominal pain as worsening. The Physician ordered diagnostic tests including a Complete Blood Count (CBC/blood test), Comprehensive Metabolic Panel (CMP/blood test), Urinalysis, Blood Urea Nitrogen/Creatinine (blood test for kidney function), and Abdominal Computed Tomography (CT) scan.

Review of a CT of the Abdomen Imaging report dated 4/4/2020 at 8:43 AM for Patient #2 showed the patient had Suspected Atelectasis Medial Lung Base Regions (collapsed lung) (the patient was recently diagnosed with pneumonia) and Distal Colonic Diverticulosis (bulging pouches in the digestive tract) without findings of Diverticulitis (infection or inflammation). No Renal or Urinary Tract Calculi (kidney stones) were noted.

Patient #2 was discharged from the ED on 4/4/2020 at 9:53 AM with diagnosis of Acute Diverticulosis of Intestine. The patient was instructed to follow up with her primary care Physician in 3 days and to ensure her diet consisted of low fat/high fiber foods. The patient was also given a prescription for Levsin (medication used to treat intestinal disorders).

During an interview on 4/7/2020 at 3:43 PM the ED Nurse Manager confirmed Patient #2 was not triaged and the patient's vital signs were not checked during the patient's visit on 4/3/2020.

During a telephone interview on 4/7/2020 at 4:28 PM ED Physician #1 stated the ED was closed on Friday 4/3/2020 at 7:00 PM because there was no RN working in the ED. The Physician stated Patient #2 presented to the ED during the time the ED was closed and the Physician stated he assessed the patient, but diagnostic studies were not done on the patient and no medications were administered to the patient before the patient was discharged from the ED. ED Physician #1 stated he told Patient #2 to return to the ED on 4/4/2020 at 7:00 AM if she still needed to be seen. The Physician stated Patient #2 returned to the ED the morning of 4/4/2020 and "received a full workup." The Physician stated a sign was posted on the ED entrance door on 4/3/2020, which read "...ER closed due to lack of RN on staff. We will reopen at 7:00 AM [4/4/2020]..."

During a telephone interview on 4/13/2020 at 9:45 AM Patient #2 stated she went to the ED the evening of 4/3/2020 due to abdominal pain and vomiting. She was told the ED was closed because the facility did not have a nurse on duty, but the ED Physician called her back and "looked" at her. Patient #2 stated no labs, x-rays, or CT scan was done while she was in the ED on 4/3/2020. The patient stated the ED Physician gave her a prescription for pain medicine and told her to return to the ED at 7:00 AM the following morning if she wasn't better. Patient #2 stated she had a history of Crohn's Disease (inflammatory bowel disease), Diverticulosis, and Congestive Heart Failure.

The facility failed to ensure that their polices were followed for Patient #2 on 4/3/2020 as evidenced by: 1.) failing to have adequate staffing on duty from 7:00 PM to 9:30 PM to provide triaging of patients; 2.) failing to provide laboratory testing, diagnostic imaging, and no medication was provided/administered to the patient despite his/her complaint of abdominal pain.

Based on review of facility policy, review of a facility untitled document (ED Advisory tracking spreadsheet), medical record review, and interview, the facility failed to provide stabilizing treatment for 1 Emergency Department (ED) patient (Patient #2) with abdominal pain of 30 ED patient's medical records reviewed.

The findings include:

Review of the facility's policy titled "Emergency Medical Treatment and Patient Transfers" revised 3/2018 showed "...When an individual comes to the Emergency Department of the hospital...an appropriate medical screening examination...shall be provided to determine whether an emergency medical condition exists...Stabilizing Treatment for Emergency Medical Conditions...If it is determined through a medical screening examination that an emergency medical condition exists...emergency department personnel shall: Provide such further medical examination and treatment as may be required to stabilize the medical condition..."

Review of the facility's policy titled "TRIAGE" revised 5/2019 showed "...Patients presenting to the ED will be cared for according to a triage system utilizing an assessment by the ED personnel...The process will occur prior to seeing the ED provider...A brief history concerning medical problems, allergies and patient's chief complaint will be obtained..."

Review of the facility's policy titled "VITAL SIGNS" revised 5/2019 showed "...A complete set of vital signs will be taken on every patient age 6 years and older on admission..."

Review of the facility's policy titled "SCOPE OF SERVICES" revised 8/2019 showed services provided by the facility included "...Emergency Department...Staffed 24 hours a day, 7 days a week, 365 days a year (24/7/365) with a physician and a minimum of 2 licensed personnel (minimum of 1 registered nurse per shift)..."

Review of the facility's policy titled "Patient Diversion" revised 2/2020 showed "...When necessary because of a lack of capacity, capability to treat additional patients or equipment failure, diversion status may be initiated...Diversion...will be avoided if possible...Individual departments must continuously evaluate resources and patient demand and implement strategies for providing continued full-service to the community and minimizing diversion..."

Review of a facility untitled document (ED Advisory tracking spreadsheet) dated 4/3/2020 showed the ED was on advisory (notification to Emergency Medical Services that the facility was not accepting patients) from 7:00 PM to 8:50 PM due to lack of a Registered Nurse (RN) working in the ED.

Review of an ED Physician's note dated 4/3/2020 at 7:06 PM showed Patient #2 complained of Abdominal Pain. Further review no documentation the physician obtained a medical history on Patient #2. ED Physician #1 performed a physical examination of the patient at 7:20 PM and noted the patient had mild, but worsening abdominal pain, nausea, abdominal distension, and dysuria (painful or difficult urination). The facility failed to ensure that stabilizing treatment was provided as required as evidenced by failing to provide further examination and treatment for patient #2's noted symptoms listed/documented above on 4/3/2020.

Medical record review showed no documentation Patient #1's vital signs were obtained or that any interventions for pain were administered while she was in the ED. Continued review revealed no documentation diagnostic studies (laboratory studies or radiologic studies) were done to determine the cause of the patient's abdominal pain.

Patient #2 was discharged from the ED on 4/3/2020 at 7:27 PM (7 minutes after the patient was seen by the ED physician) with diagnosis of "...Stone in kidney..." The patient was given a prescription for pain medication and told to return to the ED the next morning if there was no improvement in her condition.

Patient #2 presented to the ED again on 4/4/2020 at 8:09 AM (12 hours 42 minutes after discharge from the ED on 4/3/2020) with a complaint of Lower Back Pain Radiating to Both Sides of the Abdomen.

Review of an ED Physician's note dated 4/4/2020 revealed Patient #2 described her abdominal pain as worsening. The Physician ordered diagnostic tests including a Complete Blood Count (CBC/blood test), Comprehensive Metabolic Panel (CMP/blood test), Urinalysis, Blood Urea Nitrogen/Creatinine (blood test for kidney function), and Abdominal Computed Tomography (CT) scan.

Review of a CT of the Abdomen Imaging report dated 4/4/2020 at 8:43 AM for Patient #2 showed the patient had Suspected Atelectasis Medial Lung Base Regions (collapsed lung) (the patient was recently diagnosed with pneumonia) and Distal Colonic Diverticulosis (bulging pouches in the digestive tract) without findings of Diverticulitis (infection or inflammation). No Renal or Urinary Tract Calculi (kidney stones) were noted.

Patient #2 was discharged from the ED on 4/4/2020 at 9:53 AM with diagnosis of Acute Diverticulosis of Intestine. The patient was instructed to follow up with her primary care Physician in 3 days and to ensure her diet consisted of low fat/high fiber foods. The patient was also given a prescription for Levsin (medication used to treat intestinal disorders).


During a telephone interview on 4/7/2020 at 4:28 PM ED Physician #1 stated the ED was closed on Friday 4/3/2020 at 7:00 PM because there was no RN working in the ED. The Physician stated Patient #2 presented to the ED during the time the ED was closed and the Physician stated he assessed the patient, but diagnostic studies were not done on the patient and no medications were administered to the patient before the patient was discharged from the ED. ED Physician #1 stated he told Patient #2 to return to the ED on 4/4/2020 at 7:00 AM if she still needed to be seen. The Physician stated Patient #2 returned to the ED the morning of 4/4/2020 and "received a full workup." The Physician stated a sign was posted on the ED entrance door on 4/3/2020, which read "...ER closed due to lack of RN on staff. We will reopen at 7:00 AM [4/4/2020]..."

During a telephone interview on 4/13/2020 at 9:45 AM Patient #2 stated she went to the ED the evening of 4/3/2020 due to abdominal pain and vomiting. She was told the ED was closed because the facility did not have a nurse on duty, but the ED Physician called her back and "looked" at her. Patient #2 stated no labs, x-rays, or CT scan was done while she was in the ED on 4/3/2020. The patient stated the ED Physician gave her a prescription for pain medicine and told her to return to the ED at 7:00 AM the following morning if she wasn't better. Patient #2 stated she returned to the ED on 4/4/2020 because she "was not better." Patient #2 stated she had a history of Crohn's Disease (inflammatory bowel disease), Diverticulosis, and Congestive Heart Failure.