Based on hospital policy review, medical record review, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 27 sampled DED patients who presented to the hospital for evaluation and treatment and was discharged (Patient #10).
Based on hospital policy review, medical record review, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 27 sampled DED patients who presented to the hospital for evaluation and treatment and was discharged (Patient #10). Additionally, the facility failed to ensure that an appropriate medical screening examination was performed by an Emergency Department Physician prior to transferring patient #27 with persistent alcohol withdrawal symptoms.
Findings included:
Review on 01/15/2016 of current hospital policy "EMTALA", NSG-CLI #857, effective 12/17/2014, revealed "POLICY/PURPOSE Any person who comes to (Hospital A) requesting assistance for a potential emergency medical condition or emergency services will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists. ...IMPLEMENTATION ...D. MEDICAL SCREENING EXAMINATIONS 1. A medical screening exam is required when an individual: a. Seeks care at the hospital Emergency Department... 4. The requirements of a medical screening examination are as follows: a. The medical screening consists of an assessment and any ancillary tests or focused assessment based on the patient's chief complaint necessary to determine the presence or absence of an emergency medical condition. This may be a brief history and physical examination or may require complex ancillary studies and procedures such as (but not limited to) lab tests....EKG or radiology procedures. b. The medical screening examination is the process a provider must use to reach with reasonable clinical confidence whether an emergency condition does or does not exist. c. The medical screening must provide evaluation and stabilizing treatment within the scope of the hospital's abilities...
Review of current hospital policy "Standards of Patient Care Emergency Department", last revised 07/22/2014, revealed "I. ADMISSION: ...B. Emergency Severity Index: Triage Classification and Reassessment Guidelines ...3. Level III - Urgent: Condition poses a potential threat to life, limb or physiological function requiring early emergency intervention. ...Reassessment occurs at a minimum, every 3 hours or more often as condition warrants. Vitals within normal limits are repeated a minimum of every 3 hours, or more frequently as indicated. Unstable vital signs are repeated every 30 minutes until stable, then hourly x 1, and every 4 hours thereafter, or more frequently as condition warrants. ..."
1. Closed DED record review on 01/14/2016 for Patient #10, revealed a [AGE] year old male who presented ambulatory to Hospital A's DED via private transportation on 12/28/2015 at 1038. Review revealed the patient was triaged by a Registered Nurse (RN) at 1047. Review revealed a "Chief Complaint" of "Psychiatric Illness." Review of "Description of Symptoms" revealed "PT (patient) STATES HE WANTS TREATMENT FOR ALCOHOLISM. STATES HE DRANK TODAY. DENIES SI/HI (suicidal/homicidal ideation)." Review revealed vital signs (VS) were assessed as temperature (T) 98.7 degrees Fahrenheit (F); Pulse (P) 132 (high - range 60-100); Respirations (R) 18; blood pressure (BP) 169/102 (high - range 100/60-140/80); and Pulse Oxygen Saturation (SpO2) 95% on room air (RA). Pain was assessed as a "4" (numeric scale - 0 pain free to 10 worst pain). Review revealed a past medical history of chronic back pain. Record review revealed the patient's current home medication was Epinephrine [Epipen 2-Pak] for allergic reactions to bee venom. Review revealed the patient was triaged as "Priority 3 - Urgent." Review of nursing documentation at 1130 by RN #1 revealed "ED Psychiatric Assessment." Review revealed "Psychiatric Complaint" with "Is the patient under psychiatric care? No" and "Presents with Depression." Review revealed "Behavioral Health" with "Chief Complaint" of "Request Detox- Drinking 18 pack day. Sts (states) 'I need to get help. This drinking is killing me'. Review revealed "Depression" with "Depressive Symptoms" of "Worthlessness." Review revealed "Having thoughts of harming yourself or taking your life" with "No: 'drinking will kill me'." Review of "ED Primary Care Assessment" revealed "Mental Status Alert Oriented." Review revealed "Hx (history) Alcohol Use YES....18 pack day..."
Review of MSE documentation by PA #1 (Physicians' Assistant), revealed a MSE was conducted at 1139. Review revealed a "Chief Complaint: Psychiatric Illness" and "Stated Complaint: PSYCH EVAL." Review of HPI (history of present illness) revealed "PT PRESENTS FOR DETOX FROM ALCOHOL STATES DRINKS AN 18-PACK PER DAY FOR SEVERAL YEARS. BEEN DRINKING SINCE 19 Y/O (years old)." Review revealed "DRANK 18-PACK THIS AM (morning)." Review revealed "Relevant History: Reports: Alcoholism. Current Substance of Use: Reports: Alcohol (ETOH) ...Severity: None Associated Signs & Symptoms: Reports: None." Review of "ED Past Medical History" revealed "...Patient has no past medical history....Psychological History: Reports: Substance Use Disorder (ETOH)." Review revealed Review of Systems (ROS) was Negative. Review revealed: Constitutional: alert (awake), no apparent distress. Oriented to: time, person, and place. Last recorded vital signs: T98.7 F; P 132H; R 18; BP 169/102H; and Pulse Ox 95. HEENT (head, ears, eyes, nose, throat) - Head: normal (normocephalic). Eye Exam: normal (PERRL [pupils equal round reactive to light], EOMI [extraoccular movement intact], sclera white). Oropharynx: normal (pharynx: moist without exudate, gums - no swelling). Tympanic Membrane: normal. ...Nose: no symptoms reported (septum midline). Neck: normal (FROM [full range of motion], trachea at midline). Respiratory/Cardiovascular - Respiratory: normal - CTA [clear to auscultation] (BBS [bilateral breath sounds] clear to auscultation without adventitious sounds). Cardiovascular: normal (RRR [regular rate & rhythm] without murmur, gallop or rub). GI (Gastrointestinal) - Auscultation: normal (NABS [no abnormal bowel sounds). Palpation: normal (soft, No rebound or guarding, non-distended). Tenderness: non-tender. Murphy's Sign (abdominal assessment fo diagnosis of Gall Bladder disease): negative. Musculoskeletal - Back: normal (non-tender). Extremities: normal (normal tone, pulses 2+, no cyanosis or edema, FROM). Integumentary - Skin: normal, warm, and dry. Lymphatics: normal (no adenopathy). Neurologic - Memory Impaired: normal. Motor Function: normal (normal tone, pulses 2+, no cyanosis or edema, FROM). Cranial Nerve (CN): normal (CN II-XII intact sensation, strength 5/5). Cerebellar: normal. Mood Description: normal. Perception: normal. Review revealed, ED Alcohol/Sub (substance)/Withdrawal Exam documentation revealed, Neurologic - Oriented to: time, person, and place. Memory Impairment: normal. CN: normal. Motor Function Unable to Test or Normal: normal. Cerebellar Function: normal. Reflexes: normal. Thought: coherent. Affect: appropriate. Perception: normal. Insight: normal. Judgment: normal. Review revealed, Differential Diagnosis - Alcohol withdrawal syndrome, Intoxication Alcohol,
Substance abuse disorder.
Record review revealed no documentation of any physician's orders for treatments (i.e. medications, radiology, laboratory studies, etc.) or consults (psychiatric/mental health evaluation) ordered by PA #1 or Physician A.
1a. Closed medical record review on 01/15/2016 for Patient #10 revealed the patient presented ambulatory to the Hospital B's DED via private transportation on 12/28/2015 at 1401 (41 minutes Hospital after discharge from Hospital A's DED). Review revealed the patient's VS were obtained at 1313 and a urine specimen was obtained at 1325 by a Nursing Assistant. Review revealed initial VS were T 98.8 degrees F; P 110; R 18; BP 142/73; and SPO2 98% on RA. Pain was assessed as a "4/10" (numeric scale - 0 pain free to 10 worst pain). Review revealed the patient was triaged by an RN at 1400. Review of nursing documentation revealed "NURSING TRIAGE (Adult) pt went to (Hospital A) ED today and they sent him here." Review of HPI revealed "Headache - Onset a couple of days because he was banging his head on the wall ...(+) vomiting today ...(+) moderate headache. Back pain - Onset for years without injury. Pain described as sharp and non-radiating. ...Substance Abuse - alcohol abuse since he was 19. (+) patient requesting detox. Pt. [sic] (consumed) a case of beer since 7 am today. Brought to ED by self, (-) hx. of previous detox. Pt placed in a W/C (wheelchair)." Review revealed "PHYSICAL EXAM: GENERAL APPEARANCE: well nourished, alert, oriented x 3 (person, place, time), no acute distress, no obvious discomfort." Review revealed "TRIAGE SUICIDAL HOMICIDAL ASSESSMENT: Denies thoughts of hurting self or others. Review revealed the patient was assigned an acuity level 3 (1-5, with 1 least severe, 5 most severe). Review of an "ASSESSMENT BEHAVIORAL HEALTH" conducted by an RN at 1521 revealed, "pt states he went to (Hospital A) ER (emergency room ) and they told him to come here because they do not do detox there he also adm (admits) hitting his head against wall with no reasonably [sic] explanation of that [sic] he does seem impaired at this time, he is interested at [sic] in pt (inpatient) detox at this time. ...MENTAL STATUS: speech clear, oriented x4 (person, place, time, situation), normal affect, responds appropriately to questions. ...GENERAL APPEARANCE: no acute distress, no obvious discomfort. SUICIDAL HOMICIDAL ASSESSMENT: Denies thoughts of hurting self or others. All clothing and personal items removed, labeled, and locked in bin..." Review of nursing documentation at 1704 revealed ...M.D. at bedside. Pt c/o (complains of) back pain." Review revealed at 1759 the patient was administered Toradol (non-steroidal anti-inflammatory) 30 milligrams (mgs) IM (intramuscular) once for back pain of 7/10. Review revealed at 1805 the patient was administered Ativan (anti-anxiety medication) 2 mgs once by mouth. Review at 1850 revealed "DSP (disposition) ADMISSION - Patient prepared for transport to inpatient bed 504, admitted to service of....M.D. Admission orders were received. ...Transport to floor by ED Technician. ..."
Review of MSE documentation by Physician E revealed an MSE was conducted at 1652. Review of HPI revealed "[AGE] year old male presents for psychiatric evaluation. Pt is [sic] request detox from ETOH. Pt states 'I am an ass hole when I am sober and happy when I am drinking.' States last alcohol consumption was at 0900 this am. Pt reports his wife and children have given him an ultimatum to detox. Reports having the shaks [sic] and hallucinations in the past but denies today. Reports a very mild headache. Pt admits to nonspecific SI and HI to 'no one in particular.' States 'I am just so angry.' Pt reports not sleeping all night." Review of ROS revealed "In addition to the systems reviewed below, all other systems reviewed are negative except for those included in history. ...MUSCULOSKELETAL ROS: ...(+) arthralgias ...PSYCHIATRIC ROS: ...(+) suicidal ideations....(+) homicidal ideations." Review of PE revealed "GENERAL APPEARANCE: well nourished, alert, cooperative, no obvious discomfort. ...EYES: PERRL, EOMI, conjunctiva clear. ...SKIN: warm, dry, good color, no rash. NEURO: motor intact, sensory intact. MENTAL STATUS: speech clear, oriented x3, normal affect, responds appropriately to questions. DIFFERENTIAL Dx (diagnosis): PSYCHIATRIC Dx: schizophrenia, personality disorder, drug abuse, depression, anxiety, alcohol abuse, adjustment reaction. ..." Review of a physician's note at 1703 revealed "Medical clearance complete. Patient is ready for transport to EDBH (Behavioral Health Unit). Pt has been medically cleared." Review of a physician's note at 1708 revealed "Pt admits to sig (significant) alcohol problem, causing relationship problems esp (especially) with spouse and children. His family intervened and urged him to seek help. Was seen initially at (Hospital A) and was actually directed to be seen at (Hospital B) 'for detox.'"
Review revealed the following labs were ordered on the patient and reviewed by the ED Provider: CBC (complete blood count) with Differential, CMP (comprehensive metabolic panel), ETOH Level, and a UDS (urine drug screen). Review of lab results revealed a blood ETOH level of 242 mg/dL (milligrams/deciliter) [normal range less than 11 mg/dl] obtained at 1420. Review of UDS results were negative at 1320. Review revealed the patient was voluntarily admitted to Hospital B's inpatient behavioral health unit.
Review of an inpatient admission History and Physical dictated 12/29/2015 at 2031 revealed an admission date of [DATE]. Review revealed "...According to medical record, blood alcohol level was very high at 242 mg/dL. ...DIAGNOSES: AXIS I 1. Alcohol dependency and withdrawal. 2. Mood Disorder, alcohol induced. ...TREATMENT PLAN: ...At time of admission....was initiated on routine alcohol, Valium (Benzodiazepine) detox protocol..."
Review of an inpatient discharge summary dictated 12/31/2015 at 1030 revealed the patient was admitted on [DATE]. Review revealed "...admitted voluntarily for alcohol detox and mood stabilization. ...HOSPITAL COURSE: ...He was started on naltrexone (Opioid antagonist) and was placed on a Valium detox. He tolerated this detox fairly well and cleared up and made a commitment to continue treatments on outpatient basis... At the time of discharge, he has stable mood, goal directed thought process, has a normal cognition and no dangerousness to self or others. DISCHARGE DIAGNOSES: AXIS I: Alcohol dependence, alcohol-induced mood disorder. ..." The patient was discharged on [DATE].
Telephone interview on 01/14/2016 at 1305 with PA #1 revealed he recalled Patient #10. Interview revealed he conducted the MSE on Patient #10 on 12/28/2015. Interview revealed as part of the MSE he reviewed the nurse's triage notes, talked with the patient, conducted a complete physical examination and assessed for signs and symptoms of alcohol withdrawal. Interview revealed the patient was tachycardic (elevated heart rate) and hypertensive (elevated blood pressure). Interview revealed alcohol use would increase the heart rate and elevate the blood pressure. Interview revealed the patient was also overweight, a heavy smoker, and heavy drinker. Interview revealed the patient did not exhibit any signs and symptoms of alcohol withdrawal. Interview revealed the patient's vital signs were not symptomatic of withdrawal. Interview revealed he "felt" no lab tests were warranted, therefore none were ordered. Interview revealed if the patient had been symptomatic of withdrawal he would have ordered labs. Interview revealed the patient reported drinking an 18 pack of beer prior to arrival to the ED. Interview revealed "there were signs of intoxication." Interview revealed he could not remember what they were. Interview revealed the patient was accompanied by another gentleman, his father or father-in-law. Interview revealed there was not a "detox" unit at Hospital A. Interview revealed the hospital used a contracted mental health agency (MHA #1) to perform mental health assessments and assist with bed placements and psychiatric transfers. Interview revealed he did not order a psychiatric mental health evaluation on the patient. Interview revealed if the patient had been symptomatic of alcohol withdrawal he would have admitted the patient to a medical bed and then transferred the patient to a detox facility. Interview revealed he "did not feel the patient had to go directly to a detox facility." Interview revealed he was made aware by MH staff that the patient did arrive at Hospital B and was seen in the ED and admitted to an inpatient detox unit. Interview revealed the patient "did not have an EMC. Interview revealed Physician A co-signed the patient's chart. Interview revealed Physician A did not evaluate the patient. Interview revealed he did not consult or discuss the patient's care with Physician A while the patient was in the ED. Interview revealed as a PA he can perform a MSE, treat, and discharge patients without an attending physician being consulted or laying hands on the patient. Interview revealed there is an attending physician on-duty at all times in the ED for consultation and supervision.
Telephone interview on 01/15/2016 at 1120 with Physician B, revealed he was Hospital A's DED Medical Director. Interview revealed he was familiar with the 12/28/2015 ED record for Patient #10. Interview revealed he had discussions with PA #1 about the case. Interview revealed Hospital A did not provide alcohol detoxification services. Interview revealed PA #1, "does not work here that often." Interview revealed the patient had been drinking heavily on the morning he arrived in the ED. Interview revealed the patient's heart rate and blood pressure were elevated. Interview revealed the patient's elevated vital signs were not associated with alcohol withdrawal symptoms. Interview revealed elevated blood pressures in an asymptomatic patient are normally not addressed in the ED setting. Interview revealed "the patient's increased heart rate could have been addressed." Interview revealed the patient's vital signs should have been reassessed prior to discharge. Interview revealed the patient "was nontoxic." Interview revealed he (Physician B) "thought" the patient was only given a list of detox facilities and Hospital B was his preference. Interview revealed the MSE by PA #1 was "adequate." Interview revealed "Could it have been done better? Absolutely." Interview revealed there was "no science behind doing blood work." Interview revealed blood work was normally obtained because certain State facilities required certain lab tests for admission. Interview revealed admission requirements vary for each individual facility. Interview revealed there was no history or symptoms to suggest alcohol withdrawal. Interview revealed the patient had "no EMC." The patient "was fine." Interview revealed the patient was "stable" when discharged .
Telephone interview on 01/14/2016 at 1415 with MH #1 (Mental Health Staff) revealed he recalled Patient #10. Interview revealed he was working on 12/28/2015 when he received a call from the PA requesting a list of detox referrals. Interview revealed the PA stated he did not want an assessment on the patient.
The facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital ' s emergency department including ancillary services (labs, complete psychiatric/mental health evaluation) routinely available to the emergency department to determine whether or not an emergency medical existed for patient #10 on 12/28/2015.
2. Hospital A, closed DED record review on 01/14/2016 for Patient #27 revealed a [AGE] year old male presented to the DED via Emergency Medical Services (EMS) ambulance on 11/24/2015 at 1244 with police escort after being found intoxicated. Patient #27 was triaged as " Emergent. " Review of DED triage documentation at 1244 revealed "...EMS reports pt is violent and assaulted EMS crew." Review of physician's documentation by Physician F dated 11/25/2015 at 1135 revealed "EMS reports patient stated SI (suicide ideations). Patient is non-cooperative for the most part - on my arrival patient is calm - telling me he is suicidal with a plan to shoot himself. States 'If I had a gun I'd be dead'. Record review revealed on 11/24/2015 at 1416 the patient's blood alcohol level was 0.34 (normal less than 10). The patient ' s Home medications were listed as: Disulfiram (medication used to treat chronic alcoholism) 250 mg (milligrams) by mouth daily; Lisinopril/Hydrochlorothiazide (medication used to treat high blood pressure) 10-12.5 mg; 1 tablet by mouth daily; and Sertraline (anti-depressant medication) HCL 100 mg by mouth daily. The ED physician documented the patient ' s final diagnosis as Alcohol Abuse, Alcohol Intoxication and Suicidal Ideation. Further review of the medical record revealed the patient ' s vital signs were abnormal: 11/24/2015: 12:44 p.m.-Blood Pressure 160/100 (normal Blood Pressure range- 100/60-140/80) Heart Rate: 111 (normal range heart rate 60-100); 2:55 p.m. Heart Rate: 117; 10:45 p.m. Heart Rate: 133; 11/25/2015: 5:17am- Blood Pressure-172/105; 7:37 am Heart Rate: 120, Blood pressure 155/97; 11:44 am - Heart rate 120 Blood Pressure 155/89; 12:18 p.m.- Heart Rate -126, Blood Pressure-162/92; 3:11 p.m. heart rate -110, Blood Pressure- 142/92; and 5:39 p.m.- Heart rate-102, Blood pressure 152.84.
The ED nurse documented on 11/25/2015 at 03:39 am the patient " c/o (complained) of shaking, Ativan 4mg po (by mouth) Clonidine 0.1 mg given as ordered ...11/25/2015 11:44 am ...anxious, tremors, restless, ...Ativan given ...11/25/2015 13:55 (1:55 pm) ...continues with minor tremors and restlessness ...11/25/2015 15:11 (3:11 pm) ...still trembling. Some anxiousness ...restless ...meds given ...11/25/2015 17:39 (5:39 PM)- ...still some tremors and restlessness. " Record review revealed the patient was last re-evaluated at bedside by a DED Physician's Assistant (PA #3) at 1135 (6 hours and 30 minutes prior to the patient's transfer from the DED) and was evaluated via Telepsychiatry (delivery of psychiatric assessment and care usually through videoconferencing) by a Psychiatric PA (PA #4) at 1305 (5 hours prior to the patient's transfer from the DED). Review of the record revealed that patient #27 ' s condition had demonstrated continued tachycardia, elevated blood pressure despite multiple doses of clonidine and being on an alcohol withdrawal protocol of Ativan. The ED nurse notes after the patient was accepted for transfer continued to document, " tremors, " " trembling, " " anxiousness, " and " restlessness. " Record review failed to reveal any available documentation of re-evaluation of Patient #27 ' s condition (persistent alcohol withdrawn symptoms) on 01/14/2016 by the on-duty ED physician (Physician F) prior to transfer. The facility failed to ensure that an appropriate medical screening examination was provided for patient #27 as evidenced by failing to have a physician re-evaluate patient (#27) with persistent alcohol withdrawal symptoms prior to transfer
Interview on 01/15/2016 at 1105 with Director #1 during medical record review revealed Patient #27's patient transfer form identified Physician D as the transferring physician. Interview revealed 11 00 was documented as the time and transfer accepted by receiving MD and time accepted transfer on the patient transfer form. Physician D was not on-duty when the patient was transferred out of the ED. Interview revealed Physician F was on-duty. Interview revealed no documentation of re-evaluation by Physician F prior to the patient's transfer. Interview revealed no documentation of re-evaluation by Physician F prior to the patient's transfer. Further Interview revealed "I do not disagree with the findings of the medical record review."