Chi St Lukes Health Memorial Livingston

“ORGANIZATION AND DIRECTION CFR(s): 482.55(a) Organization and Direction. If emergency services are provided at the hospital -- This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure emergency services were directed in a manner to ensure patient safety in 5 of 23 sampled patients (Patent #’s 1, 2, 3, 7, 19 and 22). The facility failed to ensure: A. Patients received accurate pain assessment, timely pain reassessment, and continual assessment of abdominal pain in pregnant females (Patient #’s 2, 3, 7 and 22). B. Proper documentation for patients classified as against medical advice (AMA). (Patient #’s 1 and 19). C. Fetal heart rates were documented in the record when assessing pregnant females (Patient #3). This deficient practice had the likelihood to cause harm to all patients entering the emergency department (ED). Patient #7 Review of the ED record of Patient #7 revealed she was a 22-year-old female who presented to the ED on 06/11/2024 with complaints of pregnancy cramping, severe flu symptoms, severe sore throat, hot flashes and “very painful.” A triage assessment at 5:40 p.m. revealed Patient #7 had a pregnancy less than 20 weeks and had an Emergency Severity Index (ESI) level of 3 (meaning Urgent). Nursing staff documented Patient #7 had lower abdominal cramping, had a positive pregnancy test 2 weeks ago, last menstrual period was 03/20, had not had an OB (obstetrician) appointment yet and denied vaginal bleeding. There was no documentation of a pain level to describe how severe the lower abdominal cramping or sore throat was. At 5:42 p.m. Patient #7’ vital signs were a blood pressure of 143/91, heart rate of 75, respirations of 20 and a temperature of 98.1 degrees Fahrenheit. Review of the ED record revealed that the physician was in to see Patient #7 at 6:06 p.m. The physician documented the chief complaints were a cough, sore throat, body aches, muscle aches and sinus pain. Patient #7 had a pain level of 5. The physician documented “normal findings: no organomegaly, no distention and non-tender” underneath the abdomen category on the assessment. There was no documentation in the physician’s assessment about the status of the pregnancy or abdominal cramping. Patient #7 was counseled on “laboratory results, diagnosis, need for follow-up, PCP/OB; self-isolation instructions: contacts; and a prescription” for the antibiotic Zithromax. Patient #7 was discharged at 7:39 p.m. with a diagnosis of an upper respiratory infection. During an interview on 12/10/2024 after 1:00 p.m. Staff #5 confirmed the missing assessments. Patient #2 Patient #2 was a 22-year-old female who presented to the Emergency department (ED) on 10/21/2024 at 10:08 p.m. with of complaints abdominal cramping. Patient #2 was triaged at 10:18 p.m. had an emergency severity index (ESI) of 3 (meaning urgent) and a pain level of 4. There was documentation that Patient #2 was less than 20 weeks pregnant. At 10:35 p.m., a pregnancy test was completed which was negative. Review of the record revealed that the physician’s medical screening exam was started at 12:20 a.m. Patient #2 was given a diagnosis of urinary tract infection and a prescription for an antibiotic. Patient#2 was discharged from the ED at 1:10 a.m., over 3 hours after presenting to the ED. There was no reassessment of the abdominal pain during the 3-hour timeframe nor prior to discharge. During an interview on 12/09/2024 after 2:34 p.m., Staff #3 confirmed the missing assessment and stated that pain assessment should be done within 60 minutes of discharge and after medication administration. Patient #1 Patient #1 was a 35- year- old female who presented to the ED on 10/21/2024 at 10:35 p.m. with complaints of a miscarriage, fever and very bad pain on left side of “tummy.” Patient #1 was triaged at 10:49 p.m. and was documented as having and an ESI level of 3 (meaning urgent). There was documentation that Patient #1 revealed to nursing staff that she was seen on 10/09 at this facility for a miscarriage. Patient #1 informed the staff that she went to another hospital about a week later for continued bleeding and was told that she had swelling in her fallopian tubes and “cervix was closed” at that time. Patient #1 did a follow-up with her obstetrician (OB) and was told to go to the emergency room (ER) with any new signs and symptoms. Tonight, she developed chills, generalized abdominal pain, and sharp pain in her joints. Patient #1 had taken a Tylenol around 9:30 p.m. Patient #1 was also documented as having a pain level of 6 (meaning moderate pain). A urinalysis and a pregnancy test were collected on Patient #1 at 10:57 p.m. There was no documentation of anyone talking to Patient #1, a refusal of care nor was there any against medical advice (AMA) paperwork on the record. During an interview on 12/09/2024 after 2:34 p.m., Staff #3 confirmed she could not find if the patient was in an ED bay or had been placed back into the waiting area because it was not documented. Staff #3 confirmed there was no documentation in the chart of when Patient #1 was last seen. Staff #3 said the process was to have the patient sign an AMA form and have the physician sign also. This should be documented in the medical record. Staff #3 said that staff were logging AMA incorrectly and that it should be a left without being seen or treated. Patient #3 Patient #3 was a 19- year- old female who presented to the ED on 10/21/2024 at 3:35 p.m. Patient #3 was triaged at 3:48 p.m. and had an ESI of 4 (meaning intermediate). According to the ED record a deer jumped out in front of them while driving and they had to slam on the brakes. Patient #3 was wearing a seatbelt and was 10 weeks pregnant. According to the ED record Patient #3 was requesting an evaluation to make sure the baby was healthy. The provider documented assessing Patient #3 at 4:14 p.m. There was documentation that a bedside ultrasound was performed. There was clear evidence of intrauterine pregnancy, spontaneous fetal movement, spontaneous heartbeat, and no hemorrhaging around the placenta. The provider failed to document an assessment of what the fetal heart rate was. During an interview on 12/09/2024 after 2:34 p.m., Staff #3 confirmed the provider failed to document what the fetal heart rate was. Patient #19 Patient #19 was a 68-year-old male who presented to the ED on 12/05/2024 at 1:45 p.m. with complaints of a urinary tract infection. Patient #19 was triaged at 2:04 p.m. and had an ESI level of 3 (meaning urgent). Patient #19 had a history of cancer of the kidney, complained of difficulty urinating and had a pain level of 7 out of 10 (meaning moderate). At 2:04 p.m., Patient #19 had vital signs of a temperature of 98.7 degrees Fahrenheit, elevated pulse of 101, respirations of 16, blood pressure of 136/77 and oxygen saturation of 96 percent. At 2:10 p.m., there were physician orders for a urinalysis and to insert a Foley catheter. At 2:47 p.m., Patient #19 signed his registration paperwork which included the consent to treat, privacy, release of information, assignment of insurance benefits and financial responsibility. There was no documentation of a medical screening by a physician on the record prior to signing the registration paperwork. According to the record Patient #19 left without being seen and that Patient #19 left after triage. There was no documentation of anyone talking to Patient #19 about a refusal of care nor was there any against medical advice (AMA) paperwork on the record. During an interview on 12/10/2024 after 1:00 p.m. Staff #5 confirmed there was no documented information on the reason Patient #19 left the ED and that there was no medical screening on the record. Patient #22 Review of the ED record of Patient #22 revealed she was a 25-year-old female who presented to the ED on 12/10/2024 at 8:15 a.m. for a swollen face and a spot between her eyes. Patient #22 was triaged at 8:18 a.m. and was given an ESI level of 4 (meaning intermediate). According to the ED record Patient #22 was first seen by the physician at 8:15 a.m... At 8:20 a.m. Patient #22 had a pain level of 4 and again at 8:23 a.m. it was 4. The next documented pain assessment was over 3 hours later at 11:56 a.m. and it was a level 2. Review of a facility’s policy named “Emergency Department Triage” dated January 2019 revealed: ..1. Triage Process a. Perform a brief visual and verbal assessment which may include: i. The patient’s complaint. ii. Vital signs including blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. iii. Pain assessment ..... ...2. Documentation.. c.Reassessments made should be documented in the electronic medical record. “...Addendum D: CHARTING REQUIREMENTS PER ED STANDARD OF CARE..” Physical Reassessments (physical, pain and vital signs) All patients in the ED are reassessed as warranted by ESI acuity and presentation: Including a complete set of vital signs and pain assessments.” “...Reassessments Prior to leaving the ED Within 60 minutes...” Review of a facility policy named “MODEL POLICIES AND PROCEDURES FOR THE EXAMINATION, TREATMENT AND TRANSFER OF INDIVIDUALS IN NEED OF EMERGENCY MEDICAL SERVICES” with a review date of 06/19/2023 revealed the following: “...F. Individual Who Does Not Consent to Examination or Treatment or Transfer 1. If the Individual Does Not Consent to Examination or Transfer. If the Hospitals offers examination and treatment and informs the individual or the person acting on the individual’s behalf of the risks/benefits to the individual of the examination and treatment, but the individual or Designated Representative acting the individual’s behalf does not consent to the examination and treatment, the Hospital will take reasonable steps to have the individual or person acting on the individual’s behalf sign a “Refusal to Permit Medical Examination, Treatment or Transfer” ...In the case of the individual who refuses examination and /or treatment following triage, the Hospital will use its best efforts to complete the individual’s registration, open a medical record, document offers made to the individual that he or she undergo further medical examination and treatment as may be required to identify and stabilize an EMC, log the individual in the Central Log (or EMTALA Log), document discussions with the individual regarding the risks and benefits involved in leaving prior to the medical screening and /or treatment and describe in the medical record the examination and treatment was refused. If such individual refuses to sign Exhibit C, Hospital staff will document steps taken to secure the individual’ s care and/or other personnel (for example, registrar personnel, triage nurse) who witness or are made aware that an individual has departed from the DED without signing Exhibit C may complete the form...””