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The hospital failed to comply with the provisions of 42CFR, Section 489.24 for 2 of 21 sampled patients when it failed to:

* Provide a medical screening examination for Patient 1 in a timely manner. When the family member requested wheelchair assistance from the ED Registration Clerk to transport the patient from the car to the ED, Patient 1 waited for approximately 40 to 60 minutes before receiving assistance from the ED staff. Cross reference A2406.

*Provide further stabilizing treatment for a facial injury within its licensed capability and capacity for Patient 2. The hospital had a surgeon on call for consultation; however, the ED physician did not consult the surgeon for stabilizing treatment. The patient was sent to another hospital with the paramedics applying pressure with their fingers on the inside and the outside of the patient's mouth to prevent the patient from bleeding excessively. Cross reference A2407.

* Provide an appropriate transfer to a higher level of care for Patient 2. Patient 2 was transferred to another acute care hospital in an unstable condition without a signed certification by the physician that the medical benefits of the transfer outweighed the risks of transfer; a confirmation the receiving facility had the capacity and capability to accept the transfer, and the name of a physician willing to accept care of the patient. The hospital did not forward a copy of the patient's medical record to the receiving hospital. Cross reference A2409.

Based on observation and interview, the hospital failed to conspicuously post signage in eight of the eight cubicle areas where patients waited for examination and treatment in ED 2. This could result in patients being unaware of their rights for examination in the event of an emergency medical condition.

Findings:

ED 2 was toured with the Director of Clinical Care on 12/12/11 at 0945 hours. Signage specifying the rights of individuals for examination and treatment with respect to emergency medical conditions and women in labor was observed posted on the wall at the entrance to the unit. There was no signage posted in the eight cubicles where patients would wait for treatment and examination. The lack of signage was confirmed by the Director.

Based on interview and review of documents, the hospital failed to maintain an on-call list of specialty physicians in order to provide the necessary treatment to stabilize individuals with an emergency medical condition. This had the potential to delay the stabilizing treatment of patients with an emergency medical condition.

Findings:

Unit Secretary A was interviewed on 12/12/11 at 0930 hours. When asked to provide the on-call list of specialty physicians for the ED, the Unit Secretary removed the list from her desk. The list, dated 12/6-12/13/11, showed for the vascular surgery specialty, a physician's group name was listed. The Unit Secretary stated if MD B was the surgeon on-call he would also cover vascular surgery, otherwise the office or the answering service of the physician's group listed would be called to inquire as to whom was available.

The ED Director was interviewed on 12/12/11 at 0915 hours. The Director confirmed the posted on-call list of specialty physicians did not list a physician's name for all of the specialties available. The Director stated the Unit Secretary would have to call the vascular surgery group to find out who was on-call that day.

ED Unit Secretary B was interviewed on 12/12/11 at 0920 hours. The Unit Secretary stated when a call was made to the vascular surgeon's group the answering service asked for a lot of patient information before paging the surgeon on-call. The Unit Secretary stated the process could be time consuming.

Based on interview and review of the medical record and hospital documentation, the hospital failed to provide a necessary medical screening examination in a timely manner for one of 21 sampled patients (Patient 1). When a family member of the patient requested wheelchair assistance from the ED Registration Clerk to transport the patient from the car to the ED, Patient 1 waited for approximately 40 to 60 minutes before receiving assistance from the ED staff. This potentially delayed the process of determining whether or not an emergency medical condition existed for Patient 1. Patient 1 was admitted to the hospital after his ED evaluation. His discharge diagnosis was acute myocardial infarction (heart attack).

Findings:

In a complaint filed with the Department of Public Health, Patient 1's family member stated the patient's cardiologist (heart specialist physician) was called on 4/11/11, as the patient was complaining of non-stop coughing and chest pain. The physician instructed the family member to take the patient to the nearest hospital. The family member stated the patient had been discharged from another hospital only a few days before. The family member stated she did not remember the time she arrived at the hospital but she parked the car by the ED, walked inside, and asked Registration Clerk 1 for a wheelchair. Registration Clerk 1 contacted staff in the ED by telephone and asked for wheelchair assistance. The family member stated she went out to the car to check on the patient. After an unknown time span, the family member stated she approached Registration Clerk 1 for the second time to inform her no assistance had arrived. The family member told the clerk Patient 1 was very sick, was coughing, and was unable to walk. The family member stated no staff person with a wheelchair came to help Patient 1 to the ED for approximately 42 minutes after she had requested assistance for Patient 1 who had a potential emergency medical condition.

On 12/13/11 at 1125 hours, an interview was conducted with Registration Clerk 1. The Clerk stated the family member of Patient 1 came into the ED on 4/11/11, and asked her for wheelchair assistance. The Clerk called ED station 1 and requested wheelchair assistance. The Clerk stated after calling the ED station, another patient came in to register. The clerk stated after finishing the registration, she asked Patient 1's family member if anybody had assisted her yet. When the family member told her they had not, the Clerk stated she walked back into the ED and personally told the Unit Secretary a family member needed wheelchair assistance. The Clerk stated a second walk-in ED patient came up to her window to register. The Clerk stated after registering the second patient, she asked Patient 1's family member a third time if anybody had assisted her with the wheelchair. The family member stated no, and informed the clerk Patient 1 was complaining of chest pain. The clerk stated she went back into the ED for the second time and told staff a patient with chest pain needed a wheelchair "now." Registration Clerk 1 stated EMT 1 came out to assist Patient 1 from his car to the ED. The Clerk stated she was unable to state how long Patient 1 had been waiting for wheelchair assistance. The Clerk stated she had called into the ED once and walked back to the ED nurses' station twice to ask for wheelchair assistance. The clerk confirmed she had registered two walk-in patients before the assistance arrived.

On 12/13/11 at 0915 hours, EMT 1 was interviewed. The EMT stated on 4/11/11, she had returned to the ED after transferring a patient to the nursing floor. EMT 1 stated the ED Unit Secretary and Registration Clerk 1 were talking about calling "four" times for wheelchair assistance. EMT 1 stated she went out to assist Patient 1 into ED.

On 12/13/11, review of the ED Daily log dated 4/11/11, showed two walk-in patients were registered prior to Patient 1. The first patient was registered at 1545 hours, 60 minutes before Patient 1's arrival into the ED. The second patient was registered at 1602 hours, 43 minutes before Patient 1 was brought into the ED. Documentation showed Patient 1 was brought into the ED on 4/11/11 at 1645 hours.

The medical record for Patient 1 was reviewed on 12/12/11. When he was brought into the ED, his blood pressure was 139/110, he had a fever of 99.5 degrees Fahrenheit and he rated his pain as 10, with 10 being the worst on a 1 to 10 scale. He was placed in the lobby to wait to be seen in the ED. At 1751 hours, Patient 1 was moved to a bed in the ED. He was given oxygen at 1830 hours. At 1842 hours the patient's blood pressure had decreased to 111/60; however, his heart rate had increased from 88 to 149. There was no temperature or pain rating documented.

The ED physician documented at 1847 hours on 4/11/11, a medical screening examination for Patient 1. Patient 1's chief complaint was mild chest pain that was still ongoing and not relieved by anything. The ED physician documentation showed further evaluation would be necessary in the ED to determine if Patient 1 had an emergency medical condition. At 1853 hours he was given aspirin and nitroglycerin. At 1928 hours an electrocardiogram showed Patient 1 had an abnormal heart rhythm of atrial fibrillation (the patient had a history of this rhythm). At 1928 hours a decision was made to admit the patient to the cardiac monitoring (telemetry) unit of the hospital with diagnoses of pneumonia and atrial fibrillation. The physician's History and Physical dated 4/12/11 for Patient 1 showed an additional diagnosis of acute myocardial infarction (heart attack).

During interviews on 12/12 and 12/13/11, the Director of Clinical Quality Improvement stated the hospital was made aware of Patient 1 ' s long wait for wheelchair assistance into the ED the same day of the occurrence, 4/11/11. A meeting with the hospital staff was held immediately that same day to address the issue. The system to provide wheelchair assistance was reviewed and changes were made. In-services on 4/15/11, were given to address the new procedure which called for the registration clerks to directly notify the ED charge nurse of a request for wheelchair assistance. In addition, the registration clerk would ask the individual requesting assistance the reason for their request and would relay the information to the charge nurse. The Director of Quality stated the Director of ED monitored the process for four months. When asked, the Director of Quality was unable to show documentation of monitoring follow up. The Director stated there had been no documented instances of further problems with a delay/complaint related to wheelchair assistance. Review of documentation showed inservices to staff were accomplished on 4/11 and 4/15/11.

Based on interview and review of hospital documents and the medical record, the hospital failed to provide further medical examination and treatment within the capabilities of the hospital staff for one of 21 sampled patients (Patient 2) prior to transfer of the patient to Hospital A, a designated trauma hospital. The hospital provided surgical services to its patients; however, the ED physician did not attempt to call the designated on-call surgeon to evaluate the patient.

Findings:

A complaint was received by the California Department of Public Health which alleged Hospital A had received Patient 2 as a trauma patient, transferred by paramedics from another hospital's ED. The complaint stated Patient 2 did not meet the trauma criteria necessary for the transfer as the patient only needed suturing of a wound. The complaint stated it took 18 minutes to transfer the patient to Hospital A.

The Los Alamitos Medical Center medical record for Patient 2 was reviewed on 12/12/11. Documentation showed the patient arrived at the hospital's ED accompanied by paramedics on 10/10/11 at 2359 hours.

Review of the Nurses' Notes showed Patient 2 presented to the ED with a stab wound laceration to the right cheek with apparent arterial involvement. The patient was alert and oriented. The patient had informed the paramedics she was currently on the medication Coumadin (blood thinner). There was a pressure dressing on the wound.

Physician documentation dated 10/11/11 at 0015 hours, showed Patient 2 had a 2 cm right cheek laceration with active pulsatile (forceful) bleeding. At 0022 hours, documentation showed the bleeding was controlled with direct pressure. Continuation transfer through the base station via paramedics to Hospital A's trauma center was ordered by the ED physician with the paramedics applying pressure to the patient's cheek with fingers on the outside and inside of the mouth. IV fluids and an antidote medication to counteract the effects of the Coumadin had been administered.

Physician documentation dated 10/11/11 at 0045 hours, showed Patient 2 responded to medication and direct pressure to the wound. The patient's symptoms had "markedly improved after treatment." The physician documented a transfer to Hospital A was ordered on 10/11/11 at 0030 hours. Diagnosis was a stab wound to head/face with active arterial bleeding controlled with pressure. "Patient in Stable for transfer condition."

The medical record for Patient 2 from Hospital A was reviewed. The ED physician documented the patient was transferred from an outside hospital. Documentation showed the patient's vital signs were within normal limits. The physician documented the patient had a 3 cm laceration to the right cheek with an obvious arterial bleed involvement.

Review of the Bedside Surgical Procedure Note by the surgeon dated 10/11/11 at 0119 hours, showed the laceration in the right cheek was repaired with absorbable sutures with no complications under a local anesthesia. The physician documented the patient's blood loss during the procedure to be less than 50 mL.

Patient 2 was discharged home two hours after her arrival at Hospital A.

The Los Alamitos Medical Center ED Director was interviewed on 12/12/11 at 1430 hours, and was asked to review the medical record for Patient 2. The Director was asked to state the reason for the transfer of Patient 2 to Hospital A as the physician's discharge documentation showed the patient was in a stable condition at the time of the transfer. The Director stated she had been called at midnight when Patient 2 was brought to the ED. The Director stated she was told staff was unable to control the bleeding. The Director stated this was the reason a continuation of a trauma run with the paramedics had been activated.

The Orange County EMS Interhospital Emergency Patient Transfer Guidelines, dated 6/23/06, were provided for review by the Director of the ED. The guidelines defined an Immediate Retriage (call-continuation) as the receiving ED physician determining that a critical patient required the specialty capabilities of a designated specialty center while the paramedics were still on the premises of the hospital and requesting the paramedics immediately transport the patient to the appropriate county EMS designated specialty receiving center. The guidelines showed copies of all documents should be available for transfer with the patient or may be faxed; the transferring physician shall notify the receiving trauma center of the immediate retriage of a trauma patient and communicate the patient's apparent injuries or reason for retriage.

On 12/12/11 at 1430 hours when asked to review the physician's documentation dated 10/11/11 at 0045 hours, "Patient in Stable for transfer condition," the Director stated she would contact the physician, MD A, for clarification as the discharge documentation was unclear.

MD A was interviewed by telephone on 12/13/11 at 1405 hours. MD A stated at the time of arrival on 10/10/11 at midnight, Patient 2 had an arterial bleed from a stab wound to the cheek. The MD stated the patient's blood pressure was decreased and when she removed the dressing, the bleeding was pulsatile. The MD stated she was able to stop the flow of blood with pressure between the inside and the outside of the cheek (fingers inside and outside of the patient's mouth).

MD A stated when the paramedics arrived with Patient 2 they told her they were thinking the patient needed a trauma center and suggested a continuation of care transport by paramedics. MD A stated she had not been familiar with this type of transport previous to this patient.

MD A stated she felt Patient 2 might need a specialist which was not available at this hospital to repair the laceration. When asked if she had contacted the surgeon on-call for the ED, MD A stated she had not. The MD stated the on-call surgeon was not required to present to the hospital in a specified time. She felt the patient was in danger of bleeding to death in the next 30 minutes and needed a higher level of care.

MD A was asked to clarify the discharge documentation for Patient 2 dated 10/11/11 at 0045 hours. The MD stated the statement "Patient in Stable for transfer condition" was an electronic documentation default. The MD stated the patient was not stable; however, she had mistakenly entered the incorrect prompt into the electronic record.

The ED Director was re interviewed on 12/13/11 at 1420 hours. The Director provided the hospital's P&P titled Emergency Department On-Call Failure, dated 11/08 for review. The P&P showed a physician scheduled to take ED call must respond to all calls from the ED by telephone within 30 minutes of a call or page from the ED. If the ED physician determined the on-call physician must come in to examine the patient, the on-call physician must timely come to the ED to examine the patient.

Based on interview and review of hospital documents and the medical record, the hospital failed to ensure the appropriate transfer of one of 21 sampled patients (Patient 2) to Hospital A, a designated trauma hospital. There was no documented evidence to show the transferring ED physician had signed a certification the medical benefits of the transfer outweighed the risks to Patient 2, who had not been stabilized prior to the transfer. There was no documentation to show the receiving hospital had confirmed they had the available space for the treatment of the patient or the name of a physician who had agreed to accept the care of the patient. In addition, a copy of the patient's medical record related to the patient's care and treatment at the hospital was not sent with the patient upon transfer to Hospital A.

Findings:

A complaint was received by the California Department of Public Health which stated Hospital A had received Patient 2 as a trauma patient. The patient had been transferred to Hospital A by paramedics from Los Alamitos Medical Center. The complaint alleged staff from the Los Alamitos Medical Center had not called or spoken to anyone in Hospital A's ED to request acceptance of Patient 2 prior to the transfer. No request was made for the name of a physician to accept the care of the patient. The complaint stated Patient 2 did not meet the trauma criteria necessary for the transfer as the patient only needed suturing of a wound. In addition, Hospital A had to contact the Los Alamitos Medical Center to request Patient 2's medical record. No paperwork had accompanied the patient.

During a tour of the ED on 12/12/11 at 0910 hours, RN A was interviewed. When asked to state the procedure to transfer an ED patient to another hospital, the RN stated they would need to obtain an accepting physician at the other hospital and confirm a bed was available for the patient. The RN stated consent from the patient for the transfer was also required and the medical record would be copied and sent with the patient. RN A stated a Call Continuation Transfer by paramedics might be done if the hospital was unable to provide a service required by the patient in an emergency; however the same transfer procedures applied. The RN provided a two page Acute Interfacility Transfer Consent/Physician Certification form used at the hospital to document the requirements of a transfer to another facility.

Review of the Acute Interfacility Transfer Consent/Physician Certification form showed, on page one, an area for the patient to sign a request for transfer, a transfer acknowledgement that the reason(s) for the transfer had been explained to them, or the patient's refusal of the transfer. At the bottom of page one was an area for physician certification that after an examination and evaluation of the patient, the physician had concluded the benefits of the transfer outweigh the risks. The reason(s) for the transfer as well as the benefit(s) and risk(s) were to be documented by the physician. An area to assess the patient's stability at the time of transfer was to be completed and signed by the physician at the time of transfer.

Page two of the form was to be completed by the RN. Patient information included diagnosis, vital signs, IV access and infusion solutions, medical records accompanying the patient, and the reason for the transfer. The name of the physician ordering the transfer, the name of the physician accepting the transfer, and the name of the hospital and hospital staff person accepting the transfer were to be documented, and the form signed by the RN.

The medical record for Patient 2 was reviewed on 12/12/11. Documentation showed the patient arrived at the hospital's ED accompanied by paramedics on 10/10/11 at 2359 hours.

Review of the Nurses' Notes showed Patient 2 presented to the ED with a stab wound laceration to the right cheek with apparent arterial involvement. The patient was alert and oriented. The patient had informed the paramedics she was currently on the medication Coumadin (blood thinner). There was a pressure dressing on the wound.

Physician documentation dated 10/11/11 at 0015 hours, showed Patient 2 had a 2 cm right cheek laceration with active pulsatile (forceful) bleeding. At 0022 hours, documentation showed the bleeding was controlled with direct pressure. A Continuation Transfer by paramedics through the EMS (Emergency Medical Services) base station to Hospital A's trauma center was ordered by the ED physician with the paramedics applying pressure with their fingers to the outside and the inside of the patient's mouth. IV fluids and an antidote medication to counteract the effects of the Coumadin had been administered.

Physician documentation dated 10/11/11 at 0045 hours, showed Patient 2 had responded to medication and direct pressure to the wound. The physician documented transfer to Hospital A was ordered on 10/11/11 at 0030 hours. Diagnosis was a stab wound to head/face with active arterial bleeding controlled with pressure. "Patient in Stable for transfer condition."

There was no documentation found in Patient A's medical record to show the physician had documented the reason for the transfer, the benefit(s) and risk(s) of a transfer had been evaluated and that the benefit(s) and risk(s) had been explained to the patient prior to the transfer to Hospital A's trauma center. There was no documentation to show Hospital A had been contacted and a physician had agreed to accept the care of the patient.

The ED Director was interviewed on 12/12/11 at 1430 hours, and was asked to review the medical record for Patient 2. The Director was asked to state the reason for the transfer of Patient 2 to Hospital A's trauma center as the physician's documentation showed the patient was in a stable condition at the time of the transfer. The Director stated she had been called at midnight when the patient was brought to the ED and was told staff was unable to control the bleeding. The Director stated this was why a continuation of a trauma run with the paramedics had occurred. When asked to review the physician's documentation dated 10/11/11 at 045 hours, "Patient in Stable for transfer condition," the Director stated she would contact the physician, MD A, for clarification as the discharge documentation was unclear.

MD A was interviewed by telephone on 12/13/11 at 1405 hours. MD A stated at the time of arrival on 10/10/11 at midnight, Patient 2 had an arterial bleed from a stab wound to the cheek. The MD stated the patient's blood pressure was decreased and when she removed the dressing, the bleeding was pulsatile. The MD stated she was able to stop the flow of blood with pressure between the inside and the outside of the cheek.

MD A stated when the paramedics arrived with Patient 2 they told her they were thinking the patient needed a trauma center and suggested a continuation of care transport by paramedics. MD A stated she was not familiar with this type of transport previous to this patient.

MD A stated she felt Patient 2 might need a specialist who was not available at the hospital to repair the laceration. The MD stated she felt the patient was in danger of bleeding to death in the next 30 minutes and needed a higher level of care. When asked, the MD confirmed a surgeon was on call for the ED; however, she had not called the surgeon.

MD A was asked to clarify the discharge documentation for Patient 2 dated 10/11/11 at 0045 hours. The MD stated the statement "Patient in Stable for transfer condition" was an electronic documentation default. The MD stated the patient was not stable; she had mistakenly entered the incorrect prompt into the electronic record.

When asked if she had completed an Acute Interfacility Transfer Consent/Physician Certification form for Patient 2 prior to the transfer, MD A stated she had not known the form was available. When asked, MD A was not aware an accepting physician was required prior to transfer of a patient.

MD A stated she informed Patient 2 a specialist might be required to repair her wound and that those services were not immediately available at this hospital. The MD stated at that time the patient requested a transfer to a trauma center. MD A confirmed she had not documented the patient's refusal of services at the hospital or the patient's request for transfer.