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Based upon interview and record review, the hospital failed to provide an appropriate medical screening examination within the capability of the hospital's Emergency Department (ED), including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition existed by failing to obtain a CT Scan of the head (radiological exam to assess for skull fracture and bleeding into the brain) for 1 applicable patient. The patient was 1 of 20 targeted patients that presented to the ED during the sampling period (Patient #4). Finding includes:

Per record review on 5/22/12, Patient #4 was seen in the ED on 6/22/11 at 12:45 PM per ED Nursing Record for "hit in head with tree". On 6/22/11 at 14:50 PM, the ED Physician Record states Patient #4 was seen for " injury to face, direct blow ". The physical exam sheet diagram states "spurting artery, attempted hemostasis unsuccessfully" (unable to stop bleeding). In addition, the ED physician failed to complete the assessment for a head examination. Per ED Physician's record, the head exam questions were left blank. In addition, the ED Nursing Record documents that Patient #4 received 3 doses of pain medication, one Percocet by mouth at 2:13 PM and Morphine IVP (Intravenous Push) at 2:15 PM and 3:19 PM.

Per interview on 5/22/12 at 1:00 PM, the ED On-Call Surgeon stated he/she was called by the ED Physician on 6/26/11 to come in and suture Patient #4's head laceration. Subsequently, Patient #4 was seen by him/her on 6/30/11 for a routine follow-up post ED visit. On 6/30/11, the Surgeon ordered a CT Scan of the head which was done on 7/1/11. Stated Patient #4 was sent to a tertiary hospital for treatment following the CT Scan which was positive for a depressed skull fracture and bleeding into the brain.

Per record review and confirmed during an interview with the Quality Specialist on 5/22/12 at 3:05 PM, radiological testing, including a CT Scan of the head, was not ordered for Patient #4 prior to discharge from the ED on 6/26/11. The Quality Specialist stated Patient #4 was admitted to the ED on 6/26/11 for a head contusion and laceration secondary to a falling tree. Per record review, the ED On-Call surgeon sutured Patient #4's head laceration. The same surgeon saw Patient #4 on 6/30/11 in his/her private office for a routine follow-up post ED visit. On 7/1/11, a CT Scan of the head was done for "laceration on forehead and lightheadedness". The CT Scan was positive for a depressed fracture of the head, cerebral hematoma & subdural hematoma (skull fracture and bleeding into the brain).

Per interview on 5/22/12 at 11:49 AM, the ED Medical Director stated a clinical indication for ordering a CT Scan of the head is for suspicion of a skull fracture and either the ED Physician or the ED On-Call Surgeon should have ordered a CT Scan of Patient #4's head prior to discharge.

Per record review on 5/22/12 Patient #4 was discharged home from the ED on 6/22/11 at 4:40 PM without having a CT Scan of the head. The 6/26/11 ED Physician Record for Patient #4 states Clinical Impression: Contusion forehead, laceration forehead - sutured; Disposition: "Home" and "Improved" were checked off. The 6/26/11 ED On-Call Surgeon note for Patient #4 states: "Came to Emergency Room, bleeding from head wound left forehead, 5 centimeter, secondary to tree falling tree; Suture bleeder, Follow-up my office June 30, Call for appointment". In addition, the ED On-Call Surgeon's Report of Operation dated 6/26/11 states: "Preoperative diagnosis: scalp laceration left forehead secondary to falling tree, Post-operative diagnosis: scalp laceration left forehead secondary to falling tree. Patient was discharged home following procedure".

Based upon staff interview and record review, the hospital failed to assure that 1 applicable patient ' s emergency medical condition was stabilized prior to discharge from the Emergency Department (ED). The patient was 1 of 20 targeted patients that presented to the ED during the sampling period (Patient #4). Finding includes:


Per record review on 5/22/12, Patient #4 was seen in the ED on 6/22/11 at 12:45 PM per ED Nursing Record for "hit in head with tree". On 6/22/11 at 14:50 PM, the ED Physician Record states Patient #4 was seen for " injury to face, direct blow ". The physical exam sheet diagram states "spurting artery, attempted hemostasis unsuccessfully" (unable to stop bleeding). In addition, the ED physician failed to complete the assessment for a head examination. Per ED Physician's record, the head exam questions were left blank. In addition, the ED Nursing Record documents that Patient #4 received 3 doses of pain medication, one Percocet by mouth at 2:13 PM and Morphine IVP (Intravenous Push) at 2:15 PM and 3:19 PM.

Per interview on 5/22/12 at 1:00 PM, the ED On-Call Surgeon stated he/she was called by the ED Physician on 6/26/11 to come in and suture Patient #4's head laceration. Subsequently, Patient #4 was seen by him/her on 6/30/11 for a routine follow-up post ED visit. On 6/30/11, the Surgeon ordered a CT Scan of the head which was done on 7/1/11. Stated Patient #4 was sent to a tertiary hospital for treatment following the CT Scan which was positive for a depressed skull fracture and bleeding into the brain.

Per record review and confirmed during an interview with the Quality Specialist on 5/22/12 at 3:05 PM, radiological testing, including a CT Scan of the head, was not ordered for Patient #4 prior to discharge from the ED on 6/26/11. The Quality Specialist stated Patient #4 was admitted to the ED on 6/26/11 for a head contusion and laceration secondary to a falling tree. Per record review, the ED On-Call surgeon sutured Patient #4's head laceration. The same surgeon saw Patient #4 on 6/30/11 in his/her private office for a routine follow-up post ED visit. On 7/1/11, a CT Scan of the head was done for "laceration on forehead and lightheadedness". The CT Scan was positive for a depressed fracture of the head, cerebral hematoma & subdural hematoma (skull fracture and bleeding into the brain).

Per interview on 5/22/12 at 11:49 AM, the ED Medical Director stated a clinical indication for ordering a CT Scan of the head is for suspicion of a skull fracture and either the ED Physician or the ED On-Call Surgeon should have ordered a CT Scan of Patient #4's head prior to discharge.

Per record review on 5/22/12 Patient #4 was discharged home from the ED on 6/22/11 at 4:40 PM without having a CT Scan of the head. The 6/26/11 ED Physician Record for Patient #4 states Clinical Impression: Contusion forehead, laceration forehead - sutured; Disposition: "Home" and "Improved" were checked off. The 6/26/11 ED On-Call Surgeon note for Patient #4 states: "Came to Emergency Room, bleeding from head wound left forehead, 5 centimeter, secondary to tree falling tree; Suture bleeder, Follow-up my office June 30, Call for appointment". In addition, the ED On-Call Surgeon's Report of Operation dated 6/26/11 states: "Preoperative diagnosis: scalp laceration left forehead secondary to falling tree, Post-operative diagnosis: scalp laceration left forehead secondary to falling tree. Patient was discharged home following procedure".