HospitalInspections.org

Based on staff interview and record review, the Medical Staff Bylaws and facility policies and procedures failed to establish written response times, specific in minutes, for on-call physicians. Findings include:

Per record review on 6/10/10, the Medical Staff Bylaws (last approved/revised May 2010) fail to address response time for those physicians who provide on-call coverage for Emergency Services. "Article XV -
Active Medical Staff On-Call Coverage for Emergency Department Consultation and Admission" addresses participation, exemptions and scheduling, however response time Emergency Service coverage is not addressed.

Based on staff and patient interviews and record review, the CAH (Critical Access Hospital) failed to provide a Medical Screening Exam (MSE) for 3 of 25 patients who presented to the Emergency Department (ED) for assessment of an Emegency Medical Condition (EMC). (Patients #1, 14 , 25 ) Findings include:

1. Per review on 6/10/10, Patient #25, who was approximately 14 weeks pregnant with twins, presented to the ED on 3/31/10, 4/7/10 and 4/8/10 with the same complaint of abdominal pain, but did not receive a Medical Screening Exam (MSE) on 4/7/10.

Per review of "Emergency Room Note", Patient #25 presented to the ED on 3/31/10 at 1:35 AM with "...pain in the epigastric and right upper quadrant...stating she never had this discomfort before." Per nursing clinical report the patient rated her pain at a 10 (pain rating scale 1-10 with 10 defined as the worst pain). The ED physician prescribed Demerol 25 mg IV, which was administered twice with only "some relief". The patient was discharged to home and was requested to return for an ultrasound which was conducted on the morning of 3/31/10. Patient #25 then returned to the ED after the procedure and was informed by the ED physician the results of the abdominal ultrasound was "...normal common bile duct, normal liver, gall bladder, pancreas and spleen".

On 4/7/10 at 3:02 PM Patient #25 returned to the ED with the same complaint of abdominal pain. The patient was seen by the triage nurse who determined the patient should be evaluated by a physician in the obstetrical department and was sent to the Womens Wellness Clinic (WWC) located on the hospital campus. Per review of ED policy " Unexpected Obstetrical Patients with Obstetrical Complaints" revised 02/08 states "Less than 20 weeks will be registered and evaluated in the Emergency Department by the ED physician or OB provider if appropriate which may include nurse mid-wives". Per interview on 6/10/10 at 9:30 AM, Nurse #1 confirmed h/she failed to follow hospital policy by not properly assessing and triaging the patient, to include taking the patient's vital signs and as a result prevented Patient #25 from receiving a MSE. Nurse #1 also stated h/she failed to consult with the ED physician prior to the decision to send patient #25 to the WWC. Nurse #1 failed to perform a triage assessment as per CAH policy to include vital signs and failed to document communication with staff from the WWC.

Per interview on 6/10/10 at 4:00 PM, Physician #1 stated any patient that is less then 20 weeks (pregnant) would expect to be seen in the ED and the triage nurse would ".....presume I would see them.........to let me check them to see where they are...." in their pregnancy and chief complaint. " I would make contact with OB to recheck for any other information". Per interview on 6/9/10 at 4:35 PM the ED nurse manager confirmed Nurse #1 failed to follow ED policy and as a result the ED physician did not conduct a MSE for Patient #25.

Per interview on 6/9/10 at 12:05 PM, Patient #25 stated when she presented to the ED on 4/7/10, with the same symptoms and increased pain and requesting to be seen, she met briefly with the triage nurse who then sent her to the WWC. Patient #25 stated she was not offered a choice to remain in the ED and receive a MSE by the ED physician. The patient stated after arriving at the WWC she then sat waiting for at least 1 hour before being examined by an obstetrician. The obstetrician/physician #2 who examined Patient #25 confirmed on 6/9/10 at 4:00 PM the patient continued to complain of right upper quadrant pain and h/she contributed the patient's pain complaints to constipation. No further lab test or diagnostic imaging was ordered. Further interview on 6/10/10 at 10:30 AM Physician #2 confirmed " I did not think it was obstetrical". In addition, Physician #2 dictated in their office visit note of 4/7/10 that Patient #25 had been seen on the previous day (4/6/10) in the ED which was inaccurate.

Per interview on 6/10/10 Patient #25 stated late in the evening of 4/8/10 prior to her 3rd visit to the ED, she felt a "pop" in her abdomen that was associated with increased pain. Per record review, on 4/8/10 at 11:28 PM Patient #25 returns to the ED again with abdominal pain. Physician #3 conducts a MSE and determines an emergency medical condition does exist, orders lab work and pain medication and admits the patient to the obstetrical service. The physicians's emergency room note states " 35 year old who appears quite uncomfortable...there is significant upper quadrant tenderness to palpation". ED Physician #3 contacts Physician #2, the on-call obstetrician, who was the same physician who had seen Patient #25 in the WWC on 4/7/10 for similiar symptoms. The ED physician informed the obstetrician Patient #25 would be admitted for observation to the obstetrical service with a final diagnosis "abdominal pain in pregnancy". Per the ED Clinical Report the nurse documents the patient's blood pressure on admission was 120/60 however, over the course of 2 hours the patients blood pressure drops to 86/45 and temperature increases from 37.3 C (99.1 Fahrenheit (F)) and to 38 C (100.4 F.) Prior to transfer to the observation bed, the nurse documents in the Clinical Report Patient #25 describes pain as "Sharp, burning, crampy pain....starts in the middle outward to sides."

Per interview on 6/9/10 at 3:35 PM and 6/14/10 at 6:00 PM, Physician #3 confirmed h/she had contacted Physician #2 on 4/8/10 regarding Patient #25, however did not recall what he had reported to Physician #2 and why h/she did not ask the physician to come and assess the patient in the ED. Documentation only revealed contact was made. Patient #25 was transferred to an observation bed on medical/surgical unit. On the morning of 4/9/10 the patient experienced continued pain, elevated temperature and white blood cell count, with subsequent emergent surgical intervention for ruptured appendix and peritonitis. Four days post surgery, Patient #25 experienced preterm delivery of the nonviable fetuses. Per review of perinatal autopsy report stated the cause of the preterm delivery of the fetuses "...is likely acute-onset underperfusion of the placental bed, due to ruptured appendicitis."

2. Per record review Patient #14 did not receive a MSE when s/he presented to the ED on the evening, following a same day surgical procedure, seeking assistance and treatment for bleeding from the surgical wound site.

Per review of nurses notes on the ED Clinical Report, on 6/9/10, the patient presented to the ED on 12/9/09 at 6:53 PM, with a stated complaint of "Surg Bleed". The note stated that the patient had undergone "surgery for excision of cartilage/bone between two joints today.....excessive bleeding noted....attempted to call (Physician #5) - no reply". A subsequent nurse's note, at 7:11 PM stated that Physician #5 (the surgeon who had performed the patient's surgical procedure) had been notified that the patient was in the ED. The note further stated; "Instructed by Dr.(Physician #5) to pack area that's bleeding and tell pt. (patient) to f/u at office for cast change in morning. Pt verbalizes understanding of instructions and agrees with plan." Although the Status Event History indicated that at 7:06 PM the patient was in a room with the nurse and; "To be seen by MD", at 7:14 PM it stated; "Other...Not an ER pt/problem", and there was no evidence that the patient was examined by the ED Physician #3 prior to discharge.

During a telephone interview, at 3:40 PM on 6/14/10, Nurse #3, who had provided care for Patient #14 in the ED, stated that the patient had attempted to contact Physician #5 because there was bleeding through the cast, was unable to reach the physician and "s/he freaked" and came to the ED. The nurse stated that following his/her assessment of Patient #14, s/he discussed the reason for the patient's visit with Physician #3 (the ED physician on duty at the time), and Physician #3 had instructed the nurse to contact Physician #5. Nurse #3 then stated that s/he had contacted Physician #5, by telephone, and was instructed by Physician #5 to pack the area that was bleeding and have the patient follow up with Physician #5's office in the morning for a cast change. Nurse #3 further stated that s/he did not know if Physician #3 had seen Patient #14.

During interview, on 6/14/10 at 6:05 PM, Physician #3, who reviewed Patient #14's chart at the time of interview, confirmed that s/he had not completed a MSE on the patient on the evening of 12/9/09. Physician #3 further stated that there have been other occasions when s/he may not have provided MSE for patients presenting to the ED. S/he stated "if I didn't write a note I probably didn't see the patient. When things get crazy in the ED.....there may be times I wouldn't see a patient; but the nurse assesses them."

3. Per record review on 6/10/10, Patient #1 was brought via ambulance to the ED on 12/31/09 at 10:20 PM with a chief complaint of abdominal pain. The patient was examined by the ED physician #4 at 10:40 PM and after lab work results were received, the physician determined the patient was stable, required no further intervention from ED services and ordered the patient to be discharged. Discharge instructions were provided to Patient #1 and per the ED Clinical Report was discharged at 11:44 PM.

Per review of a second ED record for Patient #1, at 4:01 AM on 1/1/10 the patient's stated complaint was a "Recheck abdominal Pain". Per interview on 6/14/10 at 3:00 PM, ED Nurse #2 who provided care to Patient #1 for both ED visits, stated after discharge on 12/31/09, Patient #1 experienced difficulty obtaining a ride home and was observed in the waiting area. Approximately 4 hours after discharge, while still noted to be in the waiting area, Patient #1 requested a MSE and was again registered via "tracker system" to initiate receiving care and services. Nurse #2 stated she contacted the ED physician #4 by phone to inform h/she Patient #1 had returned and was requesting to be seen. Nurse #2 documented ED Physician #4 stated "...there was not anything to do tonight and h/she could follow-up with PCP as instructed at discharge". The ED physician would not see the patient and a MSE was not performed.

Per interview on 6/10/10 at 3:08 PM, the ED Nurse manager confirmed upon review of the ED record for the 1/1/10 visit by Patient #1, the patient did not receive a MSE and the nurse had also failed to conduct the routine nursing assessment of the patient as required.

Per interview on the afternoon of 6/15/10, ED physician #4 stated "I did not realize the patient had been booked back in, h/she never left the ED, this second request to be seen would normally be incorporated into the first visit". However, per interview on 6/15/10 at 3:30 PM the VP of Quality Management Programs stated after discharge from the ED each visit is entered as a discharge on the electronic record and subsequent visits by a patient would be entered into the "tracker system" at the time of registration and considered a new visit.