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Based on policy and procedure reviews, medical records reviews, hospital documentation reviews, physician schedule review, staff and physician interviews, the Dedicated Emergency Department (DED) physician failed to ensure a Medical Screening Exam was completed per the facility policy within the capabilities of the hospital that provided for the stabilization of a patient prior to discharge from the DED; staff failed to provide further medical examination and treatment within the capabilities of the staff and facilities available at the hospital, as required to stabilize the medical condition; physician failed to complete the physician certification closely to the time of the transfer and/or document the increased risks associated with the transfer to the individual in 2 of 7 DED patients having an Emergency Medical Condition (EMC) and transferred to another hospital.

The findings include:

1. ~ cross refer to 489.24(d)(1-3) Stabilizing Treatment, Tag A2407.
2. ~ cross refer to 489.24(e)(1)(2) Risks and Benefits, Tag A2409.

Based on Policy and Procedure reviews, closed medical record reviews , staff and physician interviews, the hospital's DED (Dedicated Emergency Department) staff failed to provide further medical examination and treatment within the capabilities of the staff and facilities available at the hospital, as required to stabilize the medical condition in 1 of 4 individuals with an emergency medical condition transferred (#7).

The findings include:

Review of hospital policy "PC 210.59 EMTALA Medical Screening & Stabilization, Refusal of Treatment" effective 8/1/2011 revealed "E. Stabilization 1. If an Emergency Medical Condition exists, medical treatment, within the capabilities of the staff and facilities routinely available ("Capacity"), will be provided to stabilize the individual prior to consideration of discharge, admission or transfer. Stabilized means (for individuals with emergency medical conditions other than those who are pregnant and having contractions) that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility".

Review of policy "PC 210.60 EMTALA, Transfer-To Other Medical Facilities" effective 09/2008 revealed "C. For All Transfer (Stable and Unstable) to another medical facility: 1. (Name of hospital) must provide medical treatment within its capacity that minimizes the risk to the individual's health... "

Medical record review of patient #7 revealed a 10 year old child presenting to the DED on 12/31/2013 at 1003 with a chief complaint of hyperglycemia, Diabetes, nausea vomiting x 2 days and elevated blood sugar. Medical record review revealed at 1017 Physician A initiated the medical screening exam (MSE) at 1016. Review of the MSE revealed ""10 year-old Hispanic female history of insulin dependent diabetes presents to the emergency department fatigued, vomiting since yesterday, abdominal cramping tachycardic, pale. Accu-Chek 494. Patient's mother and sister state she has been vomiting since yesterday glucose measured as "high"...Patient's mother does not seem to understand the dosing/frequency of the patient ' s insulin". Record review revealed the patient was administered 10 units of regular insulin intravenous (IV) per physician order at 1030. Record review revealed Sodium chloride 1000 ml was started IV at 1030 at a rate of 2000 ml per hour per physician's order. Review of nursing documentation at 1040 during triage revealed "pt (patient) has been having nausea and vomiting for 2 days. mother reports BS (Blood sugar) was reading "high" all day yesterday.

" Further review revealed the patient was triaged level 2 (urgent). Vital signs documented at triage Temperature 97.9 F, Pulse rate 140 (high per hospital criteria), Blood pressure 133/87 (high per hospital criteria) and respirations 22. Record review revealed lab results received at 1135. Review of the results revealed: White Blood Cell count 24.6 High ( range 4.0-10.0), Red Blood Cells 6.33 High (range 4.00-5.00), Hemoglobin 18.0 High (range 12.0-15.5), Hematocrit 52.2 High (range 35.0-46.0), Blood urea nitrogen 25 High (7-17), Creatinine 1.10 High (range 0.44-1.0), potassium 3.2 Low (range 3.5-5.5), Calcium 11.9 High (range 8.4-10.2), Magnesium 3.0 High (range 1.8-2.4), Total protein 9.4 High (range 6.0-8.5), Alkaline phosphates 417 High (range 117-390). Medical record review revealed the patient had a blood glucose level at 1135 of 499 "Critical Lab Test: Glucose less than 50 or greater than 400".

Record review revealed at 1226 Physician A documented the patients ' electrocardiogram was "rate 166, The rhythm is sinus tachycardia". Medical record review revealed the last set of vital signs documented were at 1353 heart rate 133, respirations 21, Blood pressure 108/61. Medical record review revealed written physician certification for transfer of the patient to another hospital. Review of the physician certification revealed physician A signed the certification at 1220 on 12/31/2013. Further review of the certification for transfer revealed "2nd signature validating certification transferred within 30 minutes of initial certification" signed by physician D at 1335 on 12/31/2013. Review revealed documentation on the physician certification for transfer by nursing staff the transfer summary was completed with Emergency services personnel on 12/31/2013 at 1355 (1 hour 35 minutes after initial certification for transfer).

Medical record review revealed the last documentation of reassessment of the patient by physician A was at 1321. Record review revealed physician A documented the patients ' condition was "guarded" and diagnosis was Dehydration and Diabetic Ketoacidosis. Medical record review revealed documentation by nursing at 1425 "Pt (patient) provided 120 ml (milliliters) Apple juice PO (by mouth) due to BSC (Blood Sugar check) = 74, pt suddenly drowsy, difficulty arousing, BSG (Blood Sugar Glucose) checked. Dr. A notified at pt was leaving with EMS (Emergency Medical Services) event. EMS provided 360 ml apple juice for ground transport to Hospital B (receiving Hospital) if po capable". Review of documentation at 1428 by the charge nurse revealed "Primary RN (name of nurse) stated pt less responsive. BS (Blood Sugar) reading 74. Dr. A made aware and states given apple juice. (name of nurse) primary RN made aware of same." Record review revealed no further documentation of a reassessment of the patient prior to leaving the DED at 1430 (1 hour 9 minutes since physician reassessment). Record review revealed no further documentation of a recheck of the patients ' blood sugar prior to transfer.

Interview with administrative staff on 01/09/2014 at 1100 revealed the last documentation by the physician was at 1321 on 12/31/2013. The interview revealed the patient was not reassessed after receiving apple juice and the patients ' blood glucose was not rechecked prior to transfer. The interview revealed there was no further documentation for the medical record.

Based on policy and procedure reviews, closed medical record reviews, staff and physician interviews the hospital's dedicated emergency department (DED) physician failed to complete the physician certification closely to the time of the transfer and/or document the increased risks associated with the transfer to the individual in 2 of 7 DED patients having an Emergency Medical Condition (EMC) transferred to another hospital (#7, #25).

The Findings include:

Review of policy "PC 210.60 EMTALA, Transfers-To Other Medical facilities " effective 09/2008 revealed "3. The request must be in writing and it must indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer."

1. Medical record review of patient #7 revealed a 10 year old child presenting to the DED on 12/31/2013 at 1003 with a chief complaint of hyperglycemia, Diabetes, nausea vomiting x 2 days and elevated blood sugar. Medical record review revealed at 1017 Physician A initiated the medical screening exam (MSE) at 1016. Review of the MSE revealed ""10 year-old Hispanic female history of insulin dependent diabetes presents to the emergency department fatigued, vomiting since yesterday, abdominal cramping tachycardic, pale. Accu-Chek 494. Patient's mother and sister state she has been vomiting since yesterday glucose measured as "high"...Patient's mother does not seem to understand the dosing/frequency of the patients ' insulin". Record review revealed the patient was administered 10 units of regular insulin intravenous (IV) per physician order at 1030. Record review revealed Sodium chloride 1000 ml was started IV at 1030 at a rate of 2000 ml per hour per physician's order. Review of nursing documentation at 1040 during triage revealed "pt (patient) has been having nausea and vomiting for 2 days. mother reports BS (Blood sugar) was reading "high" all day yesterday. " Further review revealed the patient was triaged level 2 (urgent). Vital signs documented at triage Temperature 97.9 F, Pulse rate 140 (high per hospital criteria), Blood pressure 133/87 (high per hospital criteria) and respirations 22. Record review revealed lab results received at 1135. Review of the results revealed: White Blood Cell count 24.6 High ( range 4.0-10.0), Red Blood Cells 6.33 High (range 4.00-5.00), Hemoglobin 18.0 High (range 12.0-15.5), Hematocrit 52.2 High (range 35.0-46.0), Blood urea nitrogen 25 High (7-17), Creatinine 1.10 High (range 0.44-1.0), potassium 3.2 Low (range 3.5-5.5), Calcium 11.9 High (range 8.4-10.2), Magnesium 3.0 High (range 1.8-2.4), Total protein 9.4 High (range 6.0-8.5), Alkaline phosphates 417 High (range 117-390). Medical record review revealed the patient had a blood glucose level at 1135 of 499 "Critical Lab Test: Glucose less than 50 or greater than 400". Record review revealed at 1226 Physician A documented the patients ' electrocardiogram was "rate 166, The rhythm is sinus tachycardia".

Medical record review revealed the last set of vital signs documented were at 1353 heart rate 133, respirations 21, Blood pressure 108/61. Medical record review revealed written physician certification for transfer of the patient to another hospital. Review of the physician certification revealed physician A signed the certification at 1220 on 12/31/2013. Further review of the certification for transfer revealed "2nd signature validating certification transferred within 30 minutes of initial certification" signed by physician D at 1335 on 12/31/2013. Review of the certification for transfer revealed a section titled "Risk of Transfer (Must list patient specific risks.). Review of the section revealed the line provided to document the risk was blank. Review of the section revealed two check boxes for "Deterioration of condition enroute." and "Worsening of condition or death if you stay here" below the line for risks specific to the patient. Record review did not reveal any documentation of the specific risk associated with the transfer of the patient.

Medical record review revealed the last documentation of reassessment of the patient by physician A was at 1321. Record review revealed physician A documented the patient's condition was "guarded" and diagnosis was Dehydration and Diabetic Ketoacidosis. Medical record review revealed documentation by nursing at 1425 "Pt (patient) provided 120 ml (milliliters) Apple juice PO (by mouth) due to BSC (Blood Sugar check) = 74, pt suddenly drowsy, difficulty arousing, BSG (Blood Sugar Glucose) checked. Dr. A notified at pt was leaving with EMS (Emergency Medical Services) event. EMS provided 360 ml apple juice for ground transport to Hospital B (receiving Hospital) if po capable". Review of documentation at 1428 by the charge nurse revealed "Primary RN (name of nurse) stated pt less responsive. BS (Blood Sugar) reading 74. Dr. A made aware and states given apple juice. (name of nurse) primary RN made aware of same." Record review revealed no further documentation of a reassessment of the patient prior to leaving the DED at 1430 ( 2 hours 10 minutes since physician written certification for transfer and 55 minutes since the "2nd signature validating certification transferred within 30 minutes of initial certification").

Interview with administrative staff on 01/09/2014 at 1100 revealed the last documentation by the physician was at 1321 on 12/31/2013. The interview revealed the patient was not reassessed after receiving apple juice and the patient's blood glucose was not rechecked prior to transfer. The interview revealed there was no further documentation for the medical record.

2. Medical record review of patient #25 revealed a 29 year old presenting to the DED on 11/17/2013 at 1716 with a chief complaint of All Terrain Vehicle (ATV) accident. review of the nursing triage documentation revealed the patient complained of left knee and right shoulder pain. Record review revealed the patient had "swollen lips, small amount of blood in mouth". Vital signs at triage were temperature 97.7 F, pulse rate 106 (high), blood pressure 154/99 (high) and respirations rate 16. Review of the MSE by the physician at 1732 revealed "Laceration of the mucosal surface of the upper lip left side, extensive swelling of right cheek, crusted blood bilateral nares, extensive abrasions and contusions of the facial area...Right clavicle tender to palpation...Right shoulder tenderness to palpation...Left knee tender to palpation". Record review revealed documentation by the physician of reassessment at 1957. Review of the assessment revealed "appears to have nasal fractures and possible right facial fracture over the cheek area.

Subsequent CT of the brain shows some abnormal minimal density along the falx cerebri and radiologist is quite sure whether this is calcification versus a small amount of blood represents minimal traumatic subarachnoid hemorrhage. We have no neurosurgeon on-call locally...We have confirmed nasal fractures and right maxillary sinus fracture on facial CT. Patient has received multiple doses of morphine for pain".

Record review revealed the diagnoses documented "head injury, abrasion to face, head contusion, lower extremity contusion, knee sprain, closed fracture of the facial bones. traumatic intracranial hemorrhage and closed dislocation of the shoulder". Record review revealed written physician certification for transfer completed at 2120. Review of the certification for transfer revealed a section titled "Risk of Transfer. Review of the section revealed the line provided to document the risk documented traffic accident. Review of the section revealed two check boxes for "Deterioration of condition enroute." and "Worsening of condition or death if you stay here" below the line for risks specific to the patient. Record review did not reveal any documentation of the specific risk associated with the transfer of the patient.

Interview with hospital administrative staff on 01/10/2014 at 1330 revealed the hospital had identified the risks and benefits were not being specially documented. The interview revealed the hospital changed the physician certification transfer form. The interview revealed this record was apparently completed prior to the change in the form. The interview revealed there was no further documentation for the record. The interview revealed the DED physician did not follow the hospital policy for the documentation of the specific risks for transfer.

Interview with hospital administrative staff on 01/010/2014 at 1330 revealed the EMTALA transfer form had sections for the physician to complete for the medical risks and benefits. The interview revealed the staff was aware the risk and benefits were to be specifically relative to the patient's condition during transfer. The interview revealed the hospital had identified the DED physicians had not been completing the specific risks of transfer. The interview revealed the DED physician staff had education provided informing physicians the requirement for the risks to be specific to the patient. The interview revealed the transfer form indicated in writing the risks are to be specific for the patient. The interview revealed there had not been any monitoring to ensure the DED physicians were following the hospital policy and CMS regulations. The interview revealed to date 77 % of the physicians had completed the education.


NC00094129