HospitalInspections.org

Based on a review of a patient interview, medical record reviews, policies and procedures, Bylaws/Rules and Regulations, ED Physician Schedule and employee interviews Hospital # 1 failed to ensure a medical doctor was physically present in the ED beginning at 7:00 PM on 12/24/2016. This failure also impacted ED staff and their ability to provide care to patients when the Physician was not present and / or readily available to direct staff regarding patient care. As a result of this deficient practice Patient Identifier (PI) # 27 was not evaluated by a physician when the patient presented to the Emergency Department with complaints of pain and swelling in her foot/leg after passing out and falling at home. This deficient practice also includes Patient Identifier (PI) Numbers # 1, 5, 8, 9, 26, a total of six of 27 sampled patients.


Findings Include:

Refer to findings at 2406 and A2407 for details.

Based on a patient interview, employee interviews, medical records, policies and procedures, Bylaws/Rules and Regulations and Emergency Department (ED) Physician Schedule, Hospital # 1 failed to:

1. Ensure a medical doctor was in the Emergency Department (ED) beginning at 7:00 PM on 12/24/2016 and available to provide medical screening examinations to patients who presented to the ED to determine if these patients had a medical emergency condition. This failure also impacted ED staff and their ability to provide care to patients when the Physician was not present and / or readily available to direct staff regarding patient care. Furthermore, the Physician who worked the ED (7:00 AM to 7:00 PM shift) left the ED without coverage by another physician. This affected Patient Identifier Number (PI #) 1, 5, 8, 9, 26 and 27. Refer to findings at A1111, A2404 and 2406.

2. Register PI # 27 when the patient presented to the ED on 12/24/16 with a complaint of foot and leg pain after a fall and create a medical record for the patient. Refer to findings at A2405.

3. Provide a Medical Screening Examination for six of 27 sampled patients, Patient Identifier (PI) Numbers # 1, 5, 8, 9, 26 and 27. These patients were not evaluated by the ED Physician. According to PI # 27's ED medical record at Hospital # 2, her condition was a Certified Medical Emergency as documented by the ED Physician ay Hospital # 2. Refer to findings at A2406.

4. Provide stabilizing treatment to Patient Identifier (PI # 27) after she presented to Hospital # 1's Emergency Department on 12/24/16 with a complaint of foot and leg pain after passing out and falling at home. This deficient practice also affected Patient Identifier (PI) Numbers # 1, 5, 8, 9, and 26. Refer to findings at A2407.

5. The hospital created a delay in treatment for Patient Identifier (PI # 27) after she presented to Hospital # 1's Emergency Department on 12/24/16 with a complaint of foot and leg pain after passing out and falling at home, by failing to triage, provide a Medical Screening Examination and stabilizing treatment for the patient. As a result, PI # 27 drove herself to Hospital # 2's ED and was diagnosed with foot fracture hours after presenting to the ED at Hospital # 1 and requesting treatment. Refer to findings at A2406, A2407 and A2408.

Hospital # 1's deficient practices negatively affected PI # 1, 5, 8, 9, 26 and 27, six of 27 sampled patients, and had the potential to affect all patients who presented to the ED after 7:00 PM on 12/24/16.

These citations were written as a result of the investigation of Complaint Number AL00034921.

Refer to findings at:
A 1111/ 482.55(b)(1): Supervision of Emergency Services
A 2405 / 489.20(r)(3): Emergency Room Log
A 2406 / 489.24 (a): Medical Screening Examination
A 2407 / 489.24(d): Necessary Stabilizing Treatment for Emergency Medical Condition and
A 2408 / 489.24 (d)(4) and (5): Delay in Examination or Treatment.

Based on a review of a patient interview, medical records, policies and procedures, Bylaws/Rules and Regulations, Emergency Department (ED) Physician Schedule (Hospital # 1) and Employee Interviews, Hospital # 1 failed to have a physician (physically present) in the Emergency Department on 12/24/16 beginning at or around 7:00 PM to 7:15 PM. As a result of this deficient practice, there was no documentation to verify the following patients: Patient Identifier (PI) # 1, PI # 5, PI # 8, PI # 9, PI # 26 and PI # 27 were provided a medical screening examination by a Physican when these patients presented to the hospital's ED with complaints and /or request for screening and evaluation by a physician.

This affected 6 of 27 sampled patients and had the potential to affect all patients who presented to the ED on 12/24/16 beginning at 7:00 PM when a physician (EI # 3 and/or EI # 5) was not physically present in the ED and/or hospital.

Findings Include:

Medical Staff Bylaws, Rules and Regulations (reviewed and revised August 2016):

A review of the Bylaws, Rules and Regulations revealed:

Section VII. Full-time and part-time Emergency Room Staff:

Subsection 1. The Emergency Room Medical Staff, temporary/part-time or full-time, shall consist of medical doctors or doctors of osteopathy who are licensed by the State of Alabama to practice medicine and credentialed/privileged to limit their practice to the Hospital emergency room ...and respond to code situations anywhere on the Hospital premises under their temporary or permanent emergency room status...

Subsection 2. Emergency room medical staff...shall diagnose, treat and/or stabilize emergency patients...

Interview with Employee Identifier # 5 / ED Physician on 12/29/16 at 9:35 AM:

The ED Physician (EI # 5) confirmed he worked the 7:00 AM to 7:00 PM shift on 12/24/16 and stated he left the ED at 7:00 PM. EI # 5 said, "I did not see her (EI # 3 / Physician scheduled to begin work in the ED at 7:00 PM) before I left...It's my understanding they allowed her (Physician / EI # 3) to take call from home."


Refer to findings at A2406 and A1111.

Based on interviews and review of policies and procedures, the hospital failed to document any information in the Emergency Department's (ED) Central Log regarding the presentation of Patient Identifier (PI # 27) to Hospital # 1's ED on 12/24/16 at or around 8:00 PM. PI # 27 came to the ED with a complaint of a "hurt leg/foot" after passing out and falling at home. As a result of this deficient practice, a medical record was not created for PI # 27 by ED staff to include information about PI # 27's complaint, whether the patient refused treatment, was refused treatment by ED staff or whether PI # 27 was stabilized and transferred, discharge disposition and condition at discharge, follow up instructions and/ or pertinent interaction between ED staff and the patient.

This affected PI # 27, one of 27 sampled patients and had the potential to affect all patients who presented to the ED for an evaluation of a medical and/or psychiatric complaint on 12/24/16 beginning at 7:00 PM.

Findings include:

Interview with the Interim Chief Nursing Officer (CNO) / Employee Identifier (EI) # 1 on 12/27/16 at 5:35 PM:

The state surveyor asked for a copy of the medical record for PI # 27.
EI # 1 said, "We have no medical record of that patient." According to EI # 1 the hospital has no medical record because, "She (PI # 27) did not sign in."


Interview with Patient Identifier (EI) # 27 on 12/28/16 at 9:40 AM:

PI # 27 said, "I had went up there (ED at Hospital # 1) around 7:50 PM to 8:00 PM on 12/24/16." According to PI # 27, "Mom went in and told them I was hurting while I was trying to get from the car to the Emergency Department (ED). My foot was broke. I broke it before. I knew. I was in major pain."

According to PI # 27 the "person at the window" (ED registration clerk) said, "We can't help it. There's no doctor here. She told my mom how sorry she was that I couldn't be seen."

Hospital # 1's ER (Emergency Room) Triage Policy 4/21/14:

...5. All patients presenting to the Emergency Department (ED) must be registered and assigned a medical record number and a visit number...

51.05 Inpatient / Outpatient Registration Procedures:

The function of Registration is to admit patients to the Hospital consistent with current regulations, polices and procedures. All patients will be admitted...while insuring input of current and accurate data necessary for the hospital's records.

Patient Type...Outpatient
ED (Emergency Department)

Interview with ED Registration Clerk, EI # 9, on 12/28/16 at 11:00 AM:

According to EI # 9, PI # 27 presented to the ED at or around 8:00 PM on 12/24/16. PI # 27's mother said the patient's foot was broken and PI # 27 was in serious pain. PI # 27's mother asked me to get a nurse. EI # 6 (ED RN) came to the lobby. The patient's mother asked EI # 6 if he could take PI # 27 "back" (triage area) and "let a doctor look at her (PI # 27)." PI # 27's mother asked if a doctor was here (in the ED) and the RN said no. The patient's mother asked the RN how long it would be until a physician arrived in the ED. Reportedly, the RN said it could be a few minutes or longer.

PI # 27's mother was asked if she would like to register the patient. PI # 27's mother said,"No. We are going to wait to see if the doctor comes." According to the Registration Clerk / EI # 9, "They (PI # 27 and her mother) sat in the lobby for a few minutes. The patient was crying and crying. PI # 27 said, "We just got to go" and the patient and her mother left the ED.

The surveyor asked the clerk / EI # 9 if she reported the incident involving PI # 27. EI # 9 said no. The surveyor asked the rationale for not reporting the incident. EI # 9 said, "(Name of Manager) was out of town."


Interview with Director of Patient Accounting Services / EI # 10, on 12/28/16 at 4:10 PM:

EI # 10 was asked to describe the ED registration process. According to EI # 10, the clerks ask the patient's name and complaint. The surveyor asked EI # 10 if every patient should be registered. EI # 10 replied, "Yes." The registration clerks are trained to ask how they can help patients.


Refer to A2406 for details and other patients affected.

Based on a review of a patient interview, medical records, policies and procedures, Bylaws/Rules and Regulations, Emergency Department (ED) Physician Schedule (Hospital # 1) and Employee Interviews, the hospital failed to ensure a medical doctor was in the ED at Hospital # 1 beginning at 7:00 PM on 12/24/2016 to provide medical screening examinations (MSE) to patients who presented to the ED to determine if these patients had a medical emergency condition. As a result of this deficient practice, six of 27 sampled patients, Patient Identifier (PI) Numbers # 1, 5, 8, 9, 26 and 27, were not evaluated by the ED Physician. This includes PI # 27, a patient who presented to Hospital # 1's ED and requested to be seen by a physician. Hospital # 1's ED staff failed to triage or provide a MSE to PI # 27. As a result, PI # 27 left Hospital # 1's ED and drove herself to Hospital # 2's ED. Hospital # 2's ED staff provided triage screening, a medical screening examination by a physician and treatment. Hospital # 2's ED Physician determined PI # 27 had a certified emergency medical condition and a fractured foot.

Findings Include:

A). Interview with Patient Identifier (PI) # 27:

During an interview on 12/28/16 at 9:40 AM, PI # 27 said, "I had went up there (ED at Hospital # 1) around 7:50 PM to 8:00 PM on 12/24/16." According to PI # 27, "Mom told them I was hurting while I was trying to get from the car to the Emergency Department (ED). My foot was broke. I broke it before. I knew. I was in major pain."

"By the time I got in the nurse came out to the waiting room and said, "We have no doctor here. We've (ED staff) been calling (physician scheduled to work 7:00 PM to 7:00 AM) since 7:00 PM." According to PI # 27, the nurse came back into the waiting room and said, "Our hands are tied. There is no doctor here."

The surveyor asked PI # 27 if she registered. According to PI # 27 the "person at the window" (registration clerk) said, "We can't help it. There's no doctor here. She told my mom how sorry she was that I couldn't be seen." "They (ED staff at Hospital # 1) did not refuse to let me sign in..." "They said we can't do an x-ray or anything because the physician is not here."

The surveyor asked PI # 27 if she registered at Hospital # 1's ED. PI # 27 said, "No. I asked if it would be worth my time to wait." The RN replied, "All they could do was take my vital signs. I ask if we should wait. I sat in the lobby and called another hospital. No answer..." "I told Momma we are going to have to go to Tuscaloosa (name of city with hospital -approximately 59 miles from Hospital # 1). I had to drive. Mom can't see well and I was in pain." PI # 27 described the pain as, "Bad. I had never in my life had so much pain."

According to PI # 27, she arrived at Hospital # 2 around 9:30 PM, her foot was x-rayed and she was informed her left foot was broken. PI # 27 said she was given a Toradol injection to relieve pain and a prescription for Lortab (brand name for a painkiller combining hydrocodone (a narcotic) and acetaminophen, www.urbandictionary.com). PI # 27's foot was placed in a splint.


B). PI # 27's ED Medical Record at Hospital # 2:

(PI # 27 drove herself to the ED at Hospital # 2 after leaving Hospital # 1's ED because there was no physician at Hospital # 1 to evaluate her complaint).

Triage Assessment 12/24/16 at 10:15 PM:

Vital Signs:
Temperature: 98.3
Pulse: 115
Blood Pressure: 166/102

Chief Complaint: States fell in kitchen tonight. Injury to left foot. ...Bruising noted to left side of foot.

Arrival mode: Private Vehicle

Pain:
Intensity: 9. Scale: 0-10 (0 = no pain).
Pattern: Constant

ED Physician Documentation:

Time Seen by Physician: 12:24 AM (12/25/16)

Context: Patient is a...female with a history of Insulin Dependent Diabetes Mellitus, Coronary Artery Disease, Congestive Heart Failure and
Hypertension who presents to the ED for evaluation after falling and injuring her foot this evening PTA (prior to arrival) with complaint of having left foot pain. Patient denies head injury, loss of consciousness, numbness, weakness, and any other injuries at this time.

Surgical History Includes: Lumbar Surgery, Cervical Fusion, Knee Replacement, Coronary Artery Bypass Graft...


Physical Examination:
Extremities:
TTP (Tender To Palpation) of left lateral foot. Sensation intact. Unable to bear weight secondary to pain. Sensation intact.

Certified Medical Emergency: Yes.

Clinical Impression:

Primary Impression:
Fracture of fifth metatarsal bone of left foot (a group of five long bones in the foot, wikipedia.org).
Secondary Impression:
Chronic Hypertension, Fall with injury, Insulin Dependent Diabetes Mellitus.

Condition: Stable.

Disposition: Home

12:55 AM: Ketorolac / Toradol (medication to relieve pain) 60 milligrams Intramuscular.

Posterior 3 Inch OCL (Brand name of Plaster Splint Roll) applied to left foot.


Departure Date and Time: 12/25/16 at 1:46 AM


C). Hospital # 1's ED Policies and Procedures:

I. ER (Emergency Room) Triage Policy Dated 4/21/14:

Patient Assessment and Care:

1. All patients presenting to the Emergency Department (ED) receive a medical evaluation and treatment by qualified personnel in a timely manner consistent with the severity of their illness.

2. Evaluation and care will be rendered to all patients regardless of age, sex, race...or ability to pay for care.

3. Patients presenting to the ED will be evaluated by the ED staff and the attending physician will be responsible for determining the appropriate treatment required for the patient.

4. The assessment will include, but not be limited to:
a. The initial assessment which includes the reason for visit, vital signs, health history, developmental and psychosocial status.
b. The appropriate treatment setting based on patient's severity index score. c. Appropriate discharge planning to include medical and functional needs of the patient.


Initial Screening Examination:

1. The ED will provide, within the capabilities of this facility, an appropriate triage and medical screening examination, stabilizing treatment and/or an appropriate transfer to another facility of any individual with an emergency medical condition...

3. The medical screening examination will be performed by the Emergency Department Physician on staff.

4. If the patient is deemed to have an emergency medical condition, the emergency department will provide appropriate treatment to stabilize the medical condition or make appropriate transfer arrangements.


II. ED Policy And Procedure: Notification of Physician:

Original Date: 1982
Revised Date: 1991

All patients presenting to the ED shall be treated by their personal physician, ED physician,or there physician listed on the on-call list...

All patients entering the emergency department shall be assessed and screened and a determination made as to whether the prospective patient should be:

Advised that no emergency exists, and treated per non-emergency policy or referred to the patient's local physician.

Admitted for emergency treatment.

Admitted to the hospital on an inpatient basis.

If the patient is admitted for emergency treatment, then the emergency department physician shall immediately render such treatment and assistance as indicated.

III. Cobra Regulations - Emergency Department. Original Date: 1990 (no revision date documented).

Any patient presenting to the ED with a medical emergency or in labor, has the right to receive, within the capabilities of this hospital's staff and facilities, the following:

An appropriate medical screening evaluation...


D). Medical Staff Bylaws, Rules and Regulations (reviewed and revised August 2016):

A review of the Bylaws, Rules and Regulations revealed:

Subsection 2. Emergency room medical staff...shall diagnose, treat and/or stabilize emergency patients...


E). ED Physician Schedule December 24, 2016 - Hospital # 1:

7:00 AM - 7:00 PM (Name of ED Physician / EI # 5)

7:00 PM - 7:00 AM (Name of ED Physician / EI # 3)



F). Employee Interviews (Hospital # 1):

Interview on 12/27/16 at 5:30 PM with Employee Identifier (EI # 1) /Interim Chief Nursing Officer:

EI # 1 said, "Dr... (EI # 3) took call at home and was not physically in the building. " According to EI # 1, Patient Identifier (PI # 27) never registered when the patient presented to the ED at Hospital # 1 on 12/24/16. There is no medical record for PI # 27's ED visit (at Hospital # 1) on 12/24/16.


Interview on 12/28/16 at 9:00 AM with EI # 2 / Chief Executive Officer (CEO) and EI # 7 / Director of Professional Standards:

According to the CEO / EI # 7 he asked Dr...(EI # 3 / Physician) to cover the 7:00 PM to 7:00 AM shift in the Emergency Department at Hospital # 1 on 12/24/16. The CEO reported the physician (EI # 3) said, "I will try and cover it from the house. If busy, I will come in."

The CEO stated, "I have asked them (physicians) to come in. It's not a common problem."

EI # 7 said there are two issues:

"1. Dr... (EI # 3) covered (ED) at home until the first patient arrived.
2. The Registered Nurse (RN) provided a Medical Screening Evaluation without authorization. "


Interview on 12/28/16 at 7:00 PM with Emergency Department (ED) Registered Nurse (RN) / EI # 6:

Employee Identifier (EI # 6) worked in the ED (Hospital # 1) from 7:00 PM - 7:00 AM on 12/24/16. EI # 6 was asked if he provided a triage assessment to PI # 27 when she presented to the ED on 12/24/16 and he said,"No." Based on staff and patient interviews, P # 27 presented to the ED on 12/24/16 at or around 7:50 PM with a complaint of foot/leg pain after falling at home.

EI # 6 was asked to provide the rationale for not providing a triage examination to PI # 27. EI # 6 reported the registration clerk told him someone needed a wheelchair. "EI # 6 got a wheelchair and went to the ED waiting room. PI # 27, already seated, was identified by her mother. According to EI # 6 he instructed the mother to sign in for the patient while he triaged PI # 27. The patient's mother asked for the name of the physician. EI # 6 advised staff could not give out that information until PI # 27 was registered. PI # 27's mother asked if a physician was in the ED(physically present).

EI # 6 said he reiterated two to three times to PI # 27's mother, "We will be glad to see (PI # 27). I can't give you a time frame (regarding physician's (EI # 3) arrival. I asked her (PI # 27's Mom) to sign in the patient while I assessed her. The Mom refused (registration) for the patient (PI # 27)." According to EI # 6 (ED RN), the ED Physician (EI # 3) had already been called on her cell phone several times and had not responded. ED staff was still waiting on EI # 3 / ED Physician to see PI # 26 (a patient who arrived in the ED at 7:21 PM on 12/24/16).

Medical Record Review - Patient Identifier (PI # 26) at Hospital # 1:

Date: 12/24/16

Arrival to ED: 7:21 PM.

Triage time: 7:38 PM by ED RN ( EI # 6).

Chief Complaint: "Can't breath."

Vital Signs: Respirations: 20, Pulse: 102, Blood Pressure: 132/86, Pulse Oxygenation: 98.

Nursing Notes:
12/24/16 at 7:28 PM: "Message left on Dr...(EI # 3's) voicemail that patient (PI # 26) was here in the ED. (Documented by ED LPN / EI # 8).

12/24/16 at 9:17 PM: "Dr... (EI # 3) called and gave telephone orders to let resp (Respiratory) give continuous neb (nebulizer treatment to pt. (patient) x 2 hours and then DC (discharge home)." Documented by ED RN /
EI # 6.

There was no documentation by the physician (EI # 3) to confirm PI # 26 received a medical screening evaluation by EI # 3.

Continuation of Interview on 12/28/16 at 7:00 PM with Emergency Department (ED) Registered Nurse (RN) / EI # 6:

According to the RN (EI # 6), PI # 26 said she contacted EI # 3 (oncoming ED Physician ) and they were still waiting for a response from EI # 3. This was reported to the RN when he checked on PI # 26 and apologized to the patient and family on the wait for the physician to arrive in the ED. EI # 6 said PI # 26 waited 2.5 to three hours.

According to EI # 6, PI # 27's mother may have "picked up on the wait for Dr...(EI# 3). Dr...(EI # 3) not here due to the back and forth of PI # 26's family." EI # 6 stated the oncoming ED physician (EI #3) called back sometime around 9:30 PM to 9:45 PM with a verbal order for a nebulizer treatment for PI # 26. According to EI # 6 (ED RN), the Physician (EI # 3) saw PI # 26 (while PI # 26 was receiving a continuous nebulizer treatment) and gave instructions to discharge the patient after the treatment was completed.

The RN (EI #6) said the Physician (EI # 3) directed me to call her )EI # 3) as other patients were triaged. "Then Dr...(EI # 3) left." "We called EI # 3 several times. EI # 6 was asked if the physician (EI # 3) returned to the ED and he replied, "some."

EI # 6 was asked the time of arrival of the oncoming ED physician (EI # 3)and he said the time was around 10:00 PM or 10:15 PM.

The RN (EI # 6) was asked the reason the physician (EI # 3) was not in the ED as posted on the schedule. EI # 6 replied, "That's a good question. They (Administration, everybody) knew 12/24/16 (night shift) wasn't covered. Dr...(EI#3) agreed to do it by taking call only." EI # 6 alleges the physician (EI # 3) told him about this agreement when she came in later to the ED.

According to EI # 6, "If anything came in we (ED staff) were to text, not call Dr...(EI # 3)." EI # 6 said this information was contained in a note on the staff bulletin board in the ED. EI # 6 stated the information was also reported to him by the day shift charge nurse during shift change on 12/24/16.

According to EI # 6, the hospital phones do not have "texting" capability and hospital policy prohibits use of cellular phones. EI # 6 said he called Dr. ... (EI #3's) cell phone and left messages. The day shift charge nurse also sent a text (message) to the physician (EI # 3) requesting she call the (day shift ED physician / EI # 5) because he wants to make sure you (EI # 3) are coming in."

EI # 6 said ED staff heard (on Emergency Services Radio located in the ED) an ambulance was out on a call with an obstetrical (OB) patient. The day shift ED physician (EI # 5) did not want to leave the ED without talking to the oncoming ED physician (EI # 3).

EI # 6 stated he called the local ambulance service and found out the (OB) patient went to another hospital. Allegedly, the call was made for the day shift ED physician who wanted to know the status prior to leaving the ED. The surveyor asked EI # 6 if the day shift ED physician (EI # 5) left the ED without physician coverage and he said, "Yes..."


ED Medical Records of other patients who presented to Hospital # 1's Emergency Department after 7:00 PM on 12/24/16 and did not receive a medical screening examination:

Patient Identifier (PI # 1):

Arrival time: 8:13 PM.

Chief Complaint: Laceration to head.

Triage: 8:16 PM by RN (EI # 6).

No medical screening examination was documented by EI # 3 (ED Physician). The lack of physician documentation by EI #3 in PI # 1's medical record was confirmed by EI # 7, Director of Professional Standards on 12/26/16 at 1:20 PM.

During an interview on 12/28/16 at 7:00 PM, EI # 6 (ED RN), stated the patient (PI # 1) left after EI # 6 informed the patient the ED physician (EI # 3) was not present and he (PI # 1) would have to wait.

According to EI # 6 (RN), the patient (PI # 1) reportedly said "I really did not want to see the doctor. Just wanted to know if I needed stitches." EI # 6 (RN) said, "I cleaned it (wound with normal saline) and told him (PI # 1) I thought it was an abrasion, not a laceration. (Abrasion: a wound caused by superficial damage to the skin, no deeper than the epidermis; less severe than a laceration, and bleeding, if present, is minimal. Mild abrasions do not scar or bleed, but deep abrasions may lead to the formation of scar tissue, https://en.wikipedia.org) / (Laceration: a wound produced by the tearing of soft body tissue...wound is often irregular and often contaminated with bacteria and debris from whatever object caused the cut, https://medlineplus.gov).

EI # 6 was asked if he felt uncomfortable about making this statement to PI # 1 without the evaluation/medical screening and backup by a physician. EI # 6 said, "I did. It was my opinion." EI # 6 said as he was taking PI # 1 to a room and advised the patient about the wait (for physician arrival), PI # 1 decided to leave. "His (PI # 1) disposition was Left Without Being Seen (by a physician), but we have to put eloped on the chart."


Patient Identifier (PI # 5):

Arrival time: 11:18 PM.

Chief Complaint: Cough, Congestion and Shortness of breath x two days.

Triage: 11:20 PM by RN (EI # 6).

According to the Nursing Notes, RN (EI #6) notified Physician ( EI # 3) at 11:31 PM and a verbal order was obtained for Ceftriaxone (antibiotic to treat bacterial infections, www.rxlist.com).

No medical screening examination was documented by EI # 3 (ED Physician). The Emergency Physician record contained in EI # 5's medical record is blank.


Patient Identifier (PI # 8):

Date: 12/25/16

Arrival time: 2:07 AM

Triage: 2:23 AM by RN (EI # 6).

Chief Complaint: Diarrhea and sweating tonight.

According to the Nursing Notes, RN (EI #6) notified Physician ( EI # 3) at 2:29 AM and verbal orders were obtained for lab and Imodium (Antidiarrhea medication).

No medical screening examination (MSE) was documented by EI # 3 (ED Physician).

During an interview on 12/28/16 at 12:00 PM, the ED Physician (EI # 3) said, "I didn't see the patient (PI # 8)."


Patient Identifier (PI # 9):

Date: 12/25/16

Arrival time: 2:55 AM

Triage: Not documented.

"Reason:" Stomach Rash

Nursing Note documented at 3:00 AM by RN (EI # 6): Patient left without being seen.

ED Physician: Dr...(EI # 3). No documentation and/or no MSE documented by EI # 3.

There was no additional nursing documentation in PI # 9's medical record.


Interview with Employee Identifier # 5 / ED Physician on 12/29/16 at 9:35 AM:

The ED Physician (EI # 5) confirmed he worked the 7:00 AM to 7:00 PM shift on 12/24/16 and stated he left the ED at 7:00 PM. EI # 5 said, "I did not see her (EI # 3 / Physician scheduled to begin work in the ED at 7:00 PM) before I left. No patients were in the ED. It's my understanding they allowed her (Physician / EI # 3) to take call from home."


Interview on 12/29/16 at 10:55 AM with ED Registered Nurse (RN) / EI # 4:

EI # 4 confirmed she worked (7:00 AM to 7:00 PM shift) as the charge nurse in the ED on 12/24/16. EI # 4 was asked if she recalled the Physican who worked in the ED on 12/24/16 beginning at 7:00 PM and she said, "It was supposed to be (name of EI # 3). The physician (EI # 3),"Called (the ED) a little before 6:00 PM, maybe 5:30 PM. I answered the phone and she told me she was going to church at 6:00 PM. If we (ED staff) needed her we could text her. Her ringer would be off- text her if we needed her (Physician / EI # 3)."

The surveyor asked EI # 4 the name of the physician who worked the ED on the day shift. EI # 4 said, "Dr.... (last name of physician)."

EI # 4 stated, " I actually texted her (oncoming physician/ EI # 3) before I left. " The surveyor asked the RN to identify the reason for the text. EI # 4 said, " Dr. (last name of ED Physician who worked day shift/ EI # 5) wanted to talk to her (oncoming Physician / EI # 3). I told her Dr. (last name of ED Physician who worked day shift/ EI # 5) was getting ready to leave and he wanted to talk to her. Please call the ER."

The surveyor asked EI # 4 if the oncoming Physician (EI # 3) responded to the text and she said, "I left assuming she would call. I think the reason he (off- going Physician / EI # 5) wanted to talk to her was because he was leaving and there were three ambulance calls out. We (ED staff) heard 911 calls over the radio. It doesn't mean the patient is necessarily coming here (Hospital # 1's ED)."


Interview with Chief Executive Officer / Employee Identifier # 2:

During an interview on 12/29/16 at 12:15 PM EI # 2 stated he was having difficulty finding a physician to work in the ED on 12/24/16 for the 7:00 PM shift. EI # 3 (staff physician) agreed to help out and work with the following the stipulation: EI # 3 planned to take call for the ED (Emergency Department) from home. According to the CEO, "I told her if she can cover and come (to the ED) when appropriate. Stay in touch (with ED staff) and if busy, stay (in the ED)."

The physician (EI # 3) allegedly told the CEO, " I'll just stay at home and cover." The CEO said there was not much negotiating. "I had to get some coverage. We were between a rock and a hard place. I take responsibility on that. It didn't occur to me it was a problem until the complainant reported to me on Tuesday (12/27/16) that her daughter ( a patient who presented to the ED on 12/24/16 ) was not evaluated by a physician." The complainant alleged no physician was here (in Hospital # 1's ED) at 7:00 PM on 12/24/16 and the patient was taken to Tuscaloosa. The CEO said the physician (EI # 3) was not available and did not answer voice mail messages from ED staff.

The CEO stated he made rounds in the ED on Monday, December 26, 2016, and discovered EI # 3 (the physician scheduled to work in the ED on 12/24/16 beginning at 7:00 PM) did not come out here (to the ED) until approximately 10:00 PM."

EI # 2 also reiterated the physician (EI # 3) scheduled to work in the ED on 12/24/16 beginning at 7:00 PM), "Was not available, did not answer voice mails and text from ED staff." The CEO /EI # 2 added, "Orders were given and patients were not seen. Patients were discharged from the ER without being seen."


Interview with Employee Identifier # 3 / Physician scheduled to work in the ED on 12/24/16 beginning at 7:00 PM:

During an interview on 12/29/16 at 12:28 PM, Employee Identifier # 3 was asked to describe her agreement with the CEO about working in the ED on 12/24/16 (night shift). EI # 3 stated she agreed to work as the ED Physician with the following stipulation: "I would take call from home. The nurse would call me when a patient presented (to the ED) and I would come in."

The surveyor asked EI # 3 if she received a text on 12/24/16 from ED staff. Initially EI # 3 said no. As she checked her personal cell phone EI # 3 read this message out loud: "They (ED Staff) called at 7: 04 PM. Please call ED. (Name of ED Physician who worked 7:00 AM to 7:00 PM) wants to speak to you. I did not see it. I had the ringer off. I forgot to turn it on." EI # 3 stated she lives three blocks from the hospital, it was Christmas and she was trying to help the hospital. Regarding PI # 27, the Physician (EI # 3) said, "I never knew about ( PI # 27)."

Hospital # 1 has no medical record for PI # 27. However, based on staff and patient interviews, PI # 27 presented to the ED on 12/24/16 at or around 7:50 PM with a complaint of foot/leg pain after passing out and falling at home.

Regarding PI # 26, the Physician / EI # 3 said PI # 26, a patient with pulmonary dysplasia, is was well known to her (EI # 3). PI # 26 was seen by the physician (EI # 3) on Friday and was given antibiotics. The patient (PI # 26) did not want to be hospitalized. Therefore, the physician / EI # 3 advised PI # 26 to go to the ER and get a nebulizer treatment if needed.
EI # 3 recalled she received a telephone call from EI # 26's husband who asked her (EI # 3) to notify ED staff PI # 26 was there (in the ED) for a nebulizer treatment. EI # 3 stated she called the ED at 7:37 PM and spoke with a nurse about PI # 26, but can't recall the name of the nurse. "This was outpatient." EI # 3 said PI # 26 should not have registered as an ED patient.


Interview with Employee Identifier # 3 / Physician scheduled to work in the ED on 12/24/16 beginning at 7:00 PM:

During an interview on 12/30/16 at 1:35 PM, Employee Identifier # 3
stated," I was here when PI # 8 was here and when he left...Called me at 1:00 AM regarding a gunshot wound and I saw PI # 7. I returned to see PI # 10..."

In conclusion, PI # 27 presented to Hospital # 1's Emergency Department (ED) after reportedly passing out and sustaining a fall at home. On arrival at Hospital # 1's ED, PI # 27's mother reported the patient had foot and leg pain and requested an evaluation by a physician for PI # 27. However, no physician was present in the ED when PI # 27 arrived on 12/24/16. As a result, Hospital # 1 failed to provide a medical screening examination (MSE) to PI # 27, a patient with a history of Insulin Dependent Diabetes Mellitus, Coronary Artery Disease, Congestive Heart Failure and Hypertension to determine if the alleged fall was related to one or more of these established diagnoses (Diagnoses obtained from PI # 27's ED medical record from Hospital # 2). Furthermore, Hospital # 1's staff failed to provide a MSE to evaluate PI # 27's chief complaint of foot/leg pain to determine if an emergency medical condition existed. Due to the failure of the Physician (EI # 3) to be present in the ED on 12/24/16 beginning at 7:00 PM (and continuously for the entire shift) additional patients: Patient Identifier Numbers 1, 5, 8, 9, and 26 were not provided a Medical Screening Examination to determine if a medical emergency condition existed.

Based on a review of a patient interview, medical records, policies and procedures, Bylaws/Rules and Regulations, ED Physician Schedule (Hospital # 1) and Employee Interviews, the hospital failed to provide stabilizing treatment to Patient Identifier (PI # 27) after she presented to Hospital # 1's Emergency Department on 12/24/16 with a complaint of foot and leg pain after passing out and falling at home.

This affected PI # 27, one of 27 sampled patients and had the potential to affect all patients who presented to the emergency room for medical screening of a complaint and treatment as determined by a physician.

Findings Include:

Interview with Patient Identifier (PI) # 27:

During an interview on 12/28/16 at 9:40 AM, PI # 27 said, "I had went up there (ED at Hospital # 1) around 7:50 PM to 8:00 PM on 12/24/16." According to PI # 27, "Mom told them I was hurting while I was trying to get from the car to the Emergency Department (ED). My foot was broke. I broke it before. I knew. I was in major pain."

B). PI # 27's ED Medical Record at Hospital # 2:

(PI # 27 drove herself to the ED at Hospital # 2 after leaving Hospital # 1's ED because there was no physician to evaluate her complaint).

Triage Assessment 12/24/16 at 10:15 PM:

Vital Signs:
Temperature: 98.3
Pulse: 115
Blood Pressure: 166/102

Chief Complaint: States fell in kitchen tonight. Injury to left foot. ...Bruising noted to left side of foot.

Arrival mode: Private Vehicle

Pain:
Intensity: 9. Scale: 0-10 (0 = no pain).
Pattern: Constant

ED Physician Documentation:

Time Seen by Physician: 12:24 AM (12/25/16)

Context: Patient is a...female with a history of Insulin Dependent Diabetes Mellitus, Coronary Artery Disease, Congestive Heart Failure and
Hypertension who presents to the ED for evaluation after falling and injuring her foot this evening PTA (prior to arrival) with complaint of having left foot pain. Patient denies head injury, loss of consciousness, numbness, weakness, and any other injuries at this time.

Surgical History Includes: Lumbar Surgery, Cervical Fusion, Knee Replacement, Coronary Artery Bypass Graft...


Physical Examination:
Extremities:
TTP (Tender To Palpation) of left lateral foot. Sensation intact. Unable to bear weight secondary to pain. Sensation intact.

Certified Medical Emergency: Yes.

Clinical Impression:

Primary Impression:
Fracture of fifth metatarsal bone of left foot (a group of five long bones in the foot, wikipedia.org).
Secondary Impression:
Chronic Hypertension, Fall with injury, Insulin Dependent Diabetes Mellitus.

Condition: Stable.

Disposition: Home

12:55 AM: Ketorolac / Toradol (medication to relieve pain) 60 milligrams Intramuscular.

Posterior 3 Inch OCL (Brand name of Plaster Splint Roll) applied to left foot.


Departure Date and Time: 12/25/16 at 1:46 AM


Hospital # 1's ER (Emergency Room) Triage Policy 4/21/14:

Initial Screening Examination:

4. If the patient is deemed to have an emergency medical condition, the Emergency Department will provide appropriate treatment to stabilize the medical condition or make appropriate transfer arrangements.

3. Patients presenting to the ED will be evaluated by the ED staff and the attending physician will be responsible for determining the appropriate treatment required for the patient.

In conclusion, because the ED Physician / EI # 3 was not present in the ED to evaluate PI # 27 when she presented with foot and leg pain after falling, no stabilizing treatment was rendered to the patient.

Refer to findings at A2406.

Based on a review of a patient interview, medical records, policies and procedures, Bylaws/Rules and Regulations, Emergency Department (ED) Physician Schedule (Hospital # 1) and Employee Interviews, the hospital created a delay in treatment for Patient Identifier (PI # 27) after she presented to Hospital # 1's Emergency Department on 12/24/16 with a complaint of foot and leg pain after passing out and falling at home, by failing to triage, provide a Medical Screening Examination and stabilizing treatment to the patient. As a result, PI # 27 drove herself to Hospital # 2's ED and was determined to have a certified medical emergency and a foot fracture by a physician (at Hospital # 2). Treatment was provided at Hospital # 2 hours after PI # 27 left Hospital # 1's ED because no physician was available and/or present to evaluate and provide treatment to PI # 27.

This delay of treatment affected PI # 27, PI #26, PI#1, PI#5, PI#8, and PI #9. six of 27 sampled patients and had the potential to affect all patients who presented to the emergency room on 12/24/16 beginning at 7:00 PM for medical screening of a complaint and treatment as determined by a physician.


Findings Include:

Refer to findings at A1111, A2406 and A2407.