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Based on staff and patient interview and record review, the CAH (Critical Access Hospital) failed to meet the needs of all patients who request Emergency Department treatment as evidenced by the failure to provide a Medical Screening Exam for 3 of 25 patients. ( Patient #1, 14, 25 ) Findings include:

1. Per review on 6/10/10, Patient #25, whose medical status included a multiple pregnancy at approximately 14 weeks gestation, presented to the ED on 3/31/10, 4/7/10 and 4/8/10 with the same complaint of abdominal pain, 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 s/he 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 s/he 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 s/he contributed the patient's pain complaints to constipation. No further lab test or diagnostic imaging was ordered. During a subsequent 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 returned to the ED again with abdominal pain. Physician #3 conducted a MSE and determined an emergency medical condition did exist, ordered lab work and pain medication and admitted 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 contacted Physician #2, the on-call obstetrician, who was the same physician who had seen Patient #25 in the WWC on 4/7/10 for similar 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 documented the patient's blood pressure on admission was 120/60 however, over the course of 2 hours the patients blood pressure dropped to 86/45 and temperature increased from 37.3 C (99.1 Fahrenheit (F)) and to 38 C (100.4 F.) Prior to transfer to the observation bed, the nurse documented 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 s/he had contacted Physician #2 on 4/8/10 regarding Patient #25, however did not recall what s/he had reported to Physician #2 and why s/he 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, the 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 informed Physician #4, by phone, that Patient #1 had returned and was requesting to be seen. Nurse #2 documented Physician #4 stated "...there was not anything to do tonight and s/he 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, Physician #4 stated "I did not realize the patient had been booked back in, s/he 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.

Based on staff interview and record review, the Emergency Department (ED) failed to obtain consent for transfer for 1 of 4 applicable patients who were transferred to another facility after receiving care and services in the ED. ( Patient #8 ) Findings include:

1. Per record review conducted on 6/10/10, Patient #8 was transferred to another facility on 1/30/10 without a completed transfer consent form. The area of the form labeled "Signature of pt/responsible party" was left blank. The patient at the time of transfer was not able to sign, but did have a significant other present at the time of transfer. There were no notes by the physician on the transfer consent form that indicated that the patient was not able to sign. During an interview on 6/10/10 at 3:10 PM, the Emergency Department Nurse Manager confirmed that the transfer consent form was incomplete.

Based on record review the hospital failed to obtain and include in the medical record consultive screenings and findings conducted in the Emergency Department for 1 applicable patient. (Patients # 15 ) Findings include:

1. Per review on 6/14/10 Patient # 15 was brought to the Emergency Department (ED) on 12/10/09, with a primary diagnosis of Suicidality. During the patient's course of treatment, a mental health screening was conducted by staff from the Northeast Kingdom Mental Health (NEKMH) organization. The patient was "...medically cleared" for transfer to an inpatient psychiatric facility for treatment, however, there was no record of the mental health consult conducted to reflect the decision regarding disposition and transport via private vehicle.

During interview, on the afternoon of 6/14/10, the Director of the Medical Records department confirmed that s/he had to contact the NEKMH to request that the documentation be faxed to the facility for inclusion in the medical record.

Based on record review and confirmed through staff interview the facility failed to assure that all entries in the medical record included the author's signature or time of entry for 1 of 10 records.( Patient #6 ) Findings include:

1. Per record review conducted on 6/8/10, Pediatric PACU (Post Anesthesia Care Unit) orders for Patient #6, written on 3/1/10, were not signed by the physician. Per review of the PACU orders, a nurse 'noted' the orders on 3/1/10 at 1340, but the physician's signature area, which also includes date and time, was left blank. Per interview on 6/8/10 at 5:08 PM, the VP of Quality Management Programs confirmed the lack of physician's signature, date and time on the pediatric PACU orders for Patient #6.

Based on the information obtained through staff interview and record review, the CAH failed to effectively and timely evaluate the quality and appropriateness of the diagnosis, treatment and treatment outcomes furnished to a patient who received services in the Emergency Department.

Refer to Tag: C-337

Based on staff interview and record review, the CAH failed to effectively and timely evaluate the quality and appropriateness of the diagnosis, treatment and treatment outcomes furnished to a patient who received services in the Emergency Department. ( Patient #25) Findings include:

1. After an incident report was filed on 4/9/10 regarding the unexpected admission of Patient #25 to the SCU (Surgical Care Unit) the case was initially reviewed by the surgical and obstetrical (OB) medical staff QA committee to evaluate the quality of care provided to Patient #25 as it pertained to the surgery performed on 4/9/10. Per record review on 6/10/10, the discharge summary for Patient #25, states "The patient was taken emergently to surgery and explored under spinal. She was found to have perforated appendicitis with generalized peritonitis and grossly purulent liquid. Appendectomy was performed." At the time of the surgery, Patient #25 was at 14 weeks gestation with a multiple pregnancy. Per interview on 6/14/10 at 3:30 PM, the VP of Quality Management Programs stated a collaboration between the 2 specialists, the surgeon and obstetrician, was conducted after the surgery. The review determined no further action by the Medical Staff Quality Monitoring committee was required in regards to the surgical intervention on 4/9/10.

It was also confirmed with the VP of Quality Management Programs although Patient #25 had sought treatment in the Emergency Department on 3 separate occasions for the same complaint of abdominal pain within a 10 day period, resulting in emergent surgery, the ED Medical Director was not aware of the events. Per interview on 6/14/10 at 11:00 AM, the ED Medical Director confirmed s/he was not aware of the circumstances involving Patient #25 until it was brought to his/her attention by surveyors on 6/08/10 during a previous complaint investigation. The issues including; the lack of a Medical Screening Exam for Patient #25 on 4/7/10; the inconsistent triage process for individuals seeking emergency services; a review of the care and services provided to Patient #25 on 4/9/10 in the ED prior to admission (including the delay of onsite consultation), had not been evaluated through the Medical Staff QA process or the ED Medical Director. The VP of Quality Management Programs also stated by the time Patient #25 was discharged on 4/18/10 it was apparent a quality review of Patient #25's record was necessary. However, no immediacy for review of the events was deemed necessary and consultation with the Emergency Department had not yet been conducted as of 6/14/10.