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Based on review of North Baldwin Infirmary's (NBI) Emergency Medical Treatment and Labor Act (EMTALA) policies, review of the hospital investigation memo, October Surgery On Call Schedule and Ambulance/EMS (Emergency Medical Services) reports and Patient Identifier (PI) # 1's medical record from Hospital # 2 and interviews, NBI failed to provide an appropriate medical screening examination for PI # 1, a patient involved in an Motor Vehicle Collision, who presented to the ED (Emergency Department) via ambulance on 10/4/15.

This deficient practice effected PI # 1, one of 27 sampled patients who presented to the ED and has the potential to negatively effect all patients who present to the ED for a Medical Screening Examination to determine if an Emergency Medical Condition exists.

Findings include:


Please refer to findings at A2406 - Medical Screening Examination.

Based on review of the October Surgery On Call Schedule, Ambulance/EMS (Emergency Medical Services) reports, hospital investigation memo, Patient Identifier (PI) #1's ED (Emergency Department) Medical Record from Hospital # 2, EMTALA (Emergency Medical Treatment and Labor Act) Policy and Procedure related to Medical Screening Examination and interviews, North Baldwin Infirmary (NBI) failed to provide a medical screening examination for PI # 1, a patient who presented via ambulance to the Emergency Room on 10/4/15.

A RN (Registered Nurse) went outside and advised EMS personnel no surgical services were available at the hospital. Consequently, the ambulance left North Baldwin Infirmary (Hospital # 1) and transported the patient to the ED at Hospital # 2. As a result, PI # 1 did not receive a medical screening examination at NBI.

The facility voluntarily submitted a letter dated 11/5/15 to the Regional Office as a self report of the information pertaining to the above potential 10/4/15 EMTALA violation.

This deficient practice affected PI # 1, one of 27 sampled patients and has the potential to affect all patients who present to the hospital seeking emergency medical services.

Findings include:

A review of NBI's October Surgery On Call Schedule revealed one of the two general surgeons was unavailable beginning 10/2/15 through 10/7/15. The other surgeon notified hospital administration that he was unavailable on the same dates (10/2-10/7/15) based on information obtained during an interview with the ED (Emergency Department) Manager, (Employee Identifier # 4), on 12/1/15 at 12:55.

North Baldwin Infirmary (NBI) did not have Surgery Coverage on 10/4/15 as revealed in an interview with the ED Manager at NBI (Employee Identifier # 4) on 12/1/15 at 12:55. The manager stated she notified North Baldwin EMS surgical services were not available at the hospital beginning 10/2/15 through 10/7/15.


There is no documentation of a medical record for PI # 1 from North Baldwin Infirmary.

Review of the electronic EMS report for PI # 1, which was obtained from the State EMS office revealed:
Date: 10/4/15
Type of Service: 911 Response Scene
Dispatch Complaint: Traffic Accident
Location: Highway 59...
Destination: Hospital # 2

Chief Complaint: Pain due to trauma. Location: Extremity - lower.

Primary Impression: Traumatic Injury.

Injuries:
Mechanisms: Blunt injury.

MVA (Motor Vehicle Accident) Indicators:
Rollover/Roof Deformity
Position: Right; Row 1
Safety: Lap/shoulder belt. Front and side airbags deployed

Vital Signs (14:55): Blood Pressure: 124/73, Pulse 110 and regular. Respiration: 20 and Normal. Glucose: 127. Cardiac Rhythm: regular, Alert.

Narrative: "...State Hwy 59: Incident. Destination: North Baldwin Infirmary then diverted to Hospital # 2... Arrived to find 44 yo (year old)... M (male) leaning up against... car... He is... CAO (conscious, alert and oriented x 3) and in no acute respiratory distress...cc (chief complaint): R (right) hip pain... Said he was restrained front passenger of a car that went airborne then rolled over. It (car) is laying on it's roof and airbags have deployed. He said he just got out of the car and walked around for a while... Initially said he didn't need an ambulance, but now his right hip is hurting and he thinks he needs to have it assessed...

Transported to North Baldwin Infirmary per patient choice... Upon our arrival we were advised by a nurse that North Baldwin was on trauma surgery bypass and would need to be transported to a hospital that was not on diversion. I told the patient about the diversion and said he could either be transported to a hospital in Mobile or go to Hospital # 2... He said he wanted to go Hospital # 2 so without unloading him we... went to Hospital # 2..."

Times (Central Standard Time):
Dispatch notified: 14:04
Unit notified: 14:36
Arrive Scene/Patient: 14:40
Left Scene: 14:57
Arrive Destination: 16:00

Review of the handwritten EMS Report for PI # 1: (the report was part of the ED medical record from Hospital # 2)

According to the handwritten EMS report dated 10/4/15 the patient (PI # 1) was involved in a rollover MVC (Motor Vehicle Collision) as a restrained front seat passenger with airbag deployment. The patient was airborne, but extricated himself from the vehicle. The chief complaint was right hip pain secondary to MVC with rollover.

Destination: NBI (North Baldwin Infirmary) and (Hospital # 2) were circled.


Review of PI # 1's ED Medical Record - Hospital # 2 revealed:

16:04: Patient arrived in the ED via ambulance.

Acuity: Less urgent.

Chief Complaint: Motor Vehicle Crash, Hip Pain.

16:08: Attending physician assigned.

History of Present Illness: Patient is a 44 year old male presenting with a rollover motor vehicle accident as a restrained passenger. He states airbags were deployed. The patient was ambulatory on the scene. Positive for abrasion with tenderness to the lower oblique and right sacroiliac area. Not truly the hip. No neck or back pain. No stomach pain. "

"Apparently there was some situation with the local hospital... being on diversion... Per the paramedics was in the ambulance bay when the nurse came out and said they had to leave..."

Motor Vehicle Crash
The accident occurred less than one hour ago. He came to the ER (Emergency Room) via EMS. Has pain in the back and right hip. The pain is mild: 4 out of 10 on a scale of 0-10. Has been constant since the injury.

Patient Negatives: No chest pain, no numbness, no visual changes, no abdominal pain, no disorientation, no loss of consciousness, no tingling and no shortness of breath. He was not thrown from the vehicle. The vehicle was overturned. He was found conscious and alert by EMS personnel.

Summary of Physical Examination: Blood Pressure: 121/75, Pulse: 90, Temperature: 98.5, Respirations: 18

Constitutional: He is oriented to person, place and time. No distress.

Head: Normocephalic and atraumatic.

Eyes: Pupils are equal, round and reactive to light.

Neck: Normal range of motion.

Cardiovascular: Normal rate and rhythm.

Pulmonary/Chest: Effort normal. No tenderness.

Abdomen: Soft. No distension. No tenderness.

Musculoskeletal: Normal range of motion. He exhibits tenderness. Right flank/Right superior iliac crest slight abrasion/tenderness.

Neurological: Alert and oriented to person, place and time. Normal strength. No cranial deficit. Exhibits normal muscle tone. Coordination normal. GCS (Glasgow Coma Score): GCS eye subscore is 4; GCS verbal subscore is 5, GCS motor subscore is 6. (GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters : Best Eye Response, Best Verbal Response, Best Motor Response. The GCS is an adopted standard for mental status assessment in the acutely ill trauma and non-trauma patient and assists with predictions of neurological outcomes (www.trauma.org and www.mdcalc.com/glasgow-coma-scale-score).

Skin: Rash noted.

Procedure:
Pelvis/Hip X-Ray
Date/Time:10/4/15 17:11
Result: Negative right hip fracture, left hip fracture, right dislocated hip and pelvic fracture.

Lab:
Urinalysis: Positive for blood (Trace) and protein (1+). All other components within normal limits.

ED Course/Plan:
Abrasion of Flank
Motor Vehicle Accident

Diagnosis management comments: Observed several hours and no signs of intra-abdominal pain or orthostasis to suggest hepatic, renal or other injury. No real blood in the urine. X-ray of pelvis is negative. We gave Intravenous (IV) Toradol and he is very comfortable. Ambulatory. Little friction/abrasion of the right superior iliac crest on the lateral side. Will provide prescription for pain pills. Home with wife. Ice to injury. No signs of splenic injury, pneumothorax or spine.

Patient Progress: Stable.

ED Nursing Documentation:

17:40: Patient ambulated around the ED without difficulty per orders.

18:15: Hydrocodone-acetaminophen (Norco): 10=325 milligrams (mg) per tablet and Cyclobenzapine (Flexeril) 10 mg. tablet given.

18:27: Departure Condition: Good. Mobility: Ambulatory.


Summary of Interviews:

Interview on 12/1/15 at 12:52 with EMS Paramedic (Employee Identifier # 1):

According to the paramedic, the patient had been walking around at the scene of the accident approximately 30 minutes prior to the arrival of EMS.

The paramedic said he called report to an RN (Registered Nurse) at North Baldwin Infirmary's ED (Emergency Department). The RN did not advise EMS the hospital was on diversion. When the ambulance arrived at North Baldwin Infirmary the RN came out to the ambulance bay and said the hospital was on trauma surgery bypass. According to the paramedic, he asked the patient if he wanted to go to Mobile or Hospital # 2. The patient chose Hospital # 2 and was transported to the ED at Hospital # 2 by EMS.

Interview with the ED RN at NBI (Employee Identifier # 2) at 14:30 on 12/1/15:

The RN said she received report from EMS about the patient who had been involved in a MVC with multiple rollovers advising EMS was transporting the patient to the ED at NBI on 10/4/15. According to the RN, after the call with EMS ended, she notified the NBI ED Physician about the patient. Reportedly the physician said the patient was a trauma patient and NBI did not have a surgeon on call.

The RN said she was not aware the hospital (NBI) was on diversion due to lack of availability of on-call surgery services. The RN stated she walked outside and met the ambulance carrying the patient who had been involved in the MVC. She notified EMS personnel the hospital had no surgeon on call. The RN said she heard the paramedic advise the patient about the lack of available surgical services at NBI. The paramedic informed the patient he could be transported to several other hospitals. The patient chose Hospital # 2. The ambulance left the property at NBI. Sometime later, (RN could not recall time), someone from the ED at Hospital # 2 notified ED staff at NBI of a potential EMTALA violation involving the patient.

Interview with the ED Physician (Employee Identifier # 3) at North Baldwin Infirmary on 12/2/15 at 11:15:

The physician verified he was notified the hospital was on trauma surgery diversion on 10/4/15. According to the physician, he overheard an RN discussing a report she took from EMS regarding a MVC with rollover. He asked the RN if she advised EMS the hospital (NBI) was on trauma diversion and she said no.

The physician stated he spoke with an EMS supervisor he thought was on the scene of the accident to advise the hospital was on diversion so the patient could be transported from the scene to a hospital with surgical services due to the nature of the MVC with rollover and risk to patient.

Approximately 20 minutes later, someone from Hospital # 2 called "threatening" an EMTALA violation. The ED Physician at NBI said he was then advised the patient had come to NBI and was refused. The physician stated he did not know the ambulance arrived on hospital property at NBI. According to the physician he was never informed the patient was in route to NBI or that the patient arrived at the hospital.

According to the physician, he then learned an ED RN went out to the ambulance when the ambulance arrived in the bay at NBI and told EMS staff we (NBI) were on diversion and to take the patient to another facility. "We can't do that."

The ED physician said he called the ED Physician at Hospital # 2, the hospital that received the patient after the ambulance left NBI, and advised the physician he thought he was talking to EMS personnel on the scene of the accident when advising EMS that NBI had no surgical services. The physician said he was never told the patient arrived at NBI. If he had known the patient was on hospital property, he would have evaluated, screened, stabilized and transferred the patient if indicated. "Once... on our property he (patient) would have been in our ED in a heartbeat." The physician reiterated the patient the point that he thought he was talking to EMS on the scene when discussing trauma surgery diversion due to the mechanism of injury and potential need for surgical intervention.


North Baldwin Infirmary
Medical Screening Examination Policy
Effective Date: 03/2004
Date Reviewed: 03/2015

For individuals seeking treatment on hospital property, the facility will provide a medical screening examination conducted by a qualified medical person to determine if an emergency medical condition exists. Additionally, an ambulance or private vehicle transporting a patient to the hospital which arrives anywhere on hospital property is considered having come to the hospital and the patient must be offered a medical screening examination.

Summary of Memo related to NBI's Investigation:
Date: 12/1/15; Written by the ED Manager at NBI (Employee Identifier # 4)
Situation: Received notification from...CNO (Chief Nursing Officer), and a self report from...RN... that there had been a possible compliance issue with a patient transferred to Hospital # 2 via ambulance.
Background:
10/2/15: It was determined the facility did not have Trauma Surgery Coverage available... I called North Baldwin EMS and advised that no Surgical Coverage available...

10/4/15 17:20: Received voice mail from the CNO regarding request to call back regarding a situation at the ED.

10/4/15 17:24: Received call from hospital staff...RN was self reporting possible compliance issue with a patient transferred to Hospital # 2 via ambulance. EMS responded to a rollover MVC and loaded one patient in transport to the ED at NBI. EMT-P (Paramedic) called report to the nursing staff and the report was relayed to the physician. The physician was concerned based on the mechanism of injury and lack of surgical services and requested nursing staff to contact EMS and make sure they were aware no surgical services were available.

Nursing staff contacted NBEMS (North Baldwin Emergency Medical Services) Supervisor and discussed situation. The ED physician requested to speak with the EMS Supervisor. The supervisor advised he was unaware of the status and would contact the crew and inform them of the situation. During the physician conversation with the EMS supervisor the crew transporting the patient arrived at NBI ambulance bay. The nursing staff attempted to notify the physician... but prior to confirmation of the MD being aware of the status of the ambulance being on NBI property... an RN... stated she walked out to the ambulance bay and informed the medic that we did not have surgical services available. The ambulance then left the bay and transported the patient to Hospital # 2. The NBI physician... immediately contacted the ED Physician at Hospital # 2 and explained the situation...

10/4/15 17:54: Contacted the... CNO in regards to situation...

10/4/15 18:02: I contacted NBEMS...The information received from the medic was he provided report but at the time of report was not informed of the surgical services status. Upon arriving to the hospital (NBI) the medic stated the nurse met him at the truck and advised him of the TCC (Trauma Communication Center - State Trauma System) Surgery Status... He stated he was never told we would not see the patient but did perceive that due to the lack of surgical services another facility was recommended. He informed the patient of the status and that Hospital # 2 was the next available hospital. The patient agreed to be transported to Hospital # 2...

Recommendation:

Actions completed:

Situation reviewed with Administration at NBI and Hospital # 2.

Evaluation of current EMTALA process.

EMTALA "just in time" (immediately after incident) education provided to staff and Physician involved during investigation conversations

EMTALA re-education assigned to all ED Staff, Physicians, House Supervisors, Float RN assigned to NBI ED.

Reviewed training requirements for relief staff pulled to the ED to assist and Infirmary Health Float Staff. EMTALA education requirements for NBI ED communicated to those Supervisors.

Ongoing evaluation of process and education needs.

The State Surveyor confirmed EMTALA education and other corrective measures were completed by ED nursing staff and ED physicians on 12/3/15.


Summary: The patient arrived via EMS in the ambulance bay at North Baldwin Infirmary at/or around 15:00 on 10/4/15. A staff RN went outside and advised EMS personnel no surgical services were available at the hospital. Consequently, the ambulance left North Baldwin Infirmary (Hospital # 1) and transported the patient to the ED at Hospital # 2. As a result, the patient did not receive a medical screening examination at NBI.