HospitalInspections.org

1. Based on review of medical records, ambulance trip reports, Emergency On-schedules Medical Staff Rules and Regulations, Emergency Provider Agreement, Physician Credentialing Files, Policies and Procedures, observational tours, Operating Room Logs, House Supervisor's Report and staff interviews, it was determined that the facility failed to provide an appropriate Medical Screening Examination within the capability of the hospital emergency room, on- call Orthopedic physician, that was routinely available to the emergency department, to determine whether or not an emergency medical condition existed for two (2) of 24 sampled medical records patients for patient #'s 2 and 21 presented to the Emergency Department respectively with gunshot wounds. Refer to findings in Tag A-2406.


2. Based on review of medical records, policies and procedures and on-call schedules , and interviews, it was determined the hospital failed to provide stabilizing treatment within the capabilities of the staff and facilities available at the hospital for further evaluation and treatment as required to stabilize 2 (#2 & #21) of 24 sampled patients who presented to the hospital with gunshot wounds to the foot. Refer to findings in tag 2407.

Based on review of medical records, ambulance trip reports, Emergency On-schedules Medical Staff Rules and Regulations, Emergency Provider Agreement, Physician Credentialing Files, Policies and Procedures, observational tours, Operating Room Logs, House Supervisor's Report and staff interviews, it was determined that the facility failed to provide an appropriate Medical Screening Examination within the capability of the hospital emergency room, on- call Orthopedic physician, that was routinely available to the emergency department, to determine whether or not an emergency medical condition existed for two (2) of 24 sampled medical records patients for patient #'s 2 and 21 presented to the Emergency Department respectively with gunshot wounds.

Findings were:


Medical record #2:
Review of the patient's medical record (#2) revealed the patient presented to the facility's South Campus as a walk-in patient on 10/15/16 at 4:51 a.m. with complaints of a self-inflicted gunshot wound to the right foot. The triage (assessment by a nurse to determine the priority in which patients will be seen based on their presenting signs and symptoms) nurse noted that the patient was an ESI level 1 (Emergency Severity Index level of 1- patients that require life, limb, or organ saving interventions) and the patient was immediately placed in a room. The triage nurse also noted that the patient ambulated with assistance and had received no care of the wound prior to arrival. In addition, the triage nurse noted that the patient was allergic to shrimp, was on no home medications, and that the patient denied loss of consciousness at the time of the injury. Nurses' and the ED physician's notes revealed the following:
--4:51 a.m., ED physician #9 ordered an x-ray of the right foot - results revealed four (4) of the bones in the top of the right foot were broken into multiple pieces and that there were numerous metallic foreign bodies in the surrounding area and generalized soft tissue swelling.
--4:51 a.m., ED physician #9 ordered Tetanus - Diphtheria - Pertussis Toxoid 0.5 milliliter intramuscular injection, administered at 5:05 a.m. to the right upper arm.
--4:53 a.m., ED physician #9 ordered an intravenous (IV) lines, at 5:08 a.m., the nurse noted that a 20 gauge (size of IV catheter) IV was inserted into the patient's right inner elbow area, and at 5:11 a.m., the nurse noted that a 16 gauge IV was placed in the patient's left upper arm.
--4:54 a.m., ED physician #9 ordered Ancef (antibiotic) 2 grams intravenously, administered at 5:07 a.m.
--5:01 a.m., ED physician #9 ordered Morphine (medication used to treat pain) 4 milligrams administer intravenously, Zofran ( medication used to prevent nausea and vomiting) 4 milligrams administer intravenously, Normal saline 0.9% administer intravenously, the nurse noted that these were administered at 5:10 a.m. ED physician #9 noted that the patient had been medically screened.
--5:06 a.m., the nurse noted that the patient's Glasgow Coma Scale score (assessment of eye movement, verbal response, and motor (movement) response) was 15 (normal 15) and trauma score was 12 (a score of 3-10 needs immediate care, 11 needs urgent care, and a 12 the care can be delayed).
--5:10 a.m., the nurse documented the patient's vital signs (VS) as: temperature (T) 98.0 (normal 97.8-99.1), pulse (P) 87 (normal 60-100), respirations (R) 20 (normal 12-18), blood pressure (BP) 146/97 (normal 90/60-120/80), pulse oxygenation (PO - amount of oxygen in the blood) 98% (normal 95-100%) on two (2) liters of oxygen by nasal cannula, and right foot pain level was 10 on a scale of one (1) to 10 with one (1) being mild pain and 10 being severe pain.
--5:29 a.m., financial registration completed.
--5:39 a.m., the nurse documented the patient's VS as: P 65, R 18, BP 137/89, PO 100% on two (2) liters of oxygen by nasal cannula.
--5:44 a.m., Final x-ray of Right foot completed. "Findings: There are comminuted fractures of the medial cuneiform tarsal bone and the first, second and third metatarsal bones. There are numerous foreign body densities surrounding the metatarsal bones. There is generalized soft tissue swelling. IMPRESSION: Fractures and foreign bodies as described."

--6:07 a.m., ED physician #9 ordered irrigation of the wound, Posterior right leg splint, Crutches, and Wound dressing, the nurse noted that these were completed at 6:18 a.m.
--6:08 a.m., the nurse noted that ED physician #9 ordered the patient to be discharged. ED physician #9 noted that the patient was discharged to home, that his/her impression was that the patient had broken bones in the right foot from a gunshot wound, and that the patient's condition had improved. ED physician #9 noted that the patient was provided with a work release form for three (3) days and a referral to follow-up with the Orthopedic Surgeon (#1) in two (2) to three (3) days. ED physician #9 further noted that the patient was being discharged with prescriptions for Augmentin (antibiotic) 875 milligrams 20 tablets one (1) tablet by mouth twice a day, Motrin (mild to moderate pain pill) 800 milligrams 30 tablets one (1) tablet by mouth three (3) times a day as needed for pain, Percocet (moderate to severe pain pill) 5/325 milligrams 15 tablets one (1) or two (2) tablets by mouth every four (4) to six (6) hours as needed for pain.
--6:16 a.m., the nurse noted that the patient's VS were: P68, R 18, BP 142/87, PO 99% on room air. The nurse noted that crutches were dispensed and that teaching was completed. The nurse also noted that an Ace wrap posterior (back) lower leg splint (used to stabilize the leg and help to alleviates extremity pain, swelling, and further soft tissue injury and promotes wound and bone healing) was applied to the right leg and that the ED physician (#9) checked the splint. The nurse noted that circulation, movement, and sensation remained intact. ED physician #9 noted that the patient (#2) had complained of gunshot wound to the right foot, with no loss of consciousness.
--6:17 a.m., the nurse noted that the patient was discharged home with crutches in stable condition. In addition, the nurse noted that the patient's home medications and discharge instructions were reviewed with the patient and that the patient's discharge pain level was six (6) on a scale of one (1) to 10.
--6:18 a.m., ED physician #9 noted that the patient had an acute (sudden onset) deformity, pain, and puncture wound on the right foot and that all other systems were negative.
--6:20 a.m., ED physician #9 noted that the patient appeared to be in no acute distress, had normal range of motion with painful movement of the right foot, was oriented to person, place, time and situation. The physician further noted that the patient had a 2.5-centimeter (.98 inch) diameter gunshot wound that "goes through and through".
--6:36 a.m., the nurse noted that the patient left the ED. The Discharge Instructions were signed by the patient (#2) and included the following:
Thank you for using Atlanta Medical Center South Campus for your care today. It is important for you to know that the examination, treatment and x-ray reading you have received in the Emergency Care Center today have been rendered on an emergency basis only and are not intended to be a substitute for an effort to provide complete medical care. You should contact your follow-up physician as it is important that you let him or her check you and report any new or remaining problems since it is impossible to recognize and treat all elements of an injury or illness in a single emergency care center visit.
The discharge instructions for today's visit are outlined below:
--broken bones in the foot,
--Augmentin 875 milligrams 20 tablets one (1) tablet by mouth twice a day,
--Motrin 800 milligrams 30 tablets one (1) tablet by mouth three (3) times a day as needed for pain,
--Percocet 5/325 milligrams 15 tablets one (1) or two (2) tablets by mouth every four (4) to six (6) hours as needed for pain,
--Selected Referral with Orthopedic Surgeon in (Physician #1 name was listed) two (2) to three (3) days, and
--Work release form for three (3) days.
The patient signed that he/she "hereby acknowledge that I have received and understand the above instructions and prescriptions (If any). I acknowledge that failure to follow-up with the above doctors as directed will release the ED physicians of any responsibility for any adverse outcome or worsening of my condition, I also understand that my signature authorizes Atlanta Medical Center South Campus to release all or any part of my medical record (including, if applicable, information pertaining to AIDS/HIV testing, mental health records, and drug/alcohol treatment) to the referred physician(s) listed above.
--6:40 a.m., the Consent to Routine Procedures and Treatments and Financial Responsibility Statement was signed by a staff member and noted that the patient had given verbal consent for treatment.


On-Call Schedules
The hospital's October 2016 on call schedule was reviewed. The on-call schedule revealed that on October 15, 2016 the hospital had capability to provide the ancillary services of the on-call Orthopedic physician (#1) that was available prior to discharging patient #2 from the hospital's ED on 10/15/2016. There was no documented evidence of ED physician (#9) calling the on-call Orthopedic Surgeon (#1) to request that the on-call physician come into the ED to see the patient.

Review of the patient's (#2) medical record from hospital A revealed the patient presented to hospital A at 8:01 a.m. The patient signed the consent to treat at 8:06 a.m. At 8:20 a.m., the triage nurse assessed the patient assigned the patient as a level two (2) priority. The triage nurse noted the following: patient arrived by private automobile, has a gunshot wound to the right foot, reports treatment at Wellstar Atlanta Medical Center's South Campus, has a dressing to the right foot and reports that he/she (patient) noticed bleeding through the bandage and came to the hospital (A), and temperature 100.4, pulse 65, respirations 16, and blood pressure 149/107.
--At 9:50 a.m., the ED physician noted that the patient had a shotgun wound to the right foot and reported being treated at Wellstar Atlanta Medical Center's South Campus. The physician noted that the patient reported that the previous treatment had included x-rays of the right foot, receiving antibiotic medication, and pain medication. The physician further noted that while in the car (travel time from Wellstar Atlanta Medical Center's South Campus to hospital A is approximately 30 minutes) his/her (patient #2) noticed his/her (patient) foot had started bleeding through the bandage. In addition, the ED physician noted that the patient reported severe pain that was described as achy and that he/she (patient #2) had taken two (2) Naproxen (non-steroidal anti-inflammatory drug used to reduce pain, swelling, and fever) 500 mg prior to arrival. The ED physician noted that the patient had a large wound to the top of the right foot and a larger wound to the bottom of the right foot with a foreign body protruding that was easily removed and appeared to be part of the bullet.
--Physician orders included blood work that revealed the patient had an elevated white blood cell count of 15.2 (normal 3.4-10.8), x-rays of the right foot that revealed numerous metallic fragments throughout the foot with broken metatarsal bones, intravenous fluids that were started at 10:22 a.m., Zosyn (antibiotic) 4.5 grams intravenously that was started at 10:22 a.m., and an orthopedic consult.
--At 1:45 p.m., the orthopedic physician noted that the patient had noticed that his/her (patient #2) foot had started bleeding while driving home. The physician noted that the patient had moderate soft tissue damage to the top of the foot and extensive soft tissue damage to the bottom of the foot with visible pieces of the plastic shell casing. The orthopedic physician further noted that the patient had no active problems at the time of the examination. The orthopedic surgeon suggested transferring the patient to a trauma center.
--The ED physician filled out the transfer form which revealed the patient was accepted at Wellstar Atlanta Medical Center's Main Campus by one of the facility's ED physicians. The transfer form included documentation of the risks and benefits, that the patient had been stabilized for transfer, that the patient was being transferred by ambulance, and that portions of the medical record was sent to the accepting facility.
--The transferring nurse documented that he/she called report to the receiving nurse and that the patient left the facility on 10/15/16 at 3:12 p.m.

Review of the ambulance trip report revealed the ambulance attendants turned over the patient's care to the Main Campus staff at 4:01 p.m. The ambulance trip report revealed that patient had a penetrating wound with swelling and that the bleeding was controlled. During transport the ambulance report noted that the patient's Glasgow Coma Scale score was 15 (normal), the patient had no pain, and vital signs remained within normal limits. The ambulance report revealed that the patient reported that after being discharged from Wellstar Atlanta Medical Center South Campus the wound to his/her (the patient) right foot wound would not stop bleeding so the patient went to hospital A for further treatment. The ambulance report revealed the wound was redressed prior to transport, that the patient had a 20-gauge intravenous line intact with normal saline running at 100 milliliters per hour. The ambulance report revealed the patient remained stable during transport to Wellstar Atlanta Medical Center Main Campus.

Review of the patient's (#2/#8 same patient) medical record revealed the patient presented to the facility's Main Campus by ambulance as a transfer from hospital A on 10/15/16 at 3:50 p.m. Upon arrival at Wellstar Atlanta Medical Center Main Campus the patient was triaged as an ESI 1. The triage nurse noted that the patient's vital signs were within normal limits.
--3:48 p.m. ED physician #7 ordered blood work which included a complete blood cell count, results revealed the patient's white blood cell count (signifies infection) was 11.2 (normal 5.0-10.0), red blood cell count (carries oxygen to the tissue) was 3.98 (normal 4.6-6.0), hemoglobin (carries oxygen) was 12.1 (normal 14.0-18.0), and hematocrit (volume of red blood cells in the blood) 36.2 (normal 42.0-52.0)
--3:55 p.m. ED physician #7 examined the patient.
--4:20 p.m. A family member signed the Consent to Routine Procedures and Treatments and Financial Responsibility Statement.
--4:25 p.m. The patient signed an Informed Consent for incision and debridement (I&D - to clean out the wound site) with possible fixation of the broken bones in the right foot.
--4:32 p.m. ED physician #7 noted that the patient had a gunshot wound to the right foot and that the patient had severe pain to the right foot. The physician noted that the patient had strong pulses in the foot, intact sensation to the toes, and could move his/her (patient) toes. ED physician #7 further noted that the patient had no pain with ankle movement. ED physician #7 noted that the skin was torn away from the top and bottom of the right foot but there was no active bleeding.
--4:44 p.m. ED physician #7 ordered a computerized tomography (CT scan) without contrast of the patient's right foot. This report revealed extensive fragmented broken bones in the right foot.
--4:45 p.m. ED physician #7 noted that the plan was for the patient to be admitted. Nurses' notes indicated the patient left the ED in a stable/improved condition.
--4:51 p.m. The Admission History and Physical report revealed the patient reported that he/she had a shotgun strapped to the inside of his/her leg and that the gun went off firing buck shot into the top of the patient's right foot. This report noted that the patient reported going to hospital A for treatment of continued pain and bleeding from the right foot wound. The report revealed the plan was to admit the patient to Orthopedic Services with plans for a surgical procedure / I&D with closed reduction with pinning versus open reduction with internal fixation of the broken bones.
--5:43 p.m. ED physician #7 noted that Orthopedic Services had been notified and that Graduate Resident (#6) was at the patient's bedside. ED physician #7 noted that the patient was to be admitted with broken bones in the right foot to Orthopedic Surgeon #5.
--8:22 p.m. Nurses' notes indicated the patient left the ED in a stable/improved condition.
--10/16/16 Orthopedic Surgeon #12 performed the I&D of the patient's right foot. The physician noted that a wound vac (used to increase circulation and healing to the site) was applied and that a second I&D was planned for later that week.
--10/17/16 The patient signed a second Informed Consent for an I&D procedure.
--10/18/16 Orthopedic Surgeon #12 performed a second I&D of the patient's right foot. The operative note revealed the right leg was splinted and that the patient would be non-weight bearing on the right lower extremity.
--Review of subsequent blood work revealed that the patient's complete blood cell count remained essentially the same during this admission.
Documentation revealed that during this admission the patient car included: antibiotics, pain medications, intravenous fluids, evaluation and treatment by physical therapy and occupational therapy, and evaluation by case management. Documentation revealed the patient was taught to apply wet-to-dry dressings and was discharged home with prescriptions for pain medications and antibiotics and a referral to follow-up with the Orthopedic Surgeon (#12) in 10-14 days. The Discharge Summary revealed the patient had no complications during this admission. The patient signed receipt and understanding of the discharge paperwork on 10/20/16.


Medical Record #21:
Review of patient #21's medical record revealed the patient presented to the South Campus ED as a walk-in on 05/28/17 at 11:52 a.m. with complaints of a gunshot wound to the right foot. The triage nurse noted that the patient was an ESI level 2 ... (High risk situation. Severe pain/distress ...requires help quickly but not immediately) and that the patient was placed in a trauma room at 11:54 a.m... The triage nurse also noted that the patient reported that his wife shot him in the foot with 357 magnum and that the patient had no known allergies. Nurses' and the ED physician's notes revealed the following:
--11:58 a.m. portable x-ray of the right foot was ordered and performed, results revealed multiple broken bones in the top of the right foot. Blood work was ordered, completed, and reviewed by the ED physician (#4). Review of the Final CT report of the right foot revealed in part, 1. Extensively comminuted fractures at the base of first metatarsal and at the first cuneiform ...Multiple tiny metal fragments are seen mixed with pieces of bone. 2. Smaller fractures at the base of the second metatarsal and at the second cuneiform. 3. Small fracture at the base of the third cuneiform. 4. Vertical fracture through the navicular."
--11:59 a.m. the patient's vital signs were documented as 98.7-90-20-142/101, 97% on room air, patient "appears uncomfortable, Behavior is anxious", and pain as 10/10.
--12:03 p.m. Zofran 4 mg and Toradol (Non-steroidal anti-inflammatory medication used to decrease pain, swelling and fever) 30 mg was administered IVP.
--12:04 p.m. Morphine 4 mg and Ancef 2 grams was administered IV and Tetanus Toxoid 0.5 ml was administered intramuscularly into the left upper arm.
--12:06 p.m. physician #4 noted that the patient #21 reported being shot in the right foot by his wife, that the patient had no loss of consciousness, and that police were notified. Physician #4 noted that the physical examination revealed range of motion in all extremities, good blood flow to the arteries in the foot, no nerve damage, and entrance and exit wounds to the top of the foot.
--12:29 p.m. physician #4 ordered, "Consult Orders: Physician #1 (surgery-ortho) Ordered."
--12:44 p.m. nurses' notes indicated that the patient appeared uncomfortable and that the patient's pain was now 6/10.
--12:45 p.m. the patient's vital signs were 79-18-150/97-96% on room air.
--12:46 p.m. nurses' notes indicated that a 20 gauge IV was placed in the patient's right hand and the GSW was irrigated with Betadine solution.
--12:54 p.m. nurses' notes indicated that a posterior short leg splint was applied as ordered.
--1:00 p.m. physician #4 noted that the diagnosis was GSW to the foot, that he/she discussed the results with patient #21 "regarding historical points, exam findings, and any diagnostic results, supporting the admit diagnosis. Data reviewed: vital signs, nurse's notes, lab tests results (s), radiologic studies. After a detail discussion of the patient's case, care is transferred to (Name of trauma Physician at the Main Campus) Patient has an emergent medical condition" The admission plans were discussed with the patient and patient #21 agreed with the plan.
--1:05 p.m. Disposition Summary -physician #4 ordered the transfer to the Main Campus. The diagnosis was Displaced fracture of medial cuneiform of Right foot; Reason for Transfer was for Trauma Services.
--1:18 p.m. EMS transport was arranged and report was called to the receiving nurse.
--1:24 p.m. the patient signed the consent to treat forms.
--1:27 p.m. the nurse noted that the transfer form was scanned into the chart.
--1:32 p.m. the nurse noted that the patient had no adverse reactions to the drugs the patient had received.
--1:33 p.m. nurses' notes indicated that the patient left the ED in stable condition and that the patient's pain at the time of transfer was 6/10.
--Physician #4's discharge notes indicated that the patient was transfer to the Main Campus in fair condition with a GSW and broken bones in the top of the right foot. Physician #4 indicated that the patient was accepted at the Main Campus by an accepting physician for trauma services not available at the South Campus. The hospital failed to ensure that their EMTALA policy and procedure was followed as evidenced by failing to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department, which ancillary services (Orthopedic surgeon) were available when patient #21 presented to the hospital , with an identified emergency medical condition.

Review of the South Campus ED on-call schedules for May 2017 revealed that physician #1 was the Orthopedic surgeon on-call on 5/28/2017 when patient #21 presented to the hospital. The on-call schedules had an attachment that required on-call physicians to "Please Read Carefully" the following:
ALL DOCTORS WHO TAKE ED CALL MUST
--respond by phone within 30 minutes to a call from the ED physician; and
--come to the ED as soon as possible upon request from the ED physician ...The physician covering your ER call must be on staff at AMC and have privileges to provide the service.

Review of the facility's Medical Staff Rules and Regulations, revised 01/20/16, revealed the following:
--Article 10. Miscellaneous: Section 8. Screening, Stabilization, and Transfer of Individuals with Emergency Medical Conditions (EMC):
(a) Patients presenting with EMC shall be screened, stabilized, and/or transferred pursuant to Hospital Policy for Screening, Stabilization and Transfer of Individuals with EMC.
(b) " MSE " means the screening process required to determine with reasonable clinical confidence whether an EMC does or does not exist.
(c) "Qualified Medical Person" (QMP) means an individual or individuals in one of the following professional categories who has demonstrated current competence to perform a MSE:
1. ED Physician, ED Physician's Assistant, ED Certified Nurse Practitioner.
--Article 12. ED: Section 1. Patient Evaluation: For each person who presents at the ED and who requests an examination or treatment of a medical condition, the emergency physician has the responsibility to perform an appropriate MSE to determine whether an EMC exists. If the patient does have an emergency, the emergency physician will arrange for appropriate stabilization treatment and after care (i.e., admission, surgery, etc.) and transfer if necessary, pursuant to Hospital Policy for Screening, Stabilization and Transfer of Individuals with EMC.
--Section 2. Care of Patients:
A MSE will be performed pursuant to Hospital Policy for Screening. Stabilization and Transfer of Individuals with EMC.

Review of the ED Provider Agreement, effective 04/01/16, revealed the hospital's ED physicians are contracted to provide medical services through an agreement with a professional services provider. The agreement 04/01/16 outline the provision of medical services will be provided in compliance with:
--The Hospital's Policies and Procedures, Rules and Regulations, and Bylaws of the Medical Staff.
--Current standards of medical practice.
--Applicable federal, state and local laws.
--Standards and requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Credentialing File Review for Physician #1

Review of the "Clinical Privileges in Orthopaedic Surgery" for Physician #1 that was approved by the hospital's Department Chair on 10/24/2017 was reviewed. The clinical privileges revealed the "CORE PRIVILEGES IN ORTHPPAEDIC SURGERY" for Physician #1 that were requested and accepted, revealed in part, "Admission, work-up provision of non-surgical and surgical care to patients of all ages ...
Orthopedic Surgery Core Procedure List: Performance of History and Physical ...Debridement of soft tissue ...Fracture fixation ...Management of infectious and inflammation of bones, joints and tendon sheaths ...Open reduction and internal/external fixation of fractures and dislocations of the skeleton ...treatment of extensive trauma, excluding pelvis or spine."

Review of facility policies and procedures that were in place in October 2016 included but was not limited to the following:
1. ESI 5 LEVEL TRIAGE: An instrument that categorizes ED patients by evaluating both patient acuity and resource needs. Resource needs are the number of resources a patient is expected to consume in order for a disposition decision to be reached.
--Level l: Requires immediate life, limb, or organ saving interventions. This patient is unable to wait and must be placed immediately in a treatment room.
--Level Il: High risk situation, confused, lethargic, disoriented, severe pain/distress, unstable vital signs requires help quickly but not immediately.
--Level Ill: Situation requires 2 or more resources (Including but not limited to laboratory testing, radiology studies, medications, intravenous fluid procedures J consults), patient has stable vital signs.
--Level IV: Situation requires 1 resource.
--Level V: Situation requires zero resources.

2. EMERGENCY MEDICAL TREATMENT AND LABOR ACT-EMTALA, policy number AMC-RI.280, last reviewed/revised 05/17, effective 02/14/01, revealed the purpose was to set forth policies and procedures for Hospital ' s use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA).

Definitions:
A. " Capacity " encompasses such things as numbers and availability of qualified staff, beds and equipment, as well as the Hospital ' s past practices of accommodating patients in excess of its occupancy limits.
B. " Capability " defined as the staff, equipment and specialty or specialist services available to care for a patient with an EMC
C. " Comes to the ED " For purposes of this policy, an individual is deemed to have " come to the ED " if the individual:
Presents at a dedicated ED, and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual ' s appearance or behavior, that the individual needs examination or treatment for a medical condition;
D. " EMC " means:
1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in either:
a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or
b. Serious impairment to bodily functions, or
c. Serious dysfunction of any bodily organ or part.
H. " MSE " is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. A MSE is not an isolated event. It is an ongoing process that begins, with the initial assessment by a Qualified Medical Person and ends when enough information has been gathered to determine the patient does not have an EMC.
I. " Qualified Medical Person " or " Qualified Medical Personnel " means an individual or individuals in one of the following professional categories who has demonstrated current competence to perform a MSE
1. ED: Emergency Medicine Physician, ED Physician ' s Assistant, ED Certified Nurse Practitioner ...
J. " To Stabilize " or " Stabilize " or " Stabilized " means:
With respect to an EMC, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer or discharge of the individual from the Hospital.
IV. POLICY:
If an individual comes to the ED:
A. The Hospital will provide an appropriate MSE within the capability of the Hospital ' s Dedicated ED, including ancillary services routinely available, to determine if an " EMC " exists; ... V. PROCEDURE:
A. Triage and Registration
1. Triage
a. As soon as practical after arrival, individuals who come to the ED should be triaged in order to determine the order in which they will receive a MSE.
b. Triage is not a MSE, as it does not determine the presence or absence of an EMC, but rather, simply determines the order in which individuals will receive a MSE.
2. Registration
a. The Hospital may not delay the provision of an appropriate MSE or any necessary stabilizing medical examination and treatment in order to inquire about the individual's method of payment or insurance status.
B. MSE
1. The Hospital shall provide a MSE to all individuals who have come to the ED.
2. The MSE is the examination of the patient by the QMP required to determine within reasonable clinical confidence whether an EMC does or does not exist. The examination should be tailored to the patient ' s complaint, and depending on the presenting symptoms, the MSE may represent a spectrum ranging from a simple process involving only a brief history and physical examination, to a complex process that also involves performing ancillary studies, procedures etc.
3. Monitoring must continue until the individual is stabilized or appropriately admitted or transferred. The MSE, and ongoing patient assessment, must be documented in the medical record.
4. The MSE must be provided in a non-discriminatory manner. The examination provided to an individual must be the same MSE that the QMP would provide to any individual coming to the Hospital ' s dedicated ED with those signs and symptoms, regardless of ability to pay.
D. Individuals Who Do Not Have An EMC
1. If, after the MSE is completed, a physician or other QMP determines that an individual does not have an EMC, the individual may be discharged.
2. Discharged individuals who do not have an EMC must receive at the time of discharge, follow-up instructions with written or electronic homecare instructions.

INTERVIEWS:

An observational tour of the ED was conducted on 06/11/18 at 9:15 a.m. with the Chief Nursing Officer/Chief Operating Officer (CNO/COO #3) and ED Manager (EDM #2). The EDM (#2) said that the MSE is performed by a physician, Nurse Practitioner, or Physician's Assistant. The EDM (#2) explained that although the South Campus only has one (1) trauma room (#22) that is utilized for trauma patients, there are trauma carts available in each main ED room. The EDM said that the South Campus

Based on an observational tour, review of medical records, policies and procedures and on-call schedules, and interview, it was determined the hospital failed to provide stabilizing treatment within the capabilities of the staff and facilities available at the hospital for further evaluation and treatment as required to stabilize 2 (#2 & #21) of 24 sampled patients who presented to the hospital with gunshot wounds to the foot.


Policy and Procedures
The facility's policy titled "EMERGENCY MEDICAL TREATMENT AND LABOR ACT-EMTALA', policy number AMC-RI.280, last reviewed/revised 05/17, effective 02/14/01, revealed the purpose was to set forth policies and procedures for Hospital ' s use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA) was reviewed. The policy revealed in part,
Definitions:
A. " Capacity " encompasses such things as numbers and availability of qualified staff, beds and equipment, as well as the Hospital ' s past practices of accommodating patients in excess of its occupancy limits.
B. "Capability " defined as the staff, equipment and specialty or specialist services available to care for a patient with an EMC ... "IV. POLICY: B. The Hospital will: (a) provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to " stabilize " the emergency medical condition, or (b) arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below.
C. It is the policy of the Hospital to maintain a list of physicians from its medical staff who are on-call for duty after the medical screening examination to provide further medical examination and treatment as necessary to stabilize individuals who have been found to have an EMC ... E. Individuals Who Have An EMC, if after a MSE, it is determined that an individual has an EMC, the Hospital shall:
1. Within the capability and capacity of the staff and facilities available at the Hospital (including coverage available through the Hospital's on-call roster), provide treatment necessary to stabilize the individual, at which time the individual may be discharged; or
2. Admit the individual to the Hospital in order to stabilize the individual; or
3. If stabilization of the individual is beyond the capabilities or capacity of the Hospital, arrange for appropriate transfer of the individual to another medical facility in accordance with this policy.


Medical Record for Patient #2.

Review of the patient's medical record (#2) revealed the patient presented to the facility's South Campus as a walk-in patient on 10/15/16 at 4:51 a.m. with complaints of a self-inflicted gunshot wound to the right foot. The triage (assessment by a nurse to determine the priority in which patients will be seen based on their presenting signs and symptoms) nurse noted that the patient was an ESI level 1 (Emergency Severity Index level of 1- patients that require life, limb, or organ saving interventions) and the patient was immediately placed in a room. The triage nurse also noted that the patient ambulated with assistance and had received no care of the wound prior to arrival. In addition, the triage nurse noted that the patient was allergic to shrimp, was on no home medications, and that the patient denied loss of consciousness at the time of the injury. Nurses' and the ED physician's notes revealed the following:
--4:51 a.m., ED physician #9 ordered an x-ray of the right foot - results revealed four (4) of the bones in the top of the right foot were broken into multiple pieces and that there were numerous metallic foreign bodies in the surrounding area and generalized soft tissue swelling.
--4:51 a.m., ED physician #9 ordered Tetanus - Diphtheria - Pertussis Toxoid 0.5 milliliter intramuscular injection, administered at 5:05 a.m. to the right upper arm.
--4:53 a.m., ED physician #9 ordered an intravenous (IV) lines, at 5:08 a.m., the nurse noted that a 20 gauge (size of IV catheter) IV was inserted into the patient's right inner elbow area, and at 5:11 a.m., the nurse noted that a 16 gauge IV was placed in the patient's left upper arm.
--4:54 a.m., ED physician #9 ordered Ancef (antibiotic) 2 grams intravenously, administered at 5:07 a.m.
--5:01 a.m., ED physician #9 ordered Morphine (medication used to treat pain) 4 milligrams administer intravenously, Zofran ( medication used to prevent nausea and vomiting) 4 milligrams administer intravenously, Normal saline 0.9% administer intravenously, the nurse noted that these were administered at 5:10 a.m. ED physician #9 noted that the patient had been medically screened.
--5:06 a.m., the nurse noted that the patient's Glasgow Coma Scale score (assessment of eye movement, verbal response, and motor (movement) response) was 15 (normal 15) and trauma score was 12 (a score of 3-10 needs immediate care, 11 needs urgent care, and a 12 the care can be delayed).
--5:10 a.m., the nurse documented the patient's vital signs (VS) as: temperature (T) 98.0 (normal 97.8-99.1), pulse (P) 87 (normal 60-100), respirations (R) 20 (normal 12-18), blood pressure (BP) 146/97 (normal 90/60-120/80), pulse oxygenation (PO - amount of oxygen in the blood) 98% (normal 95-100%) on two (2) liters of oxygen by nasal cannula, and right foot pain level was 10 on a scale of one (1) to 10 with one (1) being mild pain and 10 being severe pain.
--5:29 a.m., financial registration completed.
--5:39 a.m., the nurse documented the patient's VS as: P 65, R 18, BP 137/89, PO 100% on two (2) liters of oxygen by nasal cannula.
--5:44 a.m., Final x-ray of Right foot completed. "Findings: There are comminuted fractures of the medial cuneiform tarsal bone and the first, second and third metatarsal bones. There are numerous foreign body densities surrounding the metatarsal bones. There is generalized soft tissue swelling. IMPRESSION: Fractures and foreign bodies as described."

--6:07 a.m., ED physician #9 ordered irrigation of the wound, Posterior right leg splint, Crutches, and Wound dressing, the nurse noted that these were completed at 6:18 a.m.
--6:08 a.m., the nurse noted that ED physician #9 ordered the patient to be discharged. ED physician #9 noted that the patient was discharged to home, that his/her impression was that the patient had broken bones in the right foot from a gunshot wound, and that the patient's condition had improved. ED physician #9 noted that the patient was provided with a work release form for three (3) days and a referral to follow-up with the Orthopedic Surgeon (#1) in two (2) to three (3) days. ED physician #9 further noted that the patient was being discharged with prescriptions for Augmentin (antibiotic) 875 milligrams 20 tablets one (1) tablet by mouth twice a day, Motrin (mild to moderate pain pill) 800 milligrams 30 tablets one (1) tablet by mouth three (3) times a day as needed for pain, Percocet (moderate to severe pain pill) 5/325 milligrams 15 tablets one (1) or two (2) tablets by mouth every four (4) to six (6) hours as needed for pain.
--6:16 a.m., the nurse noted that the patient's VS were: P68, R 18, BP 142/87, PO 99% on room air. The nurse noted that crutches were dispensed and that teaching was completed. The nurse also noted that an Ace wrap posterior (back) lower leg splint (used to stabilize the leg and help to alleviates extremity pain, swelling, and further soft tissue injury and promotes wound and bone healing) was applied to the right leg and that the ED physician (#9) checked the splint. The nurse noted that circulation, movement, and sensation remained intact. ED physician #9 noted that the patient (#2) had complained of gunshot wound to the right foot, with no loss of consciousness.
--6:17 a.m., the nurse noted that the patient was discharged home with crutches in stable condition. In addition, the nurse noted that the patient's home medications and discharge instructions were reviewed with the patient and that the patient's discharge pain level was six (6) on a scale of one (1) to 10.
--6:18 a.m., ED physician #9 noted that the patient had an acute (sudden onset) deformity, pain, and puncture wound on the right foot and that all other systems were negative.
--6:20 a.m., ED physician #9 noted that the patient appeared to be in no acute distress, had normal range of motion with painful movement of the right foot, was oriented to person, place, time and situation. The physician further noted that the patient had a 2.5-centimeter (.98 inch) diameter gunshot wound that "goes through and through".
--6:36 a.m., the nurse noted that the patient left the ED.


Medical Record Patient #21.

Review of patient #21's medical record revealed the patient presented to the South Campus ED as a walk-in on 05/28/17 at 11:52 a.m. with complaints of a gunshot wound to the right foot. The triage nurse noted that the patient was an ESI level 2 ... (High risk situation. Severe pain/distress ...requires help quickly but not immediately) and that the patient was placed in a trauma room at 11:54 a.m... The triage nurse also noted that the patient reported that his wife shot him in the foot with 357 magnum and that the patient had no known allergies. Nurses' and the ED physician's notes revealed the following:
--11:58 a.m. portable x-ray of the right foot was ordered and performed, results revealed multiple broken bones in the top of the right foot. Blood work was ordered, completed, and reviewed by the ED physician (#4). Review of the Final CT report of the right foot revealed in part, 1. Extensively comminuted fractures at the base of first metatarsal and at the first cuneiform ...Multiple tiny metal fragments are seen mixed with pieces of bone. 2. Smaller fractures at the base of the second metatarsal and at the second cuneiform. 3. Small fracture at the base of the third cuneiform. 4. Vertical fracture through the navicular."
--11:59 a.m. the patient's vital signs were documented as 98.7-90-20-142/101, 97% on room air, patient "appears uncomfortable, Behavior is anxious", and pain as 10/10.
--12:03 p.m. Zofran 4 mg and Toradol (Non-steroidal anti-inflammatory medication used to decrease pain, swelling and fever) 30 mg was administered IVP.
--12:04 p.m. Morphine 4 mg and Ancef 2 grams was administered IV and Tetanus Toxoid 0.5 ml was administered intramuscularly into the left upper arm.
--12:06 p.m. physician #4 noted that the patient #21 reported being shot in the right foot by his wife, that the patient had no loss of consciousness, and that police were notified. Physician #4 noted that the physical examination revealed range of motion in all extremities, good blood flow to the arteries in the foot, no nerve damage, and entrance and exit wounds to the top of the foot.
--12:29 p.m. physician #4 ordered, "Consult Orders: Physician #1 (surgery-ortho) Ordered."
--12:44 p.m. nurses' notes indicated that the patient appeared uncomfortable and that the patient's pain was now 6/10.
--12:45 p.m. the patient's vital signs were 79-18-150/97-96% on room air.
--12:46 p.m. nurses' notes indicated that a 20 gauge IV was placed in the patient's right hand and the GSW was irrigated with Betadine solution.
--12:54 p.m. nurses' notes indicated that a posterior short leg splint was applied as ordered.
--1:00 p.m. physician #4 noted that the diagnosis was GSW to the foot, that he/she discussed the results with patient #21 "regarding historical points, exam findings, and any diagnostic results, supporting the admit diagnosis. Data reviewed: vital signs, nurse's notes, lab tests results (s), radiologic studies. After a detail discussion of the patient's case, care is transferred to (Name of trauma Physician at the Main Campus) Patient has an emergent medical condition" The admission plans were discussed with the patient and patient #21 agreed with the plan.
--1:05 p.m. Disposition Summary -physician #4 ordered the transfer to the Main Campus. The diagnosis was Displaced fracture of medial cuneiform of Right foot; Reason for Transfer was for Trauma Services.
--1:18 p.m. EMS transport was arranged and report was called to the receiving nurse.
--1:24 p.m. the patient signed the consent to treat forms.
--1:27 p.m. the nurse noted that the transfer form was scanned into the chart.
--1:32 p.m. the nurse noted that the patient had no adverse reactions to the drugs the patient had received.
--1:33 p.m. nurses' notes indicated that the patient left the ED in stable condition and that the patient's pain at the time of transfer was 6/10.
--Physician #4's discharge notes indicated that the patient was transfer to the Main Campus in fair condition with a GSW and broken bones in the top of the right foot. Physician #4 indicated that the patient was accepted at the Main Campus by an accepting physician for trauma services not available at the South Campus

On- Call Schedules

The on-call schedules for the South Campus ED were reviewed for the months of October 2016 and May 2017. The review revealed that Orthopedic Surgeons were on 10/15/2016 when Patient #2 presented and on 5/28/2017 when patient #21 presented to the hospital. The hospital had the capability of the staff and facilities available at the hospital to provide further medical evaluation and treatment as required to stabilize patient #2 and #21.


Interview
An observational tour of the ED was conducted on 06/11/18 at 9:15 a.m. with the Chief Nursing Officer/Chief Operating Officer (CNO/COO #3) and ED Manager (EDM #2). The EDM (#2) said that if there is a consultation with a specialist on-call the expectation is that the on-call physician will come into the ED if requested by the ED physician. The EDM (#2) said that to his/her knowledge the South Campus has had no problems with on-call physicians responding when called. The EDM (#2) said that all staff receive EMTALA training annually.