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Based on facility policy review, medical record review, medical staff bylaws review, physician interview, staff interview, interview with the local state correctional superintendent, the hospital failed to comply with 42 CFR 489.24 by failing to provide an appropriate medical screening examination (MSE) with appropriate monitoring for 1 of 2 sampled patients (#19) presenting to the hospital's OB (Obstetric Department) and failing to provide stabilizing treatment within it's capacity for 1 of 1 sampled patients (#3) presenting to the hospital's DED that was discharged with an emergency medical condition (EMC).

Findings include:

1. ~Cross refer to 489.24(r) and 489.24(c), Medical Screening Exam - Tag A2406.

2. ~Cross refer to 489.24(d)(1-3), Stabilizing Treatment - Tag A2407.

Based on facility policy review, medical record review, physician interview and staff interview, the facility failed to maintain a complete medical record in 1 of 2 sampled OB (Obstetric) patients that was discharged (transferred) from the hospital after receiving a medical screening examination to determine if an emergency medical condition existed (#20).

Findings include:

A review on 02/16/2011 of the facility's policy "Emergency Medical Treatment and Active Labor Act" (revision date 04/16/2009) revealed "Medical records shall be maintained for all persons receiving emergency services and care."

A closed medical record review on 02/18/2011 for patient #20 revealed that the patient presented to the hospital's labor and delivery unit on 02/05/2011 at 1109 with concerns of "Sudden Rupture of Membranes." The review revealed that the patient was a 24 year old female that was 37 weeks pregnant. The review of the medical record's "OB (Obstetric) Observation Record" revealed that the hospital's OB registered nurse documented at 1206 that that the patient presented from home and received a medical screening examination to rule out rupture of the patient's membranes. The documentation further revealed that the patient received a fetal assessment, her uterine activity and labor status all at 1130 by the nursing staff. The medical record documentation revealed that the patient was discharged home after her OB discharge screening examination at 1215.

The review of the closed medical record further revealed no documentation that the patient's on-call OB physician #1 documented any verbal or telephone order for discharge after the patient's emergency medical condition was removed. The documentation review of the medical record revealed no documentation from the on-call physician that would indicate a review of the OB registered nurse's medical screening examination for the patient.

A telephone interview on 02/18/2011 at 1110 with OB physician J revealed that the patient was ordered for discharge after the medical screening examination was completed by the nursing staff. The physician revealed that the physician order was given and authenticated in the patient's medical record.

An interview on 02/18/2011 at 1215 with the hospital's Director of OB services revealed "We cannot find the section of the medical record where Dr.__ (OB physician J) approved the discharge of the patient. The physician did complete the verbal order for discharge for the patient, but we cannot produce that part of the medical record."

Based on hospital policy review, medical record review, physician and staff interviews, the hospital failed to provide an appropriate medical screening examination for patients' with an emergency medical condition in 2 of 2 sampled patients presenting to the hospital's labor and delivery department (#19 and #20).

Findings include:

1. Review of the Hospital's policy "Medical Screening Examination of Obstetric Patients" (review date 01/2010) states "All patients presenting to New Beginnings Labor and Delivery Unit shall have a medical screening examination done in a timely manner. This examination is to be completed by a physician or designated Labor and Delivery nurse."...The physician on call will be notified of all patient admissions to Labor and Delivery. A. During triage, the L&D nurse will determine the patient's admission status through physical and obstetric assessment. B. All patients presenting to L&D will receive a medical screening examination by a C. physician or designated L&D nurse...F. Assessment and discharge process will be consistent with EMTALA (Emergency Medical Treatment and Labor Act) regulations."

A closed medical record review revealed patient #19 to be a 23 year old presenting to Labor and Delivery (L&D) on 12/23/2010 at 1149 with a presenting complaint of "Threatened Abortion." Review of the patient's medical record showed the patient had been transferred to another hospital "C" on 12/23/2010 at 1410 to "Obtain level of care/services not available at this facility" even though Hospital "A" provided Labor and Delivery service. Review of the "EMTALA Transfer Form" dated 12/23/2010 at 1415 revealed a telephone order was obtained by a registered nurse from Physician H for the transfer of the patient to Hospital C. Further review of the transfer form revealed Physician G (posted on call obstetric physician) electronically authenticated the "EMTALA Transfer Form" on 01/07/2011 at 0309 (15 days after the transfer). The physician who gave the telephone order to transfer the patient was Physician H, an anesthesiologist. No documentation was found in the medical record where the patient was examined by any OB (Obstetric Physician) while at Hospital A and prior to the transfer to Hospital B. Furthermore, there was no documentation in the medical record that fetal heart tones were listened to or if a fetal monitor was placed on the patient. There was no evidence that an ultrasound was performed and no evidence that an evaluation of the cervix was accomplished.

Interview on 02/18/2011 at 1400 with the Nurse Manager of the Labor and Delivery Department and review of a statement dated 02/18/2011 revealed "Patient #19 was admitted to our prenatal unit on 12/23/2010 at approximately 1200 noon complaining of vaginal bleeding at 22 weeks gestation. The following sequence of events occurred. (Nurse #1), RN called (Physician F) (listed on our call calendar) to give report. (Physician F) answered cell phone, stated he was on vacation in (out of state location), not on call. Charge Nurse called (Physician G) who stated he was not on call and was not available to come in. Charge nurse called (Physician F) and (Physician G) office who stated their record showed (Physician G) on call. Charge nurse called Nurse manager to report situation of no obstetrician available to provide care for this patient. ...call chief of staff to request orders for transfer to another hospital. .... Manager directed charge nurse to notify chief of surgery (Physician H). Charge nurse contacted (Physician H), chief of surgery who came to OB unit at 1300 and arranged for/wrote orders for transfer (no evidence of physician H medical screening examination in patient record). Hand off to (Physician I) at other Hospital, pt departed via ambulance transport at 1415.

Review of the hospital's medical staff roster revealed Physician H was an anesthesiologist. Review of Physician H's credentialing file revealed the physician was priviliged in anesthesia services and not obstetric services.

Consequently, Patient #19 presented to the hospital's labor and delivery room for complaint of threatened abortion. Physician G was posted on call on 12/23/2010 when Patient #19 presented. The patient was assessed by the registered nurse per protocol who attempted to contact Physician G for further directions regarding continued evaluation and treatment of the emergency medical condition. When Physician G was contacted, he advised he was not on call and unavailable. The nurse attempted to contact Physician F and he advised he was out of the state and not available. No other obstetric physicians were on staff at the hospital. The patient was transferred to another facility based upon an order given by Physician H (anesthesiologist). No appropriate medical screening examination nor stabilization was completed prior to transfer.

2. Facility policy review, medical record review, physician interview and staff interview revealed the facility failed to provide an appropriate medical screening examination for patient numbered 20 who presented to the hospital's labor and delivery unit on 02/05/11 at 1109 with an emergency medical condition.

A review on 02/16/2011 of the facility's policy "Emergency Medical Treatment and Active Labor Act" (revision date 04/16/2009) revealed "Medical records shall be maintained for all persons receiving emergency services and care."

A closed medical record review on 02/18/2011 for patient #20 revealed that the patient presented to the hospital's labor and delivery unit on 02/05/2011 at 1109 with concerns of "Sudden Rupture of Membranes." The review revealed that the patient was a 24 year old female that was 37 weeks pregnant. The review of the medical record's "OB (Obstetric) Observation Record" revealed that the hospital's OB registered nurse documented at 1206 that that the patient presented from home, and that an initial cervical exam was completed at 11:30 a.m. The documentation further revealed that the patient received a fetal assessment, her uterine activity and labor status all at 1130 by the nursing staff. The medical record documentation revealed that the patient was discharged home after her OB discharge screening examination at 1215. There was no follow-up cervical exam performed and no documentation indicating how frequently the contractions were. Additionally, there was no documentation to indicate what the patient's OB history was or if she had been a previous C-Section patient. Because of this incomplete medical screening examination, it was not possible to determine if the patient was stable upon discharge.

The review of the closed medical record further revealed no documentation that the patient's on-call OB physician #1 documented any verbal or telephone order for discharge after the patient's emergency medical condition was removed. The documentation review of the medical record revealed no documentation from the on-call physician that would indicate a review of the OB registered nurse's medical screening examination for the patient.

A telephone interview on 02/18/2011 at 1110 with OB physician J revealed that the patient was ordered for discharge after the medical screening examination was completed by the nursing staff. The physician revealed that the physician order was given and authenticated in the patient's medical record.

An interview on 02/18/2011 at 1215 with the hospital's Director of OB services revealed "We cannot find the section of the medical record where Dr.__ (OB physician J) approved the discharge of the patient. The physician did complete the verbal order for discharge for the patient, but we cannot produce that part of the medical record."

Based on facility policy review, medical record review, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) failed to provide stabilizing treatment within its capability and capacity for 1 of 1 sampled DED patients that was discharged with an emergency medical condition (#3).

Findings include:

Policy entitled Care of Patients Under Legal or Correctional Restrictions last reviewed 3/09 states "Length of Stay/Plan for Discharge and Continuing Care" "Length of stay and continuing care will be dictated by the condition of the person in custody. Patients from the Division of Prisons who require continued care at an acute or subacute facility will be transferred to (Hospital B).

Policy entitled Triage Guidelines revised 12/27/10 states under Level Two - Emergent "This is a high risk patient who could deteriorate if treatment is delayed. This patient will require multiple diagnostic studies and procedures along with frequent monitoring." Examples..."Open fractures"

Closed dedicated emergency department (DED) medical record review on 2/17/2011 for patient #3 revealed, a 34 year old male who presented to hospital A's DED on 11/29/2010 at 0637 via ambulance, followed by the DOC (Department of Correction) officer. The patient was triaged at the hospital A's DED as a trauma patient with a documented primary evaluation conducted. Documentation revealed that the patient at triage was "found outside on way to breakfast by guard. States does not know what happened to him. Abrasions to face and nose. Pain to right jaw." The documentation of the patient's vital signs at the time of triage (0641) revealed that the patient's heart rate was 77 and blood pressure was 111/73. Documentation of the patient's pain levels revealed that the patient continued to report his pain level as 10 of 10.

Documentation from the patient's medical record revealed the hospital A's DED physician A examined the patient at 0704 on 11/29/2010. The documentation from the DED resident physician revealed that the "Patient is an incarcerated white male who was outside on his way to breakfast. He is unsure what happened to him, but it appears he had been assaulted. He does not remember anyone assaulting him. He did not have a loss of consciousness as per guards except that he was found down with blood all over his face. He complains primarily of jaw pain. He denies any neck pain, chest pain or back pain. He does have some right foot pain." The Physical examination HEENT: states "He has multiple abrasions on his forehead, nose and left side of his face and upper lip. Examination of his oropharynx shows that he has a laceration over his right ramus. He has malocclusion of his teeth. He has a mucosal laceration on his left upper lip." EXTREMITIES: ..."His right great toe has a subungual hematoma and some ecchymosis over his proximal phalanx. This is already draining blood."
EMERGENCY DEPARTMENT COURSE: "An IV was placed and the patient was given morphine and Zofran for his pain. A CT scan was done of his head which was interpreted by radiology as negative. A CT of his mandible showed a comminuted fractured ramus of his right mandible that was an open fracture. An x-ray of his right foot was interpreted by me, four views, and it was negative for fracture. The case was discussed with Dr. B who is on call at Hospital B where the prison guard had requested his care. He has agreed to see the patient in his office today for evaluation of his open mandible fracture. I was advised to leave his IV in place and if he could not repair his fracture in the office, he would admit him and schedule him for surgery."

Telephone interview on 02/17/2011 at 1035 with DED staff RN #2 revealed Physician B called back to the hospital and said he would not see the patient.

Further DED record review revealed a physician note "ADDENDUM: This patient has an open mandible fracture. Was initially consulted to (Physician B), who was willing to see the patient in his office; however, since the patient was incarcerated in Lincolnton, they did not have a contract with (Physician B) to pay for his services. So, they did have a contract with (Physician A). (Physician C) was consulted and would not accept the patient because he felt that he was too busy with his surgery and refused to admit the patient or see the patient or accept the patient in transfer today. I called the patient's facility (prison) and was advised that I needed to speak to the oral surgeons in Chapel Hill. I went ahead and called and spoke to 2 residents and then eventually to (Physician D), who has a contract, who informed me that the patient would have to be transferred to Central Prison so that he could get approval for fixing of his mandible fracture. I then called the Central Prison, spoke with their emergency room doctor, who refused to accept the patient as he had no in-house beds. I then called (Physician C) back, who refused to admit the patient to (Hospital B) and see him the next day. I have discussed it with the nurse at the facility and she has approved that the patient be returned to the facility. He will be given a liter of fluid here. He has already been given Ancef. He will be sent home with Augmentin and Lortab, and hopefully be seen by (Physician C) in the morning." Record review revealed the patient was discharged back to the DOC on 11/29/2010 at 1654 with discharge instructions to follow-up with Physician C the next day. At this time there was no documentation to indicate the Jaw fracture had been stabilized.

Closed medical record review revealed Patient #3 presented to Hospital B's DED on 12/01/2010 at 1538 via police (DOC officers) with a "stated complaint: Patient was hit in the jaw at 0600 Monday morning. Patient seen at (Hospital A) on Monday and referred to (Physician B). Per (Physician B) he would not operate without up front pay. Patient here for assistance." Further review of nursing notes revealed "Brief description of complaint: Here for evaluation of jaw fracture to see if he can get surgery. (Physician B) would not see him without money." Review of nursing notes at 1831 recorded "(Physician B) states he did not evaluate the patient in his office and did not refuse to operate on the patient." Review of Physician E's notes revealed the patient presented from the DOC with a right mandible fracture. Notes revealed" ... He was actually seen on Monday at (Hospital A). Unfortunately the patient was unable to be admitted to the jail hospital and was seen by (Physician C) yesterday as an outpatient. (Physician C) referred the patient to an outlying facility but no beds were available. The patient was brought to the emergency department for further evaluation and hopeful care by the oral surgeon (Physician B) today .... He is actually scheduled to be released from prison tonight .... X-rays were reviewed from (Hospital A) and they did indeed show a right mandibular fracture. I discussed the case with (Physician B) who has agreed to evaluate the patient in the emergency department .... "Further review of the record revealed Physician B (oral surgeon on call) examined the patient in the DED at 1800. Review revealed the patient was transferred to the operating room for open reduction internal fixation of the jaw at 1959. Review of the patient's admission record revealed the patient was discharged on 12/02/2010.

Interview with the guard, (correctional officer) who was with the patient on 11/29/2011 at 2/17/2011 at 1145 revealed that when nothing was set up for further treatment the patient was discharged and he and the patient left the hospital and went back to the camp (prison) and from there he took the patient to Western Youth Institution because they have an infirmary for the patient to stay the night. The camp had scheduled an appointment with Dr. C in Hickory for around lunch time on 11/30/2010. Dr. C did see the patient indicating to the patient he had a bad break and said he could not treat the patient in the office and he needed to go to Central Prison. Dr. C called Central Prison himself and was told there was no availability of beds for the patient. The patient was to be released from the prison system at midnight on 12/1/2010. Dr. C told the patient I'll be glad to help you when you get out, just looking at your break that's a $10,000.00 break. Dr. C had not offered any other care or treatment. The patient was then taken back to Western Youth Institution. The next day the patient was taken into the Hospital B Emergency Department where he was see by a physician (female).

The superintendent of the prison was also present during the interview with the correctional officer,on 2/17/2011 at 1145. At 1215 the superintendent indicated Dr. A initially would not release the patient back to the prison. The UR staff at the prison said the patient was to be taken to Dr. C and an appointment was made with Dr. C. The superintendent again indicated that Dr. A wanted the patient to be sent to Hospital B, but later agreed to send the patient to the infirmary where medical care would be present. The superintendent indicated the patient was seen by Dr. C and then sent back to Western Youth Institution. Staff at Western Youth Institution were not comfortable with this patient's condition so he was sent to Hospital B Emergency Department on 12/1/2010, where the patient later had surgery, by Dr B. Following surgery the patient was admitted to the hospital until the next day.

Telephone interview on 02/17/2011 at 1130 with Physician A (Hospital A DED physician) revealed the patient was a prisoner that presented to the DED on 11/29/2010 after he was assaulted. Interview revealed the patient had an open mandible fracture and he needed to be seen "urgently, not emergently" which the physician defined as within 24 - 48 hours. The physician stated she called Physician B who was on call at Hospital B and Physician B agreed to see the patient in his office that same day. Interview revealed the plan was to give the patient antibiotics in the emergency department and send the patient to Physician B's office for evaluation to determine if surgery was needed. Physician A stated "Then the jail nurse said there was no contract with (Physician B) and I needed to talk with (Physician C). "The interview revealed Physician C is a partner in practice with Physician B. Physician A stated she called Physician C and was told that Physician C didn't have time to see the patient that day and that he wasn't on call. Interview revealed that Physician C refused to see the patient and refused to accept the transfer. Interview revealed Physician A attempted to make other arrangements by calling three physicians (including Physician D) at Hospital C. Interview revealed Physician D had a contract with the DOC and told Physician A to call Central Prison. Interview revealed Central Prison refused to accept the patient as there were no inpatient beds available. Physician A stated she called Physician C again and he refused to admit and see the patient. Physician A stated she talked with the prison nurse who told her it was okay to discharge the patient back to the prison and that they would get an appointment with Physician C the next day.

Telephone interview on 02/17/2011 at 1640 with Physician B (Hospital B Oral Surgeon On Call) revealed he received a phone call on a Monday from a female physician in the emergency department at Hospital A requesting he see a patient with a jaw fracture. Physician B stated he told Physician A to send the patient to his office (in Hickory) that day for evaluation. Physician B stated the patient never showed up. Physician B stated it was his understanding that the DOC contacted his partner, Physician C to arrange an appointment. Physician B stated the patient showed up the next day (11/30/2010) in the Hickory office where Physician C was located. Interview revealed Physician B was working out of the Morganton office the day that the patient presented to the office. Interview revealed Physician B was reviewing Physician C's office notes and stated that the patient was scheduled for release from prison and he needed surgical repair of the jaw. Physician B stated the notes recorded that the patient "opted" to see a physician in Salisbury (his home town). Physician B stated on Wednesday (12/01/2010), he was called by the emergency department physician (Hospital B) that told him that the patient was in the ED and had to be treated before midnight due to being released from prison. Physician B stated he was on call and came to the emergency department. Interview revealed the patient was taken to surgery and released the following day. Interview revealed Physician B only remembered having one phone call conversation with Physician A. Physician B stated he never refused to see the patient and Physician A never discussed transfer of the patient to Hospital B.

Telephone interview on 02/18/2010 at 1120 with Physician C (Oral Surgeon on staff at Hospital B) revealed he was paged by Physician A. Physician C stated "I was not on call. She requested I see the patient in my office. I refused. The patient shows up the next day with my name on the referral paperwork. The patient should not have been discharged without an accepting physician. "Physician C stated he evaluated the patient when he showed up in the office. Physician C stated "He should have been admitted rather than discharged. He needed to be admitted for IV antibiotic therapy and surgery. He had moderate injuries." Interview revealed he told the patient that he needed surgery and that he could do the surgery. Interview revealed the patient declined his offer for surgery.

Telephone interview on 02/17/2011 at 1715 with Physician E (Hospital B DED physician) revealed she remembered the patient and that it was an odd situation. Physician E stated the prisoner wanted to have his jaw fixed at Hospital B and the guards told her he had to have his surgery before midnight due to his pending release. Interview revealed usually the oral surgeons would see the patient in their office the next day after presenting to the emergency department. The physician stated "I felt he needed to be seen and he was. The urgency of treatment was based on DOC needs and reliability issues. He was 48 hours out from the injury. I have no concerns with the on call response."

A second telephone interview on 02/18/2011 at 1115 with Physician A (Hospital A DED physician) was conducted. Physician A was asked if Physician B refused to see the patient. Physician A stated "No, he did not refuse to see the patient. I only talked with (Physician B) one time. (Physician C) said he was not on call and would not accept the patient. I did not ask the hospital to take the patient."

Consequently, patient #3 presented to the hospital's DED via the local department of correction officers after being assaulted for screening of abrasions and jaw pain. The patient was examined by the DED's Physician A and had a diagnosis of "Open Mandible Fracture. Physician A discussed the patient's condition with the local department of correction utilization review as well as discussed the patient's treatment options with the on-call physicians at Hospital B where the local department of corrections had its patient services contract. Physician A discharged the patient back to the department of corrections without stabilizing the patient's open mandible fracture. The review of Hospital B's medical records revealed that the patient received surgery two (2) days later to repair the open mandible fracture.

Reference NC00070870.