HospitalInspections.org

Based on the findings at A2404 and 2406 the facility failed to ensure compliance with CFR 489.24.

Based on record review, interview and document review, the facility failed to ensure the physician on-call list accurately reflected coverage for ENT (Ear, Nose, and Throat) services which resulted in an inappropriate transfer for 1 of 32 sampled patients (Patient #8).

Findings include:

Record Review Hospital A

Review of Patient #8's medical record on 1/25/12, revealed the patient presented to the Emergency Room (ER) on 11/8/11 at 14:13 (2:13 PM) with complaints of a severe headache (10/10 pain level). The patient's history indicated the patient had a CSF (Cerebral Spinal Fluid) leak for several months and had seen Physician #2 (ENT) on an outpatient basis.

On admission to the ER, Patient #8's vital signs were recorded as temperature - 99.4 degrees. At 17:30 (5:30 PM), the patient's temperature was noted to be 102.2 degrees orally. Laboratory results were drawn and revealed the Patient's WBC (White Blood Count) was elevated to 16.03 (Normal value 3.91 - 9.68).

Documentation in Patient #8's physician notes dated 11/8/11 documented:
- 15:43 (3:43 PM) No ENT on call. Will transfer to Hospital B.
- 17:56 (5:56 PM) DW (Discussed with) Physician #3 (ENT), ABX (Antibiotics) appropriate for CSF leak.
Calls placed to health care provider Physician #2, ENT. Multiple messages left; calls not returned. Consult obtained with Physician #3, ENT at 16:36 (4:36 PM). Wants to transfer pt (patient) to Hospital B. Phone consult only....

Patient #8's record revealed the patient was transferred to Hospital B at 1905 (7:05 PM).

Interview with Physician #1 (ER)

On 1/25/12 at 4:30 PM, an interview with Physician #1 revealed he was the ER physician who treated Patient #8 on 11/8/11. The ER physician indicated: based on a) the presenting symtoms of the patient, which included a severe headache & CSF leak from the nares; b) results of the laboratory tests which showed an elevated WBC; and c) the patient's elevated temperature; the patient required an evaluation from an ENT physician to treat the CSF leak. The ER physician indicated based on all the presenting symptoms, he believed Patient #8 could possibly have meningitis.

The ER physician verbalized since Patient #8 was being seen as an outpatient by Physician #2 (ENT), the ER physician attempted to contact the ENT multiple times, but was not successful.

Since there was no Otolaryngeal (ENT) Physician On-Call on 11/8/11, according to the posted schedule, Physician #1 then contacted Physician #3, ENT, for a telephone consultation to discuss the appropriate antibiotics for the patient's CSF leak.

Physician #1 decided to transfer Patient #8 to Hospital B for an ENT consultation since he believed the patient needed to be seen quickly by an ENT physician to have the CSF leak repaired.

Physician #1 was asked why he did not admit the patient to Hospital A to be treated for the meningitis by an Internist, Infectious Disease physician, and an ENT physician (Physician #2), he indicated he was not aware Physician #2 had privileges at Hospital A, and he believed an ENT evaluation needed to be done right away to correct the CSF leak.

Physician #1 verbalized he did not speak to the accepting physician at Hospital B. The Physician added all transfer arrangements were made by the intake coordinator.

Interview with Physician #2

On 1/26/12 at 2:25 PM, Physician #2 (ENT) was interviewed by telephone. The physician indicated he had been treating Patient #8 as an outpatient. Physician #2 verbalized he had a conversation with Physician #1 (ER) on 11/8/11 when Patient #8 presented to the ER. Physician #2 verbalized he communicated to the ER physician that the patient did not require an ENT evaluation at that time. Physician #2 believed the patient should be evaluated for the headache, should be admitted, and have an Infectious Disease Physician follow her as an inpatient.

Physician #2 added, he would not perform any nasal procedures on Patient #8 until the symptoms of the infection were cleared.

Interview with Physician #3

On 1/26/12 at 3:10 PM, an interview with Physician #3 by telephone revealed he had been called by Physician #1 for a telephone consultation only, regarding the appropriate antibiotics to administer to Patient #8, for a CSF leak. Physician #3 added he was not on call in the ER at the time he received the telephone call.

Physician #3 revealed he had been out of town doing surgery when he first received the call from Physician #1. The physician added he gave Physician #1 several alternatives to treat Patient #8 including: transferring the patient to Hospital B, if Physician #1 believed the patient needed ENT consult and treatment immediately; contact the physician treating Patient #8 on an outpatient basis, and have the patient admitted and evaluated by Infectious Disease; or, the ER physician could admit the patient until the patient could be seen by an ENT physician.

Physician #3 verbalized he did take call on 11/8/11, since he came in to see several patients at Hospital A. The physician added he was not sure of the time he placed himself on call for 11/8/11. Physician #3 added, on 11/9/11, he notified the scheduler to retroactively add him on call for 11/8/11.

Interview with Vice President of Quality and Medical Staff

On 1/25/12, in the afternoon, the Vice President of Quality and Medical Staff verbalized the facility did not provide on-call services for Otolaryngology (ENT). Physician #3 did take call at times based on his schedule. However, the services were not always available. When a patient in the ER required an ENT consult and there was no ENT physician on call, the patient was transferred to another facility for the service.

On 1/26/12, in the afternoon, the VPQMS revealed the original Otolarygology Physician On - Call List did not indicate any physician on call for 11/8/11. The VPQMS verbalized Physician #3 had added himself to the call schedule after he had received the telephone call regarding Patient #8. The VPQMS added Physician #3 notified the scheduler on 11/9/11, to retroactively place him on call for 11/8/11. The on-call list was updated on 11/9/11 to reflect the change.

On 1/27/12 in the morning, the VPQMS indicated Physician #3 had notified the ER staff at 6:00 PM on 11/8/11, that he would assume call at that time. Then on 11/9/11, the physician notified the scheduler in medical staff to update the call log to indicate he was on call for 11/08/11.

The VPQMS added Infectioius Disease physicians did not take call in the ER. They only saw patients once they have been admitted to the facility.

Document review

Review of the physician credentialing files revealed both Physician #2 and Physician #3 had ENT privileges at Hospital A.

Information provided by the Regulatory Compliance Coordinator revealed Physician #3 was the only Otolaryngologist who had signed a professional services agreement to provide ENT call coverage for Hospital A.

The facility's policy titled Emerency Department On-Call Schedules last review date 7/2011, indicated

Policy - I. General "...The Medical Staff Office (the "MSO"), in collaboration with the clinical department/division chairpersons and/or trauma medical directors, coordinated and publishes on-call rotation schedules on a monthly basis for the following clinical practice areas:

Adult Services:
- Cardiology
- Medicine (hospitalist service)
- Medical Intensive Care (critical care)
- Neurology (adult)
- Obstetrics/Gynecology Hospitalist
- General Orthopedic Surgery (includes separate pelvic call)
- Primary Care Outpatient Referral
- Spine Surgery
- Urological Surgery

Combined Adult and Pediatric Services:
- Trauma Anesthesia
- CVT (Cardiovascular Thoracic) Surgery
- Hand Surgery
- Neurosurgery
- Oral/Maxillofacial Surgery
- Plastic Surgery
- General Trauma Surgery
- Opthalmology...

Panels Without 24/7 Availability
- Otolaryngology (ENT) (pediatric and adult)...

II Medical Staff Department Responsibilities
A. ...2. Unless otherwise noted on a particular schedule, the call assignments are for a 24-hour period from 7:00 a.m. to 7:00 a.m....

B. Schedule changes - Any changes requested to be made to a published call schedule must be submitted to the MSO no less than 24 hours prior to the scheduled assignment. Any call changes must be submitted on the prescribed Emergency Department Call Change Form...

C. After MSO Business hours - After regular business hours (7:30 am to 4:00 pm Monday through Friday), on weekends or holidays, call changes should be submitted by the on-call provider to the Emergency Department. The Emergency Department HUC (Head Unit Clerk) is responsible for completing the Physician ER Call Daily Change Log (Attachment B) communicating any changes to the call schedule(s) to the MSO within 24 hours of the change. This form is to be faxed by the night shift ED HUC to the MSO at 6:00 a.m. daily. The ED HUC will also be responsible to immediately call any assignment changes to the Intake Coordinator...."

The Medical Staff General Rules and Regulations, approved on 7/21/11, section 3.13 Response to Call indicated:
- "3.13.8 When an on-call physician is contacted by the Emergency Department and requested to respond, the physician must do so within a reasonable time period. The following guidelines have been established for responding by phone to a call from the emergency department or any nursing unit:
A. Stat calls : twenty (20) minutes
B. Routine Calls: one (1) hour

- 3.13.9 The Emergency Department physician, in consultation with the on-call physician, shall determine whether the patient's condition requires the on-call physician to see the patient immediately. The determination of the Emergency Physician shall be controlling in this regard."

On 1/25/12, the Vice President of Quality/ Medical Staff (VPQMS) provided several versions of the Otolaryngology On Call schedule dated 11/8/11.

Review of the "original" Otolaryngology (ENT) Physician Call Schedule dated 11/8/11, revealed Physician #3 was on call every day in November except 11/8 - 11/10, 11/15 - 11/16, and 11/29 - 11/30. The ENT Physician Call Schedule dated 11/8/11, indicated there was no ENT physician on call for 11/8/11.

The Otolaryngology Call schedule revised 11/9/11 at 1145, indicated - Physician #3 was on call on 11/8/11, and documented "Change called in after the call (telephone call regarding Patient #8) was taken per Doctor (Physician #3)".

There was no documented evidence Physician #3 completed a change in call schedule form for 11/8/11. There was no documented evidence of the time Physician #3 "officially" placed himself on call on 11/8/11.

Patient #8's record revealed the patient was transferred to Hospital #B at 1905 (7:05 PM). There was no documented evidence Patient #8 was seen by an ENT physician while she was in the ER of Hospital A, although Physician #3 was placed on call at approximately 6:00 PM.

Since Patient #8 had a CSF leak and several options were proposed regarding treatment of the patient, all physician on-call schedules were reviewed to determine if other specialties were available to evaluate and treat the patient. The On-Call logs indicated Internal Medicine, Neurology, Spine Surgery, and Neurosurgeon specialists were all available for ER Call, if requested.

In summary:
- Patient #8 was seen in the ER at Hospital A with a severe headache, CSF, elevated temperature and elevated WBC;
- Possible diagnoses was meningitis (as per the interview with Physician #1);
- Conflicting opinions were obtained regarding the course of treatment;
- The Otolaryngology Call Schedule was not accurate;
- The ENT physician provided a telephone consultation regarding Patient #8, then placed himself on call later in the same day;
- Patient #8 was still in the ER at the time Physician #3 placed himself on call.
- Patient #8 could have been admitted to Hospital A and treated for the meningitis by an internist, Infectious Disease physician, and ENT if needed.
- The services could have been provided at Hospital A

(Complaint #NV00030239)

Based on interviews and record review, the facility failed to ensure an appropriate medical screening examination was conducted for 2 of 32 sampled patients (Patient #8, #32).

Findings include:

Patient #8

Patient #8 arrived by private vehicle to Hospital A on 11/8/2011, with complaint of a headache. The patient was diagnosed with headache and cerebral spinal fluid (CSF) leak from the nasal passage.

Record review

Patient #8's Clinical Report-Nurses form indicated Patient #8 was triaged on 11/8/2011 at 14:00 (2:00 PM). The form documented the following:

"...Chief complaint: (HA (headache) NEUROLOGIST DX'D (diagnosed) CSF LEAKAGE). 14:13 (2:13 PM). BP (blood pressure) R (right) arm sitting 150/84 HR (heart rate): 95 RR (respiratory rate): 18 (unlabored) Temp (temperature) 99.1 oral. O2 (oxygen) SATURATION: 100% air. Alert. No acute distress.

"...History-This started today. Onset (6 hours ago) Pain level now:10/10..."

"...PHYSICAL ASSESSMENT
14:38 (2:38 PM) Appears in pain, anxious and in distress. Pupils equal, round and reactive to light. No facial asymmetry noted. Respirations not labored. breath sound within normal limits. Normal sinus rhythm noted. abdomen soft and nontender. Pulses within normal limits. Mucous membranes are pink. Skin is warm and dry..."

"...14:25 (2:25 PM) O2 saturation: 93% room air PLACED AT MOUTH (CSF LEAKAGE THRU NOSE). O2 started via nasal cannula at 3 liters/minute. RN (Registered Nurse) notified..."

"...14:50 (2:50 PM) BP: 142/69 HR: 98 O2 saturation -95 percent on nasal cannula at 4 liter/minute..."

"...17:30 (5:30 PM) late entry-. Temp 102.2 oral..."

"...18:04 (6:04 PM) TYLENOL 975 mg (milligrams) PR (per rectum)..."

"...18:58 (6:58 PM) Temp 98.7 oral..."

"...DISPOSITION/DISCHARGE 16:51 (4:51 PM) BP: 132/64. HR: 107. RR: 15. Temp: 102.2.

"...departure time: 19:50 Nov 08 2011..."

Patient #8's EMTALA (Emergency Medical Treatment and Labor Act) MEMORANDUM OF TRANSFER dated 11/08/2011 documented the following:

"RISKS AND BENEFIT FOR TRANSFER: Obtain level of care/service unavailable at this facility service: ENT (ear, nose and throat) Consult..."

"...Time of transfer: 19:05 (7:05 PM). date: 11/8/11. Vital Signs Just Prior to Transfer: Temp 98.7 Pulse 107 R 14 BP 132/68 Time: 1644 (4:44 PM)..."

Patient #8's Clinical Report-Physicians form (by Physician #1) indicated the patient was seen on 11/08/2011 at 14:19 (2:19 PM). The form documented the following:

"...Arrived by private vehicle. Historian patient and family..."

"...HISTORY OF PRESENT ILLNESS-Chief Complaint: HEADACHE. This started today 6 hours ago. It was gradual in onset and has been constant. Onset during rest. Is still present and now worse. It is described as "pain." described as a global headache. No neck pain. At its maximum severity described as moderate. Modifying factors: relieved by nothing. Not worsened by anything. She has nausea and vomiting. No numbness..."

"...Similar symptoms previously: she had previous symptoms (intermittent for the last three months). These were worse..."

"...Recent medical care: The patient was seen recently by a health care provider (seen by (Physician #2) and sent here for CSF leakage). (ENT (ear, nose and throat) Physician #2)..."

"...REVIEW OF SYSTEMS
No fever, ear pain, sore throat, head injury or difficulty breathing. No cough, abdominal pain, diarrhea or enlarged lymph nodes. All systems otherwise negative, except as recorded above..."

"...PAST HISTORY
See nurses notes. Diabetes mellitus. History of chronic headaches. No history of heart disease or hypertension..."

CT (computerized tomography) of sinuses Scan dated 10/27/11

"...FINDINGS: there is suggestion of small miningocele/encephalocele along the roof of the right nasal passage. No significant contrast is appreciated within the nasal passage itself. There is a dense air-fluid level within the left maxillary sinus which could potentially represent a small amount of contrast within the left maxillary sinus although it is unusual that no contrast is seen elsewhere within the paranasal sinuses..."

"...There is asymmetric appearance of the pituitary gland in the right sella with the relative paucity of pituitary tissue in the left sella. No definite evidence of postop change..."

CT of head dated 11/8/11

"...IMPRESSION: Findings suggesting a small encephalocele/meningocele at the roof of the right nasal passage. High resolution on coronal T2 MRI (magnetic resonance imaging) would also be helpful evaluation as clinically warranted..."

"...Abnormal appearance of the pituitary gland as described above. Consider MRI correlation..."

"...Findings discussed with Physician #2 on October 27, 2011. Facial CT performed with contrast..."(CT scan done at outpatient facility on 10/27/2011).

"...IMPRESSION: No acute hemorrhage or evidence of mass lesion or acute infarction. Head CT performed without contrast..." (CT scan done in Hospital A on 11/8/11).

"...Laboratory Tests: Laboratory tests have been ordered, with results reviewed and considered in the medical decision making process..."

"...PROGRESS AND PROCEDURES
Course of Care: BP R arm sitting 150/84. HR: 95 RR: 18 (unlabored) Temp: 99.1 oral. O2 (oxygen) saturation 100 %..."

"...14:21 (2:21 PM) Dilaudid IV (intravenous) 1 mg (milligram) Zofran IV 8 mg Reglan IV 10 mg

"...15:28 (3:28 PM) Clindamycin IV 900 mg..."

"...15:39 (3:39 PM) Droperidol IV 1.25 m (sic)

"...15:43 (3:43 PM) No ENT on call will transfer to Hospital B..."

"...16:33 (4:33 PM) Spoke with family, pt (patient) has been having CSF leak for 3 months and today's headache was the worst. Pt. has no meningsmus. Neck is supple.

"...17:56 (5:56 PM) vancomycin IV 1 gm (gram)
DW (Discussed with) DR. (Physician #3), ABX (antibiotic treatment) APPROPRIATE FOR CSF LEAK..
Calls placed to health care provider (Physician #2), ENT. Multiple messages left; calls not returned. Consult obtained from ENT. (Physician #3) at 16:36 (4:36 PM) Wants to transfer pt to Hospital B. Case discussed. Phone consult only. Agree with treatment plan. Patient counseled in person regarding the patient's test results and diagnosis. Old ED (emergency department) records reviewed (last seen on 6/8/08 by (physician's name). dx: (diagnosis) Acute mental status change with confusion. Controlled type II diabetes

Transfer orders written.
Disposition: Transfer to Hospital B. Condition stable: stable

CLINICAL IMPRESSION
Headache.
CSF leak..."

Patient #8's Laboratory Results dated 11/08/11, at 14:26 (2:26 PM) reported a white blood count of 16.03 (normal 3.91-9.68) and the Hematology Differential dated 11/08/11 at 14:26 (2:26 PM), documented, "...Bandemia is present..."

Interview with Physician #1

On 1/25/2011 at 4:30 PM, Physician #1 indicated Patient #8 came in to the ER on 11/8/11 with complaints of a persistent headache. Patient #8 was known to have a history of a cerebral spinal fluid leak. The patient brought in a CT scan she had performed previously. Physician #1 indicated he tried to contact the ENT physician (Physician #2) who had been treating the patient for months and knew about the patient's CSF leak. Physician #1 indicated he was unable to reach Physician #2 who was at a conference.

Physician #1 called Physician #3 who was also an ENT physician. Physician #1 indicated Physician #3 was in Bullhead City doing surgery. Physician #1 asked Physician #3's advice on what antibiotic to give the patient. Physician #3 indicated vancomycin was the antibiotic of choice for a CSF leak.

Physician #1 indicated a lumbar puncture was not necessary to perform on Patient #8, since there was an obvious source of the CSF leak (Patient #8's nasal passage). Physician #1 indicated the CSF leak needed to be fixed by an ENT physician regardless of the infection.

When asked why Patient #8 was transferred if Physician #2 had privileges, Physician #1 indicated he was not aware Physician #2 had privileges, and Physician #2 wanted the patient transferred. Also, Physician #3 recommended the patient be transferred. Physician #1 indicated there were different ENTs who were specialized in surgery to repair a CFS leak such as Patient #8 had.

Physician #1 indicated Patient #8 was not running a temperature when he first examined her. Physican #1 did not feel the patient's white blood cell count of 16,000 was a cause for concern.
Physician #1 indicated Physician #2 wanted the patient transferred (Physician #1 indicated he did speak to Physician #2 later in the day). Physician #1 indicated Physician #2 was pretty, "nonchalant " about the transfer. Physician #1 indicated he felt very uncomfortable leaving the patient at Hospital A, since there was no ENT on call at Hospital A.

Physician #1 indicated he did not speak to a physician at Hospital B, he indicated the intake coordinator made the arrangements with the receiving hospital.

Interview with Physician #2

On 1/26/11 at 2:25 PM, Physician #2 indicated by telephone that Patient #8 was referred by another ENT physician who felt the patient had a CSF leak. Physician #2 indicated the first time he examined Patient #8 was on 9/29/11. Physician #2 indicated Patient #8 had a work-up for the CSF leak about 12 months ago. The patient had an episode 5 years prior at Hospital A and they could not find the source of the leak.

Physician #2 indicated Patient #8 had a CT scan as an outpatient in which dye was injected into the CSF to make sure no part of her brain was poking out. Physician #2 indicated the patient needed a 2nd study but did not get the 2nd study and showed up at Hospital A. Physician #2 indicated he did not direct Patient #8 to go to Hospital A.

Physician #2 indicated someone did call him from the ER at Hospital A (did not remember physician's name). Physician #2 indicated he told the physician who called him, if the patient had meningitis she needed to be treated. Physician #2 felt that a lumbar puncture should have been done on Patient #8 at Hospital A. Physician #2 also indicated an MRI should have been done on Patient #8 to make sure no brain tissue was poking out. If indeed there was brain tissue, a neurosurgeon would need to get involved.

Physician #2 indicated he thought Patient #8 was being treated at Hospital A for meningitis. Physician #2 indicated you would not need intervention by an ENT physician on someone who was infected. Physician #2 indicated he thought he made it very clear that the infection needed to be treated by a physician specializing in infectious disease or an internist with a neurology background. Physician #2 indicated a lumbar puncture should have been done on Patient #8 so cultures taken from the CSF leak would determine the appropriate antibiotic therapy.

Physician #2 indicated he did not expect the patient to show up at hospital B. Physician #2 indicated he thought Patient #8 was being treated for the infection at Hospital A.

Physician #2 indicated he would expect the patient to have a craniotomy when she recovered from the infection.

Interview with Physician #3

On 1/26/11 at 3:07 PM, Physician #3 indicated by telephone he vaguely remembered the case. Physician #3 said he remembered the conversation he had with Physician #1 concerning Patient #8.

Physician #3 indicated he was not on call on the morning of 11/8/11; Physician #3 indicated he was doing surgery in Bullhead City. Physician #3 indicated he advised Physician #1 to call a physician who specialized in infectious disease or the doctor who was treating the patient.

Physician #3 indicated a lumbar puncture was feasible on possible meningitis; however, Physician #3 indicated a CSF leak could be caused by several things other than meningitis. Physician #3 indicated that vancomycin was the normal choice of antibiotic for a CSF leak. Physician #3 indicated he was quite sure he suggested an infectious disease physician be called for Patient #8

Physician #3 indicated he informed Physician #1 to get in touch with Physician #2.
Physician #3 indicated he was going by what Physician #1 told him on the telephone. Physician #3 indicated, one would think if Patient #8 needed an ENT physician, the patient needed to be transferred to a hospital who had an ENT physician on call.

Physician #3 indicated, a physician could not wait for the patient to get better to go in and repair the leak. Surgery would be required to fix the leak.

Physician #3 indicated that he was pretty sure he explained to Physician #1 that he was out of town. Physician #3 indicated, the best case scenario was to transfer the patient and have an ENT physician treat her. The second best scenario was to have the physician who treated Patient #8 (Physician #2) see the patient at Hospital A. The third scenario was to have Physician #1 admit Patient #8 to Hospital A.

Physician #3 indicated he came back in the evening from Bullhead City. Physician #3 indicated he did take on call later in the evening on 11/8/11 because he came in to see several patients at Hospital A.

Physician #3 indicated Patient #8 needed to see an ENT physician. Physician #3 indicated if the patient saw a neurosurgeon, the surgeon would perform a craniotomy to repair the leak. A trained ENT physician could go through the patient's nose to do a repair on the CSF leak.

Physician #3 indicated he recalled never hearing about that phone call again. Physician #3 indicated he was put on the schedule on 11/8/11, which made it seem like he was on call the whole day. Physician #3 indicated he did not get back into Las Vegas until about 6:00 PM.

In summary:
On 11/8/11 at 2:00 PM, Patient #8 was admitted to the emergency room at Hospital A with complaint of headache.
- Patient #8 was seen by the emergency room physician who diagnosed the patient with a global headache and CSF leakage.
-After consulting with an ENT physician by telephone he made the decision to transfer the patient to Hospital B, since there was no ENT physician on call.
- The patient's temperature reached 102.2 Fahrenheit and white blood count 16,000.
-It is unclear if there was an ENT physician on call. The on call schedule for 11/8/11 was changed several times to reflect when Physician #3 was actually on call by an administrative assistant.
-Hospital A did not address the patient's meningitis and the need for a lumbar puncture. The patient's medical screening was incomplete and the cause of the headache was not treated.

(Complaint #NV00030239)

Patient #32

Patient #32 signed in to the emergency room on 9/23/11 at 8:06 PM with complaints of abdominal cramps and vaginal bleeding. The triage note dated 9/23/11 documented the time the patient was triaged at 22:10 (10:10 PM) at a level 2 (emergent). These times were confirmed with the Director of Compliance on 1/27/11.

The emergency room chart of Patient #32 lacked documentation as to why there was a delay in triage of the patient.

A review of the Triage Policy: #EDADM12 last review date 3/2008 documented the following:
"...PROCEDURE
D.
2. A2
Emergent (EM) priority should be assigned to those patients who require a treatment room for definitive care to be rendered and for whom under optimal circumstances a delay of 15 to 60 minutes will not significantly affect the patient outcome. Patient should be informed that some delay may be experienced and a brief explanation should be given. Examples of patients who may receive a 2: Emergent priority are those who present with: j. Bleeding with abnormal vital signs..." (Patient #32 had low blood pressure 103/59)

Patient #32 had a medical screening and pelvic exam performed on 9/24/11 at 1:30 AM.

The NURSES PROGRESS NOTES indicated Patient #32 had light amount of bright red.
The PHYSICIAN CLINICAL REPORT dated 9/23/11 indicated time seen 1:23 AM 9/23/11.
"...The patient had abnormal bleeding described as lighter than normal and passing clots..."
"...Patient has been having vaginal bleeding. She had a US (ultra sound) done 2 weeks ago that showed a live IUP (in utero pregnancy). US done last Friday showed no fetal heart tones. She should be 9 weeks pregnant. US shows no evidence of IUP. I discussed the result with the patient. She is given OB (obstetric) follow-up. I stressed the importance of following up..."

"...DISPOSITION: Condition stable. Discharged in good condition..."

"...CLINICAL IMPRESSION
Spontaneous abortion
Missed abortion

"...Follow up in two days even if well. Call for an appointment. Or your OB/GYN (gynecologist). Understanding of the discharge instructions verbalized by patient..."
The disposition of the patient was documented as 9/24/11 at 3:19 AM.