HospitalInspections.org

Based medical record review, review of the Emergency Department (ED) log, review of the ED and hospital policy and procedures, review of the Medical Staff By-laws, review of the Medical Doctor (MD) on call schedule for ED, review of the ambulance transport register, review of the Emergency Medical Services (EMS) report of the incident, and interview, the hospital failed to ensure an initial Medical Screening Exam (MSE); stabilizing treatment; and transfer policies were completed for one patient (#21) of twenty-one patients reviewed who presented to the ED for emergency medical treatment.

REFER TO FINDINGS IN A-2404, A-2406, A-2407 and A-2409.

Based on medical record review, review of Emergency Department (ED) Back-up ED Call Schedule, review of Emergency Department Meeting Minutes, and review of hospital Quality Assurance and Performance Improvement Meeting Minutes, the hospital failed to identify and address insufficient coverage for Orthopedic Physician Coverage in the Emergency Department.

The findings included:

Review of the Emergency Department (ED) Ambulance Transport Register, dated June 19, 2011, at 12:34 p.m., revealed "...(patient information) 56 yo (year old) M (male) - fall c (with) deformity - VSS (vital signs stable) - (M.D.) Name - (Nurse) initials - (Emergency Medical Services Unit) named county -(ETA estimated time of arrival) 2 (minutes)..." This unnamed patient will be referred to as patient #21.

Review and interview with the ED Manager in the Board Room on June 18, 2011, at 1:00 p.m., of the information listed on patient #21 on the Ambulance Transport Register, dated June 19, 2011, at 12:34 p.m., confirmed the hospital had no medical record indicating patient #21 was seen in the ED or admitted to the hospital on June 19, 2011.

Interview with the ED Medical Director in the ED Medical Director's office on July 19, 2011, at 10:50 a.m., revealed the ED Medical Director was the Medical Doctor (MD) covering the ED on June 19, 2011 for the 7:00 a.m., to 7:00 p.m. time frame. Continued interview revealed the ED Medical Director recalled speaking with the Emergency Medical Technician (EMT) related to patient #21 with the "fracture and malformed" injury listed on the ED Ambulance Transport Register dated June 19, 2011, at 12:34 p.m. Continued interview revealed the MD informed the EMT the hospital did not have orthopedic coverage and they "might want to consider" taking patient #21 elsewhere and the EMT said "okay".

Continued interview revealed the MD had no knowledge of patient #21 being brought to the hospital and did not receive any information from ED staff related to patient #21 ever arriving at the ED. Continued interview confirmed the ED MD was to perform a Medical Screening Exam (MSE) and stabilization on any patient presenting to the ED; the ED MD's were able to treat simple fractures; and if needed, the ED MD's could refer a patient with a fracture which might require surgical intervention for admission to the facility's Hospitalist group for admission, immediate treatment, and consult with an Orthopedic MD the following day.

Review of the ED MD coverage schedule for June 19, 2011, day shift, revealed the physician covering the ED was the Medical Director of the ED.

Review of the Back-up Emergency Department (ED) call schedule, dated June 19, 2011, revealed "...no gen (general) ortho (Orthopedic) cov (coverage)..."

Review of the Emergency Medical Services (EMS) call report, dated June 19, 2011, at 10:52 a.m., revealed patient name, phone number, caller and address with the incident listed as "leg broken". Continued review revealed "6/19/2011 (June 19, 2011) 12:54 (p.m.)...UMC (university Medical Center) wouldn't accept patient. Transporting to (named hospital)..."

Interview in the Board Room on July 19, 2011, at 1:00 p.m., with the day shift ED Charge Nurse for June 19, 2011, revealed the day shift Charge Nurse was the primary Triage Nurse June 19, 2011, until 3:00 p.m. Continued interview revealed the Charge Nurse only recalled there was "...no Orthopedic coverage available...the Patient Focus Technician (PFT) on duty informed (the Charge Nurse) it was handled...don't know what was meant by that and didn't ask further questions...(the PFT) does not make decisions to go to the ED ambulance bay and talk to the EMT ...that's not within their duty..."

Interview by phone on July 19, 2011, at 7:30 p.m., with the EMS EMT IV driver on the ambulance run for patient #21 of June 19, 2011, to University Medical Center revealed "...call came in to go to the residence...on arrival the patient was sitting on the ground in the yard...the patient and the patient's spouse asked the patient be taken to University Medical Center...would have taken the patient to a closer hospital if we felt it was warranted...the EMT IV delivering care and monitoring the patient placed a call to University Medical Center when we were about two minutes out from arrival...I understood the facility had informed the EMT IV calling that there was no Orthopedic available and we might want to consider going elsewhere...We drove into the ED ambulance bay as requested by the patient and spouse who was driving behind us...a nurse came out and told us 'we told you we don't have orthopedic available and to go to (another named hospital)' ...the nurse spoke with the patient and the patient's spouse and the patient and spouse decided to go to (another named hospital) so we left and took the patient to the other hospital where (the patient) was taken into the ED immediately...the patient's foot was swollen, not particularly misaligned, was bruised, had good pulses and movement of the toes, and the patient had some pain...would say you could not tell without an X-Ray if the foot was fractured..."

Interview by phone with the Risk Manager on July 20, 2011, at 9:30 a.m., confirmed the facility had done further investigation and determined on the evening of July 19, 2011, the PFT on duty June 19, 2011, at 12:34 p.m., had gone to the ambulance bay and sent the ambulance away without a medical screening, treatment, and transfer notification due to lack of Orthopedic coverage.

Interview by phone on July 20, 2011, at 9:45 a.m., with the PFT on duty on June 19, 2011, at 12:34 p.m., confirmed "...it was not for me to determine health status of a patient, I was not a Registered Nurse or doctor, that is for the medical staff...I made the note in the call log...I spoke with the caller of the ambulance when the call came in...was told they had a patient with a deformity of the foot due to lower extremity injury and they were about two minutes out...I asked the nurses if we had Orthopedic coverage and the EMT caller said 'that's alright we're already here...I turned to the ED MD and was told we could treat the patient but we couldn't fix the patient so I went out and told the patient and the spouse that we could treat and transfer after stable...they decided to go to (named hospital) instead...the patient's foot was laid over where it shouldn't have been...no MD or Qualified Medical Professional (QMP) saw the patient..."

Interview on July 20, 2011, at 6:30 p.m., by phone with the EMT IV monitoring and providing care of patient #21 during transport on June 19, 2011, revealed "...We dispatched and patient reported falling and twisting ankle...splinted...family and patient requested transport to University Medical Center...about two minutes out from hospital I dialed in and was advised they had no Orthopedic services available...can't recall if I was told to go somewhere else or if I told them the patient requested to be brought to their facility...upon arrival I opened the back door while at the unloading bay of the ED...a nurse came out and told the driver to go to another facility...the patient and family did not want to go to the other facility...the nurse told the patient there was nothing they could do there...the patient, family member and the EMTs talked about going to another facility and decided to go there...the (named hospital ED) took the patient right in...the patient's foot had some swelling on top and at the ankle area...there was also some bruising but the patient had good pulses and movement of the toes...pain level was about a 3 or 4..."

Record review of the ED Triage report from hospital #2, where patient #21 received treatment, dated June 19, 2011, at 1:44 p.m., revealed "...arrived via EMS - pt (patient) slipped on wet grass...injury to right ankle ...B/P (blood pressure) 126/82, P (pulse) 88, R (respirations) 18, O2 sat (oxygen saturation) 96% - room air, T (temperature) 98.0 degrees Fahrenheit...Physician referral to ED: NO...Treatments prior to arrival in ED: NONE..."

Record review of hospital #2's ED physician's History and Physical, dated as dictated June 19, 2011, at 2:35 p.m., revealed "...56 year old male with H/O (history of) HTN (hypertension) who presents W/ (with) R (right) ankle pain after mechanical fall this AM....No other trauma...C/O (complained of) pain to medial and lateral malleoli w/ bruising already developing...Imaging: R ankle: distal fibula fx (fracture) w/ talar displacement concerning for deltoid ligament injury...ED course:...Ortho (orthopedic) c/s (consult) placed, disp (disposition) pending their w/u (work up)..."

Review of the admitting hospital's Operative report, dated June 19, 2011, at 4:17 p.m., revealed "...ORIF (open reduction internal fixation) R ankle..."

Review of the hospital's Medical Staff By-Laws and Medical Staff Rules and Regulations, dated May 31, 2011, revealed "...Emergency Services...4. The disposition of each patient shall be the physician responsibility...17. Medical Staff members in accordance with an established roster or on-call system will provide specialist coverage..."

Review of the hospital policy Emergency Medical Treatment and Active Labor Act (EMTALA), policy number AM - RI - 1.40, dated September 15, 1986 revealed "...E. 1.) The hospital must maintain a list of on-call physicians, by specialty area of practice, who are available to come to the hospital at the request of the Emergency Department...physicians or Qualified Medical Persons, to assist with the medical screening examination, stabilizing treatment, and appropriate transfer requirements...2.) Each specialty area of practice represented by physicians on the medical staff performing services in the hospital must be represented on the on-call list, in a volume reasonably proportionate to the number of physicians by specialty on the medical staff, and the volume of services being provided by those specialist...8.) In those situations in which a particular specialty is not available...the hospital must have a written plan for transfer and/or backup call coverage by a physician of the same specialty or subspecialty..."

Review of the Emergency Department Scope of Service, unnumbered and undated, revealed "...The Emergency Department is a Level II Facility, which provides emergency care 24 hours per day, seven days a week...Care and services provided within the ED include, but are not limited to:...Care of the Orthopedic injury patient...Staff Availability...A daily roster of on-call physicians representing the disciplines of...Orthopedics...is maintained in the Department. These specialist will be available within 45 minutes from the time consultation is required...Level of Care Delivery...The Emergency Department is a multi-service department providing emergency care to all patients who present themselves for treatment...the service is comprehensive in representing Orthopedics..."

Review of the Back-up ED call Schedule revealed there were four General Orthopedic MD's and one Spinal Orthopedic MD on the call schedule. Continued review revealed the Spinal Orthopedic provided coverage for seven days each month. Continued review revealed there were no General Orthopedic physicians as follows for 2011: February 10, 21, 24, 26, 27, and 28 - unavailable times 6 days total; March 10, 15, 18, 19, 20, 21, 24, 25, 26 (available after 5:00 p.m.), and 31 - unavailable time 9.5 days; April 7, 13, 28, 29, and 30 - unavailable time 5 days total; May - 1, 5, 23, 26, 27, 28, 29, 30, and 31 - unavailable times 9 days total; June -2, 16, 17, 18, and 19 - unavailable times 5 days total; and July 15, 17, 18, 19, and 21, - unavailable times 5 days total.

Review of the facility Quality Assurance Performance Improvement meeting minutes for the past six months and review of the ED meeting minutes for the past year revealed no mention of the hospital's identification of the issue related to a need for increased ED Orthopedic coverage.

Interview by phone with the Risk Manager on July 21, 2011, at 10:35 a.m., confirmed the hospital had no documentation that identified the issue related to a need for increased ED Orthopedic coverage or development of a plan to increase the Orthopedic ED coverage; this had not been addressed in the Quality Assurance Performance Improvement or ED meeting minutes, and the issue of insufficient ED Orthopedic coverage would be expected to be addressed in the Quality Assurance Performance Improvement meeting minutes.

Based on medical record review, interview, and facility policy review, the hospital failed to ensure a Medical Screening Exam was conducted on one patient (#21) of twenty-one patients reviewed who presented to the Emergency Department for care.

The findings included:

Review of the Emergency Department (ED) Ambulance Transport Register, dated June 19, 2011, at 12:34 p.m., revealed "...(patient information) 56 yo (year old) M (male) - fall c (with) deformity - VSS (vital signs stable) - (M.D.) Name - (Nurse) initials - (Emergency Medical Services Unit) named county -(ETA estimated time of arrival) 2 (minutes)..." This unnamed patient will be referred to as patient #21.

Review and interview with the ED Manager in the Board Room on June 18, 2011, at 1:00 p.m., of the information listed on patient #21 on the Ambulance Transport Register, dated June 19, 2011, at 12:34 p.m., confirmed the hospital had no medical record indicating patient #21 was seen in the ED or admitted to the hospital on June 19, 2011.

Interview with the ED Medical Director in the ED Medical Director's office on July 19, 2011, at 10:50 a.m., revealed the ED Medical Director was the Medical Doctor (MD) covering the ED on June 19, 2011 for the 7:00 a.m., to 7:00 p.m. time frame. Continued interview revealed the ED Medical Director recalled speaking with the Emergency Medical Technician (EMT) related to patient #21 with the "fracture and malformed" injury listed on the ED Ambulance Transport Registry dated June 19, 2011, at 12:34 p.m. Continued interview revealed the MD informed the EMT the facility did not have orthopedic coverage and they "might want to consider" taking patient #21 elsewhere and the EMT said "okay".

Continued interview revealed the MD had no knowledge of patient #21 being brought to the hospital and did not receive any information from the ED staff related to patient #21 ever arriving at the ED. Continued interview confirmed the ED MD was to perform a Medical Screening Exam (MSE) and stabilization on any patient presenting to the ED; the ED MD's were able to treat simple fractures; and if needed, the ED MD's could refer a patient with a fracture which might require surgical intervention for admission to the facility's Hospitalist group for admission, immediate treatment, and referral to an Orthopedic MD the following day.

Review of the ED MD coverage schedule for June 19, 2011, day shift, revealed the physician covering the ED was the Medical Director of the ED.

Review of the Back-up Emergency Department (ED) call schedule, dated June 19, 2011, revealed "...no gen (general) ortho (Orthopedic) cov (coverage)..."

Review of the Emergency Medical Services (EMS) call report, dated June 19, 2011, at 10:52 a.m., revealed patient name, phone number, caller and address with the incident listed as "leg broken". Continued review revealed "6/19/2011 (June 19, 2011) 12:54 (p.m.)...UMC (university Medical Center) wouldn't accept patient. Transporting to (named hospital)..."

Interview in the Board Room on July 19, 2011, at 1:00 p.m., with the day shift ED Charge Nurse for June 19, 2011, revealed the day shift Charge Nurse was the Triage Nurse June 19, 2011, until 3:00 p.m. Continued interview revealed the Charge Nurse only recalled there was "...no Orthopedic coverage available...the Patient Focus Technician (PFT) on duty informed (the Charge Nurse) it was handled...don't know what was meant by that and didn't ask further questions...(the PFT) does not make decisions to go to the ED ambulance bay and talk to the EMT...that's not within their duty..."

Interview by phone on July 19, 2011, at 7:30 p.m., with the EMS EMT IV driver on the ambulance run for patient #21 of June 19, 2011, to University Medical Center revealed "...call came in to go to the residence...on arrival the patient was sitting on the ground in the yard...the patient and the patient's spouse asked the patient be taken to University Medical Center...would have taken the patient to a closer hospital if we felt it was warranted...the EMT IV delivering care and monitoring the patient placed a call to University Medical Center when we about two minutes out from arrival...I understood the facility had informed the EMT IV calling that there was no Orthopedic available and we might want to consider going elsewhere...We drove into the ED ambulance bay as requested by the patient and spouse who was driving right behind us...a nurse came out and told us 'we told you we don't have orthopedic available and to (another named hospital)' ...the nurse spoke with the patient and the patient's spouse and the patient and spouse decided to go to (another named hospital) so we left and took the patient to the other hospital where (the patient) was taken into the ED immediately...the patient's foot was swollen, not particularly misaligned, was bruised, had good pulses and movement of the toes, and the patient had some pain...would say you could not tell without an X-Ray if the foot was fractured..."

Interview by phone with the Risk Manager on July 20, 2011, at 9:30 a.m., confirmed the hospital had done further investigation and determined on the evening of July 19, 2011, the PFT on duty June 19, 2011, at 12:34 p.m., had gone to the ambulance bay and sent the ambulance away without a medical screening, treatment, and transfer notification.

Interview by phone on July 20, 2011, at 9:45 a.m., with the PFT on duty on June 19, 2011, at 12:34 p.m., confirmed "...it was not for me to determine health status of a patient, I was not a Registered Nurse or doctor, that is for the medical staff...I made the note in the call log...I spoke with the caller of the ambulance when the call came in...was told they had a patient with a deformity of the foot due to lower extremity injury and they were about two minutes out...I asked the nurses if we had Orthopedic coverage and the EMT caller said 'that's alright we're already here...I turned to the ED MD and was told we could treat the patient but we couldn't fix the patient so I went out and told the patient and the spouse that we could treat and transfer after stable...they decided to go to (named hospital) instead...the patient's foot was laid over where it shouldn't have been...no MD or Qualified Medical Professional (QMP) saw the patient..."

Interview on July 20, 2011, at 6:30 p.m., by phone with the EMT IV monitoring and providing care of patient #21 during transport on June 19, 2011, revealed "...We dispatched and patient reported falling and twisting ankle...splinted...family and patient requested transport to University Medical Center...about two minutes out from hospital I dialed in and was advised they had no Orthopedic services available...can't recall if I was told to go somewhere else or if I told them the patient requested to be brought to their facility...upon arrival I opened the back door while at the unloading bay of the ED...a nurse came out and told the driver to go to another facility...the patient and family did not want to go to the other facility...the nurse told the patient there was nothing they could do there...the patient, family member and the EMTs talked about going to another facility and decided to go there...the (named hospital ED) took the patient right in".

Record review of the ED Triage report from hospital #2, where patient #21 received treatment, dated June 19, 2011, at 1:44 p.m., revealed "...arrived via EMS - pt (patient) slipped on wet grass...injury to right ankle ...B/P (blood pressure) 126/82, P (pulse) 88, R (respirations) 18, O2 sat (oxygen saturation) 96% - room air, T (temperature) 98.0 degrees Fahrenheit...Physician referral to ED: NO...Treatments prior to arrival in ED: NONE..."

Record review of hospital #2's ED physician's History and Physical, dated as dictated June 19, 2011, at 2:35 p.m., revealed "...56 year old male with H/O (history of) HTN (hypertension) who presents W/ (with) R (right) ankle pain after mechanical fall this AM....No other trauma...C/O (complained of) pain to medial and lateral malleoli w/ bruising already developing...Imaging: R ankle: distal fibula fx (fracture) w/ talar displacement concerning for deltoid ligament injury...ED course:...Ortho (orthopedic) c/s (consult) placed, disp (disposition) pending their w/u (work up)..."

Review of the admitting hospital's Operative report, dated June 19, 2011, at 4:17 p.m., revealed "...ORIF (open reduction internal fixation) R ankle..."

Review of the hospital's Medical Staff By-Laws and Medical Staff Rules and Regulations, dated May 31, 2011, revealed "...Emergency Services...4. The disposition of each patient shall be the physician responsibility...19. All patients presenting to the emergency department for care have the right to a Medical Screening evaluation by qualified personnel...Qualified Medical Personnel (QMP) means those individuals, acting under the direct or indirect supervision of the Emergency Department physician...competent in the performance of medical screening examinations and operates within the scope of practice..."

Review of the hospital policy Medical Screening Exam, policy number ED-212.00-A, undated "...process by which patients presenting to the ED receive a Medical Screening Exam...MD, Mid-Level Practitioner, RN (Registered Nurse)...All patients that present to the Emergency Department will be triaged...The medical screening exam should consist of a. Assessment of chief complaint...b. Vital signs c. Mental status d. Skin e. Ability to walk, gait f. Focused physical exam...g. General appearance...5. The results of the medical screening will be recorded on the appropriate documents...The medical facility that will receive the transfer has been contacted directly...confirmed available space and qualified personnel for treatment, and has agreed to accept the transfer..."

Interview by phone with the Risk Manager on July 21, 2011, at 10:35 a.m., confirmed the patient arrived at the ED via ambulance and was not seen by an MD or QMP for a MSE per the facility policy and EMTALA Requirement.

Based on medical record review, interview, and facility policy review, the hospital failed to ensure treatment was provided for one patient (#21) of twenty-one patients reviewed who presented to the Emergency Department (ED) for care.

The findings included:

Review of the Emergency Department (ED) Ambulance Transport Register, dated June 19, 2011, at 12:34 p.m., revealed " ...(patient information) 56 yo (year old) M (male) - fall c (with) deformity - VSS (vital signs stable) - (M.D.) Name - (Nurse) initials - (Emergency Medical Services Unit) named county -(ETA estimated time of arrival) 2 (minutes)." This unnamed patient will be referred to as patient #21.

Review and interview with the ED Manager in the Board Room on June 18, 2011, at 1:00 p.m., of the information listed on patient #21 on the Ambulance Transport Register, dated June 19, 2011, at 12:34 p.m., confirmed the hospital had no medical record indicating patient #21 was seen in the ED or admitted to the hospital on June 19, 2011.

Interview with the ED Medical Director in the ED Medical Director's office on July 19, 2011, at 10:50 a.m., revealed the ED Medical Director was the Medical Doctor (MD) covering the ED on June 19, 2011 for the 7:00 a.m., to 7:00 p.m. time frame. Continued interview revealed the ED Medical Director recalled speaking with the Emergency Medical Technician (EMT) related to patient #21 with the "fracture and malformed" injury listed on the ED Ambulance Transport Registry dated June 19, 2011, at 12:34 p.m. Continued interview revealed the MD informed the EMT the facility did not have orthopedic coverage and they "might want to consider" taking patient #21 elsewhere and the EMT said "okay".

Continued interview revealed the MD had no knowledge of patient #21 being brought to the hospital and did not receive any information from ED staff related to patient #21 ever arriving at the ED. Continued interview confirmed the ED MD was to perform a Medical Screening Exam (MSE) and stabilization treatment on any patient presenting to the ED; the ED MD's were able to treat simple fractures, and if needed, the ED MD's could refer a patient with a fracture which might require surgical intervention for admission to the facility's Hospitalist group for admission, immediate treatment, and consult an Orthopedic MD the following day; and if a patient was to be transferred to another facility the ED MD was to carry out the transfer per the facility policy.

Review of the ED MD coverage schedule for June 19, 2011, day shift, revealed the physician covering the ED was the Medical Director of the ED.

Review of the Back-up Emergency Department (ED) call schedule, dated June 19, 2011, revealed "...no gen (general) ortho (Orthopedic) cov (coverage)..."

Review of the Emergency Medical Services (EMS) call report, dated June 19, 2011, at 10:52 a.m., revealed patient name, phone number, caller and address with the incident listed as "leg broken". Continued review revealed "6/19/2011 (June 19, 2011) 12:54 (p.m.)...UMC (university Medical Center) wouldn't accept patient Transporting to (named hospital)."

Interview in the Board Room on July 19, 2011, at 1:00 p.m., with the day shift ED Charge Nurse for June 19, 2011, revealed the day shift Charge Nurse was the Triage Nurse June 19, 2011, until 3:00 p.m. Continued interview revealed the Charge Nurse only recalled there was "...no Orthopedic coverage available...the Patient Focus Technician (PFT) on duty informed (the Charge Nurse) it was handled...don't know what was meant by that and didn't ask further questions...(the PFT) does not make decisions and it is not within the scope of the PFA's duties to go to the ED ambulance bay and talk to the EMT..."

Interview by phone on July 19, 2011, at 7:30 p.m., with the EMS EMT IV driver on the ambulance run for patient #21 of June 19, 2011, to University Medical Center revealed "...call came in to go to the residence...on arrival the patient was sitting on the ground in the yard...the patient and the patient's spouse asked the patient be taken to University Medical Center...would have taken the patient to a closer hospital if we felt it was warranted...the EMT IV delivering care and monitoring the patient placed a call to University Medical Center when we were about two minutes out from arrival...I understood the facility had informed the EMT IV calling that there was no Orthopedic available and we might want to consider going elsewhere...We drove into the ED ambulance bay as requested by the patient and spouse who was driving right behind us...a nurse came out and told us 'we told you we don't have orthopedic available and to (another named hospital)'...the nurse spoke with the patient and the patient's spouse and the patient and spouse decided to go to (another named hospital) so we left and took the patient to the other hospital where (the patient) was taken into the ED immediately...the patient's foot was swollen, not particularly misaligned, was bruised, had good pulses and movement of the toes, and the patient had some pain...would say you could not tell without an X-Ray if the foot was fractured..."

Interview by phone with the Risk Manager on July 20, 2011, at 9:30 a.m., confirmed the hospital had done further investigation and determined on the evening of July 19, 2011, the PFT on duty June 19, 2011, at 12:34 p.m., had gone to the ambulance bay and sent the ambulance away without a medical screening, treatment, and transfer notification.

Interview by phone on July 20, 2011, at 9:45 a.m., with the PFT on duty on June 19, 2011, at 12:34 p.m., confirmed "...it was not for me to determine health status of a patient, I was not a Registered Nurse or doctor...that is for the medical staff...I made the note in the call log...I spoke with the caller of the ambulance when the call came in ...was told they had a patient with a deformity of the foot due to lower extremity injury and they were about two minutes out...I asked the nurses if we had Orthopedic coverage and the EMT caller said 'that's alright we're already here'...I turned to the ED MD and was told we could treat the patient but we couldn't fix the patient so I went out and told the patient and the spouse that we could treat and transfer after stable...they decided to go to (named hospital) instead...the patient's foot was laid over where it shouldn't have been...no MD or Qualified Medical Professional (QMP) saw the patient..."

Interview on July 20, 2011, at 6:30 p.m., by phone with the EMT IV monitoring and providing care of patient #21 during transport on June 19, 2011, revealed "...We dispatched and patient reported falling and twisting ankle...splinted...family and patient requested transport to University Medical Center...about two minutes out from hospital I dialed in and was advised they had no Orthopedic services available...can't recall if I was told to go somewhere else or if I told them the patient requested to be brought to their facility...upon arrival I opened the back door while at the unloading bay of the ED...a nurse came out and told the driver to go to another facility ...the patient and family did not want to go to the other facility...the nurse told the patient there was nothing they could do there...the patient, family member and the EMTs talked about going to another facility and decided to go there...the (named hospital ED) took the patient right in".

Record review of the ED Triage report from hospital #2, where patient #21 received treatment, dated June 19, 2011, at 1:44 p.m., revealed "...arrived via EMS - pt (patient) slipped on wet grass...injury to right ankle...B/P (blood pressure) 126/82, P (pulse) 88, R (respirations) 18, O2 sat (oxygen saturation) 96% - room air, T (temperature) 98.0 degrees Fahrenheit...Physician referral to ED: NO...Treatments prior to arrival in ED: NONE..."

Record review of hospital #2's ED physician's History and Physical, dated as dictated June 19, 2011, at 2:35 p.m., revealed "...56 year old male with H/O (history of) HTN (hypertension) who presents W/ (with) R (right) ankle pain after mechanical fall this AM....No other trauma...C/O (complained of) pain to medial and lateral malleoli w/ bruising already developing...Imaging: R ankle: distal fibula fx (fracture) w/ talar displacement concerning for deltoid ligament injury...ED course:...Ortho (orthopedic) c/s (consult) placed, disp (disposition) pending their w/u (work up)..."

Review of the admitting hospital's Operative report, dated June 19, 2011, at 4:17 p.m., revealed "...ORIF (open reduction internal fixation) R ankle..."

Review of the hospital's Medical Staff By-Laws and Medical Staff Rules and Regulations, dated May 31, 2011, revealed "...Emergency Services...4. The disposition of each patient shall be the physician responsibility...19. All patients presenting to the emergency department for care have the right to a Medical Screening evaluation by qualified personnel...Qualified Medical Personnel (QMP) means those individuals, acting under the direct or indirect supervision of the Emergency Department physician...competent in the performance of medical screening examinations and operates within the scope of practice..."

Review of the hospital policy Examination, Treatment, policy number ED-219.02, dated September 15, 1986 revealed "...to ensure safe, expeditious transfer of patients to other facilities...Individuals presenting to the Emergency Services area...will be medically screened...and will be provided within the staff and facilities availability...such treatment as may be required to stabilize the medical condition..."

Interview by phone with the Risk Manager on July 21, 2011, at 10:35 a.m., confirmed the patient arrived at the ED via ambulance; and was not seen by an MD or QMP for stabilization of the injury per the facility policy and EMTALA Requirements.

Based on medical record review, interview, and facility policy review, the hospital failed to ensure transfer protocals were followed for one patient (#21) of twenty-one patients reviewed who presented to the Emergency Department (ED) for care.

The findings included:

Review of the Emergency Department (ED) Ambulance Transport Register, dated June 19, 2011, at 12:34 p.m., revealed "...(patient information) 56 yo (year old) M (male) - fall c (with) deformity - VSS (vital signs stable) - (M.D.) Name - (Nurse) initials - (Emergency Medical Services Unit) named county -(ETA estimated time of arrival) 2 (minutes)." This unnamed patient will be referred to as patient #21.

Review and interview with the ED Manager in the Board Room on June 18, 2011, at 1:00 p.m., of the information listed on patient #21 on the Ambulance Transport Register, dated June 19, 2011, at 12:34 p.m., confirmed the facility had no medical record indicating patient #21 was seen in the ED or admitted to the hospital on June 19, 2011.

Interview with the ED Medical Director in the ED Medical Director's office on July 19, 2011, at 10:50 a.m., revealed the ED Medical Director was the Medical Doctor (MD) covering the ED on June 19, 2011 for the 7:00 a.m., to 7:00 p.m. time frame. Continued interview revealed the ED Medical Director recalled speaking with the Emergency Medical Technician (EMT) related to patient #21 with the "fracture and malformed" injury listed on the ED Ambulance Transport Registry dated June 19, 2011, at 12:34 p.m. Continued interview revealed the MD informed the EMT the facility did not have orthopedic coverage and they "might want to consider" taking patient #21 elsewhere and the EMT said "okay".

Continued interview revealed the MD had no knowledge of patient #21 being brought to the hospital and did not receive any information from ED staff related to patient #21 ever arriving at the ED. Continued interview confirmed the ED MD was to perform a Medical Screening Exam (MSE) and stabilization treatment on any patient presenting to the ED; the ED MD's were able to treat simple fractures; and if needed, the ED MD's could refer a patient with a fracture which might require surgical intervention for admission to the facility's Hospitalist group for admission, immediate treatment, and referral to an Orthopedic MD the following day.

Review of the ED MD coverage schedule for June 19, 2011, day shift, revealed the physician covering the ED was the Medical Director of the ED.

Review of the Back-up Emergency Department (ED) call schedule, dated June 19, 2011, revealed "...no gen (general) ortho (Orthopedic) cov (coverage)..."

Review of the Emergency Medical Services (EMS) call report, dated June 19, 2011, at 10:52 a.m., revealed patient name, phone number, caller and address with the incident listed as "leg broken". Continued review revealed "6/19/2011 (June 19, 2011) 12:54 (p.m.)...UMC (university Medical Center) wouldn't accept patient Transporting to (named hospital)."

Interview in the Board Room on July 19, 2011, at 1:00 p.m., with the day shift ED Charge Nurse for June 19, 2011, revealed the day shift Charge Nurse was the Triage Nurse June 19, 2011, until 3:00 p.m. Continued interview revealed the Charge Nurse only recalled there was "...no Orthopedic coverage available...the Patient Focus Technician (PFT) on duty informed (the Charge Nurse) it was handled...don't know what was meant by that and didn't ask further questions...(the PFT) does not make decisions and it is not within the scope of the PFT's duties to go to the ED ambulance bay and talk to the EMT ..."

Interview by phone on July 19, 2011, at 7:30 p.m., with the EMS EMT IV driver on the ambulance run for patient #21 of June 19, 2011, to University Medical Center revealed "...call came in to go to the residence...on arrival the patient was sitting on the ground in the yard...the patient and the patient's spouse asked for the patient be taken to University Medical Center...would have taken the patient to a closer hospital if we felt it was warranted...the EMT IV delivering care and monitoring the patient placed a call to University Medical Center when we were about two minutes out from arrival...I understood the facility had informed the EMT IV calling that there was no Orthopedic available and we might want to consider going elsewhere...We drove into the ED ambulance bay as requested by the patient and spouse who was driving right behind us...a nurse came out and told us 'we told you we don't have orthopedic available and to go to (another named hospital)'...the nurse spoke with the patient and the patient's spouse and the patient and spouse decided to go to (another named hospital) so we left and took the patient to the other hospital where (the patient) was taken into the ED immediately...the patient's foot was swollen, not particularly misaligned, was bruised, had good pulses and movement of the toes, and the patient had some pain...would say you could not tell without an X-Ray if the foot was fractured..."

Interview by phone with the Risk Manager on July 20, 2011, at 9:30 a.m., confirmed the facility had done further investigation and determined on the evening of July 19, 2011, the PFT on duty June 19, 2011, at 12:34 p.m., had gone to the ambulance bay and sent the ambulance away without a medical screening, treatment, and transfer notification.

Interview by phone on July 20, 2011, at 9:45 a.m., with the PFT on duty on June 19, 2011, at 12:34 p.m., confirmed "...it was not for me to determine health status of a patient, I was not a Registered Nurse or doctor...that is for the medical staff...I made the note in the call log...I spoke with the caller of the ambulance when the call came in ...was told they had a patient with a deformity of the foot due to lower extremity injury and they were about two minutes out...I asked the nurses if we had Orthopedic coverage and the EMT caller said 'that's alright we're already here'...I turned to the ED MD and was told we could treat the patient but we couldn't fix the patient so I went out and told the patient and the patient and spouse that we could treat and transfer after stable...they decided to go to (named hospital) instead...the patient's foot was laid over where it shouldn't have been...no MD or Qualified Medical Professional (QMP) saw the patient..."

Interview on July 20, 2011, at 6:30 p.m., by phone with the EMT IV monitoring and providing care of patient #21 during transport on June 19, 2011, revealed "...We dispatched and patient reported falling and twisting ankle...splinted...family and patient requested transport to University Medical Center...about two minutes out from hospital I dialed in and was advised they had no Orthopedic services available...can't recall if I was told to go somewhere else or if I told them the patient requested to be brought to their facility...upon arrival I opened the back door while at the unloading bay of the ED...a nurse came out and told the driver to go to another facility ...the patient and family did not want to go to the other facility...the nurse told the patient there was nothing they could do there...the patient, family member and the EMTs talked about going to another facility and decided to go there...the (named hospital ED) took the patient right in".

Record review of the ED Triage report from hospital #2, where patient #21 received treatment, dated June 19, 2011, at 1:44 p.m., revealed "...arrived via EMS - pt (patient) slipped on wet grass...injury to right ankle...B/P (blood pressure) 126/82, P (pulse) 88, R (respirations) 18, O2 sat (oxygen saturation) 96% - room air, T (temperature) 98.0F...Physician referral to ED: NO...Treatments prior to arrival in ED: NONE..."

Record review of hospital #2's ED physician's History and Physical, dated as dictated June 19, 2011, at 2:35 p.m., revealed "...56 year old male with H/O (history of) HTN (hypertension) who presents W/ (with) R (right) ankle pain after mechanical fall this AM....No other trauma...C/O (complained of) pain to medial and lateral malleoli w/ bruising already developing...Imaging: R ankle: distal fibula fx (fracture) w/ talar displacement concerning for deltoid ligament injury...ED course:...Ortho (orthopedic) c/s (consult) placed, disp (disposition) pending their w/u (work up)..."

Review of the admitting hospital's Operative report, dated June 19, 2011, at 4:17 p.m., revealed "...ORIF (open reduction internal fixation) R ankle..."

Review of the hospital's Medical Staff By-Laws and Medical Staff Rules and Regulations, dated May 31, 2011, revealed "...Emergency Services...4. The disposition of each patient shall be the physician responsibility...19. All patients presenting to the emergency department for care have the right to a Medical Screening evaluation by qualified personnel...Qualified Medical Personnel (QMP) means those individuals, acting under the direct or indirect supervision of the Emergency Department physician...competent in the performance of medical screening examinations and operates within the scope of practice..."

Review of the hospital policy Examination, Treatment, Transfer policy number ED-219.02, dated September 15, 1986 revealed "...to ensure safe, expeditious transfer of patients to other facilities...Individuals presenting to the Emergency Services area...will be medically screened...and will be provided within the staff and facilities availability...such treatment as may be required to stabilize the medical condition or provide arrangements for transfer from the facility for stabilization...The medical facility that will receive the transfer has been contacted directly...confirmed available space and qualified personnel for treatment, and has agreed to accept the transfer...""

Interview by phone with the Risk Manager on July 21, 2011, at 10:35 a.m., confirmed the patient arrived at the ED via ambulance; the facility ED did not arrange for transfer per the facility policy and EMTALA Requirements.