HospitalInspections.org

Based on interviews and review of Emergency Medical Services (EMS) Report, and Hospital 1's Emergency Medical Treatment and Labor Act (EMTALA) Policies and Procedures, Hospital 1 failed to:

A. Provide an appropriate medical screening examination for Patient Identifier (PI) # 1, a patient with an open wound to the arm with exposed tissue and muscle secondary to a gunshot wound, who was transported to the Emergency Department (ED) at Hospital 1 by EMS on 6/6/2013.


B. Provide stabilizing treatment to PI # 1.


C. Arrange, implement and document an appropriate transfer for PI # 1, a patient determined by the Emergency Department (ED) Physician at Hospital 1 to need the services of a trauma surgeon (service not available at Hospital 1), to Hospital 2.


Hospital 1's deficient practice effected PI # 1, one of 27 sampled patients who presented to Hospital 1's Emergency Department and has the potential to negatively effect all patients who present to Hospital 1's ED for a Medical Screening Examination to determine if an Emergency Medical Condition exists, require stabilizing treatment, and / or require or request transfer from Hospital 1 to another facility.


Findings include:

PI # 1 was transported via ambulance to Hospital 1's Emergency Department (ED) after sustaining a gunshot to the left humerus on 6/6/2013.
Documentation in the EMS report reveals, "Open wound to left humerus area...entrance and exit wounds to this area...with powder burns. Noted Fx (fracture) bone ends and could see muscle and tissue..." Hospital 1's ED physician informed EMS staff that the patient needed to be seen by a trauma surgeon (no trauma surgeon at Hospital 1) and advised transport of the patient to Hospital 2.

The ED physician failed to provide and document a Medical Screening Examination for PI # 1. The physician also failed to provide stabilizing treatment and an appropriate transfer of PI # 1.

These citations were written as a result of the investigation of Complaint Number AL00029139.

Please refer to findings at:

A - 2406 / 489.24(r) and 489.24(c) - Medical Screening Examination;
A - 2407 / 489.24(d)(1-3) - Stabilizing Treatment and
A - 2409 / 489.24(e)(1-2) - Appropriate Transfer.

Based on interviews, review of the EMS (Emergency Medical Services)report dated 6/6/2013, hospital EMTALA (Emergency Medical Treatment and Labor Act) Policies and Procedures and the Coverage Services Agreement between the ED (Emergency Department) Physicians and Hospital 1, Hospital 1 failed to provide an appropriate medical screening examination for Patient Identifier (PI) # 1, a patient with an open wound with exposed tissue and muscle to the arm as the result of a gunshot wound, who was transported via ambulance to Hospital 1's Emergency Department (ED) on 6/6/2013.

Findings include:
A review of the Emergency Medical Services (EMS) Run report #68901 dated 6/6/13 revealed the following:
EMS arrived at the patient on 6/6/13 at 01:31 AM and left the scene with the patient at 02:03 AM. The patient's chief complaint was: GSW (Gun Shot Wound) to Upper Extremity with bleeding. Primary Impression: Traumatic Injury.
Injuries included: Mechanisms: Penetrating Injury, Upper extremity with Bleeding Uncontrolled, Soft tissue swelling/bruising, Gunshot, Dislocation Fracture; Cause: Firearm Injury (accidental); Mechanisms: Penetrating.

The patient's vital signs were:
01:46 - B/P (Blood pressure) 149/90, Pulse 112, Regular; Respirations 18, Normal
02:11 - B/P 138/88; Pulse 112, regular; Respirations 18, normal
02:34 - B/P 146/96; Pulse 108, regular; Respirations 20, normal
02:56 - B/P 149/96; Pulse 106, regular; Respirations 18, normal
03:18 - B/P 139/88; Pulse 104, regular; Respirations 18, normal
03:37 - B/P 135/89, Pulse 104, regular; Respirations 20, normal
03:58 - B/P 132/87, Pulse 103, regular; Respirations 18, normal

An IV (Intravenous) access was obtained at 01:50 and Normal Saline (NS) IV began at 01:57.

A review of the EMS Run Report dated 6/6/13 revealed the following documentation in the Narrative portion of the document:

"... S (Subjective)...Open wound to left humerous (humerus) area; There was enterance (entrance) and exit wounds to this area, along with powder burns... Noted Fx (fractured) bone ends and could see muscle and tissue; Pain was sharp, burning pain; 10/10 (rated 10 on 0-10 scale with 0 being no pain and 10 being extreme pain)... Pt. also stated he waited about an hour or so before he called 911... Notified TCC (Trauma Communication Center) since obvious for Trauma Surgeon...

... O (Objective) - 65 y/o/W/M (year old, white male); Alert and Oriented x (times) 3; A (Airway) - patent; BBS (bilateral breath sounds) - clear and equal; Skin - warm and dry; Pupils - equal and reactive ... Chest - burn pattern to left chest area ... Left arm noted entrance and exit wound to this area with gapping hole that tissue and muscle could be seen; Movement of wrist and fingers is possible but no muscle function to upper arm...

... P (Plan) - Monitor pt (patient) and VS (vital signs) above; Entered pt into TCC; Advised by TCC to go to (Hospital A) ER (Emergency Room) since (Air Transport Service) not able to let know if could fly to area and Level 1 is 1 ? hours away ... "

A review of the Narrative of run report # 68901 revealed, "P- Placed pt. on O2 (Oxygen) - 4 L (liters) NC (nasal cannula) for comfort and poss. (possible) shock; Established IV - 16 G (gauge) in right hand with NS (Normal Saline) bolus going for poss. shock; IV - 14 G in right FA (forearm) with heplock; Arrived at (Hospital A) at 0207 but before entrance to hospital were notified that (Air Transport Service) could meet in Atmore and was instructed by TCC to head there. Then headed with pt. to met (meet) helicopter at (Hospital 1) Helipad. Okay with...(physician's name) for 2 mg (milligrams) of Morphine (medication for pain) IVP (intravenous push) for pain for transport...

... As arrived at Hospital 1 @ 0248 were advised that helicopter was turned around due to fog and to take pt. straight to (Hospital 2) by ground; Once pt. heard of this he stated, "No, I want to go into this hospital here to for some pain relief to get easy! He stated that he could not tolerate the ride otherwise." Called to tell Hospital 1 by HEAR (Hospital Emergency Administrative Radio) system of this; As we started to unload pt. from unit we were met at the hospital doors by ER (Emergency Room) MD (Medical Doctor) (name of physician) and the ER RN (Registered Nurse). They stated, "You are not to bring that patient in here! We do not have a trauma surgeon and TCC advised to take patient to (Hospital 2)." We advised the ER staff that the patient requested to come in there for some pain relief that our unit only had 4 mg of Morphine for a hour ride; They advised this unit that, "He was not to be brought into there (their) ER that they didn't have a surgeon." The Doctor looked over the patient and stated that he was stable; The patient and the doctor then got into it over this matter because he wanted to come inside the facitility (facility); They then (started) walking back into the ER with doors closing and wouldn't allow entrance; They then came back out with a phone stating, "Here is the phone we have called the TCC for you and they want you to head to (Hospital 2)."

... I talked with the TCC rep (representative) and told him my situation that the patient requested to go into the hospital for pain relief and to see a MD since he hadn't seen one. I was placed on hold and they then told me that they didn't know what to tell me but that if (Hospital 1) refused to allow entrance to hospital just to load the patient and give what meds we had for pain relief and take to (Hospital 2); We then loaded pt. back into the unit and @ 0256 went en route to (Hospital 2) by ground; I contacted (Hospital A's physician) about this incident and to have the conversation recorded; Also asking to give the patient 4 mg of Morphine for the transport; it was confirmed and ok; Pt. was administered 4 mg of Morphine IVP; Per patient pain did go down some but was still a 10/10; Maintained interventions and VS of pt enroute ... No change; (Hospital 2) was then contacted by HEAR system approx. (approximately) 10-15 mins (minutes) out of the incoming Trauma pt; Care was then turned over to (Hospital 2) ER RN without incident..."

An interview was conducted on 6/12/13 at 3:55 PM with the ED Physician (EI # 3), on duty on 6/5/13 to 6/6/13. The surveyors asked EI # 3 about the incident when PI # 1 was brought to Hospital 1's ED.

The physician (EI # 3) stated he was involved in trying to facilitate communication with TCC. "I got involved when the Air Transport Service (ATS) first called us. The ATS tried to call the (Name of Ambulance Service) and was unable to reach them. TCC called us so, we were trying to reach the ambulance. I was outside in ambulance bay. I was trying to help with transfer (of PI # 1) to Hospital 2. I thought I was trying to facilitate with the transfer of PI # 1, when ambulance pulled up at our ED doors. The Ambulance driver talked with TCC (on the phone). He (ambulance driver) said I guess we are going to Hospital 2."

EI # 3 stated, "I eyeballed the patient (PI # 1). PI # 1 was generally stable. I looked at the patient. Injury could be arterial and (patient) was already past the 'golden hour' and needed to go to Hospital 2. The patient was stable enough to get up off the gurney. The patient had an open wound with bandages. It was a gaping wound. A quick look at the patient and EI # 3 stated he was concerned more about the patient losing his arm."

The surveyors asked the physician (EI #3) if the patient requested to come into the ED. The physician (EI # 3) replied, "No." EI # 3 said he explained to the patient that he had been directed to go to Hospital 2. EI # 3 stated that he asked the ambulance personnel if they had enough pain medication. The surveyors asked EI # 3 if he told the EMS crew not to bring the patient into Hospital 1's ED and EI # 3 replied, "No."

EI # 3 stated that he asked the ambulance personnel if they had called TCC. EI# 3 stated he talked to the patient and explained that Hospital 1 did not have a surgeon. EI # 3 denied arguing with the patient and/or the ambulance personnel. EI # 3 stated that the patient was irritated. EI # 3 stated he assumed the patient was upset because he (patient) had already been to two hospitals. EI # 3 denied he said, "Do not come in here," (Hospital 1's ED) to the EMS personnel.

The surveyors asked EI # 3 (ED Physician - Hospital 1) to explain his understanding of EMTALA (Emergency Medical Treatment and Labor Act). EI # 3 said it means, "If a patient requests to be seen, then we see them.

During an interview on 6/12/2013 at 4:35 PM, the ED RN (EI # 4), described herself as the "second nurse" working on 6/6/2013 and EI # 2 was the Charge Nurse. According to EI # 4, the patient was brought to Hospital 1 to meet the helicopter, but the helicopter was grounded. Hospital 1's ED received a call from the (Air Transport Service) advising the ambulance was to meet the helicopter at our Helipad (Hospital 1) for air transport of a patient with a GSW to Hospital 2. The (Air Transport Service) called back to advise they could not land at Hospital 2 and they had not been able to contact EMS personnel. Next, the ED received a call (unsure if radio or telephone) from EMS advising they were aware of the helicopter cancellation, but stated they might need to bring the patient to Hospital 1 for stabilization. The RN said she was in the process of notifying the other RN and the physician when the ambulance backed up to the doors of the ED. "I think it was all a miscommunication." The RN said she moved a patient out of the trauma room in order to make the trauma room available. EI # 2(ED Charge Nurse) and EI # 3 (ED Physician) assumed responsibility for the EMS patient. EI # 4 stated the ambulance doors are not locked, but a code is required to open the doors.

An interview was conducted on 6/13/13 at 8:45 AM with EI # 2, Emergency Department Registered Nurse (RN), who verified she was the Charge Nurse on duty the night of 6/5/13 to 6/6/13 and worked from 7:00 PM to 7:00 AM.

The surveyors asked EI #2 to describe what she recalled about the incident when Patient Identifier (PI) # 1 was brought to the Emergency Department at Hospital 1 on 6/6/13 by EMS (Emergency Medical Services). EI # 2 stated she recalled "running interference" with (Air Transport Service) and the ambulance service. EI # 2 stated the (Air Transport Service) called Hospital 1's ED either by phone or HEAR system to advise they were to pick up a patient at Hospital 1's Helipad and transport the patient to Hospital 2. The RN said she turned on the Helipad lights. Later, the (Air Transport Service) contacted us (ED staff at Hospital 1) and said they were unable to land at Hospital 1, had no way of contacting the ambulance and that TCC couldn't get in touch with the ambulance. "I was running back and forth from the ED to the Helipad so that I could let them know that the helicopter wasn't able to land. The next thing I know is the ambulance showed up and came to our back door. I was coming from the Helipad. EI # 3 (ED Physician) was walking out towards the ambulance bay doors and the Medic was unloading the patient. The Medic said the helicopter couldn't land. The patient wanted pain medication and the paramedic said he had "x" amount of Morphine on board." EI # 2 was unable to hear all of the conversation between the paramedic and EI # 3 (ED Physician) because of the noise generated by a fan located above the automatic doors between the ED and ambulance bay. EI # 2 stated the patient was already in the TCC (Trauma Communication Center) system. EI # 2 stated she phoned TCC and asked them if Hospital 1 was to see the patient. EI # 2 stated the TCC said EMS was supposed to go straight to Hospital 2 because the helicopter could not land at Hospital 1.
EI # 2 stated at that point she handed the phone to the paramedic who was at the front of the truck and the driver was at the back of the truck talking to the patient. After a few minutes the Medic came to the back of the truck and loaded the patient back into the truck.

EI # 2 verified the stretcher was out of the truck and in the ambulance bay. EI # 2 stated the patient wasn't distressed or agitated. The patient was confused about the hospital not having a surgical team. EI # 2 stated the patient never said he wanted to be seen at Hospital 1, but did say he wanted something for pain. "I heard the Medic say something about having Morphine on the truck, but not the quantity available."

When EI # 2 was questioned if the ED Physician assessed the patient. EI # 2 stated the ED physician did assess the patient and thought the patient needed to be at a facility that had a surgical team. The patient was pulling his gauze down and showing his wound to the physician. The ED Physician touched the patient's hand and felt the patient's pulse. EI #2 said she heard the physician ask the paramedic about the patient's vital signs.

EI # 2 stated that before the ambulance arrived, there was another patient in the trauma room. "We moved the patient out of the trauma room after having talked with the (Air Transport Service), just in case. We didn't get a report, so we moved the other patient out because we didn't know what was coming."

EI # 2 stated the ED Physician (EI # 3) asked the paramedic why the patient wasn't given more Morphine. EI # 2 stated the entire episode (time ambulance at Hospital 1) lasted about 6 or 7 minutes. EI # 2 was asked if the paramedic and/or the driver told her/him or the ED Physician that the patient wanted to come into the ED at Hospital 1. EI # 2 stated, "No, just that he (PI # 1) wanted something for pain."
EI # 2 stated the paramedic said the patient was in pain and he had not seen a physician. The ED Physician was mad because the patient wasn't given any pain medication.

The surveyors asked EI # 2 if she reported the incident to any one. EI # 2 stated the House Supervisor was making rounds in the middle of the incident and came to the ED. EI # 2 stated she had spoken to EI # 6 (ED Manager), EI # 7 (Director of Nursing), EI # 8 (Performance Improvement) and EI # 9, (Risk Manager) on 6/12/13.

During an interview on 6/14/2013 at 8:50 AM, EI # 5, RN / House Supervisor from 3:00 PM to 7:00 AM on 6/5/13 to 6/6/13, was asked to describe the incident involving PI # 1 on 6/6/13.

EI # 5 stated she was not called to the ER (Emergency Room), but she went to the ER as she was making rounds in the hospital. EI # 5 stated she saw an ambulance in the ambulance bay and the doors to the ambulance bay were open. EI # 3 (ED Physician) was facing the ambulance and his back was to me. According to EI # 5, a white male patient was on a stretcher, outside of the ambulance. The paramedic and driver were at the foot of the stretcher and EI # 3 was talking to the paramedic.

According to the House Supervisor (EI # 5), the ED Charge Nurse (EI # 2) and EI # 3 (ED Physician) then came inside the ED and were discussing the incident. "I heard parts of the story. (Air Transport Service) couldn't meet here (Hospital 1) and the ambulance was told to go to Hospital 2." EI # 5 stated the events sounded like an EMTALA violation. The Charge Nurse (EI # 2) and the ED Physician (EI # 3) said TCC directed the ambulance to go straight to Hospital 2. "I told EI # 2 (Charge Nurse) I didn't even know how I'm going to write this up." The Supervisor (EI # 5) stated the ED Charge Nurse (EI # 2) asked her not to write it up until she (EI #2) could talk with the ED Manager (EI # 6) in the morning ( 6/6/13). EI # 5 stated she did not put the incident in writing, nor did she report the incident to any hospital staff because the Charge Nurse (EI # 2) was going to report the incident.

The House Supervisor (EI # 5) stated she thought the ED Physician (EI # 3) felt the incident was a possible EMTALA violation if Hospital 1 accepted the patient. EI # 5 stated, "For some reason they didn't want to take the patient. They were not letting them come in. That's why the patient was in the ambulance bay. They were disputing that EMS (Emergency Medical Services) wanted the patient to be seen here. EMS said that the patient was stable and they stopped here for pain medication. According to EI # 5, the ED Physician (EI # 3) said EMS had to have pain medications on board the (ambulance).

EI # 5 stated that she advised the ED Charge Nurse and Physician that when the patient shows up in your ER, he/she wants to be seen. They (EI # 2 and EI # 3) said, "No, no, no. He didn't come in." EI # 5 stated that she told them the patient was at their back door and if TCC is taken out of the picture, "You clearly have an EMTALA violation." EI # 5 stated the Charge Nurse (EI # 2) justified her actions because TCC told her this patient was assigned to go to Hospital 2. The House Supervisor (EI # 5) said she, "Left it in the hands of the Charge Nurse (EI # 2) to report to the ED Nurse Manager." EI # 5 stated she did not include this incident in her report to the next shift.

During an interview on 6/17/2013 at 8:40 AM, Employee Identifier (EI) # 1 / EMT- P (Emergency Medical Technician - Paramedic), stated Hospital A advised the EMS crew to transport Patient Identifier (PI) # 1 to the Helipad at Hospital 1 as directed by the Trauma Communication Center (TCC). As the ambulance was about to drive onto the grounds of Hospital 1 at Atmore, the crew received a call from their base notifying them that the helicopter could not land and they should transport the patient to Hospital 2.


According to EI # 1, PI #1 heard the communication about the grounding of the helicopter and the plan to transport the patient via ambulance to Hospital 2. The patient said "No," he had not been seen by a doctor and he verbalized his desire to go into Hospital 1 and get something for pain. The patient reportedly said, "There ain't no way I can make it another hour to another hospital." The paramedic reports he contacted Hospital 1's ED via HEAR (Hospital Emergency Administrative Radio) and advised a female (name unknown) that the helicopter could not fly, the patient was requesting to come to their facility (Hospital 1) and they were on the way with the patient (PI # 1). EI #1 was asked to describe the response of the ED staff at Hospital 1. EI # 1 said the staff person sounded, "Confused and said, Okay. We'll tell them."


According to EI #1 (paramedic), when the EMS staff arrived at the ambulance bay at Hospital 1, "They (physician and a nurse) started screaming at me." They said we were not to bring the patient into the ER, they did not have a trauma surgeon and we (EMS) were to transport PI # 1 to Hospital 2. EI # 1 said he told the ED physician and the nurse that the patient wanted to come in their facility. The nurse reportedly said, "This is an EMTALA violation." The physician said the patient was stable and there was no reason to divert the patient to Hospital 1. The paramedic (EI #1) responded that the patient was brought directly from the scene of the incident and was not a transfer. The ED physician then told the EMS staff to, "Just come in then." The ED physician and the nurse walked back into the ED and the automatic doors closed. The EMS staff unloaded the patient and waited because they did not have the code to open the ambulance bay doors. Next, the doors opened and the hospital ED staff said, "Hold on. Do not bring that patient in here. We have TCC on the telephone." The paramedic reports he talked with TCC. "TCC said they didn't know what to tell me. The best thing was to go on to Hospital 2 and use the medication I had on board."


EI #1 (paramedic) stated that the ED physician listened to the patient's breath sounds and said, "The patient is stable, needs a surgeon and we (Hospital 1) don't have one." The paramedic reiterated the patient's request to come into the ED and his request for pain medication. The physician said, "You've got morphine on the truck."

EI #1 (paramedic) stated he contacted the Medical Control physician on call in order to have the conversation recorded and to obtain authorization to give additional morphine to the patient. The patient had previously been given Morphine 2 milligrams. The patient was transported via ambulance to Hospital 2 and received Morphine 4 milligrams en route.



Review of Hospital 1's Policies/Procedures

A. Admission to the Emergency Department

Key Function: Assessment of Patients

Purpose: To ensure appropriate patient admission to the ER (Emergency Room).

Policy: Nursing staff will conduct an initial triage and the Medical Staff will complete a thorough medical screening of any individual who comes to the department and requests an examination or treatment and to determine if an "Emergency Medical Condition" exists or if the individual is in active labor. Once such a determination is made, the hospital must provide for either stabilization treatment or an appropriate transfer of the individual.

COBRA (Consolidated Omnibus Budget Reconciliation Act) 1985 defines the term "Emergency Medical Condition" as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
1. Placing the patient's health in serious jeopardy.
2. Serious impairment to bodily functions or serious dysfunction of any organ or part ...

B. Policies/Procedures
Title: Triage
Key Function: Assessment of Patients
"Purpose: The purpose of triage is to conduct an appropriate medical screening of any individual who comes to the department and requests an examination or treatment and to determine if an "emergency medical condition" exists or if the individual is in active labor. Once such a determination is made, the hospital must provide for either stabilizing treatment or an appropriate transfer of the individual."

Definitions:
Triage: Is a process of sorting out illnesses and injuries of patients who present to the Emergency Department. It is a mechanism to evaluate all patients seeking EM (Emergency medical) treatment and prioritize patient care needs based on chief presenting complaints. By prioritizing and determining triage classification (level), patients presenting with emergent conditions can receive immediate care.

Qualified Medical Provider: Emergency Department Physician, Mid-level Provider (Physician Assistant or Nurse Practitioner) ..."

C. Policies/Procedures
Title: MSO (Medically Screening Out) Process - Medical Screening Guidelines
Key Function: Assessment of Patients

Statement of Purpose: To delineate the guidelines for triaging less acute patients to the MSO Process for their medical screening examination, and to set forth the treatment options for patients who are determined not to have and emergency medical condition ...

... Definitions:
... 3. Medical Screening Examination (MSE): A process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist.

4. Qualified Medical Provider (QMP): a physician or qualified medical provider designated by the hospital to perform Medical Screening Examinations.

5. MSO Process: A process designated for less acute Emergency Department patients completion of a Medical Screening Examination by a QMP to determine whether an emergency medical condition does or does not exist and then ensures that the patient is provided with stabilizing care or transfer if an emergency medical condition does not exist...

... Policy: All patients who present to the Emergency department for medical care or treatment, regardless of ability to pay, will be triaged and receive a MSE by a QMP. Upon completion of the MSE, patients who have emergency medical conditions shall be stabilized or transferred in accordance with state and federal law...

Procedure:
A. Triage. All patients requesting evaluation for a medical condition will be triaged and assigned an acuity level based on the ESI (Emergency Severity Index). Acuity is determined by the stability of the vital functions or potential for life, limb, or organ threat ...

... D. MSE Completion in the QMP Process
After the MSE is completed via the MSO Process, the QMP will make one of the following determinations:

1. The QMP cannot determine whether an emergency medical condition exists in the MSO Process because the patient needs further screening (x-rays, labs, etc.). In this case the patient will remain in the Emergency Department for further screening, stabilization, or transfer in accordance with federal and state law and Hospital policy.

2. The patient does have an emergency medical condition which cannot be stabilized in the MSO Process. In this case, the patient will remain in the Emergency Department in accordance with federal and state law and Hospital policy ...

... Expected Outcomes: Patients will be triaged, receive a MSE by a QMP, and either be stabilized or transferred if their condition is emergent. If the patient's condition is non-emergent he/she will be offered options for the care and treatment of their condition ...

A review of the Coverage Service Agreement between the ED Physicians and Hospital 1:
1.12 - Physician's Responsibilities with Respect to Patients...All physicians providing services in any Hospital facility shall:
(a). Provide the necessary medical services in a manner so that the medical needs of each patient are met consistent with Hospital and medical staff bylaws, rule and regulations, and policies and patient expectations.

There was no documentation by hospital staff to indicate PI # 1 presented to Hospital 1's ED on 6/6/2013. There was no documentation PI #1 was triaged or that a MSE was performed by a QMP at Hospital 1.

Based on interviews and review of Emergency Medical Services (EMS) Report, Hospital 1's Emergency Medical Treatment and Labor Act (EMTALA) Policies and Procedures, and review of Patient Identifier (PI) # 1's medical record from Hospital 2, Hospital 1 failed to provide stabilizing treatment for PI # 1, a patient who presented to Hospital 1's ED (Emergency Department) status post gunshot wound on 6/6/2013.

This deficient practice affected PI # 1, one of 27 sampled ED patients, but has the potential to negatively affect all patients who present to Hospital 1's emergency Department and require stabilizing treatment of an Emergency Medical Condition identified during a Medical Screening Examination.


Findings include:

Review of the Emergency Medical Services (EMS) Run report #68901 dated 6/6/13 revealed the following:
... As arrived at (Hospital 1) at 0248 were advised that helicopter was turned around due to fog and to take pt straight to (Hospital 2) by ground; Once pt heard of this he stated, "No, I want to go into this hospital here to for some pain relief to get easy! He stated that he could not tolerate the ride otherwise. ... started to unload pt from unit we were met at the hospital doors by ER (Emergency Room) MD (Medical Doctor) ... and the ER RN (Registered Nurse). They stated, "You are not to bring that patient in here! We do not have a trauma surgeon and TCC advised to take patient to (Hospital 2)." We advised the ER staff that the patient requested to come in there for some pain relief that our unit only had 4 mg of Morphine for a hour ride; They advised this unit that, "he was not to be brought into there ER that they didn't have a surgeon. "The Doctor looked over the patient and stated that he was stable; The patient and the doctor then got into it over this matter because he wanted to come inside the facitility (facility)...
... I talked with the TCC rep (representative) and told him my situation that the patient requested to go into the hospital for pain relief and to see a MD since he hadn't seen one. I was placed on hold and they then told me that they didn't know what to tell me but that if (Hospital 1) refused to allow entrance to hospital just to load the patient and give what meds we had for pain relief and take to (Hospital 2). We then loaded pt back into the unit and @ 0256 went en route to (Hospital 2) by ground; I contacted (Physician at Hospital A) about this incident... asking to give the patient 4 mg of Morphine IVP; Per patient pain did go down some but was still a 10/10... "

There was no documentation PI # 1 received stabilizing treatment at Hospital 1.


A review of PI # 1's medical record from Hospital 2 revealed the following:

Triage Time: 03:40 6/6/2013
Complaint: GSW (Gunshot Wound)
Vital Signs:149/81, 97, 18, 97.2, O2 (Oxygen) Saturation: 100 % RA (Room Air)
Pain: Pain level 10...using faces pain scoring...Location: Left upper arm.



History and Physical:
This physician first made contact with this patient at the following time:
6/6/2013 at 03:40.
Chief Complaint: GSW left arm...
Emergent Condition: An emergent condition was evaluated.
Severity: Currently symptoms are severe.



Physical Examination: Vital signs reviewed...Blood pressure hypertensive...
Patient appears in severe pain, distress...

Upper Extremity: Open gaping wound left upper arm from GSW...

"Doctor Notes: ... Has an open fragmented humerus fracture. Given IV abx (antibiotics)...

Surgical History and Physical:
6/6/2013 at 07:06
Chief Complaint: Gunshot wound to the arm.
Neurologic: In the left upper arm, there are 2 wounds. Anteriorly, there is a
large wound that is at least 8 cm. About 4 - 5 cm posterior to this is another smaller wound that measured about 4 cm. There is obvious destroyed muscle identified within the cavity/ There is some pooled venous blood. There appears to be no active arterial bleeding. The bone is not readily identifiable...All distal neurovascular intact...moving the hand...grip is strong...radial pulse palpable. Ulnar pulse is not readily palpable, but it is dopplerable and a pulse of the palmar arch is a dopplerable pulse. Capillary refill is normal.

Laboratory Studies: X-ray of the humerus shows a severely comminuted
fracture (fracture that is splintered or crushed) of the mid humerus.

Impression: Gunshot wound to the left arm...has an opened fracture because of the large wound...patient will likely be brought to the operating room for cleaning out of the wound and fixation of fracture.


Medication :
Ancef (antibiotic) 2 grams IV solution piggyback given at 04:15
Morphine (pain medication) 5 milligrams (mg.) IV push given at 04:15
Tetanus Toxoid (to prevent Tetanus infection) 0.5 mg. IM (Intramuscular) given at 05:34

Operative Reports:

1. Date of Procedure: 6/6/2013

Preoperative Diagnosis: Open comminuted humerus fracture secondary to gunshot wound of the left upper extremity.

Procedures Performed:
1. Multiplanar external fixator to the left upper extremity.
2. Incision and drainage of open fracture to include bone.
3. Wound closure 7-10 cm.

Postoperative Diagnosis: Open comminuted humerus fracture secondary to gunshot wound of the left upper extremity.

2. Date of Procedure: 6/7/2013
Procedure: Incision and drainage, open humerus fracture.
Condition: Fracture remained relatively clean without evidence of purulence or malodor.


An interview was conducted on 6/13/13 at 8:45 AM with Employee Identifier (EI) # 2, Emergency Department (ED) Registered Nurse (RN) who verified she was the ED Charge Nurse on duty the night of 6/5/13 to 6/6/13 and worked from 7:00 PM to 7:00 AM.

The surveyors asked EI #2 what she recalled of the incident when Patient Identifier (PI) # 1 was brought to the Emergency Department on 6/6/13 by EMS (Emergency Medical Services).

"... The next thing I know is the ambulance showed up and came to our back door... EI # 3 (ED Physician) was out towards the ambulance doors and the Medic was unloading the patient. The Medic said the (Helicopter) couldn't land. Patient wanted pain medication, Medic said he had so much Morphine on board...

... EI # 2 stated the patient never said he wanted to be seen here, but did say he wanted something for pain. I heard the Medic say something about having Morphine on the truck, but not the quantity available.

When EI # 2 was questioned if EI # 3 (ED Physician) assessed the patient, EI # 2 stated that EI # 3 did assess the patient and thought the patient needed to be at a facility that had a surgical team...

... EI # 2 was asked if the Paramedic and/or the driver said the patient wanted to come into the ED at Hospital 1. EI # 2 stated no, just that he wanted something for pain. EI # 2 stated the paramedic stated the patient was in pain and he had not seen a physician. EI # 3 was mad because the patient wasn't given any pain medication.

An interview was conducted on 6/12/13 at 3:55 PM with EI # 3, ED Physician on duty on 6/5/13 to 6/6/13 ...I thought I was trying to facilitate with the transfer of PI # 1, when ambulance pulled up at our ED doors...

I eyeballed the patient (PI # 1). (PI # 1) was generally stable. I looked at the patient. Injury could be arterial and (patient) was already past the "golden hour" and needed to go to Hospital # 2. The patient was stable enough to get off the gurney. The patient had an open wound with bandages. It was a gaping wound. EI # 3 stated he looked at the patient and was more concerned about the patient losing his arm.

The surveyors asked, "Did the patient ask to come in?" EI # 3 replied, "No." That he explained to the patient that (he/she) had been directed to go to Hospital 2. EI # 3 stated that he asked the ambulance if they had enough pain medication. The surveyors asked if he said do not bring the patient into Hospital 1's ED? EI # 3 replied, "No." He stated that he asked the ambulance personnel if they had called TCC. I talked to the patient and explained that Hospital 1 did not have a surgeon. EI # 3 stated that the patient was irritated... EI # 3 stated that he did not tell EMS not to bring the patient into Hospital 1's ED.

An interview was conducted on 6/12/2013 at 4:35 PM with the EI # 4, ED RN, who was working in Hospital 1's ED on 6/6/2013. EI # 4 stated the ED received a call from EMS advising they were aware of the helicopter cancellation, but stated they might need to bring the patient to Hospital 1 for stabilization. EI # 4 stated she moved a patient out of the trauma room in order to make the trauma room available.

Review of Hospital 1's Policies/Procedures

Title: Admission to the Emergency department

Key Function: Assessment of Patients

Purpose: To ensure appropriate patient admission to the ER (Emergency Room).

Policy: Nursing staff will conduct an initial triage and the Medical Staff will complete a thorough medical screening of any individual who comes to the department and requests an examination or treatment and to determine if an "Emergency Medical Condition" exists or if the individual is in active labor. Once such a determination is made, the hospital must provide for either stabilization treatment or an appropriate transfer of the individual.

COBRA (Consolidated Omnibus Budget Reconciliation Act) 1985 defines the term "Emergency Medical Condition" as a "Medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
1. Placing the patient's health in serious jeopardy.
2. Serious impairment to bodily functions or serious dysfunction of any organ or part ...

B. Policies/Procedures
Title: MSO Process - Medical Screening Guidelines
Key Function: Assessment of Patients
Statement of Purpose: To delineate the guidelines for triaging less acute patients to the MSO Process for their medical screening examination, and to set forth the treatment options for patients who are determined not to have and emergency medical condition ...

Definitions:
... 5. MSO Process: A process designated for less acute Emergency Department patients completion of a Medical Screening Examination by a QMP to determine whether an emergency medical condition does or does not exist and then ensures that the patient is provided with stabilizing care or transfer if an emergency medical condition does not exist.

Policy: All patients who present to the Emergency department for medical care or treatment, regardless of ability to pay, will be triaged and receive a MSE by a QMP. Upon completion of the MSE, patients who have emergency medical conditions shall be stabilized or transferred in accordance with state and federal law...

Procedure:
D. MSE Completion in the QMP Process

After the MSE is completed via the MSO Process, the QMP will make one of the following determinations:
1. The QMP cannot determine whether an emergency medical condition exists in the MSO Process because the patient needs further screening (x-rays, labs, etc.). In this case the patient will remain in the Emergency Department for further screening, stabilization, or transfer in accordance with federal and state law and Hospital policy.

2. The patient does have an emergency medical condition which cannot be stabilized in the MSO Process. In this case, the patient will remain in the Emergency Department in accordance with federal and state law and Hospital policy ...

Expected Outcomes: Patients will be triaged, receive a MSE by a QMP, and either be stabilized or transferred if their condition is emergent...

Based on interviews, review of hospital Emergency Medical Treatment and Labor Act (EMTALA) Policies and Procedures and review of the Emergency Medical Services (EMS) Report, Hospital 1 failed to follow their EMTALA policy and procedures as it relates to an appropriate transfer of Patient Identifier (PI) # 1, a patient with a gunshot wound to the left arm, determined by the Emergency Department (ED) Physician at Hospital 1 on 6/6/2013 to need the services of a Trauma Surgeon (service not available at Hospital 1), to Hospital 2.

This deficient practice effected PI # 1, one of 27 sampled patients who presented to Hospital 1's Emergency Department and has the potential to negatively effect all ED patients requiring or requesting transfer from Hospital 1 to another facility.


Findings include:

Review of the Emergency Medical Services (EMS) Run report #68901 dated 6/6/13 revealed the following:
"... Narrative: ... As arrived at (Hospital 1) at 0248 were advised that helicopter was turned around due to fog and to take pt straight to (Hospital 2) by ground; Once pt heard of this he stated, "No, I want to go into this hospital here to for some pain relief to get easy! He stated that he could not tolerate the ride otherwise." Called to tell Hospital 1 by HEAR (Hospital Emergency Administrative Radio) system of this; As we started to unload pt from unit we were met at the hospital doors by ER (Emergency Room) MD (Medical Doctor) ... and the ER RN (Registered Nurse). They stated... We do not have a trauma surgeon and TCC advised to take patient to (Hospital 2)....

... Here is the phone we have called the TCC for you and they want you to head to (Hospital 2). I talked with the TCC rep (representative) and told him my situation that the patient requested to go into the hospital for pain relief and to see a MD since he hadn't seen one... they didn't know what to tell me but that if (Hospital 1) refused to allow entrance to hospital... load the patient and give what meds we had for pain relief and take to (Hospital 2). We then loaded pt back into the unit and @ 0256 went en route to (Hospital 2) by ground..."


Review of Hospital 1's Policies/Procedures


Title: Transfers
Key Functions: Care of patient.
Statement of Purpose: To insure high quality care to all patients if a service is not available to Atmore Community Hospital (Hospital 1), the patient will be transferred to a facility equipped to provide the service required via the most efficient transportation method available at the time.
Policy:
1. No patient will be transferred arbitrarily.
2. The attending physician must give the order to transfer a patient to another facility and complete the Transfer Form - Important Legal Notice ...
... 4. Physician to physician contact will be made prior to transfer.
5. There must be confirmation from the receiving institution that they are able to accommodate the patient and the patient must be sufficiently stabilized prior to transport ...
11. Patient Transfer Form/Authorization form must be completed.

Expected Outcomes: Safe and efficient transfer of the patient ...



Hospital 1 failed to follow their EMTALA policy and procedures as it relates to the appropriate transfer of PI # 1 on 6/6/13 to Hospital 2, in that Hospital 1 failed to:

1. Provide an appropriate medical screening exam and stabilizing treatment,including pain management, which the facility had the capacity and capability to perform.

2. Provide physician to physician contact with Hospital 2 prior to the transfer of PI # 1.

3. Receive confirmation from Hospital 2 that they were able to accommodate and care for PI # 1.

4. Provide and complete Patient Transfer/Authorization forms for PI # 1.