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Based on policy review, medical record review, and staff and physician interview the hospital failed to comply with 489.24 by failing to ensure that an orthopedic specialist physician on call for duty in the dedicated emergency department (DED) responded to a request from the DED physician to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition for 1 of 8 sampled DED patients with fractures (Patient #7) and failing to ensure an appropriate medical screening examination was completed for a patient with an emergency medical condition for 1 of 25 sampled patients that presented to the hospital's dedicated emergency department (Patient #3).

The findings include:

1. ~cross refer to Tag A2404

2. ~cross refer to Tag A2406

Based on policy review, medical record review, and staff and physician interview the hospital failed to ensure that an orthopedic specialist physician on call for duty in the dedicated emergency department (DED) responded to a request from the DED physician to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition for 1 of 8 sampled DED patients with fractures (Patient #7).

The findings include:

Review of current hospital policy entitled "EMTALA Policy" dated 12/31/2009 revealed, "On-Call Physicians Hospitals must maintain an 'on-call' list of physicians to see patients with potential medical conditions in the emergency department....An on-call Physician must come to the Medical Center or provide follow-up care when requested by a Physician who is on the Medical Staff, another Physician, a nurse, or any Medical Center worker making the request on behalf of a Physician or nurse who is not available to call the on-call Physician directly. In the event that the on-call Physician disagrees with the Physician making the request about the need to come to the Medical Center or provide follow-up care, the on-call Physician must still render the requested care....If requested, the on-call Physician shall be physically present in the Medical Center to assist in providing an appropriate medical screening examination, as well as ongoing stabilization and treatment of a patient prior to transfer or treatment. Seeing the patient at the on-call Physician's office or clinic is not an option until the patient is determined to be 'stable' or not to have an 'emergency medical condition'."

Closed record review for Patient #7 revealed an 8 year old male presented to the DED on 7/01/1010 at 1911 following a left wrist injury. Record review revealed a Physician Assistant (PA #1) evaluated the patient at 1945 and ordered a left wrist x-ray. Review of the x-ray results revealed a fracture of the left distal Radius (wrist). Record review revealed on 7/01/2010 at 2144 PA #1 called the on-call orthopedic specialist physician (Physician #1) regarding Patient #7's condition. Review of PA #1's progress note at 2144 revealed, "Physician consultation: (Physician #1) regarding patient's condition, (Physician #1) states that the ED can take care of this dislocation and he refused to come in to see the patient. He gave us the option of sending him to outpatient surgery tomorrow if we do not reduce the joint or if we reduce the joint, he will see them next week in the office." Record review revealed the fracture was reduced by the DED physician (Physician #4) and then splinted. Record review revealed the patient was discharged to home at 2151 with instructions to return to the hospital's outpatient surgery department on the following morning to be checked by Physician #1.

Interview on 7/08/2010 at 1210 with the PA #1 revealed Physician #4 (the DED physician) instructed the PA to call the on-call orthopedic specialist physician (Physician #1) and request that he come to the DED to evaluate and treat Patient #7. Interview revealed the DED was very busy that day and the DED physician was involved with a serious emergency and could not reduce the fracture. Interview revealed the PA was unable to reduce the fracture without the physician being present. Interview revealed the PA called Physician #1 and told him that the DED physician wanted him to come see Patient #7. Interview revealed Physician #1 stated that this was a reduction that could be handled by the DED staff and he would not come in to see the patient. Interview revealed, "Most of time he (Physician #1) doesn't come in when asked....He has never come in on any of my cases." Interview revealed PA #1 estimated that she had asked Physician #1 to come in on a total of 5 or 6 cases.

Physician #4 was not available for interview.

Interview on 7/08/2010 at 1255 with Physician #1 revealed PA #1 called him on 7/01/2010 and requested he come to the DED to reduce a left distal Radius fracture on Patient #7. Interview revealed PA #1 reviewed the x-ray findings with Physician #1. Interview revealed the physician did not have access to x-ray reports because he was not at home, but thought the DED physician could reduce the fracture. Interview revealed Physician #1 was aware the DED physician had requested him to come in and see Patient #7. Interview revealed when Physician #1 asked why he was being asked to come see Patient #7, the PA stated it was because the DED was very busy and the DED physician had an emergency. Interview revealed, "Not having time to do the reduction was not a reason for me to come in." Further interview revealed Physician #1 had not received any EMTALA training at Hospital A and he was not aware he was required to go to the DED to provide further evaluation or treatment when requested to do so by the DED Physician.

Interview on 07/07/2010 at 1730 with the DED Medical Director (Physician #3) revealed if a DED physician requests the on-call specialty physician to come to the hospital and see the patient, then the on-call specialty physician must come in and see the patient. Interview revealed there had been some discussion between DED physician staff and Physician #1 regarding what types of orthopedic procedures the DED physicians could perform. Interview revealed, "I am having a meeting on Friday with (Physician #1) about the appropriateness of fractures we (DED physicians) can reduce."

Based on policy review, closed medical record review, and staff and physician interview the hospital failed to ensure an appropriate medical screening examination was completed for a patient with an emergency medical condition for 1 of 25 sampled patients that presented to the hospital's dedicated emergency department (Patient #3).

The findings include:

Review of current hospital policy entitled "EMTALA Policy" dated 12/31/2009 revealed, "An appropriate medical screening examination (MSE) must be performed on the presenting individual by 'qualified medical personnel' (QMP)....in the emergency department, the MSE may be performed by a QMP who is a physician or physician assistant....The full capabilities of the Medical Center and its staff must be utilized if necessary to determine whether an 'emergency medical condition' (EMC) exists. An EMC is defined as a conditions that manifests itself by acute symptoms of sufficient severity, including symptoms of pain,...such that the absence of immediate medical attention could reasonably be expected to result in: (1) placing the individual's health...in serious jeopardy, (2) serious impairment to bodily function or dysfunction of any bodily organ or part...."

Review of current hospital policy entitled "Role of the Advanced Practice Clinician (APC) in the ED (emergency department) dated 10/30/2009 revealed, "The Physician Assistant (an APC)...functions at all times under the supervision of the Emergency Physician on duty in the emergency department. Supervision of the APC does not require direct involvement or the personal presence of the supervising physician during each patient encounter. A physician will however, review the case with the APC and visit the patient....Patients should be given the option of seeing the attending physician prior to discharge....The primary function of the APC is to manage triage level 4 and level 5 patients (Minor Acuity). However, APCs will also function in the main ED during times when there are few minor acuity patients, or when the physician on duty deems necessary...."

Medical record review for Patient #3 revealed a 51 year-old male that presented to Hospital A's dedicated emergency department (DED) accompanied by his caretaker on 05/25/2010 at 1705 with complaints left leg numbness and pain following a fall onto his left leg that he sustained on 05/27/2010. Record review revealed at 1718 the triage nurse assessed the patient and assigned the patient an acuity level of 4. Review of the triage nurse's note at 1718 revealed, "Complains of pain in left leg. Pain currently is 10 out of 10 on a pain scale (of 0-10 with 10 being the worst pain)." Record review revealed at 1822 a physician assistant (PA #2) evaluated the patient and ordered a left knee X-Ray, which was done at 1837. Review of the left knee X-Ray results revealed no fracture, rather "meniscal calcification/chondrocalcinosis (calcium deposits associated with arthritis)". Record review revealed at 1848 the PA ordered an Ace Wrap to the patient's left knee. Record review revealed at 1921 the patient was discharged to home with his caretaker with instructions to follow up with his primary care physician in 2-3 days if his symptoms worsened or did not improve. Review of PA #2's progress notes at 1926 revealed, "This 51 year old Caucasian Male presents to ED via Wheelchair with complaints of Fall injury, Leg Injury - LT (left)....The patient fell from seated position, out of a chair....The patient sustained left knee, contusion, ecchymosis, painful injury, swelling....At their worst the symptoms were mild, in the emergency department the symptoms are unchanged. The patient has experienced similar episodes in the past, several times.......PMHx (past medical history): Atrial Fib (irregular heart rhythm); GERD (gastric reflux)....Exam:...The patient appears in no acute distress, comfortable, non-diaphoretic, non-toxic, well developed. Musculoskeletal/extremity: Extremities: noted in the left knee: contusion, ecchymosis, pain, swelling, Perfusion: the extremity is pink, warm, with brisk capillary refill, Calf tenderness, is absent, Edema, 1+ to the left knee is noted, Sensation intact....Differential diagnosis: contusion, fracture, sprain, strain...." Review of the DED physician's (Physician #2) note at 1927 revealed, "Attestation: The patient's history, exam findings, diagnostics, and a summary of any interventions or procedures was reviewed in detail with (PA #2)." Record review revealed, "Disposition: 05/28/10 18:50 Discharged to Home. Impression: Contusion (Bruise) Knee."

Further record review for Patient #3 revealed the patient returned to the DED (second visit) accompanied by his caretaker on 06/02/2010 at 1431 with complaints of left leg swelling and pain (5 days after his first visit to the DED). Record review revealed the triage nurse assessed the patient at 1434. Review of the triage nurse's note at 1434 revealed, "Patient states: he fell last Thursday and came in to be evaluated. Reports that they couldn't find anything last week. States that he did fall again yesterday. Swelling noted to left leg. Rates pain 10/10." Record review revealed the triage nurse assigned the patient an Acuity Level of 3 (more acute than a Level 4). Record review revealed at 1448 PA #2 evaluated the patient. Review of PA #2's progress notes at 1512 revealed, "The patient presents with a contusion, an injury, pain, that is acute, swelling. The complaints affect the left knee, left shin, anterior aspect of left ankle and dorsum of left foot. Context: The problem was sustained at a nursing home or assisted living facility, resulted from the patient falling, while walking, the patient is not able to bear weight, the patient is not able to ambulate. Onset: The symptoms/episode began/occurred yesterday. Modifying factors: the symptoms are aggravated by bending the knee....Pertinent positives: calf tenderness, swelling, warmth....At their worst the symptoms were moderate, in the emergency department the symptoms are unchanged....PMhx: GERD; Atrial Fib....Exam:...The patient appears in no acute distress, non-diaphoretic, non-toxic, well developed, well hydrated....Musculoskeletal/extremity: Extremities: noted in the dorsum of left foot and anterior aspect of left ankle and left shin and left leg and left knee: contusion, ecchymosis, pain, swelling, tenderness, DVT (Deep Vein Thrombosis) Exam: pain, swelling, tenderness, bluish discoloration, increased warmth, that is moderate, of the left leg....Differential diagnosis: contusion, abrasion, DVT. Record review revealed at 1449 the PA ordered X-Rays of the left knee and left tibia and fibula (lower leg) and a venous ultrasound of the left leg. Record review revealed the X-Ray results of the left knee and left lower leg showed no fracture, but rather "Generalized soft tissue swelling. Chondrocalcinosis.". Record review of the venous ultrasound results showed no evidence of DVT. Record review revealed at 1516 the PA ordered the following lab tests: Complete Blood Count with Differential (CBC with Diff), PT (Prothrombin Time), PTT (Partial Thromboplastin Time), and BMP (Basic Metabolic Panel). Review of the lab test results revealed a hemoglobin of 8.5 gm/dl (grams per deciliter; low - reference range = 13.2 - 17.5 gm/dl) and a hematocrit of 24% (low - reference range = 39 - 51%). Review of past medical records for Patient #3 revealed the last documentation of the patient's hemoglobin and hematocrit prior to 06/02/2010 was on 10/10/2009. Review of the 10/10/2009 record revealed a hemoglobin of 13.3 gm/dl (within normal limits) and a hematocrit of 39% (within normal limits). Record review revealed the PA ordered for a Hemoccult test of the patient's stool (test to check for blood in the stool). Review of PA #2's progress notes at 1551 revealed, "Heart sounds normal....the patient does not display signs of respiratory distress....Rectal exam:...Stool: brown, soft, Guaiac (Hemoccult) testing: results were negative for occult blood." Review of PA #2's progress notes at 1554 revealed, "...I discussed with the patient/guardian in detail that at this point there is no indication for admission to the hospital. It is understood, however, that if the symptoms persist or worsen the patient needs to return immediately for re-evaluation." Review of the DED physician's (Physician #2) note at 1552 revealed, "Attestation: The patient's history, exam findings, diagnostics, and a summary of any interventions or procedures was reviewed in detail with (PA #2)." Record review revealed no documentation that Physician #2 saw the patient. Record review revealed, "Disposition: 06/02/10 15:54 Discharged to Home. Impression: Fall, Contusion Lower Leg, Anemia (low red blood cells)....Follow up: (Name of primary care physician); When: Tomorrow; Reason: Further diagnostic work-up...." Record review revealed at 1602 the patient was discharged to home with his caretaker.

Further record review for Patient #3 revealed the patient returned to the DED (third visit) accompanied by his caretaker on 06/05/2010 at 0949 with complaints of swelling of his left leg and bruising of his penis (3 days after his second visit to the DED). Record review revealed the triage nurse assessed the patient at 0951. Review of the triage nurse's note at 1004 revealed, "Large amount of swelling noted to left leg. bruising in left side of penis and groin area. pt reports pain in leg." Record review revealed the triage nurse assigned the patient an Acuity Level of 3. Record review revealed at 1008 the DED physician (Physician #3) examined the patient. Record review revealed lab tests performed on the patient included: CBC with Diff, PT, PTT, Urinalysis and CMP (comprehensive metabolic panel). Record review the patient had X-Rays done of his left hip, left knee and chest. Review of left hip X-Ray results timed 1026 revealed, "Impression: Comminuted left-sided intertrochanteric fracture with mild varus angulation." Review of the lab test results revealed a hemoglobin of 8.3 gm/dl (low) and a hematocrit of 25% (low). Review of Physician #3's progress notes revealed, "10:27 The patient or guardian reports deformity, an injury, pain, swelling. that occurred at a nursing home or assisted living facility, sustained from a fall, There is no obvious deformity. 10:31 The complaints affect the left leg. Onset: The symptoms/episode began/occurred 1 week(s) ago....The symptoms are alleviated by nothing, the symptoms are aggravated by any movement, extension, flexion....per caretaker patient normally walks....Exam:...left hip, lateral aspect of left thigh, left gluteal fold, left hamstring, left inner thigh, medial aspect of left thigh, left upper thigh and left quadriceps: contusion, deformity, ecchymosis, pain, swelling...." Record review revealed Physician #3 planned to admit the patient, but the patient's mother and sister (co-guardians of the patient) requested for the patient to be transferred to Hospital B (another acute care hospital). Record review revealed at 1537 the patient was transferred to Hospital B via EMS (Emergency Medical Services).

Interview on 07/07/2010 at 1400 with PA #2 revealed on Patient #3's first DED visit (05/28/2010) the patient had fallen from a seated position, out of a chair at the group home where the patient lived. Interview revealed the patient complained of pain in his left knee and had swelling of his left knee and lower leg. Interview revealed the patient was accompanied by a group home worker. Interview revealed the PA ordered an X-ray of the patient's left knee, which showed some arthritis in the knee. Interview revealed the PA diagnosed a contusion and discharged the patient back to the group home with instructions to use ice to his knee and keep the knee elevated. Interview revealed the PA was not sure whether or not the patient could walk during the first DED visit. Interview revealed the patient returned to the DED accompanied by a group home worker on 06/02/2010 for a second time. Interview revealed the patient had fallen at the group home again on 06/01/2010. Interview revealed the patient had more bruising and swelling of his left calf, lower leg and foot. Interview revealed the patient complained of pain below his left knee and in his left lower leg. Interview revealed the PA ordered X-Rays of the patient's left knee and lower leg and an ultrasound of the left leg to rule out DVT. Interview revealed the X-Ray results showed generalized soft tissue swelling. Interview revealed the PA checked the patient's lab work because of the amount of bruising that was present. Interview revealed, "He had chronic anemia. His hemoglobin was 8.5 (gm/dl)." Interview revealed the PA knew the patient's anemia was chronic, rather than an acute change, because he had reviewed the patient's medical records from a previous hospitalization and found that he also had a low hemoglobin and hematocrit then. Interview revealed the PA was not sure whether or not the patient could walk during the second DED visit. Interview revealed the PA diagnosed contusion of the left lower leg and anemia. Interview revealed the PA discharged the patient back to the group home with instructions to use ice to his knee, keep the knee elevated and no weightbearing on the left leg. Interview revealed the PA instructed the patient to follow up with his primary care physician the next day. Interview revealed the DED physician routinely sees all patients that the PA evaluates in the DED. Interview revealed, "As far as I know (Physician #2) saw the patient on both visits." Further interview revealed the PA was aware the patient had returned to the DED for a third visit and was diagnosed with a left hip fracture. Interview revealed, "It was mentioned to me by one of the nurses or providers."

Interview on 07/08/2010 at 0940 with Physician #2 revealed PAs can evaluate and treat patients that are triaged as acuity levels 3, 4 and 5 in the DED. Interview revealed, "(If a patient is) level 3 or higher, we (DED physicians) see the patient. Level 4 or 5, we use our discretion as to determine if we see the patient." Interview revealed Patient #3 was triaged as Acuity Level 3 on 06/02/2010, during the second DED visit. Interview revealed, "I don't recall seeing the patient on the first or second visit. My signature in the record during the first and second visits means that (PA #2) reviewed the chart, workup and findings with me and I agreed that the evaluation and treatment were appropriate." Interview revealed Physician #2 had reviewed the patient's medical record again on the morning 07/08/2010 (morning of the interview). Interview revealed, "Most often (one would) X-Ray above and below the area of pain. X-Rays of the pelvic area and hip could have been, should have been done on the first and second visit." Interview revealed the physician did not recall if he had reviewed the patient's hemoglobin and hematocrit results on 06/02/2010 (second visit). Interview revealed, "I don't know if I was aware of it (low hemoglobin and hematocrit results) during the second visit." Interview revealed the DED Medical Director (Physician #3) had previously (unsure of date) told the physician that the patient had returned to the DED in less than 72 hours after he was discharged on 06/02/2010. Interview revealed, "(Physician #3)discussed the case with me. I don't recall the exact discussion. I know he (the patient) was diagnosed with a hip fracture and was transferred to another facility."

Interview on 07/07/2010 at 1730 with Physician #3 (DED Medical Director) revealed for patients with extremity injuries, X-Ray studies should be done of "the joint above and below" the site of injury. Interview revealed, "I review all 72 hour returns. I spoke with (PA #2) and made recommendations for future care of patients with extremity injuries." Interview revealed the Medical Director did not recall having discussed the return visit incident with Physician #2. Further interview revealed Patient #3's evaluation and treatment during the second visit (06/02/2010) should have included: (1) X-Rays of the joint above and below the left knee (hip and ankle) and (2) more questions related to the patient's recurrent falls and anemia.

Interview on 07/07/10 at 1630 with the Vice President (VP)of Operations revealed the VP became aware of the incident on 06/25/2010 when he received an e-mail complaint on behalf of Patient #3. Interview revealed the complaint stated that the patient was seen in the DED three times before a hip fracture was diagnosed. Interview revealed the VP investigated the complaint and found the patient had Prader-Willi syndrome (genetic disorder characterized by an extreme and insatiable appetite) and mild mental retardation. Interview revealed the VP also found that the normal practice of the group home was to send a patient's medical history to the hospital with the patient. Interview revealed there was no documentation the DED staff had reviewed the patient's medical history provided by the group home staff. Further interview revealed there were no X-Rays done of the proximal and distal areas of the patient's injury. Interview revealed, "That's something we missed."


NC00064972