HospitalInspections.org

Based on findings from document reviews and interview, in 1 of 20 medical records (MRs) reviewed for patients presenting to the Emergency Department (Patient #9), the medical screening examination (MSE) provided was not timely. Findings include:-- Review of Patient #9's MR reveals the following information: At 1213 on 12/30/13, this 70 year old female patient presented to the emergency department (ED) at this hospital (Hospital #1) via ambulance following a fall, with chief complaint of a head injury without loss of consciousness. She had history of atrial fibrillation (an abnormality in cardiac rhythm) for which she was on Coumadin (anticoagulation medication). At 1220, ED Registered Nurse (RN) #1 triaged Patient #9 as level 2, urgent (on a scale of 1 - 5, level 1 being life-threatening). Large hematoma to occipital (back of the head) area of scalp was noted and normal findings from neurological and vital signs assessments were described. At 1225, ED RN #1 documented "physician evaluation expedited" and that the patient was "next to be evaluated by physician."At 1328, one hour after Patient #9 presented to the ED, Physician #1 began his/her MSE of the patient. -- Review of the ED Log for 12/30/13 did not reveal any increase in patient volume compared to other days. The patients presenting to the ED were mainly low acuity, not requiring emergent care.-- During interview of the hospital ED Medical Director on 2/19/14 at 3:10 pm and on 2/20/14 at 9:30 am, the findings above were discussed.
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Based on findings from document reviews and interview, in 1 of 7 medical records (MRs) reviewed for patients who required transfer to another hospital after presenting to the Emergency Department (Patient #9), there was failure to provide stabilizing treatment prior to the transfer.

Findings include:

-- Review of Patient #9's MR reveals the following information: At 1213 on 12/30/13, this 70 year old female patient presented to the emergency department (ED) at this hospital (Hospital #1) via ambulance following a fall, with chief complaint of a head injury without loss of consciousness. She had a large hematoma to the occipital (back of the head) area of scalp. This patient also had history of atrial fibrillation (an abnormality in cardiac rhythm) for which she was on Coumadin (anticoagulation medication).

A medical screening examination, which included a CT (computed tomography) scan of the head, was completed. At 1401 the CT report called to the ED identified the patient had a small to moderate subarachnoid hemorrage (a bleed into the cerebrospinal fluid-filled space between the arachnoid and pial membranes on the surface of the brain). The patient remained alert with no neurological changes. However, blood drawn at 1405 revealed her INR (International Normalized Ratio, a measurement of blood clotting time) was increased at 2.1 (normal 1.0 - 1.2).At approximately 1420, Physician #1 contacted Hospital #2, requesting to transfer the patient to a higher level of care for neurosurgical evaluation due to intracranial hemorrhage. Hospital #2 accepted the patient. At 1435 Physician #1 signed a transfer form, indicating the transfer by ambulance would occur with EMT ( emergency medical technician) staff trained in ALS (advance life support).At 1507 Registered Nurse (RN) #2 called a summary report to Hospital #2. At 1607 Patient #9 departed the ED from Hospital #1. (The patients' neurological and vital signs did not change between 1220 and 1607, and during the transport.)-- Due to the increased INR in this patient with subarachnoid hemorrhage, stabilizing treatment in the form of Vitamin K (which facilitates adequate blood clotting) should have been given to reverse the effects of the Coumadin prior to transfer. The increased INR was not addressed by Physician #1 in the MR documentation; Vitamin K was not given. -- During interview of the hospital ED Medical Director on 2/19/14 at 3:10 pm and on 2/20/14 at 9:30 am, the findings above were discussed.