HospitalInspections.org

Based on interview, policy review, Emergency Department (ED) logs, and record review the hospital had a failure to provide a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#18) of 31 ED patients records reviewed. The hospital's ED average monthly census over the past six months was 7251.

The patient presented from another ED with a confirmed fracture of her cervical vertebra, which had been immobilized with a hard cervical collar. The attending physician then consulted neurology via phone, and neurology recommended treatment plan of immobilization, stabilization, and pain management.

The patient was kept in a hard cervical collar for immobilization, had been given analgesics for pain control, and had been discharged and transferred via ambulance to a skilled nursing facility. Patient had been given instructions to follow up with neurology in 1-2 weeks at time of discharge. No bedside visit from neurology had been conducted prior to discharge from the ED.

The complaint was found to be unsubstantiated with no citations.

Based on interview, policy review, Emergency Department (ED) logs, and record review the hospital had a failure to provide a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#18) of 31 ED patients records reviewed. The hospital's ED average monthly census over the past six months was 7251.

Findings included:

Review of the "Medical Staff Bylaws for Mercy Hospital Springfield," approved 05/21/19, showed that:
- When a patient presents to the Emergency Trauma Center (ETC) they must receive an appropriate medical screening examination (MSE) in order to determine whether or not an emergency medical condition (EMC) exists.
- An EMC is a condition that if left untreated may place the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
- The facility will provide treatment in order to stabilize the EMC.

Review of the facility's policy titled, "Emergency Medical Treatment and Active Labor Act - EMTALA," approved 08/22/18, showed that:
- An MSE is to be provided to each individual presenting to the ED to determine if an EMC exists.
- If it is determined that an individual has an EMC, they should receive necessary stabilizing treatment, appropriate transfer to another hospital, or if necessary be admitted as an inpatient for further care.
- A stabilized patient is one who has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be reasonably performed on an outpatient basis, provided they are given a plan for follow-up care.
- A patient is stabilized even if his/her underlying medical condition has not been resolved.

Review of the facility's policy titled, "Medical Screening Exams in the Emergency Trauma Center," approved 10/17/18, showed that:
- The MSE is performed to determine if an EMC exists;
- Any person presenting to the ED will receive an MSE;
- The MSE is an ongoing process, and should include a generalized assessment and a focused assessment based on the patient's chief complaint.

Review of the ED log showed presentation by Patient #18 on 05/16/19 at 3:45 AM, had an MSE by attending physician directly after, and Neurology had been consulted at 4:10 AM.

Review of Mercy Emergency Trauma Center - Incoming Patient Date Sheet (documentation of a brief ambulance crew report, nurse to nurse report, and doctor to doctor report, that occurred prior to the patient being transferred to the facility), dated 05/16/19 at 1:36 AM, showed that:
- Patient #18 was a 93 year old female that had been transferred for evaluation after a fall from a bar stool at home.
-She had a history of hypertension (HTN, high blood pressure) and had been taking medication for the HTN along with blood thinners (a high risk medication that can cause unwanted bleeding).
- The ambulance vitals had been documented as a blood pressure (BP, a measurement of the pressure of blood flow in two different parts of the heart, normal is approximately 90/60 to 120/80) of 190/88, heart rate (HR, the rate at which the heart beats, normal adult range is 60 to 100 beats per minute) of 92 bpm, and oxygen saturation (O2 sat, a percentage of how much oxygen is being carried in a person's blood) of 95% without oxygen.
- The nursing report vital signs had been documented as BP 188/107, HR 86, O2 sat of 92% without oxygen.
- The transferring facility (Hospital B) had determined that she had a cervical (neck) vertebrae (a series of small bones that protect the spinal cord from brain to tail bone) C1 (first vertebrae) fracture (fx, a crack or break in a bone), and had placed her in a cervical collar (C collar, neck brace used to support a person's neck).
- Staff I, ED MD, had been the Medical Control Physician, whom spoke with transferring facility to obtain a history and to accept transfer. She noted that her neuro status (the examination of a person's mental status, muscle strength, reflexes, coordination, sensory function, and gait) had been intact, and the computed tomography (CT, a combination of X-rays and a computer to create pictures of your organs, bones, and other tissues, which shows more detail than a regular X-ray) of her head had been negative (no abnormal findings).

Review of Staff M's, RN ED, arrival note for Patient #18, dated 05/16/19 at 3:50 AM, showed that:
- She had arrived by ambulance to the ED at 3:45 AM.
- She had fallen off a stool at home, and developed severe neck pain.
- She lived alone, but had been able to activate her life alert button (a wireless button worn by the elderly that they can activate to contact emergency help if they have fallen, or are injured).
- She had been evaluated at the outside hospital and had been found to have C1/C2 fx. During transport from the outside hospital, the ambulance crew had given her Fentanyl (a narcotic given to treat severe pain) 50 micrograms (mcg, a measure of dosage strength) intravenous (IV, in the vein) and Zofran 4 mg IV, to manage her pain, and to provide prophylaxis for nausea.
- Upon arrival she had been able to communicate to the nurse that she self-catheterized (to insert a urinary catheter, a small flexible tube inserted into the body through an opening of the urinary tract to drain urine) at home.
- She had been alert and orientated (aware of herself, those around her, her location, and date and time), and she had not shown signs or symptoms of acute distress.

Review of Patient #7's ED medical record dated 05/16/19 showed:
- MSE had been conducted by Staff I, ED MD at 3:45 AM and noted that she had denied any weakness, numbness, headaches, or visual disturbance.
- She had indicated that she had some neck pain, self- catheterized at home, and bruised or bled easily due to anticoagulants.
- Physical exam noted she had appeared to be well developed and well nourished.
- She had not been noted to be in any distress. The cervical collar had been in place.
- There had been a superficial abrasion to her right forehead. Her pupils were noted to have been equal, round, and reactive to light. Her heart sounds were documented as had been normal, distal pulses intact, and she had an irregular rhythm. Her breath sounds had been documented as normal. She had documented normal range of motion (ability to move arms and legs in a normal fashion). She had normal strength.
- She had been alert, with normal mood and affect, her behavior had been normal, and she had denied any sensory deficits.
- At 4:10 AM, Staff I, ED MD, noted that she had spoken with Staff K, MD, Neurosurgeon, whom recommended that Patient #18 continue to wear the C collar, and follow-up in his office.
- At 4:11 AM, Patient #18 had a urinary catheter inserted by Staff M, ED RN.
- AT 4:23 AM, Staff M, ED RN, documented a Trauma Primary Assessment. Patient #18's airway had been patent, lungs were clear, spinal precautions were in place, she had been alert, and her pupils were equal and reactive to light.
- There had been no obvious external injuries noted. Her motor and sensory function of all extremities were documented as normal.
- She had rated her pain in her neck at an 8 on the pain scale, and had described it as a constant ache.
- At 5:13 AM, Staff I, ED MD, noted that Patient #18 had been resting comfortably in bed, and not in any distress. She had discussed the plan of care with Patient #18 and her family. The family had expressed concern that she would not be safe to discharge to home since she lived alone, and would need to self-catheterize. So it had been planned that case management would be consulted for potential disposition options.
- At 5:30 AM, Staff I, ED MD, had placed an order for case management to assist with discharge planning.
- At 5:40 AM she had been moved from a trauma room into another room pending discharge.
- At 5:56 AM, Staff M, ED RN, noted that there had been concerns regarding her discharge. She had spoken with the ED physician and facilitated an order for case management.
- Family agreed to wait in the ED along with the patient until case management's arrival. She had been moved to another room pending discharge.
- At 7:33 AM, she had been rounded on while family spoke with case management. No needs were voiced.
- At 7:34 AM, Staff H, RN, Case Manager, started the assessment process for proper placement of her.
- At 11:00 AM, she had requested pain medication, day shift physician had been notified of request.
- At 12:08 PM, Staff H, RN, Case Manager, documented the final discharge plan for Patient #18 to include transfer to LTC facility by ambulance.

Review of the medication administration report (MAR, a list of medications that have been ordered for the patient by the physician, and where RN's document administration of medication) dated 05/16/19 at 5:05 AM, showed that:
- She had been given Lopressor (a medication for high blood pressure) 25 mg and Hydrochlorothiazide (a medication used in conjunction with a blood pressure medicine to lower a patient's blood pressure) 12.5 mg by mouth to lower her blood pressure.
-At 12:36 PM she had been given Fentanyl 50 mcg IV for pain rated at a 10 on a pain scale of 1 to 10, by Staff L, ED RN.
-At 1:00 PM, Staff L, ED RN, had rounded on her and documented that she had been resting quietly.
-At 2:49 PM she had been given Fentanyl 50 mcg IV for pain rated at an 8 on a pain scale of 1 to 10, by Staff L, ED RN. He documented that he had discussed the plan of care with her at that time.
-At 3:00 PM, Staff L, ED RN, had removed her IV catheter.
-At 3:18 PM, she had been discharged to LTC facility by ambulance stretcher.

During an interview on 6/24/19 at 3:30 PM, Staff A, RN, stated that she had EMTALA training upon hire and has had it annually thereafter. And that during triage, acuity level is determined based on assessment and if emergent care is needed patients would be sent back and roomed immediately.

During an interview on 6/24/19 at 3:45 PM, Staff C, RN in training, stated that he had received EMTALA training upon hire, and he had verbalized understanding. He stated that the patient assessment tool helps to determine acuity and that the flow facilitator would also assist if needed to prioritize care based on need.

During an interview on 6/25/19 at 10:14 AM, Staff H, RN Case Manager, stated:
- They are asked to get involved with discharge planning and placement needs are needed and she would assess the needs for placement on an individual basis.
- They use an assessment tool to help them determine physical and cognitive ability to assist with discharge planning.
- The age of the patient, their insurance, their activity level at home, and whether they live alone or with others, would determine the type of placement that they may be eligible for.
- If long term care or skilled nursing services are indicated, and the patient meets criteria, case management works with family by providing a referral list of facilities based on Medicare Guidelines.
- They provide education on the financial responsibilities of each party.
- The patient/family must give her consent to inform a potential facility of the anticipated needs of the patient and permission to send over the medical record for review.
- She would inform the patient/family of the potential financial obligation that may be incurred if they would transfer into a LTC facility.
- Once a bed is located, the patient/family would need to decide about whether or not to pursue the placement, and accept the financial options.
- It is common practice for a LTC facility to require a patient/family to relinquish their social security check, or to agree to private pay at an average of $185.00 per day for the duration of their stay.
- Case Management stays involved all the way through discharge, to include assistance with transportation when needed.
- If a family does not wish to transport the patient, or is unable to transport the patient in their private vehicle, she would then assist them with transport via ambulance.
- She would advise them that if Medicare did not cover the transportation, they would be obligated to pay for that transportation out of pocket. It could be very expensive for ambulance transport.
- She is responsible for making sure that patients and their family members are well aware of the potential financial burden that a transfer to an LTC facility can be to them.
- During the assessment process the physician would be updated with any decisions that are made to ensure that the appropriate level of care is obtained.

During a concurrent interview on 6/25/19 at 11:00 AM, Staff I, Medical Doctor (MD), ED Physician, and Staff J, MD, Medical Director stated:
- Physicians are educated during their residency, and yearly by computer about EMTALA.
- The purpose of EMTALA is to identify, treat, and stabilize an Emergency Medical Condition (EMC) within the capability of the facility.
- Each patient that presents to the ED would receive an MSE specific to their chief complaint to include a review of vital signs, past medical history, and body system assessments.
- The MSE is tailored to the individual complaint, and the goal is working to identify the problem and stabilize.
- The facility routinely receives patients form outlying facilities and Critical Access Hospitals (CAH) for the purpose of being evaluated by a neurosurgeon.
- If a patient already had a CT, images would be uploaded for the neurosurgeon to review, and unless there had been a change in the patient's condition, there would not be a need to repeat the CT.
- Anytime a patient presents to the ED for an evaluation by a specialist, the ED physician would always communicate with them to determine a clear plan of treatment.
-It is physician's discretion and clinical judgment, based on case and need, that would determine if bedside visits would be needed from specialists when consulted.
- When fractures are involved, cases are reviewed on a case-by-case basis and an appropriate treatment for any patient with a C1/C2 fracture would be to determine if the fracture was stable or not, stabilize it, and provide pain management.
- Multiple factors go into determining if surgical repair of a cervical fracture is warranted, with the main factor being type and stability of fracture.
- Even when surgery is considered a possible solution for repair, the fracture would be stabilized and the patient would be discharged with instructions and a follow-up with the specialist.
- A stable C1/C2 fracture would be treated the same as a stable wrist fracture, stabilize the fracture (brace), manage pain, and have the specialist re-evaluation at a later date to determine if surgery would be necessary.

During an interview on 6/25/19 at 11:58 AM, Staff K, Neurosurgeon, stated:
- He had been practicing since 1998.
- He is often called for consults of fractures that involve the spinal cord.
- When asked to review Patient #18's CT images, he stated he would classify her C1/C2 fracture as a type 2, borderline type 3 odontoid/dens, (a tooth-like projection from the second vertebrae on which the first vertebrae pivots) fracture.
- He did not see any malalignment (incorrect or imperfect alignment or displacement) of the cervical (neck) spine which meant the cervical curve was normal.
- That all the joints were visibly normal, which indicated this to be a stable fracture, and even more stable due to her advanced age and the amount of arthritis in her spine, which naturally fused (connected the individual bones together making them solid with little to no movement) the vertebrae.
- There are three ways to treat this type of fracture. Immobilization with a hard cervical collar, surgical repair, or a HALO (a vest and ring that stabilize the spine using screws inserted into the patients skull, and tightened enough to prevent movement).
- The typical surgical candidate with this type of fracture would be between the ages of 12 to 60 years old.
- Children under 12 and adults over 60 have an increased risk of instability which would make surgical repair too risky.
- A risk/benefit analysis is always conducted on a case-by-case basis to include best plan of action.
- The gold standard or best practice with regards to an elderly patient would be to immobilize, send them home with a hard c-collar, manage their pain, and reassess the alignment in one to two weeks.
- Typically elderly patients do not tolerate the surgical intervention, and do poorly when immobilized with a HALO device.
- It is common practice to review any films or images electronically.
- If there would be a difference of opinion related to treatment plan, or any change in the patient's status, a bedside consult would have been appropriate.
- He had not consulted at bedside for Patient #18.

During an interview on 06/25/19 at 1:13 PM, Staff L, ED RN, stated:
- The main role of the nurse would be to assess their patient, monitor their orders, take care of any bedside needs, and monitor their vital signs and any diagnostic equipment.
- The patient's primary nurse would be involved in relaying to case management any patient needs, and any concerns voiced by the patient or their family. This would help to ensure that the proper level of care was obtained upon discharge or transfer.
- Part of the patient assessment would be to ask them to describe their pain utilizing a pain scale. With a complaint of pain, the patient would typically be given medications as quickly as possible.
- Once the medication was removed from the dispenser it would be given immediately, and he had never witnessed pain medications lying at the nurses' desk.
- Upon discharge, the patient/family would be given any new prescriptions, detailed instructions for continued care at home, and any information that may be needed regarding follow-up.
- He had administered pain medication to Patient #18 twice prior to her discharge from the ED.
- He had provided her family with discharge instructions, and ensured that proper documentation had been sent with her to the LTC facility.

During an interview on 06/25/19 at 2:09 PM, Staff M, ED RN, stated:
- When a patient arrived by ambulance, the paramedics on that trip would give the receiving nurse a bedside report.
- Prior to arrival, any patient being transferred to the ED for evaluation would have already had their information reviewed by the flow coordinator or a charge nurse. There would have been a doctor to doctor report, and a nurse to nurse report.
- Upon arrival to the ED, the patient would be placed in a bed for initial assessment. The ED physician would evaluate the patient and clear any spinal precautions (precautions taken to completely immobilize the spine and restrict movement to prevent injury to the spinal cord, ex. log rolling, or rolling as one to maintain proper alignment).
- When patient #18 arrived at the ED she had already had her C-collar in place. If any discs or images accompany the patient, they would be taken over to the CT technician so that they could be uploaded into the computer immediately. This would allow them to be ready for the physician to review.
- Pain level is always part of the assessment, and any medications removed from the medication dispenser are given right away.
- Patient #18's images had been uploaded. This had allowed the neurosurgeon to review them from a remote location and determine her plan of care.
- She had provided discharge instructions, in which the family had voiced concerns over.
- She had facilitated the order for case management to get involved and for Patient #18 to be moved from a trauma room, into a holding area to rest and await case management.

Patient #18 had arrived at the facility's ED department on 5/16/19 at 3:45 AM, she was discharged to a LTC facility the same day at 3:18 PM. The neurosurgeon had not physically examined her, nor had not spoken with the family. The CT results from Hospital B showed that she had a fracture involving the anterior arch and bilaterally posterior arch of C1; mildly displaced type 11 dens fracture. When the neurosurgeon reviewed the CT images, he stated that he would classify her C1/C2 fracture as a Type 2/Borderline Type 3 odontiod/dens fracture. He had determined that the fracture was stable and had recommended the treatment of immobilization and re-evaluation in 1-2 weeks.

The complaint was found to be unsubstantiated with no citations.