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Based on observation, interview, review of medical records, policy and procedure, medical by-laws, and physicians' on-call schedule, the facility failed to provide stabilizing treatment for one patient (Patient #1), in the selected sample of twenty (20) patients. On 03/26/14 at approximately 9:07 AM, Patient #1 arrived at the emergency room (ER) via ambulance with the chief complaint being injury, pain, and tenderness on the forehead and cheek areas, which were sustained after a fall at the nursing home. A medical screening was completed and an emergency medical condition was determined to exist. Patient #1 was diagnosed with a facial bone fracture, closed head injury without cranial wound, and head injury and cervical sprain. Physician #4 [Emergency Room (ER) physician] did not contact the Ear, Nose, and Throat specialist (ENT) on-call for specialty consultation. Patient #1 was discharged back to the nursing home with pain medication and instructions to follow-up with his/her physician if there was no improvement.

The Findings include:

Review of Patient #1's emergency room (ER) record revealed he/she arrived at the ER on 03/26/14 via ambulance, at approximately 9:07 AM, with his/her guardian. The patient or guardian reported Patient #1 had an injury, pain, and tenderness after the patient rolled out of his/her bed onto the floor at the nursing home. The complaints concerned his/her forehead, right eye, right cheek, and back of the neck. Additionally, the guardian reported Patient #1's symptoms occurred just prior to arrival at the ER, with associated signs and symptoms to include loss of consciousness. Patient #1 was assessed and a medical screening was completed by Physician #4 (ER physician), who also completed a review of systems (ROS). Physician #4 (ER physician) ordered a Computerized Tomography (CT) of the head without contrast, a CT of facial bones without contrast, and a CT of the cervical area without contrast. CT interpretations were as follows: CT of the head revealed normal with no acute intercranial bleed, mass, or fracture, and an old right lacunar infarct. A CT of the facial bones revealed abnormal, right maxillary lateral wall fracture without entrapment, and a right lateral orbital wall fracture. A CT of the cervical area revealed "normal", except, severe cervical degenerative disc disease with no fracture and no subluxation. Patient #1 was given Phenergan 12.5 milligrams (mg), Demerol 50 mg, and a routine intramuscular (IM), site left gluteus.

Review of the medical record revealed Patient #1 was discharged to the nursing home at 12:32 PM with a facial bone fracture, closed head injury without cranial wound, head injury, and cervical sprain with a prescription for Norco 7.5 - 325 mg tablet with instructions to take one (1) tablet by mouth (oral route) every six (6) hours as needed (PRN) for pain. The quantity was 20 tablets. The ER record for Patient #1 revealed his/her condition was stable. Physician #4 (ER physician) noted Patient #1 was to follow-up with his/her physician in one (1) to two (2) days to re-check his/her complaint if no improvement. Physician #4 (ER physician) did not document calling Physician #2 (on-call ENT) for consultation or another ENT. Review of the physician on-call schedule, revealed Physician #2 (ENT) was on-call on 03/26/14. Patient #1 was discharged to the nursing home with a prescription for pain medication and instructions to follow-up with his/her physician for a re-check, if no improvement.

Interview with Licensed Practical Nurse (LPN) #1 (from the nursing home), on 05/22/14 at approximately 9:00 AM, revealed she received a report from the hospital regarding Patient #1; however, she did not recall who the caller was.

Review of the progress notes from the nursing home revealed, on 04/03/14, Physician #5 (primary care physician), was at the facility to examine the residents. He documented in Patient #1's chart about his/her complaint of pain with attempts to open his/her mouth very far. He discussed options with the patient's daughter and wrote an order for an ENT consult with Physician #2 (ENT). Due to a scheduling conflict, Patient #1 was referred to Physician #6 (ENT), and, on 04/09/14 Patient #1 had surgery the injuries he/she sustained on 03/26/14, which was the day the patient visited the ER.

Observation on 05/20/14 at approximately 2:15 PM, revealed the physician on-call list was at the nurse's station in the on-call notebook binder.

Interview with Physician #2 (ENT), on 05/21/14 at approximately 9:10 AM, revealed he was the on-call ENT on 03/26/14. He stated he would have expected to receive a call from the ER physician regarding a patient with a facial fracture. Additionally, he reported he did not recall receiving a call for a consult for Patient #1 on 03/26/14. The physician stated, in his professional opinion, he would have sent the patient home to allow swelling to subside with prescriptions for steroids, antibiotics, and pain medication.

Interview with Physician #4 (ER physician) on 05/21/14 at approximately 10:20 AM, revealed he recalled Patient #1. He reported they do not always have an ENT on-call, but he believed he called Physician #6 (ENT).

Interview with Physician #6 (ENT), on 05/22/14 at approximately 8:05 AM, revealed he would have expected to receive a call for a consult for a patient in the ER with an orbital floor fracture or fracture of maxillary sinus. He stated he would have sent the patient home to allow swelling to subside with prescriptions, pain management, and possibly antibiotics. The nursing home would have been instructed to call my office for follow up appointment.

Interview with Registered Nurse (RN) #6, on 05/21/14 at approximately 12:47 PM, revealed he did not recall any consult being made regarding Patient #1.

Interview with RN #4, on 05/22/14 at approximately 11:35 AM, revealed she did not recall this specific case. She reported Med/Host (facility's electronic medical record software) has an icon for the physician to click on indicating who the physician wanted to consult.

Interview with RN #5, on 05/22/14 at approximately 12:35 PM, revealed she did not recall the case.

Interview with the Chief Nursing Officer, on 05/21/14 at approximately 8:15 AM, revealed in order to complete stabilizing treatment of this emergency medical condition, she expected the ER physician to directly consult the on-call ENT.

Based on review of the Emergency Room (ER) record, record review, review of the facility's ER Medical Staff By-laws, and interviews, the facility failed to provide appropriate stabilizing treatment for Patient #1's Emergency Medical Condition (EMC) that included blunt trauma to head, face and neck with complex facial fractures. The ER's obligation to provide stabilizing treatment failed to include specialty on-call Ear, Nose, and Throat (ENT) Physician services.
The Findings include:
Review of the ER record revealed Patient #1 arrived at the facility's ER, on 03/26/14 at 9:07 AM, via the Emergency Medical Service (EMS)(ambulance) with an admission priority of emergent. Further review revealed the patient's reason for the visit was injury due to a fall.

Review of Patient #1's ER physician chart revealed, at 9:33 AM, the Medical Decision-Making (MDM) was documented and Patient #1 was medically screened. Further review of the ER physician chart revealed the physician ordered a diagnostic Computerized Axial Tomography (CT scan) of Patient #1's head without contrast, facial bones without contrast, and cervical spine without contrast. Further review of the ER physician's chart revealed, at 10:32 AM, the ER physician on duty documented the patient reported injury, pain, and tenderness to the forehead, right eye and right cheek which he/she sustained in a fall from his/her bed at a nursing home. Further review of the record revealed this fall occurred just prior to arrival and the patient experienced a loss of consciousness. Additionally, the Review of Systems (ROS) documentation revealed Patient #1 was positive for neck stiffness and tenderness, ecchymosis (bruising) of the right eye and right cheek, and headache. The ER physician further documented an exam of Patient #1 revealed head/face contusions (bruising and swelling) of the forehead, right eye and right cheek. Documentation by the ER physician, at 11:11 AM, revealed he received the radiology interpretation of the diagnostic CT scans, which included normal CT head, and normal CT cervical area, except for degenerative disc disease; however, the CT facial bones revealed abnormal findings of the right maxillary lateral wall fracture without entrapment, and a right lateral orbital wall fracture.

Interview with Physician #4, (ER physician, who was also a Specialist in facial and plastic surgery), on 05/21/14 at 9:10 AM, revealed he was on-call for the ER from 03/23/14 through 03/28/14. Further interview revealed he would have expected a call from the ER physician in regard to any patient who was found to have facial fractures. He stated, "I would think a call from the ER physician would have been made to me." He further stated, "In my professional opinion, a call to inform me of the issues would have been made, and I feel somebody, a specialist, should have been called." The physician also stated, in his professional opinion, he would have sent the patient home to allow swelling to subside with prescriptions for steroids, antibiotics, and pain medication.

Further interview with Physician #4 (ER physician), on 05/21/14 at 10:20 AM, revealed he recalled Patient #1. He reported they do not always have an ENT on-call, but he believed he notified Physician #6 (ENT).

Interview with Physician #6 (ENT), on 05/22/14 at 8:05 AM, revealed he would have expected to receive a call for consult for a patient in the ER with an orbital floor fracture or a fracture of the maxillary sinus. He stated he would send a patient home to allow swelling to subside with prescriptions, pain management, and possibly antibiotics. The nursing home would be instructed to call my office for a follow-up appointment. Further interview revealed he did not recall receiving a call from the ER physician, on 03/26/14, for a consult in regard to Patient #1.

Interview with Registered Nurse (RN) #7, on 05/21/14 at 11:22 AM, revealed he did not recall Patient #1's ER visit on 03/26/14. Further interview revealed if the ER physician wanted a consult, the Med-Host Electronic Medical Record (EMR) system would flag the order and the consulting physician would be notified by the nurse or clerk, and when the contact was made, the flag was removed in the system.

Interview with RN #4, on 05/21/14 at 11:35 AM, revealed she did not recall the specific case in regard to Patient #1's ER visit on 03/26/14 and if the ER physician ordered a consult, an icon would appear in the EMR. After the contact was made the icon "goes away." She did not recall if the ER doctor requested a consultation.

Interview with RN #6, on 05/21/14 at 2:47 PM, revealed he did not recall any consult regarding Patient #1.

Interview with RN #5, on 05/22/14 at approximately 12:35 PM, revealed she did not recall the case. Further interview revealed she said "the ER physician generally would write the disposition order and leave it up to the patient, family or nursing home to make the call to the specialist."

Interview with the Chief Nursing Officer, on 05/21/14 at approximately 8:15 AM, revealed she believed in order to complete stabilizing treatment of this emergency medical condition, she expected the ER physician to directly consult the on-call ENT.

Interview with Physician #3 (ER Medical Director), on 05/21/14 at 9:37 AM, revealed he would have tried to call the ENT on-call in regard to any patient having a facial fracture who presented to the ER. He further stated, "I would hope the ER physicians would try to get in touch with a specialist, especially if they were on-call, as part of the stabilizing treatment, to make them aware of the patient."