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Based on staff interviews and review of hospital policies and closed patient medical records, the hospital failed to provide an appropriate medical screening exam to determine whether an emergency medical condition existed for two (#2 and #13) of 21 patients, whose closed emergency department (ED) medical records were reviewed out of a sample selected from September, 2012 through February, 2013.

Findings included:

1. Review of hospital policy, "EMTALA - PROVISION OF CARE - MEDICAL SCREENING EXAMINATION/TREATMENT AND TRANSFER/ACCEPTANCE OF PATIENTS WITH EMERGENCY MEDICAL CONDITIONS" dated 01/99, showed that an appropriate Medical Screening Examination (MSE) will be conducted based on the history, signs, symptoms and complaints as presented by the patient and shall reflect appropriate documentation of the patient's clinical status.

Review of hospital policy, "EMTALA - EMERGENCY DEPARTMENT ON-CALL PHYSICIAN RESPONSIBILITIES" dated 01/99, showed that the on-call physicians shall be readily available by telephone or pager 24 hours a day for telephone consultation or personal examination and treatment of Emergency Department patients. If outpatient follow-up care is needed, it may be limited to the acute condition which prompted the patient's Emergency Department visit. The Vice President of Medial Affairs will be notified of physicians who fail to comply with the on-call policy.

Review of hospital "Rules and Regulations" revised 09/24/12, showed that practitioners who are on call to the ED shall promptly respond to calls or pages from the ED within 30 minutes.

Review of the closed medical record dated 01/27/13 showed Patient #2 presented by ambulance to the ED on Sunday at 10:54 AM, after falling and fracturing his right arm. ED Physician R documented that the patient slipped on ice, fell on his right side, hit his forearm on a rock, and that the "amount of blood lost was no blood loss" and that "the pain is severe." At 11:48 AM patient # 2 received a dose of oxycodone (pain medication) for "severe pain." At 11:50 AM x-rays showed that the patient had displaced fractures of the radius and ulna (bones in the forearm). And at 1:45 PM, a splint was applied to patient # 2's forearm prior to discharge at 2:19 PM with instructions to take 1 - 2 pain pills every four hours as needed and to follow up with Dr. (orthopedist S) at 10:00 AM on Monday 1/28/13. The medical record did not contain evidence that patient # 2 received a sufficient medical screening examination, resulting in a missed open fracture (when the bone breaks in such a way that it pierces through the skin) which required immediate consultation with orthopedic surgery. In addition, the medical record did not contain evidence that any attempt was made to restore Patient # 2's broken bones to their correct alignment to reduce the likelihood of neurovascular compromise (damage to the nerves or blood vessels), an emergency medical condition.

In an interview on 2/27/13 at 8:55 AM, ED physician R confirmed he examined patient # 2 and stated that the patient's fracture "was bad - it was badly displaced on the x-ray." "I didn't know if the surgeon (orthopedist) would want to take him immediately to the operating room." "The orthopedist didn't come in, I discussed the case over the phone. The orthopedist instructed me to place the patient in a splint and have him follow-up with him first thing in the morning." When asked whether it was typical to discharge a patient with a forearm fracture like patient # 2's, ED physician R stated, "we do discharge them as long as the patient's pain is controlled, this case could have gone either way." ED physician R stated that if the patient had an open wound, if the bone had gone through the skin, the patient would need emergent surgery because it would get infected.

In an interview on 2/27/13 at 11:15 AM, ED RN W stated, "I went in and looked at it (patient # 2's broken arm), it had been unwrapped by the doctor (ED physician R), I just kind of moved it and there was no support for his forearm." "There was dried blood underneath his broken forearm." "I wasn't able to assess the arm well." "When I mentioned it to the patient and his wife they kind of freaked out." "I pulled up the x-ray on EPIC (the computer), I'm not a trained radiologist, and I was not able to assess it properly because it was so unstable." "It just hung there when you lifted it up." "If the bone comes through the skin, that indicates an increased risk of infection, so they need to stay in the hospital." "I told the nurse that an ace wrap wasn't going to be enough, it needed more support than that."

In an interview on 2/28/13 at 12:06 PM, ED Technician BB stated she was contacted to apply an ace bandage wrap to patient # 2's arm. "I went into the room and thought I am not going to put an Ace bandage on it because it wouldn't provide any support and the patient was bleeding. The patient was bleeding on the underside of his forearm, similar to a laceration." "(ED RN V) came into the room and a second nurse, and they both saw the blood." "I explained to them that this patient needed more than an ace wrap." "I don't know if the patient's arm was in anything when I came in, but the patient was cradling his forearm against his chest." "The bleeding was still active, but not profuse, but it hadn't clotted." "I have never seen bleeding with a fracture before, which is why I brought it to the nurses' attention." ED Technician confirmed that she applied a splint to patient # 2's forearm as ordered by ED physician R. "I didn't have any problems applying the splint, other than the patient's pain, but they did give him pain medication before we applied the splint."

Review of the on-call orthopedic list revealed Orthopedic Surgeon T was on-call to the Emergency Department when Patient #2 presented to the ED on 1/27/13.

Review of the ED "Telephone Log" revealed on call orthopedist, Surgeon T was called at 12:07 PM, 12:25 PM and at 12:53 PM on 1/27/13, but did not respond, so Orthopedic Surgeon S (who was not on call) was consulted.

In an interview on 2/27/13 at 11:10 AM, the ED secretary X stated, "I don't remember anything directly about the patient." "I attempted to contact on call orthopedic surgeon T three times, then I contacted orthopedic surgeon S, it was the first doctor that came to mind." "ED physician R said I really need someone now, you could tell he needed an orthopedic doctor like now."

In an interview on 2/27/13 at approximately 1:00 PM, orthopedic surgeon S confirmed that he was not on call when Patient # 2 presented to the ED on 1/27/13. Orthopedic surgeon S stated that he was consulted by ED physician R, "it was a snowy day, things were busy and the ED physician asked if he could talk to me." Orthopedic surgeon S stated he did not remember whether he saw Patient # 2's x-ray over the Internet the day he was consulted and could not recollect that the ED physician ever said if patient # 2 had an open wound. Orthopedic surgeon S stated he could not remember if he told his office staff that Patient # 2 would be coming (the next day).

In an interview on 03/05/13 at 2:00 PM, Patient # 2 stated that ED physician R looked at the top part of his arm, but not the bottom part. "He never lifted it up." Patient # 2 stated he did not think the nurses told the ED physician about his arm bleeding. "Originally the doctor said they were going to admit me and do surgery tomorrow, but then they changed their mind, I don't know why." "Every time that I called Dr. (ED physician R) back into the room, because I was in pain, he would walk by saying, I'm trying to get a hold of the doctor, I'm waiting for him to call me back." "As far as I know, he never got a hold of a doctor." "Then he told me that he made an appointment for me at Dr. (orthopedic surgeon S's) office, and said I needed to be there at 10:00 AM on 1/28/13 and told me where his office was." "I didn't see him again." "I repeatedly asked the ED staff if the appointment was made and they told me three times, yes." "When I went to Dr. S ' s (orthopedic surgeon S) office on 1/28/13, the office staff told me that I didn't have an appointment and that they didn't know anything about Dr. (orthopedic surgeon S) seeing me at 10:00 AM." "So, I went back to the ED and told them that Dr. (orthopedic surgeon S) didn't know anything about the appointment." "The staff at the registration desk said "we don't make appointments in the ED" and the gentleman (who was speaking to me) came back and said "Dr. (orthopedic surgeon S) wasn't even on call, it was Dr. (on call orthopedic surgeon T)." "Here is his office number, you're going to have to call him." "They did not offer to see me or register me as a patient in the ED." Patient # 2 stated he called Dr. (on call orthopedic surgeon T) on 1/28/13 but he wasn't in his office, so he went in the following day (1/29/13). Patient # 2 stated that Dr. (on call orthopedic surgeon T) unwrapped his arm, looked at it and said that the fracture was too difficult for him to repair, "so he referred me to another doctor." Patient # 2 confirmed that he went to see that orthopedic surgeon on 1/30/13 and the doctor noticed his arm was really red and infected. Patient # 2 stated the orthopedic surgeon probed his wound and felt the bone and was immediately admitted to Hospital B to receive intravenous antibiotics and surgery. Refer to tag A2406 for further details.

2. Record review of an email from Risk Manager E, dated 03/06/13 at 3:42 PM, showed there was no facility policy related to care of the ED patients presenting with alcohol or drug abuse.

Review of a closed medical record showed Patient #13 presented by ambulance to the ED on 10/25/12 at 6:52 PM, with alcohol intoxication. The patient was "unable to sign" the Conditions of Admission Agreement. ED Physician CC documented that the patient was "extremely sleeping (sic) and will not cooperate with questions. I cannot obtain information from her at this time." Further documentation by the ED Physician indicated that the patient's history included seizures, depressive disorder, bipolar disorder, alcohol abuse, drug abuse and schizophrenia. A blood draw at 7:30 PM showed that the patient's blood alcohol level was critically elevated at 304 (80 is legally intoxicated). Psychiatrist DD evaluated the patient at 9:13 PM and documented that the patient was obtunded and difficult to arouse, with slurred speech, and a history of seizures which may be alcohol related. "I have asked the emergency room staff (ED Physician CC) to let her 'sober out' and then reassess her level of mentation in the morning" before discharging her. Approximately two hours later, at 11:10 PM, ED RN W documented that the patient was discharged. The medical record did not contain evidence that the patient's critical blood alcohol level was rechecked, that a drug of abuse screen was performed, that the patient was evaluated for suicidal or homicidal ideations, or that the patient was safe to care for herself when discharged.

During a telephone interview on 02/28/13 at 9:55 AM, Psychiatrist DD stated that when he evaluated Patient #13, in the ED, sometime before 9:13 PM, she was "drunk out of her mind", very agitated and irritable, and could not be assessed for suicidal or homicidal ideations. Psychiatrist DD confirmed that a drug of abuse screen had not been performed. Psychiatrist DD stated "suicidal and homicidal ideations (are) always a concern and should be assessed." Psychiatrist DD stated that he told the ED Physician that the patient needed to stay until the morning and be discharged after she was evaluated for suicidal and homicidal ideations and offered chemical dependency treatment. Psychiatrist DD stated that psychiatry rounds in the ED in the morning, we are there by 8:00 AM." "We usually try to admit her (patient # 13) for at least a few days and try to get her some help."

During a telephone interview on 02/28/13 at 10:00 PM, ED Physician CC stated that while Patient #13 was in the ED, she wouldn't answer any questions. "She was sleeping on the mattress, covered up with a blanket and kept pushing me away." ED Physician CC stated that the patient had a history of alcohol related seizures, that the patient had a critical alcohol level while in the ED, and that her alcohol level was not rechecked before she was discharged. "I guess it (alcohol level) would have been about 220, which would mean she was still legally intoxicated" when she was discharged. ED Physician CC stated that she did not assess whether the patient was suicidal or homicidal before the homeless patient was discharged. Refer to tag A2406 for further details.

Based on record review and staff interview, the hospital failed to provide a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two (#2, and #13) of 21 patients, whose records were reviewed after they presented to the hospital Emergency Department (ED) seeking care, out of a sample selected from September, 2012 through February, 2013.

Findings included:

Review of a closed medical record showed patient #2 presented by ambulance to the ED on Sunday 01/27/13 at 10:54 AM, with a right arm deformity. ED Physician R documented that the patient slipped on ice, fell on his right side, hit his forearm on a rock, and that the "amount of blood lost was no blood loss" and that "the pain is severe." At 11:48 AM, patient # 2 received a dose of oxycodone (pain medication) for "severe pain." X-ray of the right forearm showed that the patient had displaced fractures of the radius and ulna (bones in the forearm). Documentation showed that the on-call orthopedist couldn't be reached, so Orthopedic Surgeon S was contacted and "agrees to office consult tomorrow." At 1:45 PM, a splint was applied to patient # 2's forearm prior to discharge at 2:19 PM, with instructions to take 1 - 2 pain pills every four hours as needed. The medical record did not contain evidence that patient # 2 received a sufficient medical screening examination, resulting in a missed open fracture (when the bone breaks in such a way that it pierces through the skin) which required immediate consultation with orthopedic surgery. In addition, the medical record did not contain evidence that any attempt was made to restore Patient # 2 ' s broken bones to their correct alignment to reduce the likelihood of neurovascular compromise (damage to the nerves or blood vessels).

In an interview on 2/27/13 at 8:55 AM, ED physician R confirmed he examined patient # 2 and stated that the patient's fracture "was bad - it was badly displaced on the x-ray" "I didn't know if the surgeon (orthopedist) would want to take him immediately to the operating room." Attempts were made to contact orthopedist T without success. "If I can't get a hold of the on-call physician, there is no real process" to follow, so "I contacted (orthopedist S)." The orthopedist didn't come in, I discussed the case over the phone. The orthopedist instructed me to place the patient in a splint and have him follow-up with him first thing in the morning." When asked whether it was typical to discharge a patient with a forearm fracture like patient # 2's, ED physician R stated, "we do discharge them as long as the patient's pain is controlled, this case could have gone either way." ED physician R stated that if the patient had an open wound, if the bone had gone through the skin, the patient would need emergent surgery because it would get infected.

Review of the on-call orthopedic list revealed Orthopedic Surgeon T was on-call to the Emergency Department when Patient #2 presented to the ED.

Review of the ED "Telephone Log" revealed three attempts were made to contact the on-call orthopedist, Surgeon T, for consultation regarding Patient #2, but the orthopedist did not respond, so Orthopedic Surgeon S (who was not on call) was consulted.

In an interview on 2/27/13 at 11:10 AM, the ED secretary X stated, "I attempted to contact on call orthopedic surgeon T three times, then I contacted orthopedic surgeon S, it was the first doctor that came to mind. " "ED physician R said I really need someone now, you could tell he needed an orthopedic doctor like now."

During an interview on 02/27/13 at 10:13 AM, Staff Y, ED Technician stated that Orthopedic Surgeon T did not respond to the ED's consult requests for Patient #2, until approximately two hours after the consult was requested, after Orthopedic Surgeon S had been consulted.

During a phone interview on 02/27/13 at 12:30 PM, Orthopedic Surgeon T stated that he did not initially respond to the ED's consult requests for Patient #2. "Several times this seems to happen, if you can't get to a phone or if the phone is dead." Orthopedic Surgeon T added that a fracture of the radius and ulna would be considered an emergency if the patient had neurological compromise or an open fracture. Orthopedic surgeon T stated that open fractures usually have to be washed out. "If I had known that it was an open fracture, it would need to be washed out and taken to surgery."

In an interview on 2/27/13 at 11:15 AM, ED RN W stated, "I went in and looked at it (patient # 2's broken arm), it had been unwrapped by the doctor (ED physician R), I just kind of moved it and there was no support for his forearm." "There was dried blood underneath his broken forearm." "I wasn't able to assess the arm well." "When I mentioned it to the patient and his wife they kind of freaked out." "I pulled up the x-ray on EPIC (the computer), I'm not a trained radiologist, I was not able to assess it properly because it was so unstable." "It just hung there when you lifted it up." "If the bone comes through the skin, that indicates an increased risk of infection, so they need to stay in the hospital." "I told the nurse that an ace wrap wasn't going to be enough, it needed more support than that."

In an interview on 2/28/13 at 12:06 PM, ED Technician BB stated she was contacted to apply an ace bandage wrap to patient # 2's arm. "I went into the room and thought I am not going to put an Ace bandage on it because it wouldn't provide any support and the patient was bleeding. The patient was bleeding on the underside of his forearm, similar to a laceration." "(ED RN V) came into the room and a second nurse, and they both saw the blood." "I explained to them that this patient needed more than an ace wrap." "I don't know if the patient's arm was in anything when I came in, but the patient was cradling his forearm against his chest." "The bleeding was still active, but not profuse, but it hadn't clotted." "I have never seen bleeding with a fracture before, which is why I brought it to the nurses' attention." ED Technician confirmed that she applied a splint to patient # 2's forearm as ordered by ED physician R. "I didn't have any problems applying the splint, other than the patient's pain, but they did give him pain medication before we applied the splint."

In an interview on 03/05/13 at 2:00 PM, Patient # 2 stated that ED physician R looked at the top part of his arm, but not the bottom part. "He never lifted it up." Patient # 2 stated he did not think the nurses told the ED physician about his arm bleeding. "Originally the doctor said they were going to admit me and do surgery tomorrow, but then they changed their mind, I don't know why." "Every time that I called Dr. (ED physician R) back into the room, because I was in pain, he would walk by saying, I'm trying to get a hold of the doctor, I'm waiting for him to call me back." "As far as I know, he never got a hold of a doctor." "Then he told me that he made an appointment for me at Dr. (orthopedic surgeon S's) office, and said I needed to be there at 10:00 AM and told me where his office was." "I didn't see him again." Patient # 2 stated that when he went to Orthopedist S's office (Monday 1/28/13), they didn't have an appointment for him, so he returned to the ED. " The staff at the registration desk said "we don't make appointments in the ED" and the gentleman (who was speaking to me) came back and said "Dr. (orthopedic surgeon S) wasn't even on call, it was Dr. (on call orthopedic surgeon T)." "Here is his office number, you're going to have to call him." "They did not offer to see me or register me as a patient in the ED." Patient # 2 stated he called Dr. (on call orthopedic surgeon T) but he wasn't in his office, so he went in the following day (Tuesday 1/29/13). Patient # 2 stated that Dr. (on call orthopedic surgeon T) unwrapped his arm, looked at it and said that the fracture was too difficult for him to repair, "so he referred me to another doctor." Patient # 2 confirmed that he went to see that orthopedic surgeon who noticed his arm was really red and infected. Patient # 2 stated (on Wednesday 1/30/13) the orthopedic surgeon probed his wound and felt the bone and was immediately admitted to Hospital B to receive intravenous antibiotics and surgery.

In an interview on 3/5/13 at 5:21 PM, Patient # 2's family member stated that "by the time we got to Dr. (orthopedist GG's) office at 9:00 AM on Wednesday 1/30/13, the muscles in (patient # 2's) forearm had already shortened." "Dr. (orthopedist GG) took x-rays and showed us the bones were now side by side instead of at the end of each other ..." The family member stated that Dr. (orthopedist GG) removed the wrap that Dr. (orthopedist T) had placed and noticed the bandage and said "oh what is this?" Dr.(orthopedist GG) removed the bandage and an associate took a long q-tip and put it in the wound and said, "it goes all the way back to the bone." The family member stated that Dr. (orthopedist GG) said "what happened is that the bone went all the way through the skin and then went back in, which sometimes happens."

Review of a closed medical record from Hospital B showed that Patient #2 was admitted to the hospital for Intravenous (IV - in the vein) antibiotics for a wound infection and surgical repair of the wound and forearm fractures.

2. Record review of an email from Risk Manager E, dated 03/06/13 at 3:42 PM, showed there was no facility policy related to care of the ED patients presenting with alcohol abuse.

Review of a closed medical record showed Patient #13 presented by ambulance to the ED on 10/25/12 at 6:52 PM, with alcohol intoxication. The patient was "unable to sign" the Conditions of Admission Agreement. ED Physician CC documented that the patient was "extremely sleeping (sic) and will not cooperate with questions. I cannot obtain information from her at this time." Further documentation by the ED Physician indicated that the patient's history included seizures, depressive disorder, bipolar disorder, alcohol abuse, drug abuse and schizophrenia. A blood draw at 7:30 PM showed that the patient's blood alcohol level was critically elevated at 304 (80 is legally intoxicated). Psychiatrist DD evaluated the patient at 9:13 PM and documented that the patient was obtunded and difficult to arouse, with slurred speech, and a history of seizures which may be alcohol related. "I have asked the emergency room staff (ED Physician CC) to let her 'sober out' and then reassess her level of mentation in the morning" before discharging her. Approximately two hours later, at 11:10 PM, ED RN W documented that the patient was discharged. The medical record did not contain evidence that the patient's critical blood alcohol level was rechecked, that a drug of abuse screen was performed, that the patient was evaluated for suicidal or homicidal ideations, or that the patient was safe to care for herself when discharged.

During a telephone interview on 02/28/13 at 9:55 AM, Psychiatrist DD stated that when he evaluated Patient #13, in the ED, sometime before 9:13 PM, she was "drunk out of her mind", very agitated and irritable, and could not be assessed for suicidal or homicidal ideations. Psychiatrist DD confirmed that a drug of abuse screen had not been performed. Psychiatrist DD stated "suicidal and homicidal ideations (are) always a concern and should be assessed." Psychiatrist DD stated that he told the ED Physician that the patient needed to stay until the morning and be discharged after she was evaluated for suicidal and homicidal ideations and offered chemical dependency treatment. Psychiatrist DD stated that psychiatry rounds in the ED in the morning, we are there by 8:00 AM." "We usually try to admit her (patient # 13) for at least a few days and try to get her some help."

During a telephone interview on 02/28/13 at 10:00 PM, ED Physician CC stated that while Patient #13 was in the ED, she wouldn't answer any questions. "She was sleeping on the mattress, covered up with a blanket and kept pushing me away." ED Physician CC stated that the patient had a history of alcohol related seizures, that the patient had a critical alcohol level while in the ED, and that the her alcohol level was not rechecked before she was discharged. "I guess it (alcohol level) would have been about 220, which would mean she was still legally intoxicated" when she was discharged. ED Physician CC stated that she did not assess whether the patient was suicidal or homicidal before the homeless patient was discharged.