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Based on interviews and documentation review, it was determined:
1.) the Hospital failed to provide an appropriate MSE to Patient #16.
2.) Hospital bylaws, rules and regulations or other document approved by the governing body did not specify the individuals qualified to conduct MSEs.

Findings included:

1.) Pre-hospital documentation indicated Patient #16 was a restrained driver and Patient #15 was a restrained front-seat passenger in a roll-over motor vehicle accident (MVA) that occurred a little over 3 miles from the Hospital. The vehicle; a SUV, sustained significant front-end damage and landed on its roof. Patient #15 was the first to be extricated from the vehicle and was transported to the Hospital's Emergency Department (ED); by ambulance.

The ED physician who was on duty at the time of and following Patients #15 and #16's MVA (ED Physician #1) was interviewed in person at 1:50 PM on 7/15/10. ED Physician #1 said ED RN #1 received C-MED (an Emergency Medical Service [EMS]/Hospital Physician radio communication system) communication regarding Patients #15 and #16's MVA and told her: the accident was a roll-over accident; the Patients were in their 80s; extrication had been prolonged; Patient #15, a restrained passenger, was awake, alert, without complaints and boarded and collared (the spine of a patient with a possible traumatic cervical spine injury is immobilized with a spine board and cervical collar to prevent spinal cord damage [that can be life-threatening and/or result in paralysis]; patients remain collared and boarded until a cervical spine injury is ruled out with imaging or an injury is treated) with stable vital signs, and on the way; Patient #16, the driver, had been unrestrained and would be transported to the ED following Patient #15 and; Patient #16 was complaining of back pain and had stable vital signs.

ED Physician #1 said ED Staff RN #1 asked her if considering the mechanism of injury, she was concerned about Patient #16 coming to the Hospital (a community hospital), and she told ED RN #1: Yes, he/she should be transported to a trauma center. ED Physician #1 said a (telephone) call was then placed to the Ambulance Company (that owned the ambulances at the accident scene) to tell them to transport Patient #16 to Hospital #2 (a tertiary care hospital with a trauma center). ED Physician #1 did not know who placed the call.

The Massachusetts Statewide Trauma Field Triage Criteria and Point-of-Entry Plan for Adult and Pediatric Patient Algorithm indicates that EMS providers are to consider using medical control regarding the destination hospital when patients who are not in cardiopulmonary arrest and do not have an uncontrolled airway, a persistent loss or decreasing level of consciousness, severe respiratory distress, a flail chest, a low systolic blood pressure, open or depressed skull fractures, penetrating trauma to the head, neck, torso, or extremities proximal to the elbow or knee, a tender or rigid abdomen, complex pelvic fractures, paralysis or motor/sensory deficit, 2 or more proximal long bone fractures, an open proximal long bone fracture, amputations involving more than distal digits, and/or critical burns, but have an extrication time greater than 20 minutes. The Algorithm also indicates EMS providers are to transport such patients to level 1, 2 or 3 trauma centers if there is no medical control; unless the trauma center is greater than 20 minutes away. If the trauma center is greater than 20 minutes away, EMS providers are to transport the patient to the closest System Hospital.

Hospital #2 is located approximately 35 miles from the Hospital.

ED Staff RN #1 was interviewed in person at 3:10 PM on 7/15/10. She said that considering the mechanism of injury, she and ED Physician #1 thought Patient #16 should be transported from the accident scene to a trauma center, and a (telephone) call was placed to the Ambulance Company to tell them to do so. ED Staff RN #1 did not know who placed the call.

The ED Secretary who was on duty at the time of and following Patients #15 and #16's MVA (ED Secretary #1) was interviewed in person at 8:50 AM on 7/16/10. She said she heard the C-MED transmission regarding Patients #15 and #16's MVA and a short time later; ED Physician #1 told her to call the Ambulance Company and tell them to bypass the Hospital and take Patient #16 to Hospital #2. ED Secretary #1 reported telephoning the Ambulance Company and being told the EMTs (Emergency Medical Technicians) could not be contacted and she would have to relay the message when they called in on C-MED.

Patient #15's Ambulance Trip Report indicated he/she left the scene of the accident at 12:49 PM and arrived at the Hospital at 12:56 PM.

ED Physician #1 reported evaluating Patient #15 and said he/she was very concerned about Patient #16 because Patient #16 was complaining of back pain and had a history of osteoporosis and compression fractures.

Patient #16's Ambulance Trip Report indicated he/she left the scene of the accident at 12:56 PM (the same time Patient #15 arrived in the ED).

A transcript of the C-MED transmission regarding Patient #16's transfer indicated that at 1:01 PM, Ambulance personnel radioed the Hospital and the following (slightly edited to protect identity) conversation took place:
Ambulance Person: We're enroute to your facility with a 76, 7-6 year old, sorry, 79 year old unrestrained driver in a roll-over; Patient is currently alert, oriented times 3, complaining of lower back pain, denying any other pain; vitals are currently heart rate 110, sinus rhythm on the monitor, B/P of 179/100; Patient is in c-spine/long-board; we do have an IV established; we have about a 1 minute ETA (estimated time of arrival).
Hospital Person: Was there extrication?
Ambulance Person: Ah ... extended extrication, yes.
Hospital Person: Please hold for a MD.
Brief pause.
ED Physician #1: Vitals are stable in this Patient; the Patient should be diverted to Hospital #2.
Ambulance Person: I'm sorry; can you please repeat that last communication from Hospital?
ED Physician #1: Patient should be taken to Hospital #2 as his/her vitals are stable.
Ambulance Person: The vitals are stable. We are currently in Hospital Parking Lot.
ED Physician #1: You should have called earlier.
Ambulance Person: Ah ... excuse me, I did not have time to treat my patient and give _____ (inaudible).

ED Physician #1 said she told the EMTs transporting Patient #16 they should have called in (through C-MED) before getting to the (Hospital) door, because Patient #16 was going to need to go to Hospital #2/a trauma center.

Patient #16's Ambulance Trip Report indicated he/she arrived at the Hospital at 1:03 PM.

ED Physician #1 reported meeting the EMTs and Patient #16 in the hallway; between the ambulance entrance and the nursing station, introducing herself to the Patient, and asking the Patient how he/she was doing. She said Patient #16 indicated he/she had low back pain, and after performing a mini-exam that revealed equal (sized) and reactive pupils, normal eye tracking, clear ears, appropriate mentation, posterior neck tenderness, even clavicles, normal heart, lung and stomach sounds, bladder tenderness (due to a full bladder) and lower extremity movement; she told the Patient that considering he/she had been in a roll-over MVA, she thought he/she would benefit from a transfer to a trauma center/Hospital #2. ED Physician #1 said before Patient #16 could respond, EMT #2 (actually Paramedic #1) loudly and inappropriately said: Patient refused transfer to Hospital #2.

ED Physician #1 reported continuing to discuss transfer to Hospital #2 with Patient #16 and said the Patient said the Patient agreed to a transfer. ED Physician #1 said she then asked Patient #16 if he/she needed something for pain, and when he/she said no; she told Paramedic #1 she would be transferring the Patient to Hospital #2. ED Physician #1 said Paramedic #1 then took Patient #16 back to the ambulance for transport.

Patient #16's Ambulance Trip Report indicated he/she departed the Hospital at 1:07 PM (4 minutes after arriving). Laboratory testing and/or imaging studies were not performed on Patient #16 prior to his/her departure.

ED Physician #1 said she believed Patient #16 had an emergency medical condition (EMC), but was hemodynamically stable for transfer. She could not define/specify the EMC, but said based on mechanism of injury; she believed Patient #16 had an EMC.

ED Staff RN #1 said she was busy with Patient #15 when the Paramedics arrived with Patient #16 and when she finished, she asked where Patient #16 was, and ED Physician #1 told her she had sent the Patient and ambulance on to Hospital #2. ED Staff RN #1 reported saying something like What?, You can't do that, and then: instructing ED Physician #1 to immediately call Hospital #2 (regarding Patient #16 and his/her impending arrival).

ED Physician #1 said minutes after Patient #16 left the ED ED Staff RN #1 asked where the Patient was, and when she told her the Patient was gone to Hospital #2/should have gone to a trauma center; ED Staff RN #1 told her the transfer might be an EMTALA violation, and she needed to call Hospital #2 (regarding Patient #16 and his/her impending arrival).

ED Physician #1 reported calling Hospital #2 and speaking with Physician R regarding Patient #16 and his/her impending arrival at Hospital #2. She also reported asking Physician R what paperwork he needed and said Physician R indicated he did not need any paperwork; telephone report was enough.

Documentation on Patient #16's Ambulance Trip Report indicated 4 milligrams of morphine (narcotic pain medication) were ordered by Medical Control after the Patient left the ED. The time the Order was issued was not documented. Documentation indicated the morphine was administered to Patient #16, but the documentation did not include the time of administration.

Documentation in Patient #16's Hospital medical record (incorrectly) indicated he/she arrived in the ED and was registered at 3:51 PM.

ED Physician #1 said Patient #16's medical record was created and medical record documentation was completed; after the Patient was transferred to Hospital #2.

Continued review of medical record documentation revealed it indicated Patient #16: had a history of arthritis and osteoporosis; was not assessed by nursing; was visited by a radiology technician at 4:02 PM; was the unrestrained driver in a car involved in a high-speed, roll-over MVA with multiple points of impact in which the air bag deployed and the vehicle landed top down; developed symptoms suddenly at 12:00 that day; sustained injury to the low back/heard something "pop"; had moderate or severe back pain; did not lose consciousness; required prolonged extrication; had normal skin color; had contusions on his/her arms and legs and abrasions on his/her left arm and leg; did not have musculoskeletal deformities; had a C-collar and back board in place; did not have chest pain, respiratory distress, shortness of
breath, altered mental status and/or cranial nerve deficits; had a normal appearing abdomen; appeared alert, awake and uncomfortable; had equal and round pupils that were reactive to light and accomodation; was pleasant and cooperative and; had a Glasgow Coma Scale score of 15 and a Trauma Score of 12. The documentation also indicated: the Patient left the ED at 4:56 PM; the differential diagnosis was blunt trauma, closed head injury; the Patient was counseled regarding the need to transfer to another facility for higher level of care, trauma and MD request; that based on mechanism and high probability of injury and given the Patient's history of severe osteoporosis, ED Physician #1 felt it was important for the Patient to be evaluated in a trauma center and despite her requests, the Patient was brought to the (Hospital's) ED; the Patient was quickly assessed and found to be hemodynamically stable; Physician R at Hospital #2 was contacted regarding Patient transfer at 5:16 PM; Physician R accepted the Patient in transfer; the Patient agreed to the transfer and was transferred by ground, in stable condition and; paperwork was completed after the Patient was transported to Hospital #2. Medical record documentation did not include Patient vital signs, a listing of his/her usual medications or a pain rating.

2.) A review of the Hospital's Medical Staff Bylaws and Rules and Regulations revealed they did not specify individuals qualified to conduct MSEs.

The Hospital's Vice President of Quality Systems and Managed Care was interviewed in person throughout the Survey. She said the Hospital did not have a document approved by the governing body that specified the individuals qualified to conduct MSEs.

Based on interviews and documentation review, it was determined the only patient in a sample of 17 patients transferred from the Hospital's ED during the time period of 1/1-7/7/10 with an unstabilized EMC, was transferred without physician certification containing a summary of the risks and benefits upon which the transfer decision was based.

Findings included:

Patient #3 presented to the ED from a physician's office in distress; with respiratory symptoms and hypotension (low blood pressure), and was diagnosed with meningitis (an infection involving the membranes of the spinal cord and/or brain), sepsis (a serious condition resulting from the presence of microorganisms or their poisonous products in the bloodstream), bilateral pneumonia, acute renal (kidney) failure, and possible myocardial infarction (heart attack). Patient #3 was provided with medical treatment within the Hospital's capability and capacity, but could not be stabilized, and was transferred to a tertiary care hospital; in critical condition. Patient #3's Authorization For Transfer Form did not include a summary of the risks and benefits upon which the transfer decision was based.