HospitalInspections.org

Based on interviews of facility staff, ER physicians, ambulance paramedics, review of policies and procedures, and ED Physician Contract, the facility failed to follow their COBRA (Consolidated Omnibus Budget Reconciliation Act) Statement by not providing a Medical Screening Examination (MSE) for one (1) of twenty-eight (28) patients in the sample [Patient Identifier (PI) #1.]

PI #1 (an adolescent) presented to this facility's ER for evaluation and treatment in an ambulance on 02-21-10. The ambulance had pulled into an ambulance bay and was approached by an ER Charge Nurse and ER physician. Hospital A's ER physician told the ambulance to divert to Hospital B (specifically treats pediatric patients). PI #1 did not receive a MSE at Hospital A prior to leaving this facility (Hospital A).

The findings include:

1. The following information was self reported to the Alabama Department of Public Health on 2-23-10 by the facility in regards to the ambulance with PI #1 after pulling into the ambulance bay being diverted to Hospital B by the ER physician without receiving a MSE.

"The Director, Risk Management and Compliance (at Hospital A) self reports that she is writing to inform the Alabama Department of Public Health of a possible transfer violation regarding an ambulance that was driven to the (Hospital A's) Emergency Department early afternoon on February 21, 2010. She writes, the paramedics reported a motor vehicle accident involving three teenagers via a cell phone. Based on the report from the accident scene, the writer states the (Hospital A's) ED physician advised that EMS report the accident to TCC (Trauma Communication Center) for possible divert to an appropriate trauma center. There was a communication loss at some point between the hospital and the paramedics. One ambulance was diverted, but one came to (Hospital A). The physician believed that the patient was supposed to be sent to another facility per TCC and thus the ambulance was diverted to that facility."

"The physician who saw and transferred the patient is an employee of an independent physician group that provides ER services to the hospital. Physician and group have been provided notice of this potential violation, as well as additional education regarding the standards for making an appropriate transfer to another facility, including the obligation to conduct an appropriate screening and to provide stabilizing treatment (within capabilities)."

2. POLICIES
*The following information is a statement printed on a page with the facility's letterhead titled "COBRA Statement". This statement is not formatted like other facility policies and has no name, number, department, or date of approval, review, revision, or retired. This statement is:

"All patients presenting to the Emergency Department for treatment will receive a medical screening exam by a care provider with prescription writing abilities prior to referral or transfer, unless the patient refused the exam. If the patient desires to leave at any time prior to the completion of the medical screening exam, an 'Against Medical Advice' form should be completed."

*The following information was taken from the ED Physician Group Contract:
"Exhibit LA: Professional Services
I. Provisions of Emergency Medical Services...
B. (ED Physician Group) shall cause all Physicians to comply with all requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) and shall ensure that each individual presenting himself or herself to the ED receives an appropriate screening examination and (if necessary) stabilizing treatment.
C. Furthermore, (ED Physician Group) shall comply with EMTALA in the transfer of patients to or from the ED and another facility."

3. INTERVIEWS

*The Driver of the ambulance on 2-21-10 in which PI #1 was being transported was interviewed on 3-2-10 at 2:32 PM stating "When we arrived on scene, the Fire Department was bringing the patient (PI #1) to us on a back board with a cervical collar and spider straps in place. They loaded the patient in our truck, gave us report and we went on to (Hospital A). The patient was self extricated, standing along side the vehicle upon the Fire Department's arrival. The patient (PI #1) was complaining of pain in her knee and she had a small abrasion to right hip and right knee. No obvious deformities, no lose of consciousness, no altered mental status. The parents (of PI #1) were on the scene before the Fire Department got there. The mother (of PI #1) wanted her (PI #1) to go to the ER to get checked out. She (PI #1) didn't want to go to the hospital but her parents wanted to go to the hospital. I asked the parents (of PI #1) where they wanted (their daughter) to go and they said 'We would like to go to (Hospital A).' We didn't see any problems with that. Patient (PI #1) seemed stable, didn't seem to have any obvious injuries. If it were my daughter I would not have had any problem with taking her to (Hospital A) ER. The father was in the passenger seat up front with me as the driver (of the ambulance). While enroute my partner (Paramedic) called the (Hospital A's) ER.
(Hospital A's ER) asked my partner (Paramedic) to put us in the TCC system and he obliged and put the patient in the system... We pulled in the bay at (Hospital A's) ER. Another ambulance crew was calling us (there was two other ambulances in the bay and they came up to us saying that dispatch was trying to get a hold of us. I grabbed my phone to call dispatch. I saw the Charge Nurse walking towards us and I put the phone down. The Charge Nurse came to the passenger side window and told us that the ER Physician wants to divert us to (Hospital B). My response is 'We are already here.' The Charge Nurse said 'Well, that's what the (ER Physician) wants.' The father said 'Well, we want to go to (Hospital A.)' I told her (Charge Nurse) that the (ER Physician) needs to come out here. The Charge Nurse walked back to the ER. Then the (ER Physician) came out. She (ER Physician) went into the back (of the ambulance truck) and had a conversation with my partner (Paramedic) and said they (ER) had no rooms available and it would be an extended wait in the hallway. She (ER Physician) spoke with my partner in the back doing patient care. The father was upset about going to (Hospital A). I said to the father, 'It's out of my hands. I'm not in a position to argue with the doctor.' The father was not very happy with the situation but he understood my part of it. We left the bay at (Hospital A's) ER and went on to (Hospital B's) ER. As soon as we got in the ER at (Hospital B) they put us in a room right away and the doctor got in there pretty quick."

*The Paramedic of the ambulance (on 2-21-10 in which PI #1 was being transported) was interviewed on 3-2-10 at 3:08 PM stating "We pulled up on the scene and the Fire Rescue Squad (FRS) was already there and had her (PI #1) packaged on the back board and C-collar (cervical collar). We were the second ambulance on the scene. They (FRS) loaded her (patient) in the back of our truck (ambulance) and gave me a report. I did a quick rapid trauma assessment to check for any life threatening injuries and a quick set of vital signs. Once that was done we talked to the family about choice of hospitals. Any hospital would be fine because the patient didn't have any life threatening injuries. The father said he wanted her (PI #1) to go to (Hospital A). Then we got enroute towards the hospital. We had radio service but no phone service. We noted she (PI #1) had an abrasion to left knee abrasion upper right pelvis. The rest of the exam was unremarkable, no deformities... At that time we contacted (Hospital A). We gave report to a Nurse in ER taking the call and they (ER nurse) asked us to put the patient in TCC. That time we obliged her (ER nurse). I did another reassessment of the patient and vital signs, then I contacted TCC. I did inform TCC that patient had self extracted from the vehicle, was wearing a seat belts, vital signs stable, there were no deformities noted, age was 15, and we were putting patient in the system per (Hospital A's) request in case the patient needed to be transferred elsewhere. The father was present in the truck and requested that the patient go to (Hospital A)... We hung up with TCC.
Once we got to the hospital we were met by the Charge Nurse who informed us that we were to divert the patient to (Hospital B). I went over the patient's injuries with the Charge Nurse. The Charge Nurse said that she was just following the (ER Physician's) instructions. At that time I asked to talk to the (ER Physician) that was being insistent on diverting. The (ER Physician) came out and spoke with me. I asked her (ER Physician) if she wanted to get up in the back of the truck with me and the patient (PI #1) and see the patient (PI #1). She (ER Physician)) stood at the back of the truck, the doors where open. I went over the patient's injuries and/assessment. She (ER Physician)) made it clear that the patient (PI #1) was to be diverted to (Hospital B). She (ER Physician) said that the ER was full, had no beds and there would be an extended wait in the hallway. She (ER Physician) asked me why the patient was on a back board and wearing a C-collar. I explained that this was standard procedure, safety precautions. She (ER Physician) said to divert the patient to (Hospital B). At that time I informed my partner to go on to (Hospital B). I explained to the patient (PI #1)why we were going to (Hospital B). My partner explained to the father who was sitting in the passenger seat of the ambulance, why we were going to (Hospital B). Once we got back enroute to (Hospital B) I called (Hospital B) and gave them a full report from the beginning and that we were diverting from (Hospital A) to (Hospital B) at the doctor's request. She (PI #1) was stable, talking, actually joking. She (PI #1) was a cheerleader and said that they were going to the river or lake when the MVC happened. She (PI #1) was a happy camper."

*The ER Charge Nurse at Hospital A (working 7 AM - 7 PM on 2-21-10) was interviewed on 3-03-10 at 11:00 AM, stating "It was Sunday, 2-21-10, mid shift around 2 PM is when the ambulance pulled up in the ambulance bay. We were very busy that day. All the beds were full, ten plus people in the lobby, several ambulances that had arrived with patients. We had a critical patient on fast track that we had moved to a critical care bed. The (patient) acuity was very high that day. We had patients that we transferred to other hospitals that day. I had gotten a call from the Fire Department, I'm assuming, because it wasn't the (ambulance service). The caller said they were on scene with a 14 year old MVC (motor vehicle collision) roll over with belly pain and pelvic pain. I asked them if they had put the patient in TCC and they said 'No.' I then asked them to put the patient in TCC. Then I hung up the Rescue phone. I had repeated it (report received over the phone) out loud and (ER Physician) stated 'They need to go to (Hospital B).' Then she (ER Physician) got on the phone and talked to TCC. When the Rescue phone rang again, which I answered, it was (ambulance service) saying that a second ambulance was coming with two teenagers from the same MVC roll over, with two kids. That's when (ER Physician) said 'They need to go to (Hospital B). too.' That's when I said to (ambulance service) '(ER Physician) is advising that you go to (Hospital B) also.' (ER secretary) said TCC is on the line and (ER Physician) took that call while I was still on the Rescue phone with (ambulance #2) about the two teenagers so I don't know what (ER Physician) said to TCC. When she (ER Physician) hung up she said 'TCC said that's fine just let (ambulance service) know about it' meaning to divert them (ambulance) to (Hospital B) referring to the original or first ambulance truck which we did not tell them to divert to (Hospital B). I called (ambulance service) saying that (ER Physician) said that she wanted them to divert that first truck to (Hospital B)' as well as the other truck. I think I said 'Would you get in touch with the truck with the 14 year old and tell them that (ER Physician) wants them to divert to (Hospital B).' ...When I came back around the corner I saw (can look down hall to ambulance doors and see into the ambulance bay) an (ambulance) truck kind of pulled up half way in the ambulance bay. I saw the Driver motion with his hands up as if to say 'What's happened.' I went out to the ambulance. I said as the Driver rolled down the passenger window... All I know is that I said that (ER Physician) said that she wanted the patient transferred to (Hospital B). He (Driver) asked me to talk to the guy (Paramedic) in the back of the truck. I opened up the back door and the Paramedic proceeded to tell me what was going on with the patient. I somehow told him (Paramedic) that I didn't want report and asked him (Paramedic) if he wanted to talk to the (ER Physician). He (Paramedic) said 'Yes.' I went back inside in the ER and told (ER Physician) that (Paramedic) wanted to talk to her (ER Physician)... She (ER Physician) went outside to the ambulance and talked to the ambulance crew. I don't know who she (ER Physician) talked to just that she went out there and talked to (the ambulance crew)."

*The ER Physician, working in Hospital A's ER on 2-21-10, was interviewed on 03-08-10 at 1:10 PM stating "The medics (ambulance service) called in a multiple victim MVC of a 15 year old female with complaints of pelvic pain and a 16 year old male. A roll over MVC patient with pelvic pain should be entered into the TCC and they (medics) didn't. The patient was by herself no parent was present. They (medic) should enter the patient into the TCC. Our ER was full and we didn't have the capacity to treat a patient needing this level of care. The Charge Nurse was shocked that they (ambulance) showed up in the ambulance bay, went out to the ambulance bay (where ambulance was parked) and spoke with them (paramedics). The Charge Nurse told them (paramedics in ambulance) that they were suppose to divert to (Hospital B). They (paramedic) said 'Well, we want to talk to the doctor.' I went out and talked to them (paramedics). I normally don't go out and talk to the medic but I did go out to the ambulance. I told them (paramedics in ambulance) 'This patient was suppose to be diverted to (Hospital B). Why did you come here?' The medic said 'Well, it wasn't that bad. She was walking at the scene...' I asked 'Why is she (PI #1) spinal packaged if it was so minor.' He (medic) said 'It's just precautionary.' If someone is up and walking at the scene it's not necessary (spinal package the patient). I spoke with the father who was on the phone with someone about the situation that his daughter was in a car accident. I said to the father, 'I'm concerned with your daughter's injuries from the accident (MVC roll over) and her complaint.' I said that I felt that she (PI #1) would be better served at (Hospital B), a pediatric hospital. I said to the father 'Are you all right with that?' The father said 'Absolutely.' ...It sounds like the medic took it upon himself to come to (Hospital A) because it was close by. It's my job to decide what's in the best interest of the patient. This was a pediatric patient. This patient would not have been served well at (Hospital A) based on the initial report given by the medic."

*The Co-Medical Director of the ED was interviewed on 3-3-10 at 9:43 AM stating "(ER Physician) told me that this (Sunday, 2-21-10) was a busy day. The ER was full and there were no ICU (Intensive Care Unit) beds. She (ER Physician) said she had spoken on the phone to EMS (Emergency Medical Service) about an adolescent with mechanism of injury that warranted going to a trauma center, (Hospital B). She (ER Physician) said she told them (EMS) to divert, I'm assuming to (Hospital B). Somehow they (EMS/ambulance) arrived here (Hospital A's ER). She (ER Physician) said that she and the Charge Nurse went out to the ambulance bay... She (ER Physician) said that she had called and spoke to the attending (ER physician) at (Hospital B) about this patient coming to them. Apparently the father (of the child) showed up and she did speak with the child's father about, I believe, the patient going to (Hospital B). I did not orient (ER Physician). I assume an ER physician would be knowledgeable in EMTALA. I spoke with Director of Risk Management. They wished her (ER Physician) to be relieved (of her position in the ER). As of March 1, 2010 she (ER Physician) would be off the ER schedule and not work in any (Hospital A System's) ER. She (ER Physician) does understand what she did wrong. If the patient/ambulance is on the hospital's property, the patient is ours, our responsibility to triage and medically screen..."

*The ED Nurse Manager was interviewed on 3-02-10 at 1:51 PM stating "(Charge Nurse) is Baylor relief charge nurse and was suspended this past Friday, Saturday and Sunday and has been relieved from doing any relief charge. She will have to attend another EMTALA class on her time and pay. She has been to an EMTALA class in 2006 and has done the annual CBLs (computer based training) on EMTALA. I'm on call 24/7 and I did not find out about this until the following Monday AM. I will be doing this as a written conference and a 90 day probation, too, for (Charge Nurse)."

Although this (PI #1) presented to the hospital ER in an ambulance (which had pulled into the ambulance bay of Hospital A), the ER Physician at Hospital A diverted the ambulance with PI #1 to Hospital B without performing a MSE on PI #1.

Refer to 2406.

Based on interviews of facility staff, ER physicians, ambulance paramedics, review of recorded call between Hospital A's ER with paramedics and TCC (Trauma Communications Center), and the Communication Control Log, Hospital A failed to provide a Medical Screening Examination (MSE) for one (1) of twenty-eight (28) patients in the sample, [Patient Identifier (PI) #1.]

PI #1 (an adolescent) presented to this facility's ER for evaluation and treatment in an ambulance on 02-21-10. The ambulance had pulled into an ambulance bay and was approached by an ER Charge Nurse and ER physician. Hospital A's ER physician told the ambulance to divert to Hospital B (specifically treats pediatric patients). PI #1 did not receive a MSE at Hospital A prior to leaving this facility (Hospital A).

The findings include:

1. The following information was self reported by the facility to the Alabama Department of Public Health on 2-23-10 in regards to the ambulance with PI #1 after pulling into the ambulance bay being diverted to Hospital B by the ER physician without receiving a MSE.

"Director, Risk Management and Compliance at Hospital A self reports that she is writing to inform the Alabama Department of Public Health of a possible transfer violation regarding an ambulance that was driven to the (Hospital A's) Emergency Department early afternoon on February 21, 2010. She writes, the paramedics reported a motor vehicle accident involving three teenagers via a cell phone. Based on the report from the accident scene, the writer states the (Hospital A's) ED physician advised that EMS report the accident to TCC (Trauma Communication Center) for possible divert to an appropriate trauma center. There was a communication loss at some point between the hospital and the paramedics. One ambulance was diverted, but one came to (Hospital A). The physician believed that the patient was supposed to be sent to another facility per TCC and thus the ambulance was diverted to that facility..."

2. TRANSCRIPTION OF CALLS BETWEEN ER, PARAMEDICS, & TCC

The following information was taken from the recorded calls between Hospital A's ER, the paramedics, and TCC.

02-21-10 at 13:21:25 (118 KB)
Paramedic calling ER of Hospital A to give a report on PI #1. Female voice (Charge Nurse) answered. NOTE: CN for Charge Nurse and PM for Paramedic.

CN ER.

PM Yes ma'am. This is (Paramedic) enroute to your facility with a 15 year old female involved in a MVC. Ahh, car did roll over, did have seat belts on. Patient self extricated from the vehicle, ambulatory on scene, no LOC, no obvious deformities. Vital signs are as follows: 154/84, heart rate of 90, respiratory rate of 16, she's 98% on room air. She's on a spinal board and packaged. Only complaint she has is right supra pelvic pain and an abrasion to the left knee.

CN So she's got abdominal pain and she was in a roll over.

PM Yes.

CN Have you put her in TCC?

PM No ma'am.

CN I would appreciate it if you would in case she has a splenic lac or pelvic fracture, I'd like to be able to transfer her to UAB.

PM Okay, I will.

CN Thank you.

PM Thank you, bye, bye. Good-bye.

02-21-10 at 13:23:08 (212 KB)
Paramedic with second ambulance calling ER of Hospital A about the two other adolescents involved in the same MVC. ER Charge Nurse also answered this call. This call is addressed as being received because it is referred to in the following interviews.

02-21-10 13:24:07 (132 KB)
Call from TCC to ER. TCC is speaking to the ER Physician denoted as ER MD.

ER MD. Hey, I'm one of the ER docs that's here. Is this the 15 year old?

TCC This is a sixteen year old. There's a roll over. Says a restrained driver. He said he self extricated, denies loss of conscious but they say now he's got a GCS (glaso coma scale) of 14.

ER MD Right.

TCC Ahh, said that he's got left shoulder pain, his only complaint. Blood pressure 116/ palpated, heart rate is 84, respiratory rate is 18. Good bilateral breath sounds but the sats run in the low 90s like on 12 liters.

ER MD Yeah, we're going to send those to (Hospital B) just cuz, I mean just the mechanism. We can't admit them here anyway so I'm going to send those up there.

TCC The 16 year old?

ER MD Yeah, the 16 year old, just the mechanism itself I think needs to go up there.

TCC Mmm, okay have you resolved that (this sentence comes out somewhat garbled with the ER doctor talking over the TCC caller) because they weren't off yet when I called.

ER MD She's on the phone with them right now

TCC Mmm, okay. all right, let me see what I can do.

ER MD Okay. Thanks. Bye.

02-21-10 13:25:30 (47 KB)
Call between Hospital A ER with Charge Nurse speaking to paramedic with ambulance #2.
.
CN ...There's two trucks coming.

PM I have no family available to make that decision on these two.

CN Well, I don't think that's a decision, the doctor just told TCC that you all are to go to (Hospital B). It's not a request by the family. This is per the ER doctor. They are diverting you to (Hospital B).

PM All right, we'll divert to (Hospital B).

02-21-10 13:26:34 (144 KB)
Call between Hospital A's ER with Charge Nurse speaking to ambulance office/dispatcher.

CN Hey... We have one of your trucks enroute to us that we need to divert to (Hospital B)

DP Okay.

CN There were two that went to a roll over and I have talked to Unit 502 and we have diverted them to (Hospital B) but I don't know what unit is bringing us the 15 year old female roll over with pelvic pain but they, too, need to be diverted to (Hospital B).

DP Ahh, I'll let them know.

CN So you'll let them know?

DP Well, I hope they're not there... Hold on one second. (Turned away to someone in office asking...)

CN They didn't tell me were but it's a MVC roll over

DP Okay. yeah.

CN With three teenagers.

DP Yeah, Oh, great. I'll let them know.

CN Okay, bye.

3. COMMUNICATION CONTROL LOG

The following information was taken from the Communication Control Log for the date of 02-21-10. The Communication Control Log documents the calls received from ambulances.

"1322 Com (communication) method: Telephone. Unit calling: RPS 402.
Patient description: F (female), age - 15, BP - 154/84, P - 90, R - 16, (temperature) 98.1. Initial pt assessment information/orders: MVC rollover. Amb (ambulance) on scene - (negative) LOC. C/O (complaining of) pelvic pain.
Med (medical) order: Diverted to Childrens per MD (medical doctor)...

3. INTERVIEWS

*The Driver of the ambulance on 2-21-10 in which PI #1 was being transported was interviewed on 3-2-10 at 2:32 PM stating "When we arrived on scene, the Fire Department was bringing the patient (PI #1) to us on a back board with a cervical collar and spider straps in place. They loaded the patient in our truck, gave us report and we went on to (Hospital A). The patient was self extricated, standing along side the vehicle upon the Fire Department's arrival. The patient (PI #1) was complaining of pain in her knee and she had a small abrasion to right hip and right knee. No obvious deformities, no lose of consciousness, no altered mental status. The parents (of PI #1) were on the scene before the Fire Department got there. The mother (of PI #1) wanted her (PI #1) to go to the ER to get checked out. She (PI #1) didn't want to go to the hospital but her parents wanted to go to the hospital. I asked the parents (of PI #1) where they wanted (their daughter) to go and they said 'We would like to go to (Hospital A).' We didn't see any problems with that. Patient (PI #1) seemed stable, didn't seem to have any obvious injuries. If it were my daughter I would not have had any problem with taking her to (Hospital A) ER. The father was in the passenger seat up front with me as the driver (of the ambulance). While enroute my partner (Paramedic) called the (Hospital A's) ER.
(Hospital A's ER) asked my partner (Paramedic) to put us in the TCC system and he obliged and put the patient in the system... We pulled in the bay at (Hospital A's) ER. Another ambulance crew was calling us (there was two other ambulances in the bay and they came up to us saying that dispatch was trying to get a hold of us. I grabbed my phone to call dispatch. I saw the Charge Nurse walking towards us and I put the phone down. The Charge Nurse came to the passenger side window and told us that the ER Physician wants to divert us to (Hospital B). My response is 'We are already here.' The Charge Nurse said 'Well, that's what the (ER Physician) wants.' The father said 'Well, we want to go to (Hospital A.)' I told her (Charge Nurse) that the (ER Physician) needs to come out here. The Charge Nurse walked back to the ER. Then the (ER Physician) came out. She (ER Physician) went into the back (of the ambulance truck) and had a conversation with my partner (Paramedic) and said they (ER) had no rooms available and it would be an extended wait in the hallway. She (ER Physician) spoke with my partner in the back doing patient care. The father was upset about going to (Hospital A). I said to the father, 'It's out of my hands. I'm not in a position to argue with the doctor.' The father was not very happy with the situation but he understood my part of it. We left the bay at (Hospital A's) ER and went on to (Hospital B's) ER. As soon as we got in the ER at (Hospital B) they put us in a room right away and the doctor got in there pretty quick."

*The Paramedic of the ambulance (on 2-21-10 in which PI #1 was being transported) was interviewed on 3-2-10 at 3:08 PM stating "We pulled up on the scene and the Fire Rescue Squad (FRS) was already there and had her (PI #1) packaged on the back board and C-collar (cervical collar). We were the second ambulance on the scene. They (FRS) loaded her (patient) in the back of our truck (ambulance) and gave me a report. I did a quick rapid trauma assessment to check for any life threatening injuries and a quick set of vital signs. Once that was done we talked to the family about choice of hospitals. Any hospital would be fine because the patient didn't have any life threatening injuries. The father said he wanted her (PI #1) to go to (Hospital A). Then we got enroute towards the hospital. We had radio service but no phone service. We noted she (PI #1) had an abrasion to left knee abrasion upper right pelvis. The rest of the exam was unremarkable, no deformities... At that time we contacted (Hospital A). We gave report to a Nurse in ER taking the call and they (ER nurse) asked us to put the patient in TCC. That time we obliged her (ER nurse). I did another reassessment of the patient and vital signs, then I contacted TCC. I did inform TCC that patient had self extracted from the vehicle, was wearing a seat belts, vital signs stable, there were no deformities noted, age was 15, and we were putting patient in the system per (Hospital A's) request in case the patient needed to be transferred elsewhere. The father was present in the truck and requested that the patient go to (Hospital A)... We hung up with TCC.
Once we got to the hospital we were met by the Charge Nurse who informed us that we were to divert the patient to (Hospital B). I went over the patient's injuries with the Charge Nurse. The Charge Nurse said that she was just following the (ER Physician's) instructions. At that time I asked to talk to the (ER Physician) that was being insistent on diverting. The (ER Physician) came out and spoke with me. I asked her (ER Physician) if she wanted to get up in the back of the truck with me and the patient (PI #1) and see the patient (PI #1). She (ER Physician)) stood at the back of the truck, the doors where open. I went over the patient's injuries and/assessment. She (ER Physician)) made it clear that the patient (PI #1) was to be diverted to (Hospital B). She (ER Physician) said that the ER was full, had no beds and there would be an extended wait in the hallway. She (ER Physician) asked me why the patient was on a back board and wearing a C-collar. I explained that this was standard procedure, safety precautions. She (ER Physician) said to divert the patient to (Hospital B). At that time I informed my partner to go on to (Hospital B). I explained to the patient (PI #1)why we were going to (Hospital B). My partner explained to the father who was sitting in the passenger seat of the ambulance, why we were going to (Hospital B). Once we got back enroute to (Hospital B) I called (Hospital B) and gave them a full report from the beginning and that we were diverting from (Hospital A) to (Hospital B) at the doctor's request. She (PI #1) was stable, talking, actually joking. She (PI #1) was a cheerleader and said that they were going to the river or lake when the MVC happened. She (PI #1) was a happy camper."

*The ER Charge Nurse at Hospital A (working 7 AM - 7 PM on 2-21-10) was interviewed on 3-03-10 at 11:00 AM, stating "It was Sunday, 2-21-10, mid shift around 2 PM is when the ambulance pulled up in the ambulance bay. We were very busy that day. All the beds were full, ten plus people in the lobby, several ambulances that had arrived with patients. We had a critical patient on fast track that we had moved to a critical care bed. The (patient) acuity was very high that day. We had patients that we transferred to other hospitals that day. I had gotten a call from the Fire Department, I'm assuming, because it wasn't the (ambulance service). The caller said they were on scene with a 14 year old MVC (motor vehicle collision) roll over with belly pain and pelvic pain. I asked them if they had put the patient in TCC and they said 'No.' I then asked them to put the patient in TCC. Then I hung up the Rescue phone. I had repeated it (report received over the phone) out loud and (ER Physician) stated 'They need to go to (Hospital B).' Then she (ER Physician) got on the phone and talked to TCC. When the Rescue phone rang again, which I answered, it was (ambulance service) saying that a second ambulance was coming with two teenagers from the same MVC roll over, with two kids. That's when (ER Physician) said 'They need to go to (Hospital B). too.' That's when I said to (ambulance service) '(ER Physician) is advising that you go to (Hospital B) also.' (ER secretary) said TCC is on the line and (ER Physician) took that call while I was still on the Rescue phone with (ambulance #2) about the two teenagers so I don't know what (ER Physician) said to TCC. When she (ER Physician) hung up she said 'TCC said that's fine just let (ambulance service) know about it' meaning to divert them (ambulance) to (Hospital B) referring to the original or first ambulance truck which we did not tell them to divert to (Hospital B). I called (ambulance service) saying that (ER Physician) said that she wanted them to divert that first truck to (Hospital B)' as well as the other truck. I think I said 'Would you get in touch with the truck with the 14 year old and tell them that (ER Physician) wants them to divert to (Hospital B).' ...When I came back around the corner I saw (can look down hall to ambulance doors and see into the ambulance bay) an (ambulance) truck kind of pulled up half way in the ambulance bay. I saw the Driver motion with his hands up as if to say 'What's happened.' I went out to the ambulance. I said as the Driver rolled down the passenger window... All I know is that I said that (ER Physician) said that she wanted the patient transferred to (Hospital B). He (Driver) asked me to talk to the guy (Paramedic) in the back of the truck. I opened up the back door and the Paramedic proceeded to tell me what was going on with the patient. I somehow told him (Paramedic) that I didn't want report and asked him (Paramedic) if he wanted to talk to the (ER Physician). He (Paramedic) said 'Yes.' I went back inside in the ER and told (ER Physician) that (Paramedic) wanted to talk to her (ER Physician)... She (ER Physician) went outside to the ambulance and talked to the ambulance crew. I don't know who she (ER Physician) talked to just that she went out there and talked to (the ambulance crew)."

*The ER Physician, working in Hospital A's ER on 2-21-10, was interviewed on 03-08-10 at 1:10 PM stating "The medics (ambulance service) called in a multiple victim MVC of a 15 year old female with complaints of pelvic pain and a 16 year old male. A roll over MVC patient with pelvic pain should be entered into the TCC and they (medics) didn't. The patient was by herself no parent was present. They (medic) should enter the patient into the TCC. Our ER was full and we didn't have the capacity to treat a patient needing this level of care. The Charge Nurse was shocked that they (ambulance) showed up in the ambulance bay, went out to the ambulance bay (where ambulance was parked) and spoke with them (paramedics). The Charge Nurse told them (paramedics in ambulance) that they were suppose to divert to (Hospital B). They (paramedic) said 'Well, we want to talk to the doctor.' I went out and talked to them (paramedics). I normally don't go out and talk to the medic but I did go out to the ambulance. I told them (paramedics in ambulance) 'This patient was suppose to be diverted to (Hospital B). Why did you come here?' The medic said 'Well, it wasn't that bad. She was walking at the scene...' I asked 'Why is she (PI #1) spinal packaged if it was so minor.' He (medic) said 'It's just precautionary.' If someone is up and walking at the scene it's not necessary (spinal package the patient). I spoke with the father who was on the phone with someone about the situation that his daughter was in a car accident. I said to the father, 'I'm concerned with your daughter's injuries from the accident (MVC roll over) and her complaint.' I said that I felt that she (PI #1) would be better served at (Hospital B), a pediatric hospital. I said to the father 'Are you all right with that?' The father said 'Absolutely.' ...It sounds like the medic took it upon himself to come to (Hospital A) because it was close by. It's my job to decide what's in the best interest of the patient. This was a pediatric patient. This patient would not have been served well at (Hospital A) based on the initial report given by the medic."

Although this (PI #1) presented to the hospital ER in an ambulance (which had pulled into the ambulance bay of Hospital A), the ER Physician at Hospital A diverted the ambulance with PI #1 to Hospital B without performing a MSE on PI #1.

Refer to 2400.

These deficiencies were written as a result of the investigation of Complaint #AL00022155.