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Based on medical record review, document review, and staff interview the hospital failed to follow their EMTALA (Emergency Medical Treatment and Labor Act) policy to provide an appropriate and timely medical screening exam (MSE) to determine if an emergency medical condition existed for 1 (Patient #1) of 20 records selected from the Emergency Department (ED) log for review for the past six months from July 2015 to January 2016.

Failure to conduct a timely MSE to include ancillary studies and procedures as required with evidence of continued monitoring according to the individual's needs placed the patient at risk for a worsening of his condition that could potentially have lead to further complications or death.

Findings include:

Medical Staff Bylaws reviewed on 1/13/2016 at 9:45 AM directed "...The Hospital will provide an appropriate medical screening exam within its capability, including ancillary services routinely available to the Emergency Department, for persons (who are not already inpatients) on the Hospitals property requesting examination for what might be an emergency medical condition ..." and "... The screening examination may be performed by medical Staff Practitioners including physicians, advanced practice nurses and physician assistants, emergency room Registered Professional Nurses and Registered Professional Nurse sexual assault nurse examiners ..." and "Stabilizing Treatment. If an emergency medical condition is found to exist, the hospital will provide necessary stabilizing treatment or an appropriate transfer. "Stabilizing treatment" is considered as the treatment necessary to assure, within a reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility ..."

Hospital policy titled "Emergency Department Scope of Care" reviewed on 1/11/2016 directed "...Support services including but not limited to clinical laboratory studies and x-rays will be provided to the patient in a timely manner. All necessary definitive treatment will be given to the patient within the hospital's capabilities. The physician is responsible for the evaluation and treatment of the emergency room patient..."


Patient #1 presented to the ED on 12/31/15 at 11:09 pm with chest pain and shortness of breath after falling from a scooter and hitting their chest on the handlebar. Patient triaged as a level 2 patient with an urgent medical condition. Patient had labs and tests ordered on admission that were delayed for several hours. When CT, lab, and EKG results became available, patient diagnosed with a sternal fracture with a hematoma and a pleural effusion which is an emergency medical condition that the hospital did not have the capability to stabilize. The hospital transferred the patient to hospital BB (a children's trauma hospital) for stabilizing treatment. The hospital failed to provide an appropriate medical screening exam in a timely manner to determine whether an emergency medical condition existed.

See further details at C-2406.

Based on medical record review, document review, and staff interview the hospital failed to provide an appropriate medical screening exam (MSE) to determine if an emergency medical condition (EMC) existed for 1 (Patient #1) of 20 records selected from the Emergency Department (ED) log for review from the past six months from July 2015 to January 2016.

Failure to conduct a timely MSE to include ancillary studies and procedures as required and failure to provide continuous monitoring according to the individual's needs placed the patient at risk for a worsening of his condition that could potentially have lead to further complications or death.

Findings include:

- Review of the Hospital/CAH (Critical Access Hospital) worksheet updated on 1/11/2016 indicated the hospital did not provide the following service: Cardiac-Thoracic Surgery; did not have a pediatric surgeon/trauma surgeon; and was not designated as a trauma center.

- Patient #1 presented to the ED on 12/31/2015 at 11:09 PM with a complaint of chest pain and shortness of breath. Medical record review revealed the patient had fallen from a scooter and hit their chest on the handlebar. Triage nurse, Registered Nurse (RN) Staff C's, documented assessment revealed patient #1 had pain to their chest, shortness of breath, and a rash on their chest where the handlebars hit and was assigned a triage level of 2 (patient with an urgent medical condition). Physician Staff E's notes reviewed on 1/12/2016 at 10:00 am revealed a handlebar sign (injury to the chest from the handlebars of a bicycle or scooter) on lower sternum (breastbone) with hematoma (bruising) identified during the initial assessment performed on 12/31/2015 at 11:09 PM.

- Initial orders written by Physician Staff E at 11:20 PM failed to include an Electrocardiogram (EKG) (test used to monitor heart rhythm) to evaluate a patient with chest pain, a chest X-Ray (to evaluate a patient with shortness of breath), and a troponin level (a blood test used to check for heart tissue damage).

- RN Staff C collected blood for lab tests at 1:30 AM (more than 2 hours after they were ordered at 11:20 PM) when he started an IV (device used to access a blood vessel for delivering medications). The lab results came back between 1:48 AM and 2:02 AM and revealed an elevated white blood cell count (potential indicator of trauma, tissue damage, or infection) and an elevated absolute neutrophil count (indicating an inflamed or injured area).

- The CT performed at 2:16 AM (3.25 hours after patient's arrival) resulted at 4:00 AM (about 1.75 hours after the CT was completed) revealing a sternal fracture (a fracture of the breastbone that can interfere with breathing by making it more painful; however, its primary significance is that it can indicate the presence of serious associated internal injuries, especially to the heart and lungs), hematoma (a localized collection of blood outside the blood vessels), and small pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest).

Physician Staff D interviewed on 1/12/2016 at 3:10 PM indicated a reasonable amount of time to receive CT results is 30-60 minutes.

- A troponin level was not performed until 4:07 AM (with the blood that was collected 2 1/2 hours before at 1:30 AM) with results revealing an elevated level (indicating possible heart tissue injury).

- An EKG performed on 1/1/2016 at 4:42 AM (approximately 5.5 hours after the patient arrived to the hospital) and repeated at 6:05 AM revealed heart rhythm interpretations of Sinus Rhythm with marked sinus arrhythmia, T wave abnormality; consider anterior ischemia (Abnormal EKG indicating possible heart tissue damage).

- The medical record lacked evidence hospital staff completed a set of vital signs on patient #1 between 12/31/2015 at 11:09 PM and 1/1/2016 at 1:08AM (almost two hours) and between 1:09 am and 5:17 am (more than four hours). The medical record failed to contain an order for continuous heart monitoring and vital sign monitoring for a patient with a known chest injury.

- Physician Staff E consulted with Physician Staff Y at Hospital BB (a children's trauma hospital) at 5:00 AM on 1/1/16 and decided to transfer the patient. The medical record revealed patient #1 was discharged for transfer at 7:01 AM (8 hours after the patient's arrival to the ED). Hospital BB arranged for the patient's advanced life support transportation.

- Documentation from Hospital BB's admitting physician 1/1/16 at 9:52pm stated the...male sustained blunt chest wall trauma secondary to ground level fall onto a blunt object which resulted in a displaced sternal fracture...Cardiology was consulted for assessment of cardiac injury and an echocardiogram (a special ultrasound which can take pictures of the heart to see it beating and pumping blood) and EKG were performed.

Physician Staff E interviewed on 1/13/2016 at 11:20 AM acknowledged they were the physician in the ED on 12/31/2015 and was responsible for the treatment of patient #1. Physician Staff E reported a patient triaged as a level 2 (urgent emergency medical condition) with a chest injury they would routinely order a CT scan, laboratory studies to include included Lipase (to check liver function), CBC (complete blood count) (diagnostic blood test used to indicated bleeding or tissue injury), Comprehensive metabolic profile (blood test used to evaluate kidney and liver function as well as fluid balance) and the Troponin, continuous heart and vital sign monitoring, and they would offer pain medications.Physician Staff E revealed they had a "high suspicion" patient #1 had broken their sternum (bone in the center of the chest connecting the ribs). Physician Staff E acknowledged laboratory staff was available and could have been used to obtain the necessary blood sample immediately after it was ordered instead of waiting until RN Staff C established an IV. Physician Staff E indicated they discovered the troponin level was not ordered when the results of the other lab tests were available.

RN Staff C interviewed on 1/12/2016 at 1:35 PM acknowledged they had provided care for patient #1 during their ED stay. RN Staff C indicated patient #1 had difficulty breathing during the triage assessment related to the pain they were having from where the handlebars impacted their chest. RN Staff C acknowledged vital signs were not taken as often as they should have been stating they only have four machines that are capable of continuous monitoring and they were all being used in other rooms.

Certified Nurse Aide (CNA) Staff K interviewed on 1/13/2016 at 11:29 AM indicated they took vital signs on patient #1 and placed them on the cardiac monitor later in the morning but is unable to identify the time. CNA Staff K acknowledged there are portable cardiac monitors in the hospital and they could have been used to ensure continuous monitoring of patient #1's vitals.