HospitalInspections.org

Based on record review and interview, the hospital failed to ensure compliance with the requirements of CFR 489.24 as evidenced by:

1) failing to to ensure an appropriate medical screening examination, within the capability of the hospital's emergency department and ancillary services, was performed to determine whether or not an emergency medical condition existed. This deficient practice is evidenced by failure of the hospital to accept a patient who had a ground level fall with a head impact, who was en route for an assessment to determine if an emergency condition existed for 1 (#1) of 3 (#1, #2, #9) sampled patients reviewed for emergency medical service transport with injuries involving head impacts and/or neurological symptoms, from a total patient sample of 20. (see findings tag C-2406).

Based on policy review, observation and interview, the hospital failed to ensure signage (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; was posted conspicuously, in the emergency department and places likely to be noticed by all individuals entering the emergency department. This deficient practice was evidenced by failure to post EMTALA signage outside of the emergency department's ambulance bay, inside by the ambulance bay, or in the treatment area in the emergency department.

Findings:

Review of the hospital policy titled,"Transfer Policy-EMTALA", Reference Number: A-8, last revised 12/2018, revealed the following, in part: Policy: The hospital shall post a sign in a conspicuous area(s) of the emergency department, entrance, admitting areas, waiting areas, etcetera, specifying the rights of the individual with respect to examination and treatment of medical conditions and women in labor.

On 03/15/2021 at 11:25 a.m. an observation was conducted of the hospital's emergency department. Further observation revealed there was no EMTALA signage posted outside of the ambulance bay, inside by the ambulance bay, or in the treatment area in the emergency department. S1MD, present during the observation, confirmed there was no signage posted in the referenced areas.

Based on policy review, record review, and interview, the hospital failed to ensure an appropriate medical screening examination, within the capability of the hospital's emergency department and ancillary services, was performed to determine whether or not an emergency medical condition existed. This deficient practice was evidenced by failure to accept a patient who had a ground level fall with a head impact, who was en route, for an assessment to determine if an emergency condition existed for 1 (#1) of 3 (#1, #2, #9) sampled patients reviewed for emergency medical service transport with injuries involving head impacts and/or neurological symptoms, from a total patient sample of 20.

Findings:

Review of the hospital policy titled, "Transfer Policy-EMTALA" Reference Number: A-8, last revised 12/2018, revealed in part: Definitions: Hospital with an Emergency Department: A Critical Access Hospital that operates a dedicated Emergency Department is subject to the requirements of EMTALA.
Emergency Medical Condition: A medical condition with sufficient severity (including severe pain, psychiatric disturbances, symptoms of substance abuse, pregnancy/active labor, such that immediate medical attention could place the individual's health at risk.
Medical Screening Exam: The process to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not.
All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care cane be referred to a physician or clinic.

Review of the ED central log from 02/16/2021 00:00 a.m. - 02/17/2021 00:00 a.m. revealed a total of 10 patients had been seen in the ED for that time period.

Review of the radiological services provided by the hospital revealed the hospital has 24 hour a day/7 days a week capability to provide CT scans, MRIs, x-rays, and ultrasound. The hospital has a Hitachi 128 slice CT scanner and open MRI, diagnostic radiology, and echocardiogram capabilities.

S6UR confirmed during the survey team entrance conference on 03/15/2021, that the hospital had been fully staffed during the ice storm on 02/16/2021 and the hospital had not been on divert.

Review of Patient #1's run report, dated 02/16/2021, for Ambulance Company "A" revealed the following:
Unit was dispatched from town station to Patient #1's home address for a fall. Upon arrival, Patient #1, a 68 year-old female greeted EMS outside her residence. Patient #1 was ambulatory on scene. Patient #1 states she had a fall approximately 45 minutes before calling 9-1-1. Patient states she slipped and fell on ice covering grass while looking for her cat outside. Patient #1 states she landed on her hip and hit her head on the ice. ABCs (airway, breathing, circulation) intact. Patient #1 alert and oriented. Patient has a small swelling noted to left side of head above left ear. No discoloration. Patient states head pain of a 5 on a scale of 1- 10. Patient denies LOC (loss of consciousness), blurred vision, dizzy, or weakness at this time. Patient denies neck pain. Full ROM (range of motion) noted. Patient placed on stretcher in a position of comfort and secured. A C- Collar (cervical collar) was placed on Patient #1. Vitals were taken and found to be normal. Patient also states left hand pain and left knee pain. No signs of trauma. Patient #1 wanted to be transported to West Feliciana Parish Hospital. Patient report called in to West Feliciana Parish Hospital. S1MD was given the radio and suggested we take her to a hospital with neurological services due to falling and hitting her head. LERN (Louisiana Emergency Response Network) was notified and suggested 2 area hospitals with neurological capabilities.
Patient refused to go to trauma center as suggested from LERN and insisted she goes to Hospital "B".
Further review of Patient #1's run record report revealed the patient was on the following current medications: Wellbutrin, Lamictal, Seroquel, Synthroid, Singulair, Benicar, and Valtrex. Additional review revealed no documented evidence the patient was being treated with anticoagulants.
Assessment Exam: Mental status: oriented to person, event, place, time, normal baseline for patient.
Head: pain, swelling, tenderness- left side of head - pain above ear, from fall 45 minutes prior to arrival of EMS;
Eye: PERRL (pupils equal, round, reactive to light),
Hip left, knee left, hand-palm left- motor function normal - no signs of trauma.
Vital signs - Blood pressure, pulse, respiration, and Oxygen saturation (SaO2) was documented at 8:25 p.m., 8:40 p.m., 8:55 p.m., 9:10 p.m., 9:25 p.m., and 9:40 p.m.
The following vital sign ranges were noted:
SaO2s: 98% -99 % on room air;
Respiratory rates (breaths/minute): 16-18;
Pulse (beats/minute): 69 -78;
Blood pressure (mm/Hg): initial: 167/88 (highest reading) to 121/69 (lowest reading), and last assessed blood pressure was 138/72;
Response was documented as alert for all assessments;
Glascow Coma Scale (GCS) Assessments: Initial GCS score at 8:25 p.m.: Score: 15 (lowest score is 1- highest score is 15) based upon assessment of the following categories:
Eye: Opens Eyes spontaneously (All Age Groups)
Motor: Obeys commands, (>2 Years); Appropriate response to stimulation
Verbal: Oriented (>2 Years); Smiles, oriented to sounds, follows objects, interacts
Score Qualifier: Initial GCS has legitimate values without interventions such as intubation and sedation
Subsequent GCS assessments performed at 8:40 p.m., 8:55 p.m., 9:10 p.m., 9:25 p.m., and 9:40 p.m. and all scores remained at a score of 15 without interventions such as intubation and sedation.

Review of Patient #1's ED record from Hospital "B", dated 02/16/2021, revealed the following:
Chief Complaint: Fall at 8:30 p.m.; Time Seen by Provider: 02/16/2021 10:14 p.m.
Mode of Arrival: Stretcher and EMS- Ground
Limitations: No Limitations
ED Triage Description of Symptoms: Patient had ground level fall tonight, complains of buttocks, hip, knee pain as well as left cheek and left temporal region. Denies any LOC (loss of consciousness) however did have an episode of dizziness, blurred vision, and vomiting. GCS 15 at this time.
History of Present Illness: Patient states left knee pain is better, she is complaining of pain to her left buttock area with no pain to the lumbar spine. She states that she feels like these are bruises. Dizziness, blurred vision, and vomiting have all resolved.
Review of Systems: All systems reviewed and are unremarkable except as noted in History of Present Illness and below:
Spine Comments: left clavicle and upper rib pain;
Neurologic Comments: left sided head pain;
Pupils: PERRL;
Chest: localized rib tenderness with anteroposterior compression;
Effort & Inspection: Yes, normal respiratory effort and Yes able to speak in complete sentences;
Cardiovascular Palpation: Yes, capillary refill normal; Rate: regular rate; Rhythm: regular rhythm;
Extremities General: normal to inspection, full ROM and capillary refill normal;
Neurologic: General: patient alert, patient awake and patient oriented times 3; Cranial Nerves: II-XII intact bilaterally; Cognition: normal cognition; Speech: speech normal;
Motor: muscle tone normal throughout and strength 5/5 throughout;
Sensory Exam: Yes, no sensory deficits noted.

CT head without contrast performed: Technique: Axial images are obtained from skull base to the vertex.
Findings: Generalized cerebral involution/volume loss, not unexpected for
the patient's age. Gray-white differentiation is preserved without evidence of cerebral edema.
The ventricles are normal in size without evidence of hydrocephalus or
midline shift. No mass, intraparenchymal hemorrhage, extra-axial
hemorrhage, or extra-axel fluid collection is identified. The orbits and
osseous structures are unremarkable. The mastoid air cells and paranasal
sinuses are well aerated.
Impression: 1. Non-contrast head CT with no acute intracranial findings. 2.Generalized cerebral involution/volume loss, not unexpected for the patient's age.

Chest-1 View -(Portable): Heart and mediastinum are normal. Lungs are clear, with no pleural effusion
or pneumothorax. Impression: Normal chest.
Patient admitted: No; Discharge Plan: Discharge home
Clinical Impression: Musculoskeletal pain, Head injury; Encounter type: Unspecified injury of head, Fall
Patient Disposition: Home, Self-Care; Condition: Good

In an interview on 03/15/2021 at 2:17 p.m. with S1MD, ED Medical Director, he confirmed they do treat falls with head impact and they also treat concussions in the ED. He reported CT is readily available 24 hours a day/7 days a week and radiology with radiologist coverage for reading radiological studies is also available 24 hours a day/7 days a week. S1MD indicated if the patient has injuries, bleeds, and/or fractures they stabilize the patient here and utilize LERN if assistance is required for transferring the patient out. He confirmed not all head injuries are transferred out for treatment. He explained if the patient is stable, their work-up is all normal and they have someone with them, there is a comfort level with the patient continuing monitoring at home.
S1MD reported EMS has a process for assessing patient falls in the field. He indicated EMS picks the patient up and they are informed of the mechanism of injury such as a fall from height, a car accident, if patient is on blood thinners, or if they are on over the counter medications that increase risk for bleeding, or any other factors that put them at increased risk for cerebral hemorrhage. He indicated the EMTs have training for performing assessments in the field and they have LERN to help them determine the most appropriate hospital for treatment and the closest hospital may not be the most appropriate if they have risk factors.
He indicated a patient with a slip/fall at home who is a walk-in to the ED has a very similar management - a triage assessment is performed including a mental status /level of consciousness exam, determination as to whether imaging is warranted, risk factors are examined, and if the patient is at low risk for traumatic brain injury, they don't need cervical spine films, and don't need a CT scan. S1MD indicated by and large patient assessment is exam focused and if imaging is warranted and there are worrisome findings they initiate the transfer process.
S1MD was asked what made Patient #1's level of care requirement for a slip/fall with head impact different from a patient who walked in with the same history. He reviewed the run report for Patient #1 and indicated he didn't remember that particular incident, could she have been treated here, possibly, he said he could go either way. S1MD reported he had seen several patients who had slip/falls on ice during the ice storm. He indicated if Patient #1 had been taken here, having fallen with bruising on side of head and reported vomiting, they would have done a head CT scan and C-spine films. If the patient's injury was just a bruise, and the studies were not indicative of a subdural bleed or subarachnoid bleed, she could have been treated at this hospital. S1MD also said he couldn't see where she couldn't go straight to the trauma center. He confirmed they have accepted patients presenting with similar circumstances and injuries and have treated them. He confirmed the hospital's CT scan machine has not been down and they have not experienced any significant power loss that he knows of.

In an interview on 03/16/2021 at 8:57 a.m. with S2EMT, he reported when they receive a call from dispatch and they are sent to a fall scene they size up the scene upon arrival. S2EMT explained they assess whether the patient is alert and oriented, perform a trauma assessment, assess vitals, look at the patient's medical history, determine whether the patient is on blood thinners, and use this information to determine if they need neurological services. He indicated the paramedic on the call would take over if a patient required advanced life support or advanced trauma care. He indicated if no trauma the basic level EMT took over management of the patient. S2EMT explained if the patient just bumped their head they would call in to the local hospital to give them report on the patient they were bringing in. He said they would report to the ED nurse first and the nurse would get the MD to talk to them if they needed to speak to the MD. He reported between the MD and LERN they would obtain direction as to the location where the patient was to be brought based on the patient's history and current symptoms.
S2EMT indicated he remembered Patient #1, in general, and he also had a copy of the run report with him. He indicated he and S3EMT had been dispatched for a slip and fall during the ice storm. He reported Patient #1 was already walking from her door with her purse in her hands to meet them when they arrived. He indicated he told Patient #1 to stop walking, they were coming to her. He reported her bilateral pupils were equal and reactive and she had a small knot above her left ear. He said the patient had told them she decided to take a shower, had thrown up once, and had called 9-1-1, 45 minutes after she had fallen. He reported her vital signs had been stable and the patient had indicated she wanted to be brought to West Feliciana Parish Hospital. He confirmed the patient had not been on blood thinners, and he had called to give report on Patient #1 to the ED nurse when they were en route. He said the nurse had handed the phone to S1MD, the ED Medical Director, who was working in the ED at that time. S2EMT indicated S1MD told them they needed to go to a trauma center. S2EMT clarified what S1MD had told them to do and he still said they needed to go to a trauma center where neurological services were available. S2EMT reported S1MD had instructed them to put a C-Collar on Patient #1. S2EMT confirmed Ambulance Company "A" was licensed through West Feliciana Parish Hospital and indicated S1MD was also the Medical Director for Ambulance Company "A".

In an interview on 03/16/2021 at 11:14 a.m. with S4RN, she confirmed she works in the ED. S4RN reported EMTs call in patient reports on the radio to the ED nurses when they are en route with a patient. S4RN further reported the ED MD doesn't usually get involved. S4RN confirmed they would accept a patient who had slipped and fallen with a possible concussion. She confirmed the patient could be initially assessed and could receive a CT scan or C-spine x-ray at this hospital. S4RN said based on results of a CT scan or cervical spine x-ray they would then determine if a patient needed to be sent to a higher level of care or if the patient needed a service not provided here such as Neurology, Orthopedics, Surgery, or Burn specialties.