HospitalInspections.org

The Hospital reported the Emergency Department (ED) treated 8704 emergency cases for the last six months from March 2014 to September 2014. Based on medical record review, document review and staff interview the Hospital failed to follow their policy and procedure and did not provide stabilizing treatment within their capabilities or an appropriate transfer to an individual that presented to the ED with an emergency medical condition for one of 21 patients sampled (Patient # 1).

The Hospital's failure to follow their policies and procedures to provide stabilizing treatment within their capabilities and to arrange an appropriate transfer of a patient with an unstable emergency medical condition placed the patient at risk and had the potential to affect all patients treated in the Hospital's ED.

Findings included:

- Policy titled "Treatment and Transfer of Individuals Who Request Emergency Medical Services (EMTALA)" effective date 8/1/13, III. E. An Individual who Has An Emergency Medical Condition revealed the Hospital shall: 1. a. Within the capability of the staff and facilities available at the hospital, stabilize the individual to the point where the individual is either "stable" for discharge" or "stable for transfer," or b. Provide for an appropriate transfer of the unstabiized individual to another medical facility...

- Policy titled " Medical Staff Rules and Regulations; Policy for Emergency Services, " under " 3. Section III. Transfer of Patients; 3.1, " directed that a transfer from the ED to any other facility shall be made only in consultation with the patient ' s private physician or the physician on call.

- Policy titled "Treatment and Transfer of Individuals Who Request Emergency Medical Services (EMTALA)," effective date 8/1/13, directed the medical staff to treat patients, within its capability, and provide medical treatment which minimizes the risk to the individual ' s health. If a specialist or sub-specialist is unavailable at the Hospital the individual may require a transfer to another hospital.

- The hospital ' s "Emergency Department Specialty Coverage July-14 Call Schedule" reviewed in the conference room on 9/17 and 9/18/14 at 11:30am revealed the hospital lacked an on call facial trauma surgeon.

- Review of the medical record revealed Patient #1 presented to the emergency department (ED) on 7/8/14 around 10:20 AM. The ED nurse documented patient # 1 stated he was in a fight, had pain and swelling of his face, lost a tooth, and was unable to hold food or drink in his mouth. Further documentation showed patient # 1 had swelling on the left side of his face and had a temperature of 100.2 Fahrenheit (98.6 normal). At 10:30 AM ED physician A examined patient # 1 and documented the patient had been punched in the face multiple times 6 days ago and could only open his jaw 2 centimeters. At 11:29 AM patient # 1 returned from radiology after a CT scan (special type of x-ray) had been performed. At 11:40 AM the ED nurse administered a pain medication (Toradol 60 mg). At 11:30 AM the radiologist reported the results of the CT scan to ED physician A. Review of the CT scan report showed patient # 1 had multiple fractures of his jaw along with swollen lymph nodes and facial swelling. ED physician A documented in the medical record that patient # 1 had a fractured jaw and "will refer" to Hospital B (hospital located approximately 3 hours away with an available on-call maxillofacial surgeon). At 11:54 AM the ED nurse documented patient # 1 was discharged with a prescription for pain medication and home care instructions specific for patients with a broken jaw. The printed instructions specified the patient should "follow up with" an outpatient oral maxillofacial surgical practice. The medical record lacked evidence that ED physician A ordered antiobiotics to treat the patient's open fracture of the jaw, an emergency medical condition, or arranged a transfer for surgical repair of the fractures. Refer to Tag A2407 for details.

The Hospital reported the Emergency Department (ED) treated 8704 emergency cases for the last six months from March 2014 to September 2014. Based on medical record review, document review and staff interview the Hospital failed to provide stabilizing treatment within their capabilities and failed to arrange transfer for further stabilizing treatment of an emergency medical condition for one of 21 sampled patients (Patient # 1) that presented to the ED seeking care.

The Hospital's failure to provide stabilizing treatment and tranfser to a patient with an emergency medical condition placed the patient at risk and had the potential to affect all patients treated in the Hospital's ED.

Findings included:

- Policy titled "Treatment and Transfer of Individuals Who Request Emergency Medical Services (EMTALA)" effective date 8/1/13, III. E. An Individual who Has An Emergency Medical Condition revealed the Hospital shall: 1. a. Within the capability of the staff and facilities available at the hospital, stabilize the individual to the point where the individual is either "stable" for discharge" or "stable for transfer," or b. Provide for an appropriate transfer of the unstabiized individual to another medical facility...

- The hospital ' s "Emergency Department Specialty Coverage July-14 Call Schedule" reviewed in the conference room on 9/17 and 9/18/14 at 11:30am revealed the hospital lacked an on call facial trauma surgeon.

- Review of the medical record revealed Patient #1 presented to the emergency department (ED) on 7/8/14 around 10:20 AM. The ED nurse documented patient # 1 stated he was in a fight, had pain and swelling of his face, lost a tooth, and was unable to hold food or drink in his mouth. Further documentation showed patient # 1 had swelling on the left side of his face and had a temperature of 100.2 Fahrenheit (98.6 normal). At 10:30 AM ED physician A examined patient # 1 and documented the patient had been punched in the face multiple times 6 days ago and could only open his jaw 2 centimeters. At 11:29 AM patient # 1 returned from radiology after a CT scan (special type of x-ray) had been performed. At 11:40 AM the ED nurse administered a pain medication (Toradol 60 mg). At 11:30 AM the radiologist reported the results of the CT scan to ED physician A. Review of the CT scan report showed patient # 1 had multiple fractures of his jaw along with swollen lymph nodes and facial swelling. ED physician A documented in the medical record that patient # 1 had a fractured jaw and "will refer" to Hospital B (hospital with an available on-call maxillofacial surgeon). At 11:54 AM the ED nurse documented patient # 1 was discharged with a prescription for pain medication and home care instructions specific for patients with a broken jaw. The printed instructions specified the patient should "follow up with" an outpatient oral maxillofacial surgical practice. The medical record lacked evidence that ED physician A ordered antiobiotics to treat patient # 1's open fracture of the jaw, an emergency medical condition, or arranged a transfer for surgical repair of the fractures.

Registered nurse (RN) staff B documentation reviewed on 9/18/14 between 8:15am to 8:30am in the conference room revealed they provided the following discharge instructions and education for patient #1 on 7/4/14. Under "Special Instructions:" patient #1 was to follow up with an outpatient oral maxillofacial surgical practice and provided the phone number and address.

ED Physician A interviewed per phone on 9/22/14 at 2:26pm revealed they recall treating patient #1 in the ED. Physician A recalled patient #1 ' s injury occurred six days prior to presenting at the ED. Physician A acknowledged patient #1 came to the ED accompanied by a male friend who stated they were the driver. Physician A acknowledged they referred patient #1 to go to Hospital B for treatment by a maxillofacial specialist due to the need for surgery to repair the fractured jaw. Physician A verified that St. Catherine Hospital lacks a facial trauma specialist and previously was told to refer to hospital B because they had a maxillofacial specialist. Physician A verified they were concerned about patient #1's fracture telling the patient and friend to go to Hospital B that day to seek further treatment. Physician A verified they failed to transfer patient # 1 to a hospital that had the capabilities to provide the stabilizing treatment for the patient's fractured jaw.

Registered nurse (RN) staff B interviewed per phone on 9/23/14 at 9:19am acknowledged they were on duty in the ED on July 4th when patient #1 presented to the ED. Staff B verified they were not present in the ED room when physician A gave patient #1 verbal instruction to go to Hospital B for treatment. Staff B confirmed they gave patient #1 written and verbal instruction to go to the local maxillofacial office and if the physician was not there go to their office in city B. Staff B stated they instructed the patient to go that day, July 4th. Staff B verified the ED has a book that list specialty physician names and addresses of offices who they refer patients. Staff B verified the maxillofacial specialist has their offices located in city B and understands they refer patients to Hospital B.

In an interview on 9/24/14 at 11:25 AM, Physician C at the local satellite maxillofacial office confirmed that the maxillofacial surgeons were not on staff at St Catherine Hospital. Physician C confirmed that patients with facial trauma are treated at Hospital B.