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Based on observations, record reviews, interviews, and review of the hospital's medical staff By-Laws, it was determined that the hospital failed to post signage specifying the rights of individuals under section 1867 of the Act in the emergency department in places most likely to be noticed by all individuals entering the emergency department to include the entrance, waiting room, and the treatment area and failed to ensure that one (1) of 1 patients presenting to the hospital's emergency department with an open fracture of the foot from a traumatic injury was assessed by the on-call orthopedist, provided an appropriate Medical Screening Exam and stabilizing treatment, (Patient #9).

The findings are:

Cross Reference to A 2402: The hospital failed to ensure that the required signage specifying the rights of individuals under section 1867 of the Act was conspicuously displayed in the emergency department in places most likely to be noticed by all individuals entering the emergency department to include the entrance, waiting room, and the treatment area.

Cross Reference to A 2404: The hospital failed to ensure one (1) of 1 patients presenting to the Emergency Department (ED) with an open fracture of the foot from a traumatic injury was assessed by an on-call Orthopedist, (Patient #9).

Cross Reference to A 2406: The hospital failed to ensure one (1) of 1 patients presenting to the Emergency Department (ED) with an open fracture of the foot from a traumatic injury was provided a Medical Screening Exam (MSE) by the on-call Orthopedist and stabilizing treatment for his Emergency Medical Condition (EMC), (Patient #9).

Based on observations of the hospital's Emergency Department and interview, the hospital failed to ensure that the required signage specifying the rights of individuals under section 1867 of the Act was conspicuously displayed in the emergency department in places most likely to be noticed by all individuals entering the emergency department to include the emergency department entrance or the emergency department treatment areas. This had the potential to affect all patients.

The findings are:

On 07/01/2019 at 4:00 PM, observations in the Emergency Department(ED) revealed only one large sign displaying the rights of the individuals under section 1867 of the ACT was posted in an alcove in the hospital's ED waiting area that took ten (10) minutes to locate. The sign was located adjacent to the automatic swinging doors that blocked the sign as you entered the hospital's ED treatment areas.

On 07/02/2019 at 9:00 AM, observations of patient bay 7 revealed there was no signage regarding EMTALA (Emergency Medical Treatment And Labor Act) rights posted. On 07/02/2019 at 09:05 AM, observations of the ED bay areas and the ED nurse station in the treatment areas had no signs posted informing patient(s) of their rights.

In an interview on 7/02/2019 at 9:10 AM, the ED Director stated, "The only EMTALA sign we have right now is in the ED waiting room."

Based on record reviews, Medical Staff Rules and Regulations, and interviews, the hospital failed to ensure one (1) of 1 patients presenting to the Emergency Department (ED) with an open fracture of the foot from a traumatic injury was assessed by an on-call Orthopedist, (Patient #9).

The findings are:

On 07/02/2019 at 10:00 AM, review of the hospital's Medical Staff Rules and Regulations adopted by the Medical Staff on 04/29/2019, and approved by the hospital's governing body on 05/06/2015, reads:

"I. Emergency Department Consultations
Once an Emergency Department consultation is deemed necessary by the Emergency Department practitioner, the appropriate on-call practitioner or the primary practitioner will be notified and the case shall be discussed. The on-call specialist/primary practitioner must respond in a timely manner, generally thirty (30) minutes. The Director of the Emergency Department / Nursing Supervisor will then discuss the situation with the Chairman of that service who will either provide orders, make a recommendation to continue calling the on-call practitioner, to call a second practitioner on that specialty, or to place calls to the next practitioner on the on-call list."

M. Medicare
Medicare Acknowledgement Statements will be completed by all practitioner applicants upon initial staff appointment, and these statements will be maintained as a permanent record. The practitioner on-call has an obligation to come in to the Emergency Department to examine a patient if requested to do so by the Emergency Department practitioner on duty.

Record Review
Patient #9
On 07/02/2019 at 10:00 AM, the medical record review for Patient #9 revealed the patient was registered on 04/18/2019 at 10:51 AM. Admitting reason - toe laceration. The patient was triaged and seen by Physician Assistant (PA) 1 at 11:00 AM who recorded the patient's history of present illness: "The patient presents with left foot injury. The onset was just prior to arrival. The course/duration of symptoms is constant. Type of injury: Metal cylinder dropped on his left foot at work. Location: left foot but not second toe or not third toe. The character of symptoms is pain, bleeding and tingling. No numbness and no loss of mobility. The degree at present is moderate. There are exacerbating factors including weight-bearing and walking. The relieving factor is none. The location where the incident occurred was at work. Additional history: patient is a 52-year-old male who presents to the emergency room after dropping 150 pound metal cylinder on his left foot at work. Patient states he was wearing shoes at the time. Patient drove himself to the emergency room. Patient says he has an old foot injury to the same foot and all of his toes point medially since then. Patient cannot remember when his last tetanus shot was. Patient denies other injury or Paresthesia. General: alert, no acute distress, speaks in clear/complete sentences without difficulty, not anxious, not ill appearing. Skin: warm, dry, pink, large laceration and skin deformity noted to plantar aspect of left distal foot extending to the plantar aspect. Bleeding controlled. Musculoskeletal: normal are ROM(Range of Motion), normal strength, Fingers/toes: gross deformity to distal aspect of left dorsal foot, bony prominence extending out of skin noted on second and third Phalanx. Laceration extends to plantar aspect of distal foot. Patient able to flex and extend all toes. No pain on proximal foot or ankle. Toes not cyanotic and sensation intact. Toe capillary refill WNL (Within Normal Limits). X-ray of left foot: Findings: there is a comminuted fracture Of the proximal phalanx of the second toe and a fracture involving the proximal aspect of the middle phalanx of the second toe. The third distal phalanx is fractured and displaced. Deformity of the third and fourth distal metatarsals are noted which may be due to acute or chronic fracture deformity but sub-optimally visualized. Correlate clinically. There has been remote osteotomy of the medial first metatarsal head, likely from Bunionectomy. Impression: fractures of the second and third digits and possibly the fourth and fifth metatarsals as described.

Notes: Patient is an elderly male presenting with trauma to his left foot. Vital signs stable. Labs within normal limits. X-ray shows displaced fractures to the second and third digits. Also states possible fracture of the fourth and fifth metatarsal's. Patient refuses pain medication at this time. Case discussed complete detail with Orthopedist who looked at the x-ray, and recommends Betadine soak with irrigation afterwards. Also recommend discharge with Levaquin and Keflex. Orthopedist does not recommend closing the wound with sutures. Recommends large bulky dressing across the entire wound. Also further evaluation and treatment. Results and plan were discussed with patient and family. They are agreeable plan of discharge with outpatient follow-up. All questions answered. Patient is able for discharge. Follow up with: Ortho within 1 to 2 days: please follow up with orthopedist, in four days for further evaluation and treatment Disposition: discharge home, routine.

Review of the medical orders and nursing documentation in patient's chart revealed there was no documentation that the consultant's treatment was ordered or was carried out by nursing for the cleaning, soaking, irrigation, and dressing of the patient's left foot.

Interviews
During a face to face interview with Physician Assistant (PA) #1 on 07/02/2019 from 4:03 PM until 4:30 PM, PA #1 stated, "For a consult, we ask the secretary to call or page the on-call person or specialist. We don't consult for every case. It depends on the situation. We look for recommendations for treatment. Not all cases require to be seen right away. This patient had open fractures and there was a previous injury, and it(foot) looked awkward. X-rays were taken and the Orthopedist on - call (MD #3) was consulted. The secretary called the orthopedist, and I talked with him. He (MD #3) looked at the x-ray. He (MD #3) gave the order to clean, soak, irrigate, and apply a dressing to the patient's foot. Keep it(foot) closed to the elements. No, he (MD #3) did not come in to see the patient. I don't remember if I requested him to come in or not. PA #1 confirmed during the interview there were no orders entered for treatment that was recommended by MD #3 and no documentation that Patient #9's foot was cleaned, soaked and irrigated with a dressing applied.

On 7/02/2019 at 4:15 PM, MD #2 (Medical Director ED) stated, "We (Emergency Department Physicians) are available all the time. Would the PA expect the orthopedist on call to come in and see a patient? Only if there are fractures of major bones like tib-fib(tibia-fibula) or hip. The Ortho didn't think this(patient's foot) needed attention. This would be standard care for fractured toes or fingers. Clean, dress the site, and place on antibiotics. He can see them in the office." When asked who would see patients with fractures, MD #2 stated "We(Emergency Department Physicians) are available all the time.

Based on record reviews, Medical Staff Rules and Regulations, and interviews, the hospital failed to ensure one (1) of 1 patients presenting to the Emergency Department (ED) with an open fracture of the foot from a traumatic injury was provided a Medical Screening Exam (MSE) by the on-call Orthopedist and stabilizing treatment for his Emergency Medical Condition (EMC), (Patient #9).

The findings are:

On 07/02/2019 at 10:00 AM, review of the hospital's Medical Staff Rules and Regulations adopted by the Medical Staff on 04/29/2019, and approved by the hospital's governing body on 05/06/2015, reads,

L. Medical Screening Exams(MSE)
1. Medical Screening Exams is the process (which begins with the initial collection of an individual's vital signs and other medical data collection) required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition (EMC) exists or a woman is in labor. Screening is to be conducted to the extent necessary, by physicians and/or other Qualified Medical Personnel (QMP) to determine whether an EMC exists. With respect to an individual with psychiatric symptoms, an MSE consists of both a medical and psychiatric screening.

2. QMP is defined as a Physician, PA(Physician Assistant), NP (Nurse Practitioner) or L&D (Labor and Delivery) RN(Registered Nurse) with demonstrated competency in medical screening exams.

M. Medicare
Medicare Acknowledgement Statements will be completed by all practitioner applicants upon initial staff appointment, and these statements will be maintained as a permanent record. The practitioner on-call has an obligation to come in to the Emergency Department to examine a patient if requested to do so by the Emergency Department practitioner on duty.

Record Review
Patient #9
On 07/02/2019 at 10:00 AM, the medical record review for Patient #9 revealed the patient was registered on 04/18/2019 at 10:51 AM. Admitting reason - toe laceration. The patient was triaged and seen by Physician Assistant (PA) 1 at 11:00 AM who recorded the patient's history of present illness: "The patient presents with left foot injury. The onset was just prior to arrival. The course/duration of symptoms is constant. Type of injury: Metal cylinder dropped on his left foot at work. Location: left foot but not second toe or not third two. The character of symptoms is pain, bleeding and tingling. No numbness and no loss of mobility. The degree at present is moderate. There are exacerbating factors including weight-bearing and walking. The relieving factor is none. The location where the incident occurred was at work. Associated symptoms: denies altered sensation, denies nausea, denies vomiting, denies inability to bear weight, denies fever, denies chills, denies back pain, denies neck pain and denies suspected foreign body. Additional history: patient is a 52-year-old male who presents to the emergency room after dropping 150 pound metal cylinder on his left foot at work. Patient states he was wearing shoes at the time. Patient drove himself to the emergency room. Patient says he has an old foot injury to the same foot and all of his toes point medially since then. Patient cannot remember when his last tetanus shot was. Patient denies other injury or Paresthesia. General: alert, no acute distress, speaks in clear/complete sentences without difficulty, not anxious, not ill appearing. Skin: warm, dry, pink, large laceration and skin deformity noted to plantar aspect of left distal foot extending to the plantar aspect. Bleeding controlled. Musculoskeletal: normal are ROM(Range of Motion), normal strength, Fingers/toes: gross deformity to distal aspect of left dorsal foot, bony prominence extending out of skin noted on second and third Phalanx. Laceration extends to plantar aspect of distal foot. Patient able to flex and extend all toes. No pain on proximal foot or ankle. Toes not cyanotic and sensation intact. Toe capillary refill WNL (Within Normal Limits). X-ray of left foot: Findings: there is a comminuted fracture Of the proximal phalanx of the second toe and a fracture involving the proximal aspect of the middle phalanx of the second toe. The third distal phalanx is fractured and displaced. Deformity of the third and fourth distal metatarsals are noted which may be due to acute or chronic fracture deformity but sub-optimally visualized. Correlate clinically. There has been remote osteotomy of the medial first metatarsal head, likely from Bunionectomy. Impression: fractures of the second and third digits and possibly the fourth and fifth metatarsals as described.

Notes: Patient is an elderly male presenting with trauma to his left foot. Vital signs stable. Labs within normal limits. X-ray shows displaced fractures to the second and third digits. Also states possible fracture of the fourth and fifth metatarsal ' s. Patient refuses pain medication at this time. Case discussed complete detail with Orthopedist who looked at the x-ray, and recommends Betadine soak with irrigation afterwards. Also recommend discharge with Levaquin and Keflex. Orthopedist does not recommend closing the wound with sutures. Recommends large bulky dressing across the entire wound. Also further evaluation and treatment. Results and plan were discussed with patient and family. They are agreeable plan of discharge with outpatient follow-up. All questions answered. Patient is able for discharge. Follow up with: Ortho within 1 to 2 days: please follow up with orthopedist, in four days for further evaluation and treatment Disposition: discharge home, routine.

Review of the medical orders and nursing documentation in patient's chart revealed there was no documentation that the consultant's treatment was ordered or was carried out by nursing for the cleaning, soaking, irrigation, and dressing of the patient's left foot.

During a face to face interview with Physician Assistant (PA) #1 on 07/02/2019 from 4:03 PM until 4:30 PM, PA #1 stated "For a consult, we ask the secretary to call or page the on-call person or specialist. We don't consult for every case. It depends on the situation. We look for recommendations for treatment. Not all cases require to be seen right away. This patient had open fractures and there was a previous injury, and it(foot) looked awkward. X-rays were taken and the Orthopedist on - call (MD #3) was consulted. The secretary called the orthopedist, and I talked with him. He(MD #3) looked at the x-ray. He (MD #3- Orthopedist) gave the order to clean, soak, irrigate, and apply a dressing to the patient's foot. Keep it (foot) closed to the elements. No, he (MD #3- Orthopedist) did not come in to see the patient. I don't remember if I requested him to come in or not. PA #1 confirmed during the interview there were no orders entered for treatment that was recommended by MD #3 - Orthopedist and no documentation that Patient #9's foot was cleaned, soaked and irrigated with a dressing applied.

On 7/02/2019 at 4:15 PM, MD #2 (Medical Director ED) stated, "We (Emergency Department Physicians) are available all the time. Would the PA expect the orthopedist on call to come in and see a patient? Only if there are fractures of major bones like tib-fib (tibia-fibula) or hip. The Ortho didn't think this (patient's foot) needed attention. This would be standard care for fractured toes or fingers. Clean, dress the site, and place on antibiotics. He can see them in the office." When asked who would see patients with fractures, MD #2 stated "We(Emergency Department Physicians) are available all the time.

In face to face interview with the Emergency Department Director on 07/03/2019 at 10:00 AM, the ED Director stated, "From 11:00 a.m. to 11:10 a.m., the medical screening exam is done by the PA. Our goal is to see the patient in 20 minutes. The MD can do the history and physical, orders. PA can do orders, and the nurse carries out the orders. MD does the disposition. Triage does the acuity 1-5. PA doesn't see level 1. The tracking board shows the acuity."