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Based on review of medical records, policies/procedures and physician and staff interviews, it was determined that the hospital failed to comply with the provider agreement as defined in ?489.20 and ?489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

The findings were:

Refer to findings for Tag A 2406 - Medical Screening Examination:

The facility failed to ensure that Sample Patient #1 received a thorough and documented medical screening examination when the patient presented to the Emergency Department (ED) on post-operative day-5 with a history of three prior post-operative ED visits with complaints including pain, fever, swelling, numbness and blisters related to the condition of the surgical area and right arm/hand. The practitioner allegedly saw and examined the patient, but wrote no note of findings/treatment and told the nurse not to complete a nursing assessment or enter the visit into the medical record system and the patient was sent home.

Based on review of medical records, policies/procedures, personnel/credential files, other facility documents and physician and staff interviews, the facility failed to ensure that Sample Patient #1 received a medical screening examination. Specifically, the facility failed to ensure that Sample Patient #1 received a thorough and documented medical screening examination when the patient presented to the Emergency Department (ED) on post-operative day-5 with a history of three prior post-operative ED visits with complaints including pain, fever, swelling, numbness and blisters related to the condition of the surgical area and right arm/hand. The practitioner allegedly saw and examined the patient for numbness and difficulty moving fingers and a large blister on the thumb area, but wrote no note of findings/treatment and told the nurse not to complete a nursing assessment or enter the visit into the medical record system before the patient was sent home. The failure may have contributed to the negative patient outcome for Sample Patient #1.

The findings were:

1. Medical Record Review/Emergency Department Log:

On 8/30/2010, the medical record of Sample Patient #1 was reviewed and revealed the following, in pertinent parts:

The facility failed to ensure that a patient (Sample Patient #1) who had an outpatient surgery (sub-muscular transposition, right ulnar nerve) was adequately assessed and all post-operative follow-up visits and all clinical findings accurately/completely documented. In addition, the facility failed to ensure that the providers who saw and assessed the patient for symptoms (including pain, fever, swelling, numbness, blisters related to the condition of the surgical area and right arm/hand) on five occasions (on post-operative days 1, 4, 5 and 6) notified or consulted with the orthopedic surgeon about clinical findings and treatment strategies for the patient. When the patient was seen by the orthopedic surgeon on post-operative day 7 for the scheduled follow-up appointment, the patient had symptoms of pain, swelling, blistering and sloughing of skin and tissue on lower right arm, evidence of a massive infection (later determined to be gas gangrene due to Clostridium botulinum) of the right hand and forearm and no right radial pulse. The orthopedic surgeon arranged for a transfer of care to a limb preservation unit at a hospital in Denver. The patient was urgently transported by family car to the other facility, where s/he underwent an initial below-the-elbow amputation and a subsequent above-the-elbow amputation of the right arm. In addition, the patient remained in that facility for several weeks for treatment of septic shock and renal failure. The patient's condition also required ventilator support and weaning.

Review of the medical record on 8/30/10 revealed that the record contained no documentation of an ED visit that the patient made on post-surgical day 5 (7/27/10). Per staff interviews, the patient was seen by a physician assistant (PA) on the evening of 7/27/10 in the Emergency Department. Review of the Emergency Department Log on 8/31/10 revealed that sample patient #1 was not entered into the log for a visit on 7/27/10.

2. Staff Interviews:

An interview conducted on 8/31/10 at approximately 10:35 a.m., with the nurse working in the ED that day on 7/27/10 revealed the following findings:
S/he stated the patient (Sample Patient #1) came into the ED and was placed in an overflow room in the outpatient surgery area around the corner from the ED, since the two bays and the exam room were already full with other patients. S/he stated that the PA had been called from the outpatient clinic to see patients in the ED, since s/he was the provider on-call for the ED that day. S/he ran into the patient (#1) in the hallway and followed her/her into the room. The nurse went to the nurse's station to enter the patient into the computer and start the record. S/he stated s/he took out a new ED packet and wrote the patient's name on the record. The PA called the nurse and asked him/her for a pair of scissors to cut through the patient's dressings at the thumb areas to loosen the tension on the dressing. S/he provided the scissors and left again. Soon after that s/he saw the PA showing the patient out of the ED. The PA allegedly told the nurse that the patient was leaving and that s/he did not need to enter the patient into the system. The nurse stated that s/he had not assessed the patient, had not yet entered the patient into the ED log or the electronic part of the system to generate a visit number. The PA had no written documentation of the patient assessment. S/he stated s/he shredded the paperwork, which only had the patient's name on it. When asked what s/he would have assessed had s/he had the chance, s/he stated s/he would have checked capillary refill, pulses, vital signs, measure blister on hand and observe skin temperature. S/he also stated: "I knew s/he came in and had a blister on his/her finger and s/he was a diabetic and I was concerned and wanted to look at it."

On 8/31/10 at approximately 2:50 p.m., the PA was interviewed and revealed the following findings:
The PA stated: "I was 1st assistant in surgery and saw him/her 24- hours post-op with a fever (s/he thought it was 101.4). S/he was a smoker and I made the diagnosis of atelectasis."
S/he stated s/he then saw the patient briefly 7/27/10 for a small blister that s/he thought was from dressing irritation. S/he stated that s/he followed all of the orthopedic surgeon cases and frequently saw blistering in the recovery period after fractures and other orthopedic trauma and surgery. The PA showed on his/her own hand that the blister was on the skin on the webbed area between the thumb and the index finger. S/he showed the blister was round and looked about the size of a half-dollar. S/he stated the patient complained of numbness, difficulty moving fingers, but the PA stated s/he had good capillary refill. S/he stated that s/he did not "pop the blister" (as had been reported in the medical record by the next physician to see the patient on 7/28/10). The PA stated s/he released the pressure of the bandage. S/he stated: "I did not think his/her swelling of the fingers was anything unusual for this kind of surgery. I did not suspect any circulatory compromise at this time." The PA acknowledged that s/he did not document his/her findings at the time of the visit and since s/he told the nurse that s/he did not need to enter the patient in the record and sent the patient home before the nurse could do a nursing assessment, there was no way to establish or validate his/her findings and they were not available for other later providers on subsequent visits on 7/28/10 and 7/29/10.

3. Review of Emergency Department Policy/Procedure:

Review on 8/31/10 of the policy/procedure "Emergency Room Admission and Discharge Policies" revealed the following, in pertinent parts:
"...Admission Medical Screening:
1. All individuals presenting to the (facility) ED will be evaluated by a physician or certified physician's assistant (PAC), FNP (family nurse practitioner) or on call provider (OCP) and treated or stabilized as appropriate to their condition as consistent with resources generally available for such treatment or stabilization at (the facility).
2. An RN (registered nurse) will perform the initial triage assessment on all patients presenting to the (facility) ED, and these findings will be given to the on call provider (OCP). The detail and nature of the information will be dictated by the particular circumstances of the situation.
...Medical Record:
1. An emergency department record is filled out for every person seeking treatment through the ED.
...Record Maintenance:
...2. Each ED admission is recorded in the ED log..."

4. Personnel/Credential File Review Regarding EMTALA Training:

On 8/21/10, the personnel and credential files of all staff/physicians involved in the post-operative care of Sample Patient #1 were reviewed and were found to contain no documentation of facility training of staff related to EMTALA regulations and compliance. On 9/1/10 at approximately 9 a.m., the director of nursing stated that the facility did not do in-house EMTALA of nursing staff and physicians/providers and relied on all staff to have TNCC (Trauma Nurse Course Certification) and all physicians/providers to have ATLS (Advanced Trauma Life Support). The personnel/credential files reviewed revealed that all ED staff/providers did have current TNCC or ATLS certification. Despite the TNCC/ATLS training for all ED staff and providers, the nurse and PA failed to recognize that the failure to fully triage/assess and provide a medical screening exam, and document the same, for Sample Patient #1 (on 7/27/10) was a violation of EMTALA requirements for a medical screening exam (MSE).

In summary, based on medical record reviews and staff interview, the facility failed to ensure that sample patient #1, who was seeking medical care in the Emergency Department, received an initial assessment/triage by a nurse and a medical screening exam and all appropriate treatment, all of which the facility policy/procedure required to be documented in the patient medical record.