HospitalInspections.org

Based on EMTALA policy and procedure review, closed medical record reviews, and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

1. The hospital's Dedicated Emergency Department (DED) physician failed to ensure an appropriate transfer; by failing to complete a written physician's certification for transfer documenting the medical benefits and/or increased risks associated with the transfer for the specific Emergency Medical Condition (EMC) of the patient in 3 of 11 DED patients sampled that were transferred to another acute care hospital with an EMC for further treatment and stabilization (#14, #16 and #13); and failed to ensure the written physician's certification time closely matched the time the patient departed the DED for transfer in 3 of 11 DED patients transferred with and EMC to another acute care hospital for further treatment and stabilization (#14, #16 and #12).

Based on EMTALA policy and procedure review, closed medical record reviews, and staff interviews, the hospital's Dedicated Emergency Department (DED) physician failed to ensure an appropriate transfer; by failing to complete a written physician's certification for transfer documenting the medical benefits and/or increased risks associated with the transfer for the specific Emergency Medical Condition (EMC) of the patient in 3 of 11 DED patients sampled that were transferred to another acute care hospital with an EMC for further treatment and stabilization (#14, #16, and #13); and failed to ensure the written physician's certification time closely matched the time the patient departed the DED for transfer in 3 of 11 DED patients transferred with an EMC to another acute care hospital for further treatment and stabilization (#14, #16 and #12).

The findings include:

Review of the hospital policy titled "EMTALA (The Emergency Medical Treatment and Active Labor Act: Screening, Stabilization, and Transfer of Individuals with Emergency Medical Conditions)" (EMTALA - Emergency Medical Treatment and Labor Act) approved 8/2014 revealed "...) "Labor" means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a physician, certified nurse midwife, or other Qualified Medical Person acting within his or her scope of practice as defined in Medical Center medical staff bylaws and State law, acetifies that, after a reasonable time of observation, the woman is in false labor...q) "Stable for Transfer" between medical facilities means: 1. the physician, or other Qualified Medical Person in consultation with the physician, determines, within reasonable clinical confidence, that the patient will sustain no material deterioration in his/her medical condition as a result of the transfer, and that the receiving facility has the capability to manage the Emergency Medical Condition and any reasonably foreseeable complication...3. "Stable for Transfer does not require the final resolution of the emergency Medical Condition".

1. Medical record review of patient #14 revealed 41 year old presenting to the DED on 03/08/2015 at 0534 via ambulance with a chief complaint of history of diabetes, epilepsy ,headache and nausea. Review of the medical screening exam (MSE) started at 0542 by the physician revealed the patient checked his blood glucose and it was "noted to be high". The patient reported he had been "stripping a floor using a buffer requiring propane". The patient reported he gave himself 30 units of insulin and his symptoms did not improve. He developed "severe lightheadness and may have passed out". Further review of the MSE revealed upon arrival by emergency medical services the patient had a CO2 (carbon dioxide) level of 20 and "BG (glucose) noted to be critically high". The patient reported pain to be at a level of 5 out 10 with 10 being the worst pain. Review of lab test revealed PO2 (oxygen level in blood) was less than 27 (normal 80 - 100), HCO3 (bicarbonate) 21.4 (normal 22-26), oxygen saturation 45.7 (normal above 95), percent oxyhemoglobin (actual amount of oxygen combined with hemoglobin) was 32.4 (normal 96-97), percent Carboxyhemoglobin (carbon monoxide) was 28.8 (normal less than 1.5), percent Deoxyhemoglobin (reduced hemoglobin) was 38.5 (normal less than 4.5) and blood glucose 431 (normal 70-150). Review of documentation by the DED physician at 0700 revealed "presenting s/p (status post) carbon monoxide toxicity". Record review revealed written physician certification dated 03/08/2015 at 1000 for the patient to be transferred to another hospital for specialized services of hyperbaric treatment not available at the hospital. Review of the certification did not reveal any documentation of the benefits or risks of the transfer. Record review revealed the patient left the DED at 1133 (1 hour 33 minutes after physician certification". Record review did not reveal any documentation of benefits, risks or assessment of the patient's condition prior to leaving the DED.

Telephone interview on 05/01/2015 at 1130 with DED physician #4 revealed the patient did have an emergency medical condition (EMC) when transferred. The interview revealed there were risk and benefits related to the transfer for patient #14.

Interview with administrative staff #2 on 05/01/2015 at 1130 revealed there was no documentation available of benefits, risks or reassessment of patient #14 prior to transfer.

2. Medical record review of patient #16 revealed a 19 year old presenting to the DED on 02/19/2015 at 0635 with a chief complaint of abdominal and back pain. Record review revealed the patient was 34 weeks 5 days gestation and an estimated date of delivery 03/28/2015. Record review revealed the patient was a gravida 1 (first pregnancy). Record review revealed the medical screening exam (MSE) by the physician was started at 0653. Review of the MSE revealed the patient complained of pain "severe", located in "abdomen and radiates to her back". Review of the MSE revealed the pain was constant and "ebbs and flows, every 3-5 minutes". Record review revealed an obstetrical (OB) consultation was requested for "possible labor". Review of the OB consultation revealed the patient was "with a pregnancy complicated by sickle cell trait and remote prenatal care who presents with threatened PTL (preterm labor)". Record review revealed the patient had moved from out of state and was to have her first OB appointment on 02/23/2015. Record review revealed at 0723 the patient was dilated 0.5 centimeters, -3 station and fetal heart rate was 140 beats per minute. Record review revealed the patient was transferred to another hospital for OB services for continued monitoring. Record review revealed written physician certification for transfer dated 02/19/2015 at 0745. Review of the certification did not reveal any documentation of benefits or risks for transfer. Record review revealed the patient left the DED at 0937 (1 hour 52 minutes after physician certification for transfer). Record review did not reveal any documentation of benefits, risks or assessment of the patient prior to the patient leaving the DED.

Telephone interview on 05/01/2015 at 0905 with the OB attending physician for patient #16 revealed patient #16 "was in labor and was having contractions". The interview revealed a second vaginal exam was not conducted prior to the patient leaving the DED. The interview revealed a second vaginal exam would have documented any changes in dilation of the cervix. The interview revealed she was the attending physician and the care of the patient was under her direction. The interview revealed an OB resident also provided care to patient #16.

3. Medical record review of patient #13 revealed a 14 year old presenting to the DED on 04/10/2015 at 1657 via ambulance with a chief complaint of fast heart rate. Review of EMS (emergency medical services) documentation revealed upon arrival at patient's home a 12 lead electrocardiogram was performed. The patient was documented in "SVT (supraventricular tachycardia at a rate of 193 beats per minute". Review of EMS documentation revealed the patient was administered "6 mg Adenosine rapid IVP "intravenous push" at 1610 with no improvement with heart rate. Review of EMS documentation revealed a second dose of 12 mg Adenosine was given rapid IVP at 1621 with "no lasting effects". Review of EMS documentation revealed at 1627 a third and final dose of 12 mg Adenosine was given IVP "with no lasting effects". Record review revealed the patient's heart rate was continuously monitored. Review of the medical screening exam (MSE) performed by the DED physician revealed the patient had Atrial Ablation Surgery on 04/06/2015 at an outside hospital. Review of the MSE revealed the patient was administered 12 mg then 18 mg of Adenosine with out a change in heart rate/rhythm. Record review revealed the patient's cardiologist at the outside hospital was consulted and an Esmolos (antiarrythmic used to slow heart rate) drip (continuous intravenous) was started at 50 mcg/kg/min (micrograms/kilograms/minute), Record review revealed the Esmolol drip was triturated up (increased) by 50 mcg every 6 minutes until the patient's heart rate was below 150, Record review revealed the patient was given a maximum of 400 mcg/kg/minute of Esmolol before the patient's heart rate converted to a sinus tachycardia (heart rate at approximately 100). Record review revealed the Esmolol drip was tapered down slowly off to maintain heart rate greater than 65. Record review revealed the patient was to be transferred to the outside hospital where he had his initial ablation heart surgery. Review of the written physician's certification for transfer dated 04/10/2015 at 1854 did not reveal any documentation of the benefits or risks for transfer. Record review revealed patient #13 was transferred by ambulance at 2157 to the hospital he had had cardiac ablation surgery. Record review did not reveal any documentation of the benefits or risks for transfer,

Interview with administrative staff member #2 on 05/01/2015 at 1130 revealed there was no documentation available for the risks or benefits for transfer for patient #13,

4. Medical record review of patient #12 revealed 40 year old presenting to the DED on 01/13/2015 at 0521 via ambulance with a chief complaint of self inflicted pellet wound to the chest. Review of the MSE at 0536 revealed the patient reported "drinking tonight and felt like he wanted to end his life. EMS reported he wrote a suicide note, He took a pellet gun and shot himself directly in the chest. Since that time, he states he has severe pain located to the central part of his chest, described as being sharp without radiation". Review of the MSE revealed the patient had chest wall tenderness with dried blood present without active bleeding. Medical record review revealed the patient's blood alcohol level was 186 (normal less than 10). Record review revealed X-ray results of "Metallic body projects to the right of the T6 vertebral body consistent with history of self inflicted pellet gun shot to the chest...Metallic foreign body projects over the sternum, likely lodged within the anterior soft tissues of the chest,,Subcutaneous emphysema is present along the anterior chest". Medical record review revealed the DED physician ordered a psychiatric evaluation. Review of the psychiatric evaluation on 01/13/2015 at 1036 revealed " He clearly has a substance induced mood disorder and his current psychosocial stressors, poor insight and judgement, and history of previous suicide attempts in light of his attempt early this morning make him a danger to himself and he will require IVC (involuntary commitment) and inpatient psychiatric and substance abuse treatment for his safety". Record review revealed documentation the patient was IVC on 01/13/2015 at 1110. Review of the IVC documentation revealed the patient "requires immediate hospitalization to prevent harm to self or others../currently a danger to himself...Mentally ill and dangerous to self". Record review revealed documentation of written physician certification on 01/14/2015 at 0400 for the patient to be transferred to a psychiatric acute hospital for inpatient admission. Record review revealed the patient left the DED on 01/14/2015 at 1014 (6 hours 14 minutes after physician certification). Record review did not reveal documentation of reassessment of the patient's condition prior to transfer.

Interview with administrative staff member #2 on 05/01/2015 at 1130 revealed there was no further documentation of a reassessment of patient #12 after physician certification and the time the patient left the DED.

NC00105638