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ATHENS LIMESTONE HOSPITAL 700 WEST MARKET STREET ATHENS, AL 35611 Oct. 7, 2011
VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital rules and regulations, hospital policy, emergency department (ED) medical record reviews, and interviews, the hospital (Hospital # 1) failed to assure that ED patients receive services integrated with other departments and cardiac specialists (who provide services to inpatients).
On 6/7/2011, Patient Identifier (PI) # 6 presented to Hospital #1's ED and was found to have an abnormal electrocardiogram (EKG) and a critical Troponin level within 90 minutes of arrival. Tests repeated and again abnormal results reported but ED staff failed to indicate contact with the cardiologist on staff at Hospital # 1, or with a specialist at the receiving hospital (Hospital # 2) prior to, or after, PI # 6 was transferred by ambulance to Hospital # 2 (five hours after presenting to Hospital #1's ED).
On 6/22/2011, an eight year old patient (PI # 19) presented to the ED and the documented chief complaint was vaginal bleeding. ED staff failed to document an assessment of this patient's perineal area, and there is no indication that social services, or other agencies, were contacted about PI # 19 before or after discharge.
This deficient practice affected two of twenty eight sampled ED patients (PI # 6 and # 19).

Findings include:

1. Hospital # 1's Rules and Regulations (dated December 2010) include:
"...I. emergency room Call Coverage-Staff physicians are required to take unattached call per the direction and assignment of the Medical Staff Executive Committee, per the bylaws of the Hospital...All physicians on call, if not readily available at all times, should notify the Nursing Supervisor and emergency room Charge Nurse as to who is covering for them in their absence.
J. Transfers to a Higher Level of Care-Patients being transferred to another facility for a higher level of care from any location in the Hospital (#1), must be physically seen by a physician prior to transfer. This includes emergency room transfers to another facility, with the physician on call required to come to see the patient prior to transfer, if deemed necessary by the emergency room Physician, except in an emergency where delay would compromise patient care..."

2. Hospital #1's ED policy entitled "EMTALA: Definitions and Medical Screening," approved by the CEO, and dated 5/31/05 (with a revised 2/08) includes:
"POLICY
Any individual who comes to the Hospital Property or Premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening examination performed by individuals qualified to perform such examination to determine whether or not an emergency medical condition exists.
DEFINITIONS:
...Emergency Medical Condition
1. A medical condition manifesting itself by acute symptoms of [DIAGNOSES REDACTED]
a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
b. Serious impairment to bodily function; or
c. Serious dysfunction of any bodily organ or part...
Stabilized with respect to an emergency medical condition means that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility...A patient will be deemed stabilized if the treating physician of the individual with an emergency medical condition has determined, with reasonable clinical confidence, that the emergency medical condition has been resolved.
Stable for Discharge: A patient is considered stable for discharge, when with reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions...
Stable for Transfer: A patient is stable for transfer from one hospital to a second hospital if the treating physician attending to the patient has determined, with reasonable clinical confidence, that the patient is expected to leave the hospital and be received at the second facility, with no material deterioration in his/her medical condition, and the treating physician reasonably believes the receiving facility has the capability to manage the patient's medical condition and any reasonably foreseeable complication to that condition...
...6. A medical screening examination may be performed by an emergency department physician or another physician, or CRNP [certified registered nurse practioner] who is qualified to conduct such examination...and approved by the Hospital's governing board.
7. A medical Screening Examination is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition does or does not exist...
9. A medical Screening Examination is not an isolated event. It is an on-going process. The record must refect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation documented in the medical record prior to discharge or transfer..."

3. The "Emergency Services Policies and Procedures" entitled: "Nursing Assessment Process" (dated 5/01 and revised last 9/09) includes:
"...IV. Discharge Assessment
A. The patient should be assessed by an RN at the time of discharge. assessment should include vital signs, patient condition, mode of travel, and appropriate referrals for continuation of post-discharge healthcare needs..."

5. On 6/07/2011, PI #6 presented to the ED by ambulance, on a stretcher.
The "ER [emergency room ] Nurses Notes" include:
Triage Date and Time:
06/07/2011 at 22:48
Vital Signs:
Temperature 99.4,
Pulse 108
Respirations 20
B/P 102/58.
Chief Complaint:
N/V [nausea and vomiting]
L [left] shoulder and back pain.
Condition on Arrival:
P3 [Priority level 3]
Medical History positive for:
Diabetes, HTN [hypertension],
[DIAGNOSES REDACTED],
L [left] shoulder surgery 3 WKS [weeks] PTA [prior to arrival],
Surgical History positive for:
Appendectomy, Cholecystectomy,
Neck surgery,
Total knee surgery
Advanced Directives Yes
Organ Donor Yes
Pain Assessment:
Pain Scale 07 of 10
Description of pain:
Achy and Constant.
Triage Notes:
ARRIVED TO ER02 [emergency room number 02] VIA ... (Hospital # 1 emergency medical service ambulance]. PT. [patient] REPORTS HAVING L [left] SHOULDER SURGERY 3 WEEKS AGO, STATES SHE STARTED HAVING N/V [nausea/vomiting] FRIDAY. REPORTS HAVING CONSTIPATION/DIARRHEA YESTERDAY BUT NONE TODAY. COMPLAINS OF HAVING SHOULDER AND BACK PAIN DUE TO VOMITING. PLACED ON MONITOR. NSR NOTED. SKIN PALE, WARM, AND CLAMMY. RESPIRATIONS EVEN AND NON LABORED. VS STABLE. FAMILY MEMBER AT BS [bedside]. WILL CONTINUE TO MONITOR...

AT 2250 18-GAUGE IV STARTED TO RFA [right forearm] ...BLOOD AND 1ST SET OF BLOOD CULTURES DRAWN...
2255 DR...AT BS [bedside]
2307 EKG IN PROGRESS. DR...AWARE OF RESULTS...
2335 SKIN PALE, WARM, DIAPHORETIC. RESPIRATIONS EVEN AND NON LABORED. VS STABLE. ZOFRAN...GIVEN IV [intravenous push] FOR NAUSEA. NS [normal saline] ... BOLUS CONNECTED TO IV AND INFUSING PER PUMP AT 999ML/HR [milliliters per hour].
0005 PT STATES SHE STILL FEELS NAUSEATED. NO CHANGE IN PT. STATUS. DR...INFORMED...
0006 LAB CALLED TO REPORT CRITICAL TROPONIN LEVEL OF 0.52 ... DR... AWARE.
VS [vital signs] STABLE NSR [normal sinus rhythm] ON MONITOR. RESPIRATIONS EVEN AND NON LABORED. SKIN DIAPHORETIC. PT. REPORTS UPPER BACK AND L SHOULDER DISCOMFORT WITH NAUSEA. DENIES HAVING OTHER SYMPTOMS.
0010 ALL RESULTS BACK. CHART PLACED FOR DR...TO REVIEW...
0027 ZOFRAN 4 MG GIVEN IVP FOR NAUSEA. PT ANXIOUS. STATES SHE HAS NEVER BEEN SO SICK. SKIN DIAPHORETIC, WARM, PALE. VS STABLE. RESPIRATIONS EVEN AND NON LABORED. NSR ON MONITOR. BENADRYL 25 MG GIVEN IVP SON AT BS. WILL CONTINUE TO MONITOR....
0100 NO CHANGE IN PT. STATUS. DR ... AWARE.
0119 NS 250 ML BOLUS GIVEN.
0153 REPEAT TROPONIN AND BMP COLLECTED AND SENT TO LAB.
0137 PHENERGAN 25 MG GIVEN IM TO...GLUTEUS MAXIMUS.
0200 PT. NOW MORE RELAXED BUT STILL FEELS NAUSEATED.
0229 BP DROPPED TO 78/59, HR 74, R 20, 02 SAT 97% ON RA [room air]. Dr ... INFORMED ...
0242 LAB TO REPORT CRITICAL TROPONIN LEVEL OF 1.34.
0250 ANOTHER 250 ML BOLUS OF NS GIVEN PER ORDER.
0252 REPEAT EKG DONE - NSR NOTED. DR ... AWARE OF RESULTS.
0305 LEVAQUIN 500 MG CONNECTED TO IV AND INFUSING PER PUMP AT 100ML/HR WITH NS.
0308 NO CHANGE IN PT. STATUS. BP 65/53, HR 80, R 20, O2 SAT 98% ON RA. PT. TO BE TRANSFERRED TO ... [Hospital # 2] FOR CARDIAC EVALUATION ...
0332 REPORT CALLED TO... AT...[Hospital # 2]...
0345 [Hospital # 1's EMS] NOTIFIED OF PT. TRANSFER ...
0357 BP UP TO 86/50, HR 80, R 20, O2 SAT 98% ON RA. NSR ON MONITOR. SKIN DIAPHORETIC, PALE, AND WARM ... AT BS TO TRANSPORT PT. TO ... ROOM ... SEE VS [vital signs] AND TELEMETRY SHEETS ...

The "EMERGENCY PHYSICIAN RECORD Nausea / vomiting / Diarrhea" includes:
Time: 23:00
HISTORIAN
patient
HPI [history of present illness]
chief complaint: vomiting, diarrhea
onset / durations 3-4 days ago, persistent since
timing still present
severity mild / moderate
currently mild / moderate
diarrhea mild
ROS [review of systems]
...GI / GU [gastro-intestinal / gastro-urinary]
Constipation "turned to diarrhea" [hand written note]
PAST HX [history]
diabetes hypertension
old records ordered / summary : 1 year
Medications list reviewed
See nurses notes
Vitals Reviewed
Abnormals Noted
Nursing Assessment Reviewed
PHYSICAL EXAM
General Appearance
mild / moderate distress anxious
CVS
reg [regular] rate & rhythm
heart sounds nml pulses full / equil
ABDOMEN
soft
tenderness "diffuse" [and written]
BACK
nml [normal] inspection
SKIN
color nml, no rash
warm, dry
EXTREMITIES
non-tender
nml ROM [range of motion]
PROGRESS
Repeat BUN and Cr [blood urea nitrogen and creatinine]
EKG...rate 100 nonspecific [triangle abbreviation for change]
...[Hospital # 2's] Dr...Cardiology...
CLINICAL IMPRESSION
Volume Depletion
Vomiting Dehydration UTI
[arrow up indicating elevated] Troponin
CONDITION
blank
DISPOSITION
Transferred [no time or date]
Crit [critical] care 30-74 min..."
Discharge Instructions
Transfer to...[Hospital # 2] PCU [patient care unit?]..."

Administrative Staff Interviews
On 10/6/2011 at 1:30 PM, Employee Identifer (EI) # 1, Hospital #1's Chief Executive Officer, stated the hospital has two full time cardiologist on staff. These cardiologist serve as hospitalist and provide inpatient cardiac care but they do not have a formal call schedule. These cardiologist are on call as needed for the ED and they would come to the ED to see patients if needed.

On 10/6/2011 at 2:40 PM, EI # 2, Hospital # 1's Director of the ED, was asked if the hospital has a cardiologist o call. EI # 2 stated, Yes, we do. They [cardiologists] are here Monday through Friday from 8:00 AM until 5:00 PM. They (cardiologists) do not take ED calls after hours. They will take patients to see, once the patient is admitted by the ED doctor or a hospitalist. They will come to the ED during their, from 8 AM to 5 PM.
According to EI # 2, Hospital # 1's cardiologists were not at the hospital when PI # 6 presented to the hospital.

There is no documentation indicating the ED physician or the ED Nurse Practioner contacted the cardiologist on staff at Hospital # 1 (the transferring hospital) or spoke with a cardiologist at Hospital # 2 (the receiving hospital), after the EKG documented significant changes or after the laboratory reported critical Troponin levels .

6. On 6/22/2011 at 1719, PI #19, an eight (8) year old female presented to the ED. The "ER [emergency room ] PEDIATRIC ASSESSMENT" includes:
Arrival Date 00 Arrival Time 1710
MD to Bed: Date/Time 1 1735
...Age 8 [years]
Sex F [female] ...
Chief Complaint:
VAGINAL BLEEDING--LIGHT RED STARTED TODAY.
VITAL SIGNS
T 96.8 P 94 R 20 B/P 137/66
ALLERGIES
No Known
Condition on Arrival
P 3 [priority 3]
Method of Arrival
Walked w [with] parent
Medical History
Asthma ... Thyroid ...
Surgical History
T & A [tonsillectomy and adenoidectomy?]
OB / GYN
N/A LMP [last menstrual period]
Immunizations YTD [year to date] Yes
Pain Assessment 0
...Triage Note:
ALERT. RESP UNLABORED. SKIN W/D [warm/dry].
NAD [no acute distress].
... Pt [patient] is Hemodynamically Stable
Pt is able to sit unassisted ...
Fall Prevention:
Caregiver at Bedside
Infant / Peds...Spontaneous
Verbal Response
... Oriented appropro [appropriate]
Motor response
... Spont [spontaneous] & Purposeful / Obeys Com. [commands]
LOC [level of consciousness]
Awake alert
Orientation Time Person Place ...
Psychosocial Assessment
Eye contact present
Calm
[Blank sections that are not checked include: Signs of abuse / neglect ... DHR / Police notified ...]
Currently on Anti-depressant? N [no]
Hx [history] terminal / chronic illness? N
Recent life-altering event? N
Hx attempted suicide or suicidal ideation? N
RESPIRATORY ASSESSMENT
Airway
Patent Clear
Breathing
Normal
...CARDIOVASCULAR ASSESSMENT
N/A [not applicable]
Functional Status:
Appropriate for age
SKIN ASSESSMENT
Condition
Warm Dry
Color
Normal
Integrity
Intact
Nutrition
Normal
GU Assessment
Normal
Vaginal ...Discharge Describe
Blank with no notation
Musculoskeletal / Injury Assessment
N/A
GROWTH AND DEVELOPMENT
Blank with no notation
Caregivers Readiness to Learn:
Receptive
TREATMENTS / INTERVENTIONS
XRAY
Rape Exam
Blank no notations
NURSING DX. [diagnosis]
...clean catch Urine sent to lab
Time 2001
...Pain Scale 0
Discharge / Transfer
...2001 discharged
Written/Verbal Instructions given to Caregiver
Voices Understanding
Rx [prescription] given to Caregiver
Pain Level @ D/C [discharge] None
Condition at Discharge
Good Walked With Parent
Discharge Medications
Motrin...PRN [as needed]...

The "EMERGENCY PHYSICIAN RECORD
Female Urogenital Problems" includes:
Date 6/22/11 Time 1735...
HPI
chief complaint: vaginal bleeding
Onset /duration: PTA min / hrs/ days ago
content:[hand written note] vaginal bleeding (spotting) started today.
severity mild
location [the section is marked as checked and there is a line is drawn on body outline above pubic area but no notations or numerical value is noted relative to the pain assessment]
vaginal bleeding abnormal bleeding (started) is circled. The word "today" is hand written [next to the word started]
LNMP[last normal minstrel period] "?NA"
urinary symptoms checked with no notations
Similar symptoms previously No
Recently seen / treated by doctor/hospitalized No
ROS
No abnormalities noted
PAST HX
Hand written note "Asthma Thyroid..."
Surgeries
"...T & A..."
...Medications
...SOCIAL HX
...family
PHYSICAL EXAM
All sections are marked as checked, except the section entitled "PELVIC EXAM."
PELVIC EXAM
Blank except for a circle around the word "mild."
Mild is noted next to the words "active bleeding."
Hand written in this section is the word "spotting"
LABS AND XRAYS
UA [urinalysis]
Ultrasound nml / NAD [no acute distress]
Clinical Impression
Menarche [hand written note]
CONDITION
Stable
DISPOSITION
Home at 1951

The ED physician and Nurse Practioner checked and signed the following:
"PATIENT SAFETY ATTESTATION
Concerning the care of this pt. I/we have afforded the staff an opportunity to discuss findings or concerns and I either addressed them or no issues were voiced. As available, additional documentation was reviewed (Nursing, EMS or Medication list).
PHYSICIAN ATTESTATION (use when care is provided by physician with NP/PA).
For this patient encounter, I reviewed the NP or PA documentation, treatment plan, and medical decision making; and I had face-to-face time with this patient. All procedures were don by me except____" [There is no notation indicating an exception on this form].

"EMERGENCY DEPARTMENT MD-ORDER SHEET" includes
DISCHARGE INSTRUCTIONS
Return if worse
F/U [follow up] c [with] OB / GYN
Instructions / Prescriptions Given To Pt [patient] (with understanding voiced)
REFERRAL YOU SHOULD CALL FOR AN APPT. [appointment] WITH ...[another doctor name].
ALL DISCHARGE INFORMATION GIVEN TO AND REVIEWED W / PT. OR FAMILY MEMBER UNDERSTANDING VOICED.

There is no documentation indicating that the ED physician, or the ED Nurse Practioner (NP), questioned this eight year old female patient, or the parent, about the reported vaginal bleeding, no documentation indicating ED staff examined the patient's perineal or vaginal areas, and no indication that social services, other specialists, or state departments were contacted prior to, or after this patient was discharged from the ED.

This citation written as a result of the investigation of complaint AL 222.