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JACK HUGHSTON MEMORIAL HOSPITAL 4401 RIVER CHASE DRIVE PHENIX CITY, AL 36867 May 24, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interviews, record reviews and review of Hospital and EMTALA (Emergency Medical Treatment and Labor Act) Policies and Procedures, Hospital # 1 failed to:

A. Ensure a thorough pediatric Medical Screening Examination (MSE) was conducted for Patient Identifier (PI # 1), a patient who presented to the ED at Hospital # 1 on 5/5/17 with multiple episodes of vomiting and a self rated pain score of 8 (severe) after ingesting a coin.
Refer to findings at A2406.

This deficient practice effected PI #1, one of 22 ED (Emergency Department) sampled patients and had the potential to effect other patients who presented to Hospital #1's Emergency Department with similar symptoms.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on medical record review, interviews, review of EMTALA (Emergency Medical Treatment and Labor Act) Policies and Procedures, Information from the Atlas of Pediatric Emergency Medicine, the Emergency Department (ED) Physician at Hospital # 1 failed to provide a thorough pediatric medical screening examination for Patient Identifier (PI) # 1, a patient who presented to the ED at Hospital # 1 on 5/5/17 with multiple episodes of vomiting and a self rated Wong Baker pain score of 8 (severe) after ingesting a coin. As a result of this deficient practice, the removal of the foreign body lodged in PI # 1's esophagus was delayed two and 1/2 hours after the patient's arrival to the ED at Hospital # 1. Furthermore, PI # 1 was transferred twice by ambulance prior to the procedure being performed at the third Hospital (Hospital # 3).

This affected one of 22 sampled patients and has the potential to affect all patients who present to the ED with similar complaints and symptoms.

Findings include:

I. Medical Record Review 5/5/17: Jack Hughston Memorial Hospital (Hospital # 1)

17:35: PI # 1 arrives in the ED at (Hospital # 1) via private vehicle.

17:43: Triage. Chief Complaint: Mother said patient swallowed a penny. Alert 5 year old. No acute distress.

Weight: 18.5 kilograms. Height: 46 inches.

17:47: Blood Pressure: 133/74. Heart Rate: 125. Respiratory Rate: 20. Oxygen Saturation: 100 %. Temperature: 98.1. Wong-Baker Pain Scale: 8/10.

Medications and Allergies: None.

History:
Arrived by private vehicle. Historian : Mother. Accompanied by family. This occurred just prior to arrival. She (Patient Identifier / PI # 1) has had vomiting (one initial vomit and then mucous spit). She has not been choking or had stridor (abnormal, high-pitched, musical breathing sound. Caused by a blockage in the throat or voice box (larynx), medlineplus.gov). No cough, difficulty breathing or alteration in mental status.

Treatment prior to arrival: none

Physical Assessment (Nursing):

Ambulatory to room.
General/Neurological: Alert. Awakens easily. Appears in no apparent distress.
Respiratory: Respirations not labored. Breath sounds within normal limits.
Cardiovascular: Normal heart rate and rhythm...
Gastrointestinal: Has vomited several times. Patient says it feels like it is stuck in her throat. Vomited in Triage - several large episodes.

17:52: Patient ready for evaluation. ED (Emergency Department) physician notified.


18:01: Initial patient contact by EI # 1 ED Physician at Hospital # 1 (Jack Houston Memorial Hospital).

Arrived by private vehicle. Historian: patient, mother and father.

Chief Complaint: Ingestion. This just stated prior to arrival. Swallowed a penny and is still present.
Patient (PI # 1) has had no symptoms. No difficulty breathing. She has had vomiting x 2.

Physical Examination:

Vital Signs: Blood Pressure: 133/74. Heart Rate: 125. Respiratory Rate: 20. Oxygen Saturation: 100 %. Temperature: 98.1.
Wong-Baker Pain Scale: 8/10. (A pain rating scale used with people ages 3 and older, to facilitate communication about pain, wongbakerfaces.org. A score of 8 indicates severe pain).
Appearance: Alert. No acute distress. Attentive. She (PI # 1) makes eye contact.
ENT : Pharynx normal. (pharynx: a tube extending from the back of the nasal passages and mouth to the esophagus that is the passage through which air passes to the larynx and food to the esophagus,
www.merriam-webster.com).
Neck: Supple. No mass.
Respiratory: No respiratory distress. Breath sounds normal.
Skin: Normal color. Normal turgor. (The degree of elasticity of the skin, medicinenet.com).

X-Rays:
Chest X-ray: Coin lodged in the base of the throat. Views: PA. Technique: good. The X-rays were independently viewed by me (EI # 1 - ED Physician at Hospital # 1/Jack Hughston Memorial Hospital). Interpretation time: 18:19.


Hospital # 1's / Jack Hughston Memorial Hospital's Patient Transfer Transport Form:

Patient Name: (name of PI # 1)
Date: 5/5/17
Time of EMS Notification: 18:15
Clinic: Hospital # 1's ED (Jack Hughston Memorial Hospital)
Age: 5 Sex: F (Female)
Diagnosis: Distal pharynx foreign body
Accepting Facility: Hospital # 2's "Peds ED"
Accepting Physician: EI # 2 (Physician at Hospital # 2)
Patient Destination: Hospital # 2's "Peds ED"
Date/Time Contacted: 5/5/17 18:20
Risks/Benefits of Transfer: "Needs GI" (Gastrointestinal physician)
Risks of Not Transferring: Declining condition
Nursing Report called to: Area on form is blank; No documentation
By: Name of EI # 5 (ED RN at Hospital # 1) Jack Hughston Memorial Hospital
Urgency: ASAP (As Soon As Possible)
Equipment Required: Cardiac Monitor
Records Sent: Blank. Area on form is blank; No documentation
Reason to Transfer: Higher Level of Care Required
Patient Condition: Serious, Stable
Mode of Transport: ACLS (Advance Cardiac Life Support) Ambulance
Patient Status: Stretcher
Vital Signs at Time of Transfer: Heart Rate: 112, Respirations: 17, Temperature: 98.9, Oxygen Saturation:100% (Room Air)


18:20: Physician Note: EI # 1 (ED Physician at Hospital # 1) / Jack Hughston Memorial Hospital:

Patient, mother and father counseled in person regarding the patient's stable condition, test results, diagnosis and need for follow up.

Disposition: Benefits, risks and alternatives to transfer explained to patient, mother and father.

Clinical Impression: Accidental ingestion of a coin. Object is located in the stomach.

18:24: Nurse's note: Ambulance company notified of transfer to Hospital # 2's Pediatric ER. Unit present in ER department at this time. Ready to transfer pt. (PI # 1).


Interviews:
- Interview with EI # 1, ER Physician at Hospital # 1, Jack Hughston Memorial Hospital:

During an interview on 5/18/17 at 12:30 PM, EI # 1 (ER Physician), said a 5 year old presented to the ER after swallowing a coin. "We got an xray. The patient was in no distress, but the coin could move if the patient coughed or sneezed and block the trachea. "Nobody here (Hospital # 1) can do a pediatric endoscopy." EI # 1 said there was no back up if he flipped the coin into the patient's trachea. There is a pediatric referral center at Hospital # 2. Hospital # 2 had an ENT Physician (Dr. Blankenship) on call."

According to EI # 1, ER Physician at Hospital #1, he was connected by call center staff at Hospital # 1 to "Pediatric ER Physician" EI # 2 at Hospital # 2. According to EI # 1, "Hospital # 2 had an ENT Physician (EI # 3) on call who was in the building seeing a patient. EI # 2 (Pediatrician at Hospital # 2) said let me talk with EI # 3, name of ENT at Hospital # 2. Simultaneously, an ambulance arrived in the ED at Hospital # 1 to transport a patient back to the nursing home. I made the decision to transport the child (PI # 1). Ambulance staff loaded PI # 1 as I was waiting for a phone call. Anticipating a yes response from Hospital # 2."


II). Medical Record Review at Hospital # 2- Pediatric Emergency Center) Date: 5/5/17.

19:04: Arrived via ambulance.
Reason for visit: Penny stuck in throat.
19:04: Numeric Pain Scale: 6 (moderate pain)
Pain Location: throat

19:07: Triage. Priority 2: Emergent. Condition: Fair.
Pt. (patient) PI # 1 presents to ED (Hospital # 2) via EMS transfer from Jack Hughston (Hospital # 1). Penny stuck in throat.

19:07: Blood Pressure: 121/75; Pulse: 114; Temperature: 98.8; Respirations: 22; Pulse Oximetry: 98 %

History of Present Illness (HPI) - Generic Pediatric:

19:11: Seen by EI # 4, ED Physician at Hospital # 2.
Narrative History of Present Illness: "Patient (PI # 1) was sent here from Hospital # 1 due to penny stuck in throat discovered at 5:30 PM. I spoke with referring person (Staff in Transfer Center at Midtown Medical Center ) who I instructed to call ENT (Ears, Nose and Throat Physician / EI # 3) if he will remove the penny. He (EI # 3) apparently said he is not comfortable. Patient arrived apparently accepted by Dr...(name of EI # 2, pediatric hospitalist at Hospital # 2) who denied accepting patient. Patient apparently accepted by a physician at Hospital # 3. Patient said she can feel the foreign body in her throat. No cyanosis but has been gagging and looks uncomfortable."

19:22: Narrative Medical Decision Making:
Patient with swallowed foreign body allegedly in proximal esophagus. I will send patient out to another hospital due to absence of expert personnel available to remove coin.


III). Medical Record Review at Hospital # 3 on 5/5/17:

20:00 Documentation by EI # 6 / ENT Physician at Hospital # 3
Chief Complaint: Coin in esophagus (tube that connects the pharynx "throat" with the stomach,
medicinenet.com).
History of Present Illness: 5 year old who choked on a coin and it is still in the esophagus.
Examination: Vital Signs Stable
Head, Eyes, Ears, Nose and Throat: Within normal limits. No foreign body seen.

X-Ray: Coin in esophagus around cricopharynx

Assessment: Pharyngeal/Esophageal Foreign Body
Plan: To OR (Operating Room) for removal. Discussed with family.

Operative Note: 5/5/17
Preoperative Diagnosis: Esophageal foreign body
Postoperative Diagnosis: Same
Procedure Performed: Esophagoscopy and foreign body removal
Surgeon: ENT (EI # 6)
Anesthesia: General Endotracheal
Findings: Coin at circopharyngeus
Indications for procedure: 5 year old with coin in the esophagus at level of cricopharyngeus
Description of Procedure: Patient was identified in the holding area and taken to the operating room. She was placed on the OR table in the supine position and general anesthesia was induced without difficulty. A rigid espoghagascope was passed into the proximal esophagus and a coin was identified. It was removed with optical foreign body forceps. No secondary foreign body was identified and the esophagus was normal. She was awakened and transferred to PACU (Post Anesthesia Care Unit) in excellent condition. There were no complications identified at the conclusion of the procedure.


IV. Polices and Procedures/ Hospital # 1:

A. Policy: 760.178 JHMH (Hospital # 1) Emergency Department (ED): Scope of Service:

Review Date: 3/1/15

...Scope of Services
1. The ED is in operation 24 hours a day, seven days a week to provide emergency services to patients of all ages.
2. The ED is responsible for treatment of medical or surgical emergencies and for the initiation of life saving procedures...

Facilities and Supplies
...Pediatric emergency supplies are available in the pediatric crash cart...


B. Policy Number: 900.122: Plan for the Provision of Care
Reviewed Date: September 2015

...II. Purpose: To provide a mechanism to reflect the scope of services related to the provision of paitne care at Hospital # 1 (JHMH).

IV. Scope of Service:
...JHMH provides the community with an extensive range of health care services including, but not limited to:

A. Medical Staff Services (Contracted)
1. Anesthesia
2. Emergency Medicine
3. Family Medicine
4. General Surgery
5. Orthopedics
6. Radiology

B. Medical Staff Services (Consulting Staff)
1. Pediatrics *
2. Pathology
3. Nephrology
4. Neurology
5. Vascular Surgery

Interview
* During an interview on 5/19/17 at 11:00, EI # 7 / Chief Quality Officer at Hospital # 1) stated pediatric service is only available for inpatients. There is no on call pediatric service for the ED at Hospital # 1.


C. EMTALA - Medical Screening Examination and Stabilization Treatment

Policy Number 760.203
Reviewed Date: 1/18/17

...II. Policy
It is the policy of Hospital # 1 (JHMH) to provide an appropriate Medical Screening Examination to any person requesting treatment or an examination, by a physician to determine whether an Emergency Medical Condition (EMC) exists or not.

If an EMC is determined to exist, the Hospital will (without regard for the patient's insurance coverage or ability to pay) provide: Stabilizing treatment within the capabilities of the hospital and its staff (including on call physicians and diagnostic services), and /or an appropriate transfer to another medical facility (if required for the patient's treatment or per patient request).

III. Definitions

Emergency Medical Condition (EMC):
1. A medical condition presenting with symptoms in an acute nature of sufficient severity. This includes, but is not limited to, severe pain, psychiatric disturbances and /or substance abuse symptoms. Therefore, the absence of immediate medical attention could be expected to reasonably result in:
a. Serious impairment to bodily functions; or
b. Serious dysfunction of any bodily organ or part; or
c. Placing the health of the individual (with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.

IV. Procedure

A. Medical Screening Examination (MSE)
1. Any individual who comes to the ED and makes a request or a request has been made on the individual's behalf...for examination or treatment will be screened...

B. Triage
The patient will be triaged promptly by a Registered Nurse...Triage establishes the order in which an individual will be evaluated...

C. Patient Care
1. A MSE will be conducted to determine whether the individual has an EMC. The EMC will be conducted by the ED physician....The MSE is an ongoing process, it is based on the patient's needs and continues until the patient has been stabilized, admitted , or appropriately transferred...

D. Each patient that presents to the hospital...must be listed in the Central Log...

F. The ED Physician may provide all aspects of medical screening and stabilization of patients in the ED...

H. Stabilization Procedure
1. Stabilizing treatment consists of providing medically appropriate treatment within the capabilities of the hospital's medical staff and services...

I. Reassessment of the Patient's Condition
1. If a patient is deemed unstable based on the physician's reassessment, then stabilizing treatment will continue...until the patient is stable, or until an appropriate transfer...can be made. An unstable patient cannot be discharged .

J. Transfers (This section is new and is in quotes. Changes were made after Hospital # 1 self reported possible EMTALA violation).

"If a patient cannot be stabilized within the capabilities of the hospital then the hospital may appropriately transfer the patient...

1. Before transferring a patient to another hospital, either:
a. the patient must request the transfer, or
b. the expected benefits of the transfer outweighs the risks of transfer.

2. If the expected transfer outweighs the risks of transfer, then the physician shall certify as such on the transfer form. The reasons for the transfer must be described in the medical record and also certified on the transfer form.

3. A patient may not be transferred pursuant to Section 1.b above unless the following requirements are met and documented in the medical record.
c. The hospital has provided medical treatment within its capacity to minimize risk to the patient's health.
d. The receiving hospital has available space and qualified personnel for treating the patient, and has agreed to accept transfer of the patient and to provide the appropriate medical treatment, The name the accepting hospital and physician shall not be documented on the transfer form until after the hospital receives confirmation of acceptance from the accepting hospital and physician.
e. The transfer shall be affected through qualified personnel and transportation equipment...

4. The primary nurse or physician will contact an appropriate facility to coordinate transfer. Once an accepting physician has been obtained and bed availability has been validated, the transport team will be contacted for transfer. The primary nurse will then contact the receiving facility and provide a nurse to nurse report to ensure proper transfer of care has been conducted, prior to the patient transfer.

K. Documentation
The transferring hospital sends to the receiving hospital all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of transfer...All sections of the JHMH (Hospital # 1's) Patient Transfer/Transport Form will be filled out prior to the patient transferring. The transferring physician, patient/representative and a witness will sign, date and time the form... "


According to the Atlas of Pediatric Emergency Medicine, edited by Gary Robert Fleisher, Stephen Ludwig, Marc N. Baskin, pages 406 - 407: If a child presents to the ED with a history of swallowing an object and complaints of a foreign body sensation, a careful examination of the oral cavity and hypopharynx must be performed.

There was no documentation in the medical record by EI # 1, ED Physician at Hospital # 1, to indicate the physician examined PI # 1's oral cavity and hypopharnyx even though PI # 1 presented with a chief complaint of accidental ingestion of a coin as confirmed by x-ray and PI # 1's mother.