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WEST PALM HOSPITAL 2201 45TH ST WEST PALM BEACH, FL April 4, 2011
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on clinical record reviews and staff interviews, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services to determine whether or not an emergency medical condition exist for 1 of 20 sampled patients (#1). Please refer to the deficient practice cited in this report at A2406.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record reviews and staff interviews, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services to determine whether or not an emergency medical condition exist for 1 of 20 sampled patients (#1).

The findings include:

Review of the clinical record for patient #1 revealed the patient (MDS) dated [DATE] at 4:20 p.m. Documentation by the triage nurse on the "Triage Encounter Record" dated 3/27/2011 revealed in part, Chief Complaint,: GI (gastro-instestinal) Pain... Assessment...Patient presents to ER (emergency room ) with Epigastric pain times (for) 4 days, seen by PMD (Primary Medical Doctor) for same Friday.. . Priority level (Triage Level: evaluation to determine order of treatment) 3" The writer notes includes, "patient presents to ER with epigastric pain, last 5 minutes then resolves, denies N/V/D (nausea/vomiting/diarrhea); last BM (bowel movement) today soft; denies urinary S&S (sign / symptoms) tolerating PO (oral) well."

Current PO medications listed the patient on Metformin 100 (mg) milligrams twice daily and Metoprolol XL/ Toprol-Xl 100 twice daily. The patient also took the following medications only once daily: Folic Acid 1 mg; Prenatal Vitamins 1 tab, Losartan/HCTZ 100/ 25 mg , Nifedipine ER 90 mg Aspirin 81 mg and Allopurinol 200 mg. Additionally, the patient took Simvastatin/Zocar 80 mg. at bedtime . There were no allergies to drugs noted. The pain assessment on the Triage Record notes: Pain location: abdomen; Pain intensity: 2.

The Physician Assistant documented on the "Emergency Department Physician Medical Record" (medical screening examination) notes includes: History of Present Illness - A [AGE] year old female with epigastric pain times (for) 2 days. This is a noted discrepancy with the information documented in the Triage Record as epigastric pain for 4 days. The note continues to specify, "seen by primary MD for same; given suppositories for "nausea"; no N/V/D (nausea /vomiting/diarrhea); stool yellow. The time (duration of the pain) is indicated as intermittent. The quality of the pain is documented as an ache and cramping, pain worsened with meals. The severity of the pain is documented as being mild - severe, illegible note / 10. (Interview with the Physician Assistant (PA) later presented in this report identifies the illegible notation as "2".) Associated symptoms documented are: "nausea, vomiting." The patient was not experiencing nausea / vomiting / diarrhea while in the ER being examined; however patient #1 did report experiencing the occurrences prior to visiting the ER as noted in the medical screening examination note documented by the PA under Associated Symptoms. Documentation also revealed that patient#1 had a past medical history of Hypertension, Diabetes, Coronary Artery Disease and Hypercholesterolemia (high cholesterol). The patient's surgical history included a hysterectomy, neck and back. the section titled "Physical Exam" indicated in part, "ABDOM (Abdomen): Benign Abdomen." The medical screening exam note does not document the performance of any ancillary services such as laboratory diagnostic tests, x-ray, CT (computerized axial tomography scan is an x-ray procedure that combines many x-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body)abdominal scan etc. to determine if an emergency medical condition existed for patient #1. The medications Bentyl and Tagamet were prescribed for the patient with the notation to follow up with primary MD(medical doctor) tomorrow.

Patient #1 presented to another acute care hospital on March 29, 2011 at 12:09 p.m. Review of the nurses triage notes indicated that patient #1 presented with complaint of " I've been feeling nauseous and throwing up since Wednesday." Review of the history and physical dated 3/29/2011 indicated the patient presented to the ER with complaint of abdominal pain associated with vomiting. Documentation by the Emergency Department physician revealed that patient #1 reported that on Friday (3/25/2011)," Initially she had vomiting which was brown in color so she was seen on Sunday (3/27/2011) at Columbia Hospital and was discharged home. Further review revealed that Laboratory tests were ordered, intravenous (IV) fluids were administered, CT of the abdomen, GI consult, Zofran (medication used to prevent nausea and vomiting) and pain medications were administered. The physical examination included ... Abdomen: mild to moderate tenderness located in the epigastric area. No rigidity, no rebound tenderness.. A review of the consultation report dated 3/29/2011 indicated in part, "presents with 3-4 days of nausea and vomiting. An acute abdominal series was consistent with a possible distal small bowel obstruction. .. CT of the abdomen and pelvis was performed which showed only severe small bowel obstruction ...distal ileum as well as gallstones. Patient #1 was admitted to the hospital, and was taken emergently to surgery on 3/30/2011 and expired on [DATE].

During an interview, on 4/01/11 at 12 PM, with the director of the ER the director stated there was no evidence of an emergency medical condition for patient #1, and no IV fluids, no laboratory work, no CT scans, and no medications with narcotics so she was discharged home by herself.


Interview on 4/01/11 at 12:30 PM with the triage nurse revealed he remembered patient #1. The nurse stated, the patient drove herself to the facility with a bag of medications. She stated that her tummy was burning at the doctor's office on Friday but the doctor found nothing to treat. She had asked the doctor for pain medication but the physician gave her Phenergan suppositories for nausea. She told the triage nurse she had no intention of putting them in, and that every time she eats it burns. The physician told her on Sunday to go to the ER. She told the triage nurse that she had never taken any medication for heartburn. The patient had a non toxic appearance. She did not mention her bowels, nausea, vomiting or diarrhea right away. She pointed to her epigastric area with her finger and said that when she eats she has a pain right there. It lasts 5 minutes and resolves. The triage nurse stated that patient #1 did not report a history of arthritis, sickle cell disease or any other disease for the medications that she brought. The patient did have a history of high blood pressure, high cholesterol, and diabetes and had those medications with her.

Interview on 4/01/11 at 1:00 PM with the Physician Assistant (PA) who performed the medical screening examination on patient #1 in the ER revealed he remembered patient #1. The PA stated, the patient had seen the primary care physician and the physician gave the patient Phenergan suppositories for nausea. The patient asked the PA to give her a pain killer for the epigastric pain. She pointed to the location of the pain for her. She reported to the PA that she had no nausea, vomiting or diarrhea and that her stool had been yellow "that morning". The PA said, the patient had no chest pain, or she would have been admitted immediately. The patient was very specific that her pain was epigastric and that she wanted pain medication. There was no indication for labs, EKG, X-rays or CT scans.

During an interview with the medical director of the E.R., who was the ER physician who was the physician in the ER at he time patient #1 was in the ER, on 4/4/11 at 11:30 AM the medical director said the PA saw and examined the patient; the ER physician on duty must observe the patient before he/she cosigns the exam and care on the clinical record. He examined the patient and went over the clinical record with the PA. The medical director / ER physician said he found that the patient had stable vital signs with epigastric pain that subsided after 5 minutes after eating. He added, contrary to the Triage record and the PA medical screening exam note, "the patient had no pain at the time of the ER visit", no acute abdominal symptoms, no rigidity of the abdomen.