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WEST PALM HOSPITAL 2201 45TH ST WEST PALM BEACH, FL Nov. 9, 2012
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on clinical record review, facility record review and staff interviews it was determined the facility failed to comply with 42 CFR 489.24(j)(2)(i).
Review of facility license and service inventory list revealed Oral Maxillofacial Service(OMFS) is within the capability of and available at West Palm Hospital (WPH).
Review of the Hospital Emergency Services Call List April through November 2012 reveals the On - Call physician for OMFS is also the On - Call physician for Plastic Surgery on the same days.
The Oral Maxillofacial (OMFS) and Plastic Surgery listed on its license and Service Inventory list as within its capability 24 hours per day/7 days per week by direct staff or indirect parties with whom an agreement to provide that service exist.
The facility failed to render Oral Maxillofacial Services for 3 of 20 sampled patients (Patient #2, #5 and #7). Please refer to deficient practice cited in this report at A2404 and A2409.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on reviews of medical records, on -call schedules, delineation of privileges, facility license and service inventory , medical staff rules and regulations and interviews, the facility failed to ensure that the Oral Maxillofacial Services on-call physicians on staff meet the needs of the hospital patients who are receiving services required with the resources available at the hospital including the availability of on- call physicians for 2 of 20 samples patients (# ' s 5, & 7) who required Oral Maxillofacial Services.

Findings:

The hospital ' s Medical Staff Rules and Regulations, revised 10, 2012 was reviewed. The Medical Staff Rules and Regulations revealed in part, " I. emergency room ...2. Medical Staff coverage for the Emergency Department is assumed only by qualified members of the Medical Staff who are duly appointed by the Board following review of their delineation of privileges ...4. The Chief Executive Officer and the Medical Staff have adopted the following procedures for assigning emergency room coverage for primary care physicians and consultants: a. if the patient does not have a private practitioner, he/she will be assigned to the member of the staff on call in the service to which the illness or condition of the patient indicates treatment. "
The Core Privileges for Oral Maxillofacial (OMFS) and Plastic Surgery were reviewed with the Medical Director of the Emergency Department (ED) at 0910 hours on 11/9/12.

The Delineation of Privileges for the Plastic Surgery: Core Privileges include admission, workups and performance of surgical procedures for patients presenting with both congenital and acquired defects of the body's soft tissue, including the functional and aesthetic management and the provision of consultations; treatment of skin neoplasm's, diseases and trauma;surgery of the breast; treatment of facial diseases and injuries, including maxillofacial structures; surgery of the hand and extremities; reconstructive microsurgery; reconstruction of congenial and acquired defects of the trunk and genitalia; complex wound healing and burn treatment; cosmetic surgery; endoscopic cosmetic surgery; and laser therapy for vascular and crustaceous lesions. The Medical Director of the ED verified on 11/9/12 at 0915 hours the Core Privileges for Plastic Surgery are the same as for Maxillofacial Surgery.

Review of facility license and service inventory list revealed Oral Maxillofacial (OMFS) is within the capability of and available at West Palm Hospital (WPH). The Oral Maxillofacial (OMFS) and Plastic Surgery listed on its license and Service Inventory is listed as within its capability 24 hours per day/7 days per week by direct staff or indirect parties with whom an agreement to provide that service exist.

Review of the WPH Emergency Services Call List April through November, 2012 reveals the On - Call physician for OMFS is also the On - Call physician for Plastic Surgery on the same days. The ED Director verified the specialities can perform the same services.
Review of 2 sampled medical records and the "Emergency Service Call" schedules from the ED disclosed:

1) Patient # 7 was transferred to WPH on 8/3/12 from another hospital outside the county. The reason for transfer per the transferring hospital ED document is as follows:
Medical Decision: Patient had an isolated injury to the left cheek. With multiple facial/orbital fractures. Patient had a CT(computerized tomography) scan of the head which was negative. The CT of facial bones which revealed multiple fractures and possible left infraorbital nerve injury which is consistent with exam clinically. Dr. N____plastic surgery covering for oral maxillofacial surgery (OMFS) at West Palm Hospital for possible Evaluation and possible repair and definitive treatment. The patient accepted by Dr. N____. Case discussed with Dr. B___ Emergency physician. Dr. B___accepting physician in the ED. Patient had worsening pain and was given 8 mg. of Morphine total.
The ED physician documents he discussed the condition and treatment with the patient and available family after verbal consent from the patient.
The Clinical Impression: Extensive facial fractures; Comminuted fracture through left; infraorbital wall; Left infraorbital nerve injury; Zygomatic arch fracture (cheek bone fractures); Lateral maxillary (Upper jaw fractures) sinus wall fracture; Anterior maxillary sinus wall fracture and Lateral orbital wall fracture
Patient transported without consequence by EMS (Emergency Medical Services) to West Palm Hospital 8/3/12 at 0655 hours.
The patient arrived in the ED at WPH at 0745 hours. The Triage Nurse writes patient to ER (emergency room ), a transfer from ________ Hospital for Maxillofacial injury, accepted by Dr. N____.
The ED physician (at WPH) documents the time seen by Medical Provider as 0748 hours. The ED physician writes the patient was transferred here from ______ Hospital for Maxillofacial fractures (Upper jaw area fractures). The patient had CT which show comminuted fracture the Right infraorbital wall and foramen as well as zygomaticomaxillary fracture. Patient denies Headache, vomiting or visual changes. He complained of numbness to left side of face.
Under the heading MDM-Trauma Minor/Fall
Patient course: Patient transferred here because we have OMFS on call. Spoke with OMFS and will see patient as an outpatient.
Consultation:
Referral/Consultant Name: Dr. N_____. Consultant called: OMFS
Consultant: Will see patient in his office. He instructs patient to keep HOB elevated, no blowing nose and start on Keflex.
Disposition-Trauma Minor/Fall
Clinical Impression: Fracture(s) (Multiple facial)
Disposition: discharged home
Active Problems - Blow out fracture of orbit (is a fracture of one or more of the bones surrounding the eyes). The OMFS on-call physician failed to come to the ED after being notified that patient #7 had arrived from the transferring hospital, awaiting possible repair and definitive treatment for his injuries, as discussed when the on call physician accepted patient #7 on 8/3/2012.

The ED nurse documents the patient is discharged home at 0824 hours. The patient is instructed to follow up with Dr. N___ today.
The medical record was reviewed with the ED Medical Director at 0910 hours. This writer inquired as to why the patient, who was accepted by the On - Call physician Dr. N____, was not seen by the On - Call physician. The Medical Director stated we will always accept the patient. After the evaluation if there is no emergency we send the patient home.
This writer stated this patient was sent here from another county for possible evaluation, possible repair and definitive treatment and by virtue of the service capability listed on the license and On-Call coverage available on 8/3/12, requires WPH to provide that service.
The medical director stated, " It's inconvenient but it meets the standard of care in our community.
There is an agreement dated 5/1/12 between West Palm Hospital and their sister facility to offer OMFS.
The QA (Quality assurance) director and the ED Nurse Manager stated at 1240 hours that she does not know if the sister facility was called or if they were called why they did not accept patient #7. The EMTALA Log for August 2012 was sent yesterday (11/8/12) to storage, according to the ED Manager.
At the time of the survey the facility was unable to provide evidence of the EMTALA Transfer Acceptance or Denial Form for patient #7.
Review of the on-call schedule dated 8/3/2013 revealed that Dr. N was on call for " Maxillo and Plastic " The hospital failed to ensure that the OMFS on-call physician came to the ED to provide OMFS services required and available for patient #7 on 8/3/2012.

2) Patient #5 presented to ED on 11/1/12 at 12:00 a.m. The Triage nurse documents the following: Chief complaint, "Tried to kill myself, I jumped off a bridge." The nurse documented the patient complained of a right elbow, jaw pain, a 4 centimeter (cm.) laceration to chin- not actively bleeding, lip laceration and suicide attempt.
The patient is seen by the ED physician at 0004. The physician documents a Medical Screening Exam (MSE) as follows: Patient comes to the ER after trying to kill himself by jumping off a bridge. Patient ambulated here without difficulty. He states he was trying to kill himself. Complained of facial pain.
The CT of the Brain - No acute intracranial abnormality seen; CT Cervical Spine- No acute fractures or malallignment of the cervical spine.
The CT of Maxillofacial skeleton without contrast - Non- displaced fracture of the right mandibular ramus fracture and the lateral right ptergoid plate. Minimal displaced nasal bone fracture. No air fluid levels are present.
Under the heading- MDM-Psychiatric Illness the ED physician documents the following :
ED Course: CT of brain and CT of spine read as no injury. Facial bones study shows Non- displaced fracture of the right mandibular ramus fracture (Broken jaw) and ptergoid plate fractures (Facial fractures involving upper jaw bones) as well as several displaced teeth. Spoke with Dr. M___Trauma Service at ______ (county hospital) and he is accepting patient in transfer.
The ED physician documents under Consultation:
Referral/Consultant name: Dr. N___, ( On-Call physician for Maxillofacial/Plastic Surgery at WPH). Call returned: MD is a Plastic surgeon and advised patient to be seen by OMFS before being medically cleared for psych. There was no documented evidence in the medical record to indicate that on 11/1/2012 patient #5 was seen and evaluated by the on call OMS physician. A review of the on-call schedules verified that Dr. N was the OMFS physician on- call on 11/1/2012. The facility failed to ensure that the OMFS on call physician came to the ED to evaluate patient #5 on 11/1/2012 after being notified.

The Plastic Surgeon was on call for OMFS at West Palm hospital on [DATE].
Disposition: - Psych. Illness; Clinical Impression: Primary Impression: Suicide attempt
Additional Impressions: Facial Laceration, Fracture of the mandible, Fracture of tooth
On the facility document titled: EMTALA Memorandum of Transfer, the physician documented the following:
Medical Condition: Right Mandible fracture/subluxed teeth/Suicidal.
Risk and Benefits for Transfer: Obtain level of care/services unavailable at this facility.
Service: OMFS
Patient Consent to Medically Indicated Transfer or Patient Request for Transfer:
There is an X in the box adjacent the words I hereby Consent to Transfer to another facility.
The words Baker Act is written in as the reason for transfer. The patient signs the document.
Review of the Transfer Log under D/C Diagnosis a nurse documented Right Mandible Fx. Subluxed teeth/Baker Act.
Reason for the Transfer: OMFS.
EMTALA Transfer Acceptance or Denial Form: Problem or Diagnosis Right mandible fracture, subluxed teeth; Reason for Transfer: Needs specialized level of OMFS care.
Disposition : Transferred to ______(county hospital); Disposition time: 0334
In an interview at the time of the review, the ED Nurse Manager contends that the patient was accepted as a Trauma patient.
Review of the receiving hospital ED Record revealed at 0611 the Physician Assistant (PA) documented under ED Physician Notes: The need for follow-up as outpatient discussed with patient/guardian for definitive care and OMFS specialist, the need to transfer to another facility. To return to ED if symptoms worsen. The PA discussed the case with Dr. K____. The CT were reviewed. Okay for follow - up as outpatient.
At 0453 the PA writes Psychiatric Baker Act (BA) procedures completed.
The diagnosis Multiple mandibular fractures; Major Depression, Suicidal Ideation's and medically cleared. At 0845 hours the nurse documents the patient was transferred to another psychiatric facility.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on reviews of medical records, on call schedules, facility license, delineation of privileges, policies and procedures, and interviews the facility failed to provide an appropriate transfer by not providing further evaluation and medical treatment within its capacity to minimize the risks and transferring unstable individuals to a facility with the same level of care for 2 of 20 sampled patients requiring oral maxillofacial services (Patients #2 and 5).
Findings are:
The facility's policy titled " EMTALA- FL Transfer Policy " Policy # 5.10.2; effective 5/9/01 revised 5/31/12 was reviewed. The policy stated in part, " b. A transfer will be an appropriate transfers if: i. The transferring hospital provides medical treatment within its capacity that minimizes the risk of the individuals health. "
1) Review of the medical record revealed Patient # 2 (MDS) dated [DATE] at 1521 hours. The chief complaint: Hit in head with unknown object.
The patient is seen by the ED physician at 1523. The physician documents a Medical Screening Exam (MSE) as follows:
CT Scan - CT Cervical Spine without contrast - Negative non-contrast enhanced CT study of the cervical spine. No cervical spine fractures or subluxations seen.
CT Scan -CT Brain without contrast - No acute intracranial abnormalities identified.
CT Scan- Facial Bones without contrast 1531 hours. Comminuted Right zygomaticofrontal complex fracture involving lateral and inferior walls of right orbit with air within the extraconal post septal orbital fat and partial opacification of the right maxillary sinus.
This is described by the ED Medical Director at 0915 hours on 11/9/12 as a "Blow Out Fracture. "
ED Course: Patient course: stable , improved. Disposition -Head Injury:
The ED physician documents the following in the ED record: Counseled patient /family regarding: diagnosis, imaging studies, need for transfer. Patient and girl friend said they cannot afford to follow up with a Maxillofacial Surgeon. Will transfer to _______(county hospital).

On the facility document titled: EMTALA Memorandum of Transfer, the physician documented the following: Medical Condition: Orbit Fx. Multiple; Risk and Benefits for Transfer: Obtain level of care/services unavailable at this facility.
The hospital's October 2012 Emergency Service call schedule was reviewed. Review of the call schedule verified that on 10/21/12 West Palm Hospital had on call OMFS/Plastics for patient #2.

Review of the Transfer Log under D/C Diagnosis the ED physician wrote Multiple Facial Fx.
Reason for the Transfer: Maxillofacial Surgery. On the EMTALA Transfer Acceptance or Denial Form: Problem or Diagnosis Multiple Facial Fx and Reason for Transfer: Maxillofacial/Trauma.
At 1715 the ED physician calls the ED physician at ________ (county hospital). The Consultant accepts the transfer. Disposition Transferred to: _________(county hospital). Disposition time: 1720 hours.
Review of the ED record from the receiving facility revealed the patient's stay in the ED at the county hospital was 1 hour and 15 minutes. The patient was discharged home at 2204 hours with instructions for follow - up. The patient was given a referral plan.


2) Patient #5 presented to ED on 11/1/12 at 12:00 a.m. The Triage nurse documents the following: Chief complaint, "Tried to kill myself, I jumped off a bridge." The nurse documented the patient complained of a right elbow, jaw pain, a 4 centimeter (cm.) laceration to chin- not actively bleeding, lip laceration and suicide attempt.
The patient is seen by the ED physician at 0004. The physician documents a Medical Screening Exam (MSE) as follows: Patient comes to the ER after trying to kill himself by jumping off a bridge. Patient ambulated here without difficulty. He states he was trying to kill himself. Complained of facial pain.
The CT of the Brain - No acute intracranial abnormality seen; CT Cervical Spine- No acute fractures or malallignment of the cervical spine.
The CT of Maxillofacial skeleton without contrast - Non- displaced fracture of the right mandibular ramus fracture and the lateral right ptergoid plate. Minimal displaced nasal bone fracture. No air fluid levels are present.
Under the heading- MDM-Psychiatric Illness the ED physician documents the following :
ED Course: CT of brain and CT of spine read as no injury. Facial bones study shows Non- displaced fracture of the right mandibular ramus fracture (Broken jaw) and ptergoid plate fractures (Facial fractures involving upper jaw bones) as well as several displaced teeth. Spoke with Dr. M___Trauma Service at ______ (county hospital) and he is accepting patient in transfer.
The ED physician documents under Consultation:
Referral/Consultant name: Dr. N___, ( On-Call physician for Maxillofacial/Plastic Surgery at WPH). Call returned: MD is a Plastic surgeon and advised patient to be seen by OMFS before being medically cleared for psych. There was no documented evidence in the medical record to indicate that on 11/1/2012/patient #5 was seen and evaluated by the on call OMS physician. A review of the on-call schedules verified that Dr. N was the OMFS physician on- call on 11/1/2012. The facility failed to ensure that the OMFS on call physician came to the ED to evaluate patient #5 on 11/1/2012 after being notified, as this resulted in an inappropriate transfer for patient #5.

The Plastic Surgeon was on call for OMFS at West Palm hospital on [DATE].
Disposition: - Psych. Illness; Clinical Impression: Primary Impression: Suicide attempt
Additional Impressions: Facial Laceration, Fracture of the mandible, Fracture of tooth
On the facility document titled: EMTALA Memorandum of Transfer, the physician documented the following:
Medical Condition: Right Mandible fracture/subluxed teeth/Suicidal.
Risk and Benefits for Transfer: Obtain level of care/services unavailable at this facility.
Service: OMFS
Patient Consent to Medically Indicated Transfer or Patient Request for Transfer:
There is an X in the box adjacent the words I hereby Consent to Transfer to another facility.
The words Baker Act is written in as the reason for transfer. The patient signs the document.
Review of the Transfer Log under D/C Diagnosis a nurse documented Right Mandible Fx. Subluxed teeth/Baker Act.
Reason for the Transfer: OMFS.
EMTALA Transfer Acceptance or Denial Form: Problem or Diagnosis Right mandible fracture, subluxed teeth; Reason for Transfer: Needs specialized level of OMFS care.
Disposition : Transferred to ______(county hospital); Disposition time: 0334
In an interview at the time of the record review, the ED Nurse Manager contends that the patient was accepted as a Trauma patient.
Review of the receiving hospital ED Record revealed at 0611 the Physician Assistant (PA) documented under ED Physician Notes: The need for follow-up as outpatient discussed with patient/guardian for definitive care and OMFS specialist, the need to transfer to another facility. To return to ED if symptoms worsen. The PA discussed the case with Dr. K____. The CT were reviewed. Okay for follow - up as outpatient.
At 0453 the PA writes Psychiatric Baker Act (BA) procedures completed.
The diagnosis Multiple mandibular fractures; Major Depression, Suicidal Ideation's and medically cleared. At 0845 hours the nurse documents the patient was transferred to another psychiatric facility.

West Palm Hospital had the capacities and facilities to provide further medical examination and treatment for patient #2 on 11/21/12 and patient #5 on 11/1/12, as this resulted in the inappropriate transfers of these individuals.