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WEST JEFFERSON MEDICAL CENTER 1101 MEDICAL CENTER BLVD MARRERO, LA 70072 May 31, 2011
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record review and interview the hospital failed to ensure compliance with 489.24 as evidenced by failure to:
1) ensure a patient, presenting to the hospital with an emergency medical condition (Peritonsillar Abscess), received an appropriate medical screening exam for 1 of 32 sampled patients (Patient #1). See findings cited at A2406
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure a patient, presenting to the hospital with an emergency medical condition, received an appropriate medical screening exam for 1 of 32 sampled patients (Patient #1). Findings:

Patient #1's Medical Record for Emergency Department visit dated 4/28/2011, arrival time 11:07 a.m. was reviewed. Review revealed Patient #1 was a [AGE] year old female that presented to West Jefferson Medical Center's Emergency Department with presenting complaint of "throat pain x a week". Further review revealed Patient #1 had a previous medical history of [DIAGNOSES REDACTED].m. with Blood Pressure of 104/65, Pulse 74, Respirations 24, Temperature 97.0, and pulse ox of 99%. Further review revealed Patient #1 received an emergency medical screening by Advanced Practice Nurse S9 at 12:07 p.m.: "The patient presents with sore throat, Dysphagia of both solids and liquids. Onset: The symptoms/episode began/ occurred yesterday. Associated signs and symptoms: Pertinent positives: cough, sore throat. . .." Review of Patient #1's "Exam" dated 4/28/2011 at 12:09 p.m. revealed in part, "The patient appears in no acute distress, alert, awake, comfortable, well developed, well hydrated. . Mouth: is normal, no abscess, no drooling. . . Tonsils, enlarged on the right with [DIAGNOSES REDACTED], with exudate, with ulcerations." Review of Disposition revealed, "4/28/2011 at 12:11 p.m., "discharged to Facility A (a local community health center). Impression: Pharyngitis. . ." Review of Patient #1's Discharge Instructions revealed in part, "Thank you for choosing West Jefferson Medical Center for your care today. The examination and treatment you have received in the Emergency Department today have been rendered on an emergency basis only and are not intended to be a substitute for an effort to provide complete medical care. You should contact your follow up physician as it is important that you let him or her check you and report any new or remaining problems since it is impossible to recognize and treat all elements of an injury or illness in a single emergency care center visit." Patient #1's Discharge time was documented as 12:11 p.m. No medications had been prescribed. The patient was instructed to follow-up with a physician at a local Community Health Center.

Patient #1's Medical Record for an Emergency Department visit to Hospital A dated 4/28/2011 at 12:48 p.m. was reviewed (37 minutes after being discharged from West Jefferson Medical Center's Emergency Department). Patient #1's presenting complaint was "Throat, difficulty swallowing. Pt (patient) C/O (complained of) throat and right ear pain. states unable to swallow. started 3 days ago. The patient's pain is 8/10 - the patient states the pain is severe." Review of Patient #1's "History of Present Illness (HPI)" revealed in part, "C/C (Chief complaint) Sore Throat/Difficulty Swallowing History obtained from the patient. HPI: 28 yr (year) old female with no PMH (past medical history) presents to the ED (Emergency Department) complaining of sore throat and difficulty swallowing. The pain started 3 days ago and has been worsening since. The pain is rated 8/10 and constant. Associated symptoms include fevers and right ear pain. The patient believes this is an abscess at the back of her throat. The patient denies any n/v/d (nausea, vomiting, diarrhea), join pain, or diarrhea. The patient is barely eating and drinking due to the pain. There are no alleviating factors." Patient #1's "Physician Exam: 1303 (1:03 p.m.)" revealed in part, "ENT (Ear, Nose, and Throat) Throat- Left Tonsil: + (positive) [DIAGNOSES REDACTED], Right Tonsil: + [DIAGNOSES REDACTED], + exudate, + swelling, + Peritonsillar abscess. . ." Review of Patient #1's throat culture results collection date/time of 4/28/2011 at 1652 (4:52 p.m.) revealed heavy streptococcus pyogenes (Group A). Review of "Medical Decision Making" notes for Patient #1 revealed in part, "1423 (2:23 p.m.). "Patient presents to the emergency department with throat pain. Evidence of peritonsillar abscess on exam. No signs of Ludwig's angina. Give IV antibiotics and steroids. consult ENT for drainage." 1702 (5:02 p.m.). ". . . Physician S15 (ENT), evaluated the patient in the emergency department, performed an aspiration of peritonsillar abscess draining approximately 4 ml (milliliters) of purulent drainage. culture has been sent. We'll continue patient on oral antibiotics and oral steroids (Prescriptions for Prednisone 20 milligrams 2 tablets by mouth daily, Lortab Elixir 10 milliliters every 4 hours as needed pain, and Clindamycin 150 milligrams 2 capsules every 6 hours.). Outpatient Followup arranged." Review of Medications Administered to Patient #1 in the Emergency Department revealed the patient received Clindamycin 600 milligrams Intravenously at 1535 (3:35 p.m.), Decadron 4 milligrams Intravenously at 1525 (3:25 p.m.), Morphine 4 milligrams Intravenously at 1530 (3:30 p.m.), and Lidocaine 2% 20 milliliters at 1659 (4:59 p.m.). Review of Patient #1's discharge instruction handout revealed in part, "You have been diagnosed with [DIAGNOSES REDACTED]. You abscess has been drained. You must follow up in the next 24 hours for a recheck since it is possible that the pus may come back. . .You should seek medical attention immediately, either here or at the nearest emergency department , if any of the following occurs: Persistent fever, shaking chills, or vomiting, Inability to swallow liquids, Difficulty breathing, Increasing pain, You are unable to talk."

During a face to face interview on 5/31/2011 at 9:30 a.m., Advanced Practice Nurse S9 confirmed that she (S9) had performed the Medical Screening Examination of Patient #1 at West Jefferson Medical Center on 4/28/2011. S9 indicated she (S9) had determined that Patient #1 had pharyngitis and could be treated on an outpatient basis. S9 indicated no medications had been prescribed to Patient #1. S9 indicated that if she (S9) had seen any evidence of a Peritonsillar Abscess with Patient #1, she (S9) would have sent the patient (#1) to a physician's exam room in the Main emergency room for a physician's evaluation. S9 indicated she (S9) had only seen one Peritonsillar Abscess in her (S9) career and did not see anything resembling a Peritonsillar Abscess with Patient #1.

During a face to face interview on 5/31/2011 at 11:15 a.m., Medical Director of Emergency Services S4 indicated Peritonsillar Abscesses were not always considered an Emergency Medical Condition. S4 indicated it would depend upon whether there was any danger of airway compromise. S4 indicated without the danger of airway compromise, a Peritonsillar Abscess could be treated on an outpatient basis. S4 indicated the average Peritonsillar Abscess would contain approximately 1 - 2 cc (cubic centimeters) of drainage, although they could contain more. S4 reviewed Patient #1's Medical Record. S4 indicated that it appeared as if Patient #1 was reasonably stable; as evidenced by no drooling and no fever, and would be appropriate for outpatient treatment.

During a telephone interview on 5/27/2011 at 3:40 p.m., Emergency Medical Director of Hospital A (S16) indicated he (S16) was on duty when Patient #1 was treated in the Emergency Department at Hospital A by Emergency Physician S17 and Ear, Nose, and Throat Physician S15.. S16 further indicated a Peritonsillar Abscess was an Emergency Medical Condition and must be drained or the patient would run the risk of airway compromise.

During a telephone interview on 5/31/2011 at 10:00 a.m., Ear, Nose, and Throat Physician S15 confirmed that he (S15) had drained a Peritonsillar Abscess on Patient #1 in the Emergency Department at Hospital A on 4/28/2011. Physician S15 indicated a Peritonsillar Abscess had to be drained or it would continue to get bigger.