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ST VINCENT HOSPITAL 123 SUMMER STREET WORCESTER, MA 01608 March 6, 2013
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on review of the 2/24/13 Emergency Department (ED) Log and interviews, it was determined that Hospital failed to record data in the ED log related to Patient #1 who presented to the ED following a motor vehicle accident in the ED Log.

Findings include:

Please see tag A2406 for information regarding Patient #1 and his/her 2/24/13 presentation to the Hospital ED [not designated as a level 1 trauma center].

ED registered nurse (RN) #4 was interviewed at 11:55 A.M. on 3/5/13. ED RN #4 said Patient #1 arrived in the Hospital ED at approximately 1:03 P.M.on 2/24/13. ED RN #4 said Patient #1 was placed in room 6. ED RN #4 said she asked for Patient #1's name many times and no one answered.

ED Physician #2 was interviewed at 1:50 P.M. on 3/4/13. ED Physician #2 said that based on Patient #1's mechanism of injury, roll-over motor vehicle accident with ejection, the Paramedics should have transported Patient #1 to a level 1 trauma center. ED Physician #2 said that based on his quick assessment of Patient #1, awake, alert, talking, not in any acute distress and stable vital signs, he thought the short ambulance trip to Hospital B, a level 1 trauma center, with lights flashing, would not put Patient #1 in immediate danger.

ED RN #4 said that when she asked for Patient #1's name a third time, ED Physician #2 said not to register Patient #1, get Patient #1 back on the ambulance stretcher and out of the ED to the nearby level 1 trauma center.

ED RN #3 was interviewed at 11:30 A.M. on 3/5/13. ED RNs #3 and #4 said they thought Patient #1 needed more of an assessment and that his/her transfer needed to be pre-arranged, but before they could express this, Patient #1 was placed in the ambulance and transported to Hospital B. ED RNs #3 and #4 said Patient #1 was only in the Hospital A ED for 4-5 minutes.

The Hospital's 2/24/13 ED Log did not include Patient #1's name or the fact that he/she did not receive a medical screen examination prior to transfer to the level 1 trauma center.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on review of 38 Emergency Department (ED) Records of patients presenting to the Hospital A ED during the time period of 12/5/12 through 2/28/13 and interviews, it was determined that the Hospital failed to provide a medical screening examination (MSE) to 1 out of 38 patients (Patient #1 on 2/24/13).

Findings include:

An Ambulance Patient Care Report (APCR) indicated paramedics were dispatched to a motor vehicle accident (MVA) at 12:20 P.M. on 2/24/13. The APCR indicated that at 12:24 P.M., the paramedics found Patient #1 lying prone on the ground in snow, approximately 10 feet from the vehicle. The APCR indicated Patient #1 was conscious, alert and oriented. The APCR indicated Patient #1 was collared and boarded (his/her spine was immobilized to prevent spinal cord damage secondary to possible spine injuries) and placed in the ambulance for transport.

A copy of the Central Medical Emergency Dispatch (C-MED, an EMS radio communication system) tape regarding Patient #1's 2/24/13 ambulance transfer indicated the paramedic radioed that the ambulance was transporting a trauma patient to the ED. The ED RN who received the 2/24/13 C-MED communication (ED RN #2) was interviewed at 3:15 P.M. on 3/4/13. ED RN #2 said the C-MED communication was "scratchy" and difficult to hear, but heard roll-over MVA with ejection and stable vital signs. ED RN #2 said she told the C-MED Dispatcher to standby for an attending physician for possible transfer to a trauma center. ED RN #2 said she summoned ED Physician #1 to the C-MED radio and informed the Resource Nurse, ED RN #3, of the C-MED transmission..

ED Physician #1 was interviewed at 3:05 P.M. on 3/4/13. ED Physician #1 said the C-MED Dispatcher said Patient #1 had been involved in a roll-over MVA with ejection, had stable vital signs and was on his/her way to Hospital A. ED Physician #1 said she told the Dispatcher that the Hospital ED was not designated as a level 1 trauma center and that Patient #1 should be transferred to a trauma center. ED Physician #1 said the Dispatcher said she would try to re-direct Patient #1's ambulance.

ED RN #3 was interviewed at 11:30 A.M. on 3/5/13. ED RN #3 said within minutes after the C-MED call, the Paramedics and Patient #1 entered the ED. ED RN #3 said she directed the Paramedics and Patient #1 into room 6 and she, ED Physician #2, the ED Physician Assistant and ED RN #4 followed them. ED RN #3 said Patient #1 was collared, boarded, awake and alert.

The time of Patient #1's 2/24/13 arrival in the Hospital's ED was not documented on the associated Ambulance Patient Care Report or ED Record.

ED RN #4 was interview at 11:55 A.M. on 3/5/13. ED RN #4 said Patient #1 arrived in the Hospital A ED at approximately 1:03 P.M. on 2/24/13.

ED RN #3 said ED Physician #2 immediately told the Paramedics that Patient #1 should have been transported to a level 1 trauma center. ED RN #3 said the Paramedics lifted Patient #1 onto the hospital stretcher.

ED Physician #2 was interviewed at 1:50 P.M. on 3/4/13. ED Physician #2 said that considering Patient #1's mechanism of injury, the Paramedics should have transported Patient #1 to a trauma center. ED Physician #2 said the minute Patient #1 arrived in the ED, he considered that what was the best way to get this patient to the level 1 trauma center located approximately 2.5 miles away.

ED RN #3 said ED Physician #2 and the Paramedics were arguing about the fact that Patient #1 should have been transported to a level 1 trauma center in accordance with ambulance protocols.

ED Physician #2 said Patient #1 was awake, alert and not in any acute distress. ED Physician #2 said the Paramedics informed him that Patient #1's last set of vital signs taken in the ambulance where stable.

ED Physician #2 said that based on a quick assessment of Patient #1: awake, alert, talking, not in any acute distress and stable vital signs, he thought the short ambulance trip to the level 1 trauma center with lights flashing would not put Patient #1 in immediate danger. ED Physician #2 said he discussed this with the Paramedics and they agreed to transport the Patient.

ED RN #4 said that when she asked for Patient #1's name a third time, ED Physician #2 said not to register Patient #1, get Patient #1 back on the ambulance stretcher and out of there to the level 1 trauma center. ED RN #4 said Patient #1 said it felt like his/her right abdomen was shaking and asked how long it would take to get to Hospital B.

ED RNs #3 and #4 said they thought Patient #1 needed more of an assessment and that his/her transfer needed to be pre-arranged, but before they could express this, Patient #1 was placed in the ambulance and transported to Hospital B. ED RNs #3 and #4 said Patient #1 was only in the Hospital A ED for 4-5 minutes.

Patient #1's 2/24/13 Ambulance Patient Care Report (APCR) indicated that before the Paramedics could give a report regarding Patient #1 to the Hospital A ED staff, ED Physician #2 asked multiple times why Patient #1 was not at Hospital B. The APCR indicated ED Physician #2 was advised of the circumstances surrounding Patient #1's transport, but continued to state that Patient #1 should have been transported to Hospital B. The APCR indicated the Paramedics tried to give a report regarding Patient #1, but ED Physician #2 interrupted and instructed the Paramedics to put Patient #1 back onto their stretcher and get him/her out of there. The APCR indicated that ED Physician #2 was advised that an immediate transfer was not an acceptable practice, but ED Physician #2 said he didn't care, they were ordered to get Patient #1 out of there.

Patient #1 was not provided with a physical examination or diagnostic testing necessary to determine the presence or absence of an emergency medical condition prior to his/her 2/24/13 transfer to Hospital B. The staff did not create a ED record for Patient #1 until 10:21 P.M. on 2/24/13, several hours after the Patient left.

ED RN #3 said she notified the Director of ED Nursing of Patient #1's ED presentation and inappropriate transfer to the level 1 trauma center.

The Hospital's Internal Investigation regarding Patient #1's 2/24/13 ED presentation and transfer to the level 1 trauma center indicated that ED Physician #2 and the majority of the ED staff who were in Patient #1's room on 2/24/13 had been interviewed and two immediate corrective actions were implemented. The corrective actions included obtaining mandatory prior approval by the Emergency Medicine Administrator On-Call (a senior ED physician) prior to the transfer of ED patients and Emergency Medicine Treatment and Labor Act (EMTALA) mandatory re-education for all ED physicians and staff.

ED Physician #2 said he was aware that he did not provide a MSE examination to
Patient #1. ED Physician #2 said he completed EMTALA re-education on 3/2/13 and was scheduled to give a presentation regarding EMTALA to the Emergency Medicine Department on 3/5/13 (done as scheduled).

Review of Patient #1's 2/24/13 medical record from the Level 1 Trauma Center indicated he/she arrived in the Trauma Room at 1:14 P.M. The ED Record indicated a physical examination demonstrated neck, pelvic and abdominal pain, multiple minor abrasions, multiple broken teeth and lacerations. Diagnostic imaging demonstrated 2 right rib fractures, a grade II-III liver laceration (a potential emergency medical condition) and a right adrenal gland hematoma (a collection of blood located on a gland located on the surface of the kidney). The ED Record indicated Patient #1 was admitted to the Hospital for monitoring for bleeding.