The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NYE REGIONAL MEDICAL CENTER 825 ERIE MAIN ST (AKA SOUTH MAIN) TONOPAH, NV May 10, 2012
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on the findings at A2406 the facility failed to ensure compliance with CFR 489.24.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on patient record review, physician and staff interviews and review of policy and procedures, medical staff by-laws, and governing body by-laws, the facility failed to ensure medical screening exams were done by a physician for 14 of 34 patients (Patient #8, #4, #7, #10 , #6, #11, #12, #24, #25, #26, #27, #29, #30, #32).

Findings include:

Patient #8

Patient #8 presented to the facility's emergency room (ER) on 1/22/12 at 11:00 PM complaining of abdominal pain. Record review of the emergency room patient record revealed the patient reported the abdominal pain started two days before and she had experienced "a lot" of vomiting.

Review of the emergency room log (the central log tracking each individual who comes to the emergency room seeking assistance) identified Patient #8's physician as Physician #7. The log revealed the patient had an X-ray done and lab work. The log had a "? exam" written in the reason section of the log where physician screening exams were recorded. The "reason" section of the log was used to identify services provided to the patient.

The physician assessment section of the emergency room patient record for Patient #8 revealed a "?' sign next to previous medical history (PMH) and a check next to "above noted".

On 5/8/12, an interview was conducted with a Registered Nurse (RN), Employee #1, who was on duty the night Patient #8 presented to the emergency room . The RN reported Physician #7 did not come into the hospital to examine the patient and gave orders over the phone. The nurse reported the patient was discharged without seeing a physician but returned to the emergency room the next day. The nurse reported she thought the patient was seen by the physician on her second visit to the emergency room on [DATE] and the patient was transferred to another facility.


RN #1 reported one physician did not come in to examine every patient who came to the emergency room . The nurse reported that if the physician did not come in to examine the patient, she would write T.O. (telephone order) or T/O or "yes" instead of a time in the response time area on the emergency room patient record intake form. The nurse reported she sometimes wrote TO in the discharge area. The nurse reported she would note the lack of an exam by the physician by placing a null sign ( ? ) exam in the emergency room log.

RN #1 reported she had no specialized training in conducting medical screening exams in the emergency room and was not considered a Qualified Medical Personnel (QMP) to conduct the medical screening exams. The nurse reported she received no training in EMTALA regulations.

RN #1 reported the hospital physicians who were covering the emergency room , with the exception of Physician #7, usually responded on site within fifteen minutes. Physician #7 was the sole physician on call for the hospital/emergency room on [DATE].

Record review, document review and interview of the nursing staff revealed Physician #7 did not come in to conduct the medical screening exam on Patient #8 on 1/22/12. However, the patient's clinical record included a dictated/written note of a medical screening exam dated 1/22/12.

Record review of Patient #8's second emergency room visit at 12:55 PM on 1/23/12 revealed the patient continued to have abdominal pain which was described as severe per the emergency room progress notes. The patient was described as crying, holding her abdomen and laying in the fetal position. The patient was seen by Physician #7 on 1/23/12.

Record review revealed Patient #8 had acute appendicitis and was offered transfer via life flight but chose to be driven in a private vehicle to an acute care hospital three hours away.


On 5/9/12, RN #9 was interviewed. The RN reported she was in the emergency room when Patient #8 arrived on 1/23/12. The RN reported the patient was examined by the physician during the second visit. The RN reported Physician #7 told her not register the patient in the emergency room log. The nurse reported she was not comfortable voiding the chart. The nurse reported the patient's relative told her the patient was in the emergency room on [DATE] and was not seen by and physician.


Review of a Quality Review Report dated 1/30/12 revealed Patient #8 came to the emergency room on [DATE] and was not seen by a physician.

Patient #4

Patient #4 (MDS) dated [DATE] at 10:00 PM, complaining of intermittent numbness of her lips. The patients medical history revealed she was recently discharged from an acute care hospital with a diagnosis of subarachnoid hemorrhage. Nurses notes revealed "physician informed of results... telephone orders received. Pt daughter insisting on speaking with physician re: POC (Plan of Care). Daughter speaking to physician via telephone."

Record review revealed Patient #4 and her family signed AMA (Against Medical Advice) @ 2:00 AM.

Review of the facility's Quality Review report revealed all contact between Patient #4, her family and Physician #7 was done via phone.

Review of Patient #4's entry into the emergency room log revealed "? exam" documented by the nurse, RN #1.

Physician #7 was the sole physician on call for the hospital/emergency room on [DATE].

Record review, document review and interview of the nursing staff revealed Physician #7 did not come in to conduct the medical screening exam on Patient #4 on 1/27/12. However, the patient's clinical record included dictated/written notes of a medical screening exam by Physician #7, dated 1/27/12.

Patient #7

Patient #7 (MDS) dated [DATE] at 10:15 PM. Review of the emergency room log revealed the patient complained of urinary retention. The log also had the word exam written with a line through it in the reason column. RN, Employee #1 made the log entry.

Review of Patient #7's emergency room record revealed a telephone order for a Foley catheter was received from Physician #7. The patient was treated and discharged from the emergency room to home.

Physician #7 was the sole physician on call for the hospital/emergency room on [DATE].

Record review, document review and interview of the nursing staff revealed Physician #7 did not come in to conduct the medical screening exam on Patient #7 on 1/21/12. However, the patient's clinical record included a dictated/written note of a medical screening exam by Physician #7 dated 1/21/12.

Patient #10

Patient #10 (MDS) dated [DATE] at 12:00 AM complaining of chest pain. Progress notes revealed the patient described the pain as crushing and in the center of her chest radiating to her back and central abdomen.

Review of Patient #10's emergency room log entry revealed the patient was not examined by a physician.

Records revealed Patient #10 received Nitro Spray, Aspirin and intravenous fluids during her emergency room visit.

Records revealed the nurse noted at 1:30 AM discharge instructions were given as ordered via telephone by the physician. Patient #10 was discharged to home.

Physician #7 was the sole physician on call for the hospital/emergency room on [DATE].

Record review, document review and interview of the nursing staff revealed Physician #7 did not come in to conduct a medical screening exam on Patient #10 on 12/3/11. However, Patient #10's clinical record included a dictated/written note of a medical screening exam by Physician #7 dated 12/3/11.

Patient #6


Patient #6 (MDS) dated [DATE] at 10:11 AM complaining of her hands and feet tingling. The patient rated her pain was 10/10 and reported the pain was getting worse.

Review of Patient #6's emergency room log entry revealed a ? exam under the reason column.

Physician #7 was on call. The treatment noted on the emergency room record was to admit for observation but the patient signed AMA.

Physician #7 was the sole physician on call for the hospital/emergency room on [DATE].

Record review, document review and interview of the nursing staff revealed Physician #7 did not come in to conduct a medical screening exam on Patient #6 on 1/27/12. However, Patient #6's clinical record included a dictated/written note of a medical screening exam by Physician #7 dated 1/27/12.

The facility's Quality Review report dated 1/28/12 revealed only telephone orders and no mention of a medical screening exam by a physician.

Patient #11

Patient #11 (MDS) dated [DATE] at 9:05 PM complaining of a productive cough, sore throat and diarrhea for a week. The patient also reported intermittent fever.

Review of the Patient #11's emergency room log entry revealed the patient "was not examined physician".

The emergency room patient record revealed the physician was notified of Patient #11's arrival at 9:15 PM. The record shows an order for Bicillin LA was given via phone.

Patient #11 was provided discharge instructions and was discharged home at 10:35 PM.

Physician #7 was the sole physician on call for the hospital/emergency room on [DATE].

Record review, document review and nursing staff interviews revealed Physician #7 did not come in to conduct a medical screening exam on Patient #11 on 11/12/11. However, the patient's clinical record included a dictated/written note of a medical screening exam by Physician #7 dated 11/12/11. The dictated note indicated the patient had Streppharyngitis.

Physician #7 was the sole physician on call for the hospital/emergency room on [DATE].

Patient #12

Patient #12 (MDS) dated [DATE] at 10:40 PM via ambulance. The patient's chief complaint was hand swelling.

Review of Patient #12's emergency room log entry revealed Patient #12 "was not examined by the physician".

Physician #7 was on call and was notified of Patient #12's arrival at 10:57 PM. At 12:00 AM, the nurse documented "physician notified of lab/xr results et telephone orders received."

Physician #7 was the sole physician on call for the hospital/emergency room on [DATE].

Record review, document review and interview of the nursing staff revealed Physician #7 did not come in to conduct a medical screening exam on Patient #12 on 1/15/12. However, the patient's clinical record included a dictated/written note of a medical screening exam by Physician #7 dated 1/15/12.

Patient #12 was discharged from the emergency room to his home on 1/16/12 at 12:08 AM.

Patient #24

Patient #24 (MDS) dated [DATE] at 10:00 PM complaining of a cough and fever. The patient was 23 weeks pregnant.

Review of Patient #24's emergency room log entry revealed " ? exam" written under the reason column. RN, Employee #1, made the entry into the emergency room log.

Records revealed Physician #7 was made aware of Patient #8's arrival at 10:27 PM and responded with a telephone order for the patient to follow up in the outpatient clinic with no further intervention during the visit to the emergency room .

Physician #7 was the sole physician on call for the hospital/emergency room on [DATE].

Record review, document review and interview of the nursing staff revealed Physician #7 did not come in to conduct the medical screening exam on Patient #24 on 3/11/12. However, the patient's clinical record included a dictated/written note of a medical screening exam by Physician #7 dated 3/11/12.

Patient #25

Patient #25 (MDS) dated [DATE] at 10:05 PM and his mother reported he had "mucho" pain in his ear. The patient was five years old.

Review of Patient #25's emergency room log entry revealed Patient #25 was "not examined by the physician".

Physician #7 was the sole physician on call for the hospital/emergency room on [DATE].

Record review, document review and interview of the nursing staff revealed Physician #7 did not come in to conduct the medical screening exam on Patient #25 on 12/15/11. However, the patient's clinical record included a dictated/written note of a medical screening exam by Physician #7 dated 12/15/11.

Patient #25 was discharged from the emergency room to home.

Patient #26

Patient #26 (MDS) dated [DATE] at 12:45 AM complaining of chest pain. The patient also complained of tingling hands and seeing flashes of light. Nursing documented, "Dr. notified and pt (patient) instructed to follow up with stress test in clinic and if pt feels Depakote is the problem to stop taking."

Review of Patient #26's entry in the emergency room log revealed it was blank in the reason column where nurses record physician exams.

Physician #7 was the sole physician on call for the hospital/emergency room on [DATE].

Record review, document review and interview of the nursing staff revealed Physician #7 did not come in to conduct the medical screening exam on Patient #26 on 1/13/12. However, the patient's clinical record included a dictated/written note of a medical screening exam by Physician #7 dated 1/13/12.

Patient #26 was discharged from the emergency room to home on 1/13/12 at 2:12 AM.

Patient #27

Patient #27 (MDS) dated [DATE] at 12:01 AM complaining of numbness and tingling of her feet for three weeks. The patient also complained of blurry vision.

Review of Patient #27's entry in the emergency room log revealed the patient was not examined by a physician.

Physician #7 was the sole physician on call for the hospital/emergency room on [DATE].

The nurse caring for the patient documented at 1:30 AM, "Dr. phoned made aware of lab results. T/O received to D/C (discharge) pt. Pt remains unchanged & is A/O x 3(alert/oriented x 3) -cont to c/o numbness et tingling to face et hands et feet."

Record review, document review and interview of the nursing staff revealed Physician #7 did not come in to conduct the medical screening exam on Patient #27 on 1/18/12. However, the patient's clinical record included a dictated/written note of a medical screening exam by Physician #7 dated 1/18/12.

Patient #27 was discharged from the emergency room to home on 1/18/12 at 1:45 AM.

Patient #29


Patient #29 (MDS) dated [DATE] at 11:50 PM. The patient was a five month old male who's mother reported he had been coughing and wheezing for three days.

Review of Patient #29's entry in the emergency room log revealed Patient #29 was not seen by a physician.

Physician #7 was the sole physician on call for the hospital/emergency room on [DATE]

A telephone order for Azithromycin was noted on the record.

Record review, document review and interview of the nursing staff revealed Physician #7 did not come in to conduct the medical screening exam on Patient #29 on 1/15/12. However, the patient's clinical record included a dictated/written note of a medical screening exam by Physician #7 dated 1/15/12.

Patient #29 was discharged from the emergency room to home in the care of his mother.
Patient #30

Patient #30 (MDS) dated [DATE] at 8:35 PM complaining of a bladder infection.

Patient #30's entry into the emergency room log revealed the word "exam" was crossed out under the reason column.

Physician #7 was the sole physician on call for the hospital/emergency room on [DATE].

Records revealed lab work was done and Pyridium and Bactrim DS were dispensed.

Patient #30 was discharged from the emergency room to home.

Record review, document review and interview of the nursing staff revealed Physician #7 did not come in to conduct the medical screening exam on Patient #30 on 1/28/12. However, the patient's clinical record included a dictated/written note of a medical screening exam by Physician #7 dated 1/28/12.

Patient #32

Patient #32 (MDS) dated [DATE] at 10:00 PM. The patient was three years old and his mother reported he was crying when urinating.

The emergency room log entry for Patient #32 was found to be blank in the reason column where physician exams were noted by nursing staff.

Physician #7 was the sole physician on call for the hospital/emergency room on [DATE].

The nurse caring for Patient #32 wrote "dr. notified and T/O received to dispense Pediazole 3cc BID (cubic centimeters twice a day) for five days."

Patient #32 was discharged from the emergency room to home with his mother.

Record review, document review and interview of the nursing staff revealed Physician #7 did not come in to conduct the medical screening exam on Patient #32 on 1/10/12. However, the patient's clinical record included a dictated/written note of a medical screening exam by Physician #7 dated 1/10/12.

The Director of Nurses (DON), Employee #3, was interviewed on 5/8/12, and indicated she discovered the physician wasn't coming in to see patients presenting to the emergency room following her return from maternity leave on 1/30/12.

The DON reported her finding to the Assistant Administrator. The DON reported staff confirmed there was a problem with a physician not coming to the emergency room to examine patients. The DON reported she informed staff they were to report any time a physician did not come in to examine a patient.

The Assistant Administrator, Employee #6, was interviewed on 5/9/12. She was asked if anyone came to her to report concerns regarding Physician #7 not examining patients presenting to the emergency room . The Assistant Administrator reported there was currently an ongoing investigation of the incidents and provided a report regarding the investigation. She reported verbal concerns were brought to her by staff.

The Assistant Administrator reported she was told of the incidents in mid February during peer review when they reviewed the ER log. She reported reviews were done by two physicians, Physician #11 and Physician #12. She reported both physicians expressed concerns regarding the documentation. She reported Physician #11 was concerned the documentation looked as though physician Physician #7 was there, when he wasn't there.

The Assistant Administrator reported staff reviewed the emergency room logs for documentation indicating the physician did not examine a patient when they presented to the emergency room . The Assistant Administrator provided additional names of patients whom the facility believed did not receive medical screening exams while in the emergency room , which were reviewed and included in the investigation.

On 5/9/12 at 1:55 PM, RN, Employee #9 was interviewed. The RN reported Physician #7 always came in to the emergency room on day shift. She reported multiple instances where Physician #7 did not come into the emergency room to see a patient during the night shift. She reported the DON met with day shift nurses and asked them to report if a physician did not come in to examine a patient.


RN, Employee #9 reported she did not have specialized training in conducting medical screening exams and was not considered a QMP. The RN reported she did not have training in EMTALA regulations.


On 5/9/12, RN , Employee #5, was interviewed. The RN reported she was aware of incidents in which Physician #7 did not come in to the emergency room to examine patients. The RN reported all other emergency room physicians came in to examine patients. The RN reported she told the supervisor (DON) about the physician not seeing the patients. She reported the physician did not come in to see patients about three times when she was on duty.

RN, Employee #5 reported she did not have specialized training to conduct medical screening exams and was not considered a QMP.

On 5/9/12, RN, Employee #10 was interviewed. The RN reported there were many times over the years Physician #7 did not come to the emergency room to examine a patient. The RN reported telephone orders were given over the phone. The RN reported when the physician did not come in she wrote "T/O" in the response time box on the emergency room record, or "TO" in the medication area. The RN reported she noted in the ER log as not examined by physician.

On 5/9/12, Physician #7 was interviewed. The physician reported the longest stretch he worked was 90 days. He reported there were times when the hospital was overwhelmed, shorthanded, or high volume. He reported there were times when things probably were not done the way they should be according to regulations even though they were held to the same standards as everyone else.

Review of the emergency room physician schedule revealed Physician #7 was the sole physician scheduled to cover the emergency room and hospital for 24 hours a day on 1/4/12, 1/5/12, 1/9/12 through 1/29/12. Review of the emergency room /hospital schedules for 2/12, 3/12, 4/12 and 5/12 revealed it was common practice for a physician to cover the hospital and emergency room for 24 hour periods over several days to a week.

In an interview with RN #1 on 5/8/12, she reported most physicians stay in the hospital until 11:00 PM to 12:00 AM and then go to an apartment in town. The RN reported the nurses contact the physician via phone after they assess the patient and the physician is expected to come to the emergency room to examine the patient. The RN reported the usual response time for physicians to the emergency room was 15 minutes. Additional nurse interviews confirmed the usual response time for physicians was between 15 to 30 minutes.

Review of the emergency department's policy entitled "Scope of Service" reference #6003, which was undated, revealed "A minimum of one (1) Emergency Department physician is on duty at all times".

Review of the facility emergency department's policy entitled "Purpose and Objectives" approved by the governing body and dated 3/1/2002, revised 1/8/2009, revealed all patients were to receive an evaluation by the Emergency Department physician.

Review of the Governing Body and Medical by laws made no mention of Registered Nurses without advanced training functioning as qualified medical professionals.