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EASTERN NEW MEXICO MEDICAL CENTER 405 W COUNTRY CLUB ROAD ROSWELL, NM 88201 Sept. 12, 2013
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, document review, and medical record review, the hospital failed to triage or medically screen a patient who was sent to the hospital's emergency room with orders for medical tests, including a CT scan. The findings are:

A. On 09/11/13 at 11:30 am, during interview, the Infirmary Administrator stated, "The cadet [Patient #1] was brought to us on 09/04/13 at 6:25 am with severe vertigo, high blood pressure, and a severe headache. He had also had a nosebleed prior to his arrival. We put him to bed in the clinic to allow him to rest. I got him up at 10:20 am and called the physician who is our medical director, and received orders to perform an Epley Maneuver. [In an Epley Maneuver, the patient lies on his back with his head at a 45 degree angle. The head is held by the provider. Then the head is rotated in the opposite direction and maintained at a 45 degree angle by the provider. The patient turns on the side on which the head is being held. Then the head is held steady while the patient sits up.] By 10:45 am I was done with the Epley maneuver. The other order was for 1 gram of Tylenol which the patient refused and to do a urine drug screen. After the Epley maneuver, the vertigo worsened. I called the medical director back at 11:15 am. I received orders for bloodwork and to hydrate him. The medical director was going to see him the next day. We kept him here all night. The medical director came in saw him at 09/05/13, 5:40 pm. The medical director felt there was a concern and ordered Patient #1 to go to the hospital ER for an evaluation. He wanted Patient #1 to be worked up and to get a CT scan of the head. We sent him to the hospital at approximately 7:15 pm accompanied by the Troop Leader Advisor. He was back by 7:35 pm. I asked him why he was back. Patient #1 said, 'I checked in and they registered me. I sat there for a few minutes and was then told by the registration clerk that they didn't have any beds and I should come back tomorrow.' He told me that he was not triaged. I re-routed them to [another area hospital] to be seen. I called [the first hospital] and asked to speak with the charge nurse. I asked her why Patient #1 was turned away. She became defensive and was saying, 'We wouldn't do that.' She did not know the patient's name. She didn't speak to registration or ask me the patient's name. I asked her how she could say that when she hadn't looked into the issue. She said I needed to call her back when I could be nice. I said OK and hung up."

B. Review of the order from the infirmary medical director, which was brought to the hospital by Patient #1, revealed the chief complaint to be "syncope, vertigo and recent nose bleed." The treatment required was stated as "Please DX and TX." Also requested was a "CT, head with contrast, and an EKG."

C. On 09/11/13 at 1:15 pm, during interview, Patient #1 stated, "Captain [Troop Leader Advisor] and I were on our way to the hospital. We walked into the ER and went to the front desk. The Troop Leader Advisor requested that I be seen. The lady at the front desk asked for the information I had in my hand. She looked over the information and handed me some papers that I signed. Then she picked up the phone and looked at her computer. The Troop Leader and I stood there for about 15 minutes. She looked at us and said that they had too many people and were really busy and that we should come back tomorrow or some other time. We left the ER and returned to the infirmary. The nurse was very upset and contacted someone at the hospital. Finally, she said to go to [the other local hospital]. There, they checked my temperature, did some bloodwork, tested my vision,and did a CT scan of the brain."

D. On 09/11/13 at 2:00 pm, during interview, the Troop Leadership Advisor, stated, "On that day, I picked [Patient #1] up around 7:00 am from the infirmary. We were directed to go to the hospital emergency room . We arrived about 10 minutes later. We went to the front desk and presented the desk clerk with the package that was given to us at the infirmary. They asked about Patient #1's insurance information. Someone reviewed the paperwork. In about 5 more minutes, we were called back up to the front desk. The clerk said, 'You're going to have to come back tomorrow because we're extremely busy.' At that time I looked around and noted that there were three, maybe four, potential patients waiting to be seen. We picked up our paperwork, stepped outside, and I called the infirmary. We returned to the infirmary. I was called later to take him to the other local hospital. No one at [the first hospital] provided any medical care whatsoever."

E. On 09/12/13 at 9:00 am, during telephonic interview, the infirmary Medical Director stated, "I was called the day before about [Patient #1]. It sounded like vertigo. They kept the kid in the infirmary. I saw him the next day. He needed help walking. He told me about a syncope episode in his room in which he woke up on the floor. That raised my suspicion. It was about 5:30 pm. I wanted to do some tests to include an ECG and CT of the head, looking for a tumor or bleed. I didn't feel real comfortable so I sent him to the ER for evaluation. I told the nurse that was on at the infirmary that [Patient #1] should mention syncope because that raises a much different suspicion of what's going on. My intent was that he be seen and evaluated by a different physician and be given a second opinion."

F. Review of the hospital's Patient Registration Form dated 09/05/13 revealed that Patient #1 presented at the hospital at 1913 hours. There was no other medical record documentation pertaining to the patient.

G. On 09/12/13 at 9:30 am, during telephonic interview, the registrar on duty when Patient #1 arrived at the ER, stated, "He went to the front desk at registration. He handed me orders, one was for an X-ray, As I was putting him in the system, I called Radiology and asked if they wanted to come and get him or have me walk him back. At that time the X-ray tech told me that the ER was packing them with patients and to tell him to go home and come back later. I passed that information on to the patient and the person who accompanied him. He handed me a stack of papers. I saw no orders other than orders for X-rays. The policy is to put patients with orders into the outpatient system. When they have no orders, they go to the ER. When they came in, the [person] that accompanied him handed me the papers and said that [Patient #1] needed an X-ray. I did not speak with any of the nursing staff in the ER about this patient."

H. At 09/12 13 at 8:30 am, during telephonic interview, the hospital's House Supervisor on the night that Patient #1 presented at the ER, stated, "I received a call from the ER charge nurse. She was distressed and excited. She said that the on-duty commander at [the organization where the infirmary is located] had just gotten off the phone with her and had spent the last 10 minutes chewing her out. She said that evidently, the infirmary staff had sent a student over to be seen in the ER and he had paperwork with him. She [the caller] accused the hospital of poor care and said that no one should run their hospital like that. [The charge nurse] was surprised and didn't know what she was talking about. [The charge nurse] said that the commander did not give her a chance to speak. She said that there would be no way we would turn a patient away and that we see every patient that comes through our doors. [The charge nurse] then told me that when she spoke with the ER registration clerk, she was told that someone had come in for an outpatient procedure of some sort and the registration clerk told them that we were very busy and they could come back later. I don't know whether the registration clerk looked at the paperwork or not. I then called [the organization from where the patient came] and apologized and asked if we could make amends. The commander was off duty. I spoke to another person and told him that we see every patient that comes in the door. I said it was a communication error and that the registrar was a new girl and had made a mistake by not calling the charge nurse or myself. The registration clerk must have believed she knew what she was doing or she would have asked. In my opinion, the cadet should have been triaged and medically screened. That is the procedure. Every patient is to sign in and be medically screened. The registration clerk has no education or authority to make a decision as to whether a patient should be seen or not. I'm still very upset about this situation because if he were seriously ill he could have had some serious permanent damage. He came here expecting help and we did not give him help."

I. On 09/11/13 at 3:45 pm, during interview, the ER Charge Nurse, stated, "[Someone from the orgainzation] called. She identified herself as a commander. She never said she was a nurse. She said that [Patient #1] was sent to our ER for a follow up X-ray. I went up front and asked the registration clerk if a patient presented with a prescription from [the infirmary Medical Director]. The registration clerk stated 'Yes, they were here.' I asked why the patient was not in [the electronic system] . She stated that it was for an outpatient procedure. She said that she called Radiology and that they told her they were extremely busy with trauma and could not do an outpatient procedure at this time. The registration clerk told the patient that they would have to come back for an outpatient procedure. I asked her, 'Did you send the patient away?' I asked, 'Why wasn't I informed? The registration clerk had no answer. They let the patient sign for treatment and put the patient in the system as an outpatient. At that point I called {Director of Emergency Services] and [House Supervisor].

J. On 09/12/13 at 9:15 am, during follow-up telephonic interview, the Infimary Administrator stated that when she called the hospital and spoke with the charge nurse, she identified herself as the Health Services Administrator at the [name of organization] infirmary. She also stated that the paperwork that was brought over to the hospital by Patient #1 included the document showing the chief complaint of syncope and vertigo and contained the Medical Director's request.

K. On 09/11/13 at 3:30 pm, during interview, the Director of Emergency Services stated, "The morning after the cadet presented at the ER, the charge nurse from the previous night called and told me that she received a call from a commander at [the organization] stating that we refused to see a patient. The charge nurse said that she was unaware of the patient presenting to the ER and that the patient could return and we would be happy to see him. The charge nurse said she wrote up some information for me to review. I received the information via an incident report. It said that a patient presented to the ER and was told that they were too busy to see him. The incident report was sent electronically to the Risk Manager, Chief Nursing Officer, and Administrator. I also sent a copy to the Director of Registration. We all talked about it. I called the charge nurse to find out if the patient had returned to the ER. He had not. Risk Management follows up from there."

L. Review of a hospital Event Detail Summary [incident report] # 1, verified what the registration clerk had reported to the charge nuse and later reiterated to the investigator. The report also contained another entry entered by the registration clerk's manager that provided the same information.

M. On 09/12/13 at 9:40 am, during telephonic interview, the Patient Accounts Manager, who supervises the ER registration clerks, stated, "I was told about an incident report that I needed to look at. I noticed on the report that the registrar was involved. I gave [the registration clerk] a call to see if she remembered [Patient #1] coming in. She said that she did remember. I asked her to tell me what happened. She said that [Patient #1] presented with some paperwork. She looked at the paperwork. Someone was with him and made the comment that the cadet needed to get an X-ray. She called back to Radiology and told them that [Patient #1] was present. She was told by Radiology that the ER had 'slammed' Radiology and that the patient should come back later. The registrar conveyed that to the patient . He and the escort then left. The registration clerk did not contact the nurses to my knowledge. She should have called the ER nursing station and had a nurse review the situation. She was trained to do that. We don't let anyone leave the ER without being screened by a clinician. The registration clerk has been out of town and we have been unable to follow up. Based upon the information I have received so far, I would have discussed the matter with a clinical person to determine what to do."

N. Review of the Community Health Systems (corporate parent) Policy 'Procedure G2A, dated [DATE] and revised [DATE] revealed the following statement in the Introduction paragraph: "All individuals presenting on hospital property requesting emergency medical services, individuals presenting to a dedicated emergency department requesting medical services, and patients arriving/presenting via ambulance requesting medical services shall receive an appropriate medical screening examination and stabilization services as required by the Emergency Medical Treatment and Active Labor Act [EMTALA]."