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|SCOTLAND MEMORIAL HOSPITAL||500 LAUCHWOOD DR LAURINBURG, NC 28352||June 8, 2016|
|VIOLATION: COMPLIANCE WITH 489.24||Tag No: A2400|
|Based on hospital policy review, medical record reviews, physician and staff interviews the hospital failed to comply with 42 CFR 489.20 and 489.24.
The findings include:
1. The hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 23 sampled DED patients who presented to the DED (Patient #11) with complaint of a fall with no feeling in her legs after an altercation.
~ Cross refer to 489.24(a) and 489.24(c) Medical Screening Examination - Tag A2406.
|VIOLATION: MEDICAL SCREENING EXAM||Tag No: A2406|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on hospital policy and procedure review, medical record reviews, and physician and staff interviews, the hospital's DED (Dedicated Emergency Department) physician failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for 1 of 23 sampled patients who presented to the DED (Patient # 11) with complaint of a fall with no feeling in her legs after an altercation.
The findings include:
Closed DED medical record review of patient (Pt) #11 revealed a [AGE] year old female that presented via private vehicle to the DED on 04/23/2016 at 0349 with a chief complaint of "ALL (NO FEELING IN HER LEG)." Review of Nursing Triage assessment dated [DATE] at 0402 revealed "VITAL SIGNS: BP 151/69, Pulse: 67, Resp: 17, Temp: 97.8, Pain: 0, O2 Sat: 99, on ROOM AIR." Further review of Triage assessment dated [DATE] at 0403 revealed "ADMISSION: URGENCY: ESI 3 (Urgent)...TRANSPORT: Wheelchair ...CURRENT MEDICATIONS None." Review of record revealed Pt #11 was placed in a treatment room at 0405. Review of Triage assessment dated [DATE] at 0405 revealed "...SUBJECT ASSESSMENT: PT. (patient) C/O (complaining of) NOT BEING ABLE TO FEEL HER LEGS. PT'S FAMILY STATES SHE WAS PHYSICALLY ASSAULTED BY HER HUSBAND. PT. WAS SLAMMED ON THE FLOOR BY HER HUSBAND AND HAS NOT BEEN ABLE TO WALK SINCE. PT. URINATED ON HERSELF PER FAMILY. PAIN: On a scale 0-10 (pain scale 0-no pain, 10 -excruciating pain) patient rates pain as 0." Review of Physician's HPI (history of present illness) dated 04/23/2106 at 0429 revealed "CHIEF COMPLAINT: Patient presents for the evaluation of bilateral, Back, Legs, numbness, decreased use...MECHANISM: Complaint occurred by fall, Fall from standing. OCCURRED: Onset was few hours prior to arrival, Patient currently has symptoms. LOCATION: Unable to localize. QUALITY: Unable to describe pain. ASSOCIATED WITH: Alcohol: Yes, Neurologic Symptoms Prior to Patient Arrival present, LOC (loss of consciousness): none, GCS (Glasgow Coma Score-level of consciousness): 15, Patient denies clavicle pain, shoulder pain, elbow pain, wrist pain, hand pain, finger pain. Patient is able to ambulate or bear weight, Patient denies pain on walking, hip pain, knee pain, ankle pain, foot pain. RISK FACTORS: Spine Injury Risk Factors: None ...NOTES: Slammed on to Chair at Party, struck Back, denied pain, stated cannot feel or move legs." Review of Physician's Orders dated 04/23/2016 at 0429 revealed an order for an Alcohol level, a Basic Metabolic Panel, Complete Blood Count with Diff, Drug screen, Pregnancy Test, Urinalysis, Magnesium and Lumbar Spine without contrast. Review of Nursing assessment dated [DATE] at 0430 revealed "CONSTITUTIONAL: Patient is alert and oriented x 3 (person, place and time) ...Patient arrives to treatment area via hospital wheelchair, Patient lifted to cart (stretcher), History obtained from family, Patient appears intoxicated, pt anxious and tearful, verbally abusive. BACK: Patient has strong pulses to upper and lower extremities bilaterally, Patient complains of pain to lower back, Pain described as aching, Pain is continuous, Patient unable to ambulate, verbalizes numbness from waist down both lower extremities, pt has inward turn of both legs." Review of Physician's Physical Exam dated 04/23/2016 at 0431 revealed "CONSTITUTIONAL ...Patient appears comfortable, Hypertensive, Patient is agitated....BACK: There is no CVA Tenderness, There is no tenderness to palpation, Normal Inspection ...LOWER EXTREMITY: Inspection normal, No cyanosis, clubbing, edema. Normal range of motion, No calf tenderness, Normal pulses. NEURO: There is weakness in the left leg. There is weakness in the right leg. There is a sensory deficit in the left leg. There is a sensory deficit in the right leg. Subjective...PSYCHIATRIC: Oriented x 3, Normal insight, concentration. Agitated affect, Anxious affect." Review of nursing procedures revealed IV (intravenous) access was established and labs drawn with family present on 04/23/2016 at 0445. Further review of procedure notes revealed urine specimen for urinalysis and pregnancy test obtained via straight catheter at 0455. Review of Physician's orders dated 04/23/2016 at 0539 revealed an order for Morphine (Pain medication) 2mg IV Push. Review of Medication Service Records revealed Morphine 2 mg IV was administered and response to Morphine was reassessed at 0620. Review of Physician's Orders dated 04/23/2016 at 0603 revealed an order for Thiamine 100 mg IV Drip/Infusion. Review of Medication Service Records revealed Thiamine 100 mg IV piggyback infusion administered at 0623 and discontinued at 0650. Review of Physician's Order dated 04/23/2016 at 0604 revealed an order for Benadryl 50 mg IV push. Review of Medication Service Records revealed Benadryl 50 mg IV was administered at 0620 and response to Benadryl was reassessed at 0650. Review of Physician's Orders dated 04/23/2016 at 0607 revealed an order for Normal Saline 1000 ml IV bolus. Review of Physician's "LAB INTERPRETATION" Notes dated 04/23/2016 at 0623 revealed "INTERPRETATION: I reviewed the lab results, Elevated WBC (white blood count), CBC (complete blood count) otherwise normal, Decreased Sodium Bicarbonate, otherwise Chemistry normal, Urinalysis is normal, Urine toxicology positive for, cannabinoids, Alcohol level 227, by blood." Review of Physician's "RADIOLOGY INTERPRETATION" Notes dated 04/23/2016 at 0623 revealed "INTERPRETER: Preliminary review of CT by Radiologist. BACK: Interpretation of L-spine CT shows, L-spine negative, no fracture, no subluxation, no bony lesion, no cord compression, however, degenerative joint disease present." Review of "DOCTOR NOTES" dated 04/23/2016 at 0624 revealed "Moved both legs w/ (with) Painful Stimuli to Feet and Legs, appears to be more anxiety related, friends agree and will take pt home to F/U (follow-up) as an outpt (outpatient). PATIENT STATUS: Patient has improved since arrival to emergency department. PATIENT PLAN: The patient will be discharged . The patient will follow up with primary care physician." Review of Physician's Notes revealed a Final Primary Diagnosis of "Low back contusion" with Additional diagnosis of "Acute alcohol intoxication, Anxiety, CANNABIS (marijuana) ABUSE UNCOMPLICATED, CONVERSION D/O (Disorder) W/MOTOR SX (symptoms)/DEFICIT, DEHYDRATION, Hypertension, Paresthesia." Review of Physician's Orders dated 04/23/2016 at 0627 revealed an order for Hydroxyzine HCl 50 mg po and Ultram 50 mg po to take home. Review of Medications Service record revealed Hydroxyzine HCl 50 mg po and Ultram 50 mg po were given to patient's father for patient to take at home. Further review of DED record dated 04/23/2016 at 0628 revealed "DISPOSITION ...discharge ... Home/Self Care, Disposition Transport: *Wheelchair, Condition: Stable." Review of Medication Service Records revealed Normal Saline 1000 ml bolus was administered at 0630 and discontinued at 0720. Review of Nurse's Notes dated 04/23/2016 at 0700 revealed "VITAL SIGNS: BP 142/106 (SITTING), Pulse: 119 (STRONG), Resp: 20 (NORMAL), Temp: 98.3 (ORAL), Pain: 10, O2 Sat: 100 on ROOM AIR." Review of Physician's Orders dated 04/23/2016 at 0717 revealed and order for Norflex 60 mg IV Push. Review of Medication Service Records revealed Norflex 60 mg IV was administered at 0720 and response to Norflex was reassessed at 0800. Review of Nurse's Notes dated 04/23/2016 at 0730 revealed "Pt. aggressive and cussing. States she wanted to be transferred. States 'don't come close to me because I grab'. Tried to calm pt. down ..." Review of Nurse's Notes dated 04/23/2016 at 0811 revealed "...Attempted to call family and pts. boyfriend multiple times with the phone numbers pt. provided. No answer from any of the numbers will continue to call." Review of Nurse's Notes dated 04/23/2016 at 1010 revealed "Pt. gave a phone number to call that she didn't give earlier. Spoke with family member states they will be here to pick up pt." Review of Nurse's Notes dated 04/23/2016 at 1042 revealed "VITAL SIGNS: BP 133/101 (LYING), Pulse: 97 (STRONG), Resp: 22, Temp: 98.0 (ORAL), Pain: 10, O2 Sat: 99 on ROOM AIR." Review of Nurse's Notes dated 04/23/2016 at 1110 revealed "Father at bedside. States he would like for pt. to be reevaluated. 'Name' (DED Physician) to speak with pts. father." Review of "DOCTOR NOTES" dated 04/23/2016 at 1119 revealed "TEXT: Pt refusing to leave, father at bedside, pt screaming and hyperventilating, moving legs freely, states can't feel or move legs but has 10/10 pain and thrashing about, clear psychiatric component present, had discussion with father, he agrees to take pt home after a dose of pain medications, pt has nml (normal) motor/sensation/vascular in the lower extremities. CT spine nml, doubt acute cord syndrome, doubt acute vascular compromise." Review of Physician's Orders dated 04/23/2016 at 1119 revealed and order for Dilaudid 1 mg IM, Phenergan 12.5 mg IM and Valium 10 mg IM. Review of Medication Service Records revealed Dilaudid 1 mg IM was administered at 1132 and response to Dilaudid was reassessed at 1214 with documentation of pain decreased and rated an 8 on a 0-10 scale. Further review of Medication Service Records revealed Phenergan 12.5 mg IM was administered at 1133 and response to Phenergan was reassessed at 1215. Further review of Medication Service Record revealed Valium 10 mg IM was administered at 1135 and response to Valium was reassessed at 1215. Review of Nurse's Notes dated 04/23/2016 at 1203 revealed "VITAL SIGNS: BP 153/89 (LYING), Pulse: 65, Resp: 18, Temp: 98.5 (ORAL), Pain: 8, O2 Sat: 100 on ROOM AIR." There was no documentation in the medical record to indicate that prior to discharging Patient #11 on 4/23/2016 from the ED that she was able to walk/ambulate. Prior to discharge there was no explanation for the patient ' s numbness, back pain or urinary incontinence. Review of Nursing Discharge Note dated 04/23/2016 at 1215 revealed patient was discharged via wheelchair with family to home at 1215. Further review revealed discharge instructions were given to the patient and her father with discharge teaching performed. Further review revealed medication prescriptions for Hydroxyzine HCL (antihistamine used short-term to treat anxiety), Ultram (pain medication) and Norflex (muscle relaxer) given to patient at discharge. Further review of Nurse's Notes revealed "Patient counseling on medication(s) dispensed provided. Above person(s) (patient/father) verbalized understanding of discharge instructions and follow-up care, Patient treated and evaluated by physician." Review of DED record dated 04/23/2016 at 1217 revealed "...Patient left the department."
The Medical record from hospital B was reviewed. The medical record revealed that patient #11 (MDS) dated [DATE]. A review of the History and Physical documented by the emergency room physician revealed in part, " [AGE] year old with a past medical significant for Hypertension, osteoporosis. She apparently fell past Friday while drinking ...and reports since that time she has had inability to walk with burning and numbness in her feet. She reports that she was able to sense that she needed to urinate. She apparently was seen in outside emergency room and was sent home. She then presented to (Hospital B Name of Hospital) yesterday afternoon, and underwent CT scan of her lumbar spine and an MRI scan of her which showed some posterior ligament calcification ...She was recommended for MRI (magnetic reasoning imaging -technique used in radiology to perform pictures of the anatomy and physiological processes of the body) for cervical and thoracic spine, which was performed. This showed multi-level ligamentous calcification, most severe at T (thoracic) 10-T11 where there was canal compromise and spinal gliosis. Neurosurgery was then asked to evaluate and recommended was made for admission. The operative report dated 4/26/2016 revealed the Chief complaint was listed as Spinal Cord injury with evidence of severe T10-T11 thoracic stenosis secondary to calcified mass in the ligamentum Flavum. The surgical procedure performed was T10-11 laminectomy ( Surgical procedure where the back part of the vertebra is removed to relieve pressure on the spinal cord) with excision of epidural mass.
Policy and procedure
The facilities policy titled, " Emergency Medical Treatment and Labor Act (EMTALA), Effective date 3/98, Revised date 10/2011 was reviewed. The policy and procedure revealed in part, " Medical Screening Examination is to determine whether or not an emergency medical condition exists ...SMH (Scotland Memorial Hospital) shall provide an appropriate medical screening examination and provide stabilizing treatment for medical conditions ...that is within the hospital ' s capability and capacity. "
Staff interview on 06/08/2016 at 1015 with the Quality/Compliance Director [QC DIR] #1 and Patient Experience Director [PX DIR] #2 revealed the hospital first became aware of a grievance when Pt #11's sister-in-law called to hospital administration. Interview revealed the grievance process was followed and an immediate investigation was begun. Interview revealed they learned Pt #11 was currently in another hospital and attempted to reach her by phone. Interview revealed Pt #11 was contacted and information about her concerns was documented and an investigation was immediately started. Interview revealed a request was sent to the Emergency Department Assistant Medical Director, Emergency Department Medical Director and the Emergency Department Nursing Director to review Pt #11's medical record. Interview revealed physician peer review was completed by the Assistant Medical Director of the Emergency Department. Interview revealed Emergency Department Nursing Director discussed case and presented education on behaviors, and discharge during a staff meeting. Interview revealed an email requesting a review and confirmation of findings of the CT Scan Pt #11 received during her Emergency Department visit was sent to the Radiology Department. Interview revealed a review of the CT Scan images was performed and an email from the Radiology Department was received with the findings. Interview revealed a resolution letter was sent to the complainant.
Physician interview on 06/08/2016 with MD #3, the MD who reviewed Pt #11's record for the grievance, revealed MD #3 reviewed Pt #11's medical record with MD #4 and MD #7. Interview revealed MD #3 interviewed MD #4 and MD #7 there were no concerns about the decision to discharge Pt #11 home. Interview revealed Pt #11 was evaluated by 2 different Physicians in the Emergency Department, 3 hours apart and both found sensation and movement of Pt #11's legs. Interview revealed MD #3's findings after review of the record was that Pt #11's sensation and movement in lower extremities were intact. Interview revealed MD #4 and MD #7 documented in the record that Pt #11 was able to move her legs and responded to painful stimuli. Interview revealed MD #3 felt the medical care Pt #11 received was appropriate. Interview revealed "Based on review and interview, I found no issues with Medical Screening Exam, Treatment or Stabilization of Pt #11."
Physician interview on 06/08/2016 at 0925 with MD #4, the MD who completed the MSE on Pt #11, revealed Pt # 11 came to the DED with friends after an altercation with her boyfriend/significant other at a party where she had been drinking. Interview revealed the boyfriend/significant other reportedly slammed Pt #11 across a chair and onto the ground. Interview revealed that Pt #11 was agitated and belligerent. Interview revealed MD #4 performed a physical exam, reviewed vital signs and nursing assessment, ordered a CT Scan of the Lumbar Spine and ordered Labs. Interview revealed Pt #11 was not cooperative with the exam, but did retract both legs with painful stimuli. Interview revealed MD #3 was able view Pt #11 moving her lower extremities by distracting her focus on something else. Interview revealed MD #4 did not note any bruising or obvious red marks to Pt #11's back. Interview revealed MD #3 did consider transferring Pt #11 to another hospital until Pt #11 begin moving her lower extremities. Interview revealed Pt #11 did not complain of lower back pain and Benadryl and Morphine were ordered. Interview revealed "I did not want to mask her symptoms by giving too much medication. I did order Norflex after her tests (CT scan and labs) were back (completed). I was not aware of any incontinence, but she did refuse the bedpan and bedside commode. Pt was hard to assess due to her drunkenness. I did not see her stand or attempt to walk. Pt was not cooperative." Interview revealed the CT scan was read and resulted by the Radiologist.
Staff interview on 06/08/2016 at 0940 with RN #5 revealed Pt #11 presented to the DED via wheelchair with her sister and another family member. Interview revealed Pt #11's sister did most of the talking. Interview revealed Pt #11 was upset, crying, screaming and yelling. Interview revealed the family told RN #5 that the patient had urinated on herself. Interview revealed the patient smelled of alcohol and her speech was slurred upon arrival to triage. Interview revealed "Patient was cooperative in triage, but was difficult getting information from her as she was grabbing the top of stretcher, pushing/pulling herself to the top about to come off, then grabbed my arm. I told her she was going to break my arm if she didn't let go. She was very anxious. She looked like she was in terror. I didn't notice if she was using her legs to push/pull up on the stretcher." Interview revealed RN #5 did vital signs, obtained history, and performed a triage assessment. Interview revealed Pt # 11's sister requested to speak to RN #5 alone. Interview revealed other Emergency Department (ED) staff transported Pt #11 to ED treatment room while she spoke with sister. Interview revealed Pt #11's sister told RN #5 that Pt 11's boyfriend/husband punched her in the back, stood her up and she fell on to the floor. Interview revealed RN #5 did not ask family how they got her to the car to bring to the hospital. Interview revealed two ED staff members held Pt #11 under the arms and assisted her to the stretcher from the wheelchair. Interview revealed RN #5 did not recall if Pt #11 was able to bear weight on her legs/feet, but did recall that getting Pt #11 onto the stretcher was not a difficult task. Interview revealed "I charted she had '0' pain in triage. Being she was upset in triage, I went back into the room with (physician name) (MD #4) to do a sensation test on her lower extremities. Physician broke a tongue depressor to make a sharp edge, poked bottom of feet with tongue depressor. She (Pt #11) did respond by moving feet, left foot, and toes moving. I never saw her legs retracting back onto the bed. Her legs were bowed inward in triage. Family stated her legs had been like that all her whole life and she had had several surgeries on her legs. I did not see any bruising or redness on her back. She was crying with her hand over her face and yelling at times. While in room, Pt was sitting on side of bed with her feet touching the floor. She asked 'Are my feet touching the floor' nurse told her 'Yes'. Pt said 'I can' t feel my feet'."
Staff interview on 06/08/2016 at 0910 with RN #6 revealed she was the primary nurse for Pt #11. Interview revealed Pt #11 presented to treatment room via wheelchair, hollering and rude to staff. Interview revealed family told RN #6 that Pt #11 had been drinking and got involved in a fight and somehow got pushed. Interview revealed the family stated Pt #11 wanted to wait a few hours before going to hospital because she had been drinking. Interview revealed RN #6 completed an assessment on Pt #11. Interview revealed Pt #11 initially complained of no pain, but did complain that she couldn't move her legs. Interview revealed Pt #11 was seen by MD #4 who tested Pt #11's sensation in her legs by using a sharp object on her feet. Interview revealed Pt #11 responded to painful stimuli by moving her legs. Interview revealed staff attempted to assist Pt #11 with bedside commode and patient sit on edge of bed with feet on the floor. Interview revealed staff asked Pt #11 if she was able to stand up and Pt #11 jerked her feet up off the floor and stated "I didn't realize my feet were on the floor". Interview revealed Pt #11 refused to use the bedside commode and refused to use the bedpan. Interview revealed Pt #11 urinated in the bed several times and was cleaned up and eventually placed in a brief (diaper like pants). Interview revealed Pt #11 refused to allow staff to assist her to bedpan or bedside commode. Interview revealed nursing staff attempted to check mobility and sensation of Pt #11's legs, but patient would just keep cussing at staff and would not cooperate. Interview revealed Pt #11 did not respond to nursing assessment of legs by stating "she could feel something". Interview revealed Pt #11 felt no one would listen to her because she had been drinking. Interview revealed RN #6 reassured Pt #11 that she would still receive appropriate treatment. Interview revealed Pt 11's family left and did not return until after called numerous times to pick patient up after discharge. Interview revealed "I don't believe I ever saw her (Pt #11) stand or walk. She seemed to have anxiety attacks, hollering 'can't feel legs'. She would settle down if no one was in room to talk with her. She did complain of pain in her legs, but don't believe she complained of pain in her back." Interview revealed RN #6 did administer medications for pain and anxiety.
Physician interview with MD #7 revealed he was the MD that relieved MD #4. Interview revealed Pt #11 was discharged prior to MD #7 coming on shift. Interview revealed MD #7 did not get involved in Pt #11's care until 4 hours after his shift started. Interview revealed Pt #11 was quiet during the first 4 hours of his shift. Interview revealed Pt #11's father came to pick up Pt #11 for discharge around 11 a.m. and Pt #11 became very agitated and yelling from her room. Interview revealed Pt #11's father requested to speak with MD #7 about re-evaluating patient and administering pain medication prior to leaving the hospital. Interview revealed MD #7 completed a brief physical exam. Interview revealed Pt #11 was moving her legs freely, lower extremity pulses were intact, and lower extremity motor function was intact. Interview revealed MD #7 met and sat with Pt #11 and her father to review the CT findings and address pain. Interview revealed Pt #11 was complaining of low back pain and pain medication with nausea medication and anxiety medication was ordered and administered to Pt #11 prior to discharge. Interview revealed Pt #11's father was very appreciative of MD #7 speaking with him. Interview revealed MD #7 felt that Pt #11 was stable for discharge home.