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.

Based on hospital policy and procedure reviews, medical record reviews, hospital documents review and staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 489.24.

The findings include:

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 25 patients who presented to the DED (#11).

~ Cross refer to 489.24(a) and 489.24(c) Medical Screening Examination - Tag A2406.

Based on hospital policy and procedure review, medical record reviews and physician 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 25 patients who presented to the DED (#11).

The findings include:

Review of hospital policy "Emergency Medical Treatment and Active Labor Act (EMTALA)", Revised 11/13/2012 revealed..B. Medical Screening Examination: 1. Any individual who presents to XYZ Medical Center (Hospital A) seeking emergency care shall undergo a medical screening examination to determine whether that the individual is experiencing an emergency medical condition.. Generally, an "emergency medical condition" is one manifesting such symptoms (including severe pain, psychiatric disturbances, and or other symptoms of [DIAGNOSES REDACTED].. including on-call physicians...".

Closed DED medical record review on 02/03/2016 revealed Patient #11, a [AGE] year-old male, presented to Hospital A's DED on 01/21/2016 via EMS (emergency medical services) at 2130 with chief complaint of leg pain. Record review revealed Patient #11 was triaged at 2135 with vital signs documented as temperature 98.7 degrees Fahrenheit, pulse 77, respirations 16, blood pressure 188/56, oxygen saturation 98% on room air and pain reported as 8 of 10, on a scale of 1 to 10, with 10 being the greatest pain. Record review revealed nursing documentation at triage, "...PT (patient) C/O (complaining of) LEG PAIN X 2 WEEKS AND 'BEING WEAK AND NOT ABLE TO WALK'. ROOMMATE STATES PT 'PEED ON HIMSELF TONIGHT'. UPON SPEAKING WITH DAUGHTER OVER PHONE, STATES PT BECOMES DISORIENTED AT TIMES AND 'LOSES HIMSELF'. Onset of symptoms was about 2 weeks ago...Both legs are affected. ...Has diabetes. Other History: PT C/O BILATERAL LEG PAIN AND WEAKNESS X 2 WEEKS. STATES IS IT HARD FOR HIM TO WALK...". Record review revealed a medical screening examination was done by DED Physician #1 (not timed). Review of the dictated physician's note revealed, "HISTORY OF PRESENT ILLNESS: (Pt #11) is a [AGE] year-old Male who reports onset of generalized weakness x 2 weeks. Patient reports he spoke to his daughter on the phone tonight and she encouraged him to come to the ED. Patient arrived via EMS and told EMS that he urinated on himself tonight...PHYSICAL EXAMINATION: GENERALIZED APPEARANCE: Patient is alert, awake and in no distress. Patient smells very strongly of foul malodorous urine. ..NEURO AND PSYCH: Mental status as above. ...". Further record review revealed an order for a complete blood count, blood chemistry and urinalysis was ordered at 2157 and an order for 1000 milliliters of Sodium Chloride 0.9% (Normal Saline) was ordered as an intravenous bolus was ordered at 2157. Record review revealed no x-rays or computerized tomography (x-ray CT) was ordered by Physician #1. Further review of Physician #1's documentation revealed, "...EMERGENCY DEPARTMENT COURSE AND TREATMENT: During observation, patient demonstrated no evidence of cardiovascular or neurologic instability. ...Patient treated with NS (Normal Saline) 1000 ml (milliters) IV (intravenously). Labs and radiology reviewed without any acute disease indicated. Patient is ambulatory prior to discharge. After the evaluation in the Emergency Department, my clinical impression is generalized weakness...". Record review revealed nursing documentation at 0030, "...Pt ambulated to door in room and back to bed. Small steps noted but pt tolerated well". Review revealed nursing documentation at 0804, "Pt unable to locate ride will transport pt home, ambulatory with slow steady gait".

Closed DED medical record review of Patient #11 revealed the patient returned to Hospital A's DED on 01/22/2016 at 1316 (5 hours, 12 minutes after discharge from DED) via wheelchair. Record review revealed nursing documentation at triage at 1324, "...bil (bilateral) leg pain 2 weeks, was seen here last night, sent home, discharge instructions for dehydration, sent back by (Physician) office...presents with generalized weakness...". Further record review revealed nursing documentation at 1510, "...PT DAUGHTER REPORTS CALLED FATHER THIS WEEK AND DIDN'T SEEM RIGHT. PT REPORTS FALL ON TUESDAY. HAS NOT BEEN RIGHT SINCE PER ROOMMATE. STUMBLING. SLOW TO ANSWER QUESTIONS. URINATING ON SELF...". Record review revealed a medical screening examination was completed by DED Physician #2 (not timed). Review of Physician #2's dictated note revealed, "...HISTORY OF THE PRESENT ILLNESS: ...presents to the ED for evaluation of altered mental status. Pt was treated in this ED last pm for complaint of generalized weakness, discharged after labs, imaging, and receiving fluids. Pt reportedly fell 3 days ago and has not been acting normally since, has been urinating on himself. Pt's daughter states pt traveled to New York by himself two weeks ago to visit her and he was walking and site seeing the whole trip. Behavior is reportedly drastically changed from baseline. ...Pt unable to provide history due to mental status. ...PHYSICAL EXAMINATION...NEURO: Mental status: Patient is saying inappropriate things, is not a baseline mental status per daughter...". Record review Physician #2 ordered a CT (computerized tomography) of the head at 1458, which revealed "bilateral acute vs (versus) acute-on-chronic subdural hematomas (bleeding on the brain), right greater than left with mild midline shift". Record review Physician #1 arranged for transfer to Hospital B for neurosurgery not available at Hospital A. Record review Patient #11 was transported to Hospital B via advanced life support ambulance at 1819.

Review of Hospital B's open medical record for Patient #11 revealed a neurosurgeon's history and physical dated 01/22/2016 at 2211, "...Chief Complaint: Fall with subdural hematoma History of Present Illness: The patient is a 71 y.o. (year old) male who has had progressive confusion over the past weeks. Initially symptoms were mild, but the symptoms have been progressive throughout this week. Patient presented to the ER twice this week. No headache. No seizure. He did have a fall without loss of consciousness. Neurosurgery was consulted for further evaluation and treatment. ...Plan: Will plan on surgery...". Further record review revealed Patient #11 had a right frontal craniotomy (removal of portion of skull to access the brain) for evacuation of subdural hematoma on 01/24/2016. Record review revealed a physician's progress noted dated 02/04/2016, "...ASSESSMENT/PLAN 1. ...craniotomy...possible superimposed ischemic infarct (stroke) 2. Seizures...3. Acute respiratory failure...4. [DIAGNOSES REDACTED](abnormal heart rhythm with fast, irregular rate)...7. HTN (hypertension)...8. Deconditioning...9. Hyperglycemia (high blood sugar)...". Record review revealed Patient #11 was an inpatient in the critical care unit of Hospital B on 02/04/2016.

Interview with Hospital A's administrative staff on 02/03/2016 at 1430 revealed Physician #1 was no longer on staff at the hospital. Interview revealed, "it was a mutual decision".

Interview on 02/04/2016 at 0930 with Physician #2 revealed he was the DED Physician who saw Patient #11 on 01/22/2016 (2nd DED visit). Interview revealed, "(Physician #1) saw me after I had transferred him to (Hospital B) and asked me what happened. I had more information than he did. (Physician #1) told me he thought he (Patient #11) was an old, disheveled man, who smelled of urine. He did not have the history that he had fallen. I spoke with his daughter and she told me he was normally high functioning. He was a professional, mathematician of some sort. He did not have a UTI (urinary tract infection) which could cause confusion. I got a CT of his head and he had a bleed. With altered mental status, standard of practice is to get a CT of the head".

NC 655