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.

CAROLINA EAST MEDICAL CENTER 2000 NEUSE BLVD NEW BERN, NC 28560 Nov. 5, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on hospital policy and procedure review, review of the hospital's transfer form, closed DED (Dedicated Emergency Department) medical record reviews, staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 42 CFR 489.24 by failing to provide an appropriate medical screening examination (MSE) with ongoing monitoring for a patient with an Emergency Medical Condition (Patient #11) and failing to ensure an appropriate transfer by failing to document the medical benefits reasonably expected at the time of transfer outweighed the increased risks associated with the transfer to individuals in 4 of 9 DED patients having an Emergency Medical Condition (EMC) that were transferred to another hospital ( #7, #9, #3 and #4 ) .


The findings include:

1. The hospital failed to provide an appropriate medical screening examination (MSE) with ongoing monitoring for a patient with an emergency medical condition (EMC) in 1 of 27 sampled patients (Patient #11).

~cross refer to 489.24(r) and 489.24(c), Medical Screening Exam - Tag A2406.

2. The hospital failed to ensure an appropriate transfer by failing to document the medical benefits reasonably expected at the time of transfer outweighed the increased risks associated with the transfer to individuals in 4 of 9 DED patients having an Emergency Medical Condition (EMC) that were transferred to another hospital ( #7, #9, #3 and #4 ) .

~cross refer to 489.24(e)(1)-(2), Appropriate Transfer - Tag A2409.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, medical record review and staff interview, the hospital failed to provide an appropriate medical screening examination (MSE) with ongoing monitoring for a patient with an emergency medical condition (EMC) in 1 of 27 sampled patients (Patient #11).

The findings include:

Review of the hospital's policy, "EMTALA (Emergency Medical Treatment and Active Labor Act (sic)", revised 01/2014, revealed, "....(Hospital A) is committed to providing medical care to any individual presenting to the Hospital requesting emergency services or a request is made on the individual's behalf for treatment. Any individual (or a person acting on an individual's behalf) requesting medical services will receive appropriate Medical Screening, Stabilization, and appropriate transfers as established by EMTALA law...".

Review of the hospital's policy, "Medical Screening Exam", revised 04/2014, revealed, "...1. Emergency Services will provide, upon request and presentation of the patient and within the capabilities of the hospital, an appropriate medical screening exam, stabilizing treatment and/or appropriate transfer to another medical facility to any individual with an emergency medical condition. ...3. If the patient is deemed to have an emergency medical condition, further examination and treatment will be provided (within the hospital's capabilities) to stabilize the medical condition or make an appropriate transfer...".

Closed DED medical record review on 11/04/2014 for Patient #11 revealed the patient was brought to the DED on 09/22/2014 at 0932 by the police who reported patient was seen walking down the road naked with suitcases. Record review revealed the patient was triaged at 0936. Record review revealed a MSE was started by a DED physician (Physician A) at 0938. Review of the physician ' s documentation revealed, "History of Present Illness Patient is a [AGE] year-old-female who is seen frequently here for psychiatric problems. She was recently treated and released from psych. She was apparently seen this morning several times on the road with a suitcase ...she was seen naked trying to cross the street with the suitcase. Patient is agitated and not giving me much of a history ...Medical Decision Making .This is a [AGE] year-old female who presents today acutely psychotic. She was found outside the hospital earlier today naked trying to cross the street. She was taken to her family ' s house and RHA then IVCed her. Patient was very violent and aggressive when she first got here. After medication she is calm (sic) down. She is noncompliant. She has a court date tomorrow. This is her typical pattern whenever she has a court date coming up. She is stable in the department. She is medically cleared. Care coordinator independently evaluated this patient " . Further record review revealed documentation by a DED physician on 09/23/2014 at 0439, " ...Patient received psychiatric medicines earlier in the day and was calm. The patient is up threatening staff. The patient threatening to hurt staff and raising her hand to the nurses. Patient stated that she wanted to kill everybody. We went in to assess her, she was noncooperative. Patient doesn ' t ' t (sic - does) have a history of schizophrenia though after observing this behavior I think it is mainly behavioral. We tried to reason with her and she did not want to listen. She is communicating threats to the officers at present. The patient has court in the morning. I do not think sedating her at this time is in her best interest. I have spoken with the officers and they will take her to jail. She will be able to make her court appearance in the morning. She is to remain on psychiatric medicines. The judge may order the patient back for reevaluation. We will release IVC at this time patient will go to jail have her court appearance in the morning " . Record review revealed the patient was discharged to jail via the police at 0437. Record review revealed no documentation of a psychiatric consult ordered for Patient #11.

Closed DED medical record review of Patient #11 revealed the patient was brought to the DED in police custody for psychiatric evaluation on 09/26/2014 at 1620 (4 days after discharge from the DED). Review revealed the patient had IVC papers for making threatening statements to jail staff. Review revealed a MSE was performed by a DED physician (Physician F). Documentation by the DED physician revealed, " ...patient is well known to our facility. On evaluation, patient denies suicidal or homicidal ideation. Patient has been wandering around ED room and behaving at baseline. Initially, patient did not make any threatening statements and denied any suicidal thoughts. At this time, patient does not meet IVC criteria and papers will be reversed ....patient will be discharged into their (police) custody. On discharge ...patient transported to jail. At this time, although patient is aggressive and violent towards staff members, she does not appear to be psychotic. Patient is stable for discharge to police custody at this time " . The patient was discharged to jail at 1915. Record review revealed no documentation of a psychiatric consult ordered for Patient #11.

Closed medical record review of Patient #11 revealed the patient was brought to the DED in police custody for psychiatric evaluation on 09/27/2014 at 0158 (5 hours after discharge from the DED). Review revealed a MSE was started at 0310 by Physician B. Documentation by the DED physician revealed, " ...Patient reportedly assaulted a jailer at the (Name of County) Jail. Patient has had multiple recent evaluations in the emergency department for psychiatric complaints. Patient has history of paranoid schizophrenia for which she is currently prescribed medications " . Further documentation by the DED physician revealed, " ...on my exam patient is well behaved. Answers questions appropriately and is subdued in her responses toward me. During the course of her care in the emergency department however she has been yelling angrily at staff and local law enforcement ...patient is able to apparently controlled (sic) some of these anger impulses and I suspect there is a behavioral compounded as well as her underlying history of paranoid schizophrenia contributing to these outbursts " . Further review revealed the patient was discharged to local law enforcement at 0602. Record review revealed no documentation of a psychiatric consult ordered for Patient #11.

Interview on 11/05/2014 at 0910 with administrative staff revealed the hospital has pressed charges against Patient #11 for assault on staff and physicians. Interview further revealed the patient had charges pending for " trying to outrun an officer while driving ".

In summary, Patient #11 was transferred from jail to Hospital A's DED with an emergency psychiatric condition. Hospital A's DED physician did not obtain a psychiatric consult for medical screening of Patient #11.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on hospital policy and procedure reviews, review of the hospital's transfer form, closed DED (dedicated emergency department) medical record reviews, staff and physician interviews the hospital's Dedicated Emergency Department (DED) failed to ensure an appropriate transfer by failing to document the medical benefits reasonably expected at the time of transfer outweighed the increased risks associated with the transfer to individuals in 4 of 9 DED patients having an Emergency Medical Condition (EMC) that were transferred to another hospital ( #7, #9, #3 and #4 ).

The findings include:

Review of the hospital's policy, "EMTALA (Emergency Medical Treatment and Active Labor Act", revised 01/2014, revealed, " ...(Hospital A) will adhere to guidance established through EMTALA regulations...". Review of the policy revealed no documentation that medical benefits and risk of transfer were to be documented by the physician prior to transfer.

Review of the hospital's form, "Authorization for Transfer", revised 08/2009, revealed, "...II. Risk and Benefit for Transfer...". Form review revealed a check box under Medical Benefits for "Obtain level of care/service NA (not available) at this facility" and "Benefits outweigh risks of transfer". Further form review revealed a check box under Medical Risks for "Deterioration of condition en route" and "Worsening of condition or death if you stay here".

1. Closed DED record of Patient #7 revealed a [AGE] year-old male who presented to Hospital A's DED on 09/21/2014 at 1925 with chief complaint of "trouble with my nerves". Record review revealed Patient #7 was seen by Physician A at 1946. Review of Physician A's dictated notes revealed, "HISTORY OF PRESENT ILLNESS: [AGE] year-old male history of schizophrenia presents to emergency department complaining of suicidal thoughts and hearing voices...MEDICAL DECISION MAKING: Command hallucinations with suicidal ideation. ...Patient is IVC (involuntary commitment). We'll try to place him for inpatient psych". Record review revealed an "Authorization for Transfer" form with the risk and benefits for transfer section of the form blank, with no date documented. Further record review revealed no documentation in the medical record by the physician that the risks and benefits of transfer were explained to Patient #7. Record review revealed Patient #7 was transferred to Hospital B on 09/22/2014 at 1325.

Interview on 11/05/2014 at 0920 with Physician B revealed the physician was the medical director for Hospital A's DED. Interview revealed, "the physician should include the risks and benefits for transfer in their documentation". Interview confirmed that there was no documentation in the medical record or on the transfer form for the risks and benefits of transfer for Patient #7.




2. Closed DED record of Patient #9 revealed a [AGE] year-old female who presented to Hospital A's DED on 09/22/2014 at 0310 with a chief complaint of "having bad thoughts...having suicidal thoughts." Record review revealed Patient #9 was seen by Physician C at 0335. Review of Physician C's Emergency Documentation - Physician Notes revealed, "History of Present Illness [AGE]-year-old female who presents with complaint of being suicidal and depressed. She says this is because she is a chronic alcoholic...Medical Decision Making Patient is medically stable for psychiatric evaluation and placement. (Hospital C) says they will most likely except (sic, accept) her once her alcohol level is below 100. We will have a redraw (of) her alcohol level at 8 AM. Patient admits to suicidal ideations and depression as well as alcohol abuse. Clinical impression: #1 suicidal ideations, #2 alcoholism." Record review revealed an "AUTHORIZATION FOR TRANSFER" form with risk and benefits for transfer section of the form blank, with neither medical benefits nor medical risks listed. Review revealed the "AUTHORIZATION FOR TRANSFER" form was signed on 09/22/2014 at 1150 by Dr. A. Further record review revealed no documentation in the medical record by the physicians that the risks and benefits of transfer were explained to Patient #9. Record review revealed Patient #9 was transferred to Hospital C on 09/22/2014 at 1330.

Interview on 11/05/2014 at 0920 with Physician B revealed the physician was the medical director for Hospital A's DED. Interview revealed, "the physician should include the risks and benefits for transfer in their documentation". Interview confirmed that there was no documentation in the medical record or on the transfer form for the risks and benefits of transfer for Patient #9.

3. Closed DED record of Patient #3 revealed a [AGE] year-old female who presented to Hospital A's Labor and Delivery Department on 07/23/2014 at 1134 from the Physician's Office at 32 weeks gestation (Estimated Delivery Date 09/17/2014) with confirmed Spontaneous Rupture of Membranes. Record review revealed Patient #3 was seen and MSE (Medical Screening Exam) begun by a RN (Registered Nurse) at 1541, with a fetal monitor placed at 1541 and ongoing assessment and care. Review revealed Patient #3 was seen by Physician D at 1834. Review of Physician D's Discharge Summary, dictated 07/23/2014 at 1906 revealed "...HISTORY: The patient is a [AGE]-year-old gravida 1 (first pregnancy) at 32 weeks, who presented to the office today with some spotting and dampness....HOSPITAL COURSE: The patient was sent to labor and delivery where she had a reactive tracing for her gestational age and she was not having contractions. Ultrasound was obtained....IMPRESSION: Intrauterine pregnancy at 32 weeks estimated gestational age with leaking membranes and no labor. I discussed the patient with (physician name) and she agreed to take her in transfer." Record review revealed an "AUTHORIZATION FOR TRANSFER" form the Emergency Medical Condition identified as Premature Rupture of Membranes and with the risk and benefits for transfer section of the form left blank, with neither benefits nor risks documented. Record review revealed the form was signed on 07/23/2014 at 1845. Further record review revealed no documentation in the medical record by the physician that the risks and benefits of transfer were explained to Patient #3. Record review revealed Patient #3 was transferred to Hospital B on 07/23/2014 at 2053.

Interview on 11/05/2014 at 1405 with Administrative Staff (AS) #2 confirmed AS #2 had reviewed the medical record of Patient #3 and found no physician documentation of risks and benefits of transfer in the medical record.

4. Closed DED record of Patient #4 revealed a [AGE] year-old female who presented to Hospital A's Labor and Delivery Department on 09/09/2014 at 1821. Review revealed the patient arrived from the Physician's Office. Record review revealed Patient #4 was seen and MSE begun by a RN at 1845, with a fetal monitor placed at 1845 and the Antepartum Exam and History performed at 1903. Review revealed Patient #3 was seen by Physician E at 2042. Review of Physician E's Transfer Summary, dictated 09/09/2014 at 2119 revealed "...REASON FOR hospitalization : the patient is a [AGE]-year-old prima gravida (1st pregnancy) at 28 and 6/7 weeks' gestation....who presents to labor and delivery after being seen in the office today where on ultrasound she was found to have a cervix 8 mm in length. She denies any history of contractions, leakage of fluid or vaginal bleeding, and reports good fetal movement....Pregnancy has been complicated by probably Class D diabetes. She did have an abnormal 3 hour GTT (glucose tolerance test) at 16 weeks' gestation....PELVIC: cervix is 2 cm dilated, about 1 cm thick with a vertex at -2 station....ASSESSMENT: Intrauterine pregnancy at 28 and 6/7 weeks' gestation, with premature cervical dilatation without evidence of active labor. PLAN: Given the patient's early gestational age and considerable dilatation, the decision has been made to transfer her to (Hospital B). The case was discussed with (Physician name), who accepted her in transport. ..." Record review revealed an "AUTHORIZATION FOR TRANSFER" form with the medical risks section left blank, with no risks of transfer documented. Review revealed the medical benefits were documented as "Obtain level of care/ service NA (not available) at this facility Service MFM / NICU (Maternal Fetal Medicine/ Neonatal Intensive Care Unit)." Record review revealed the form was signed by Dr. E on 09/09/2014. Further record review revealed no documentation in the medical record by the physician that the risks of transfer were explained to Patient #4. Record review revealed Patient #4 was transferred to Hospital B on 09/09/2014 at 2230.

Interview on 11/05/2014 at 1405 with Administrative Staff (AS) #2 confirmed AS #2 had reviewed the medical record of Patient #4 and found no physician documentation of the risks of transfer in the record.

NC 898