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NEW HANOVER REGIONAL MEDICAL CENTER 2131 S 17TH ST BOX 9000 WILMINGTON, NC 28402 Oct. 28, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on hospital policy review, medical record review, physicians and staff interviews the hospital failed to comply with 42 CFR 489.20 and 489.24.

Findings include:

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 31 sampled DED patients (#3) who presented to the hospital for evaluation and treatment.

~ Cross refer to 489.24(r) 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 review, medical record review, and physician and staff interviews, 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 31 sampled DED patients (#3) who presented to the hospital for evaluation and treatment.

Findings include:

Review of the hospital's "EMTALA - Medical Screening" policy effective July 2014 revealed "...C. Medical Screening Examination: 1. A medical screening examination will be provided when an individual comes by him/herself or with another person to the emergency department of the hospital, and a request is made on the individual's behalf for a medical examination or treatment. ... 6. A medical screening examination includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of an emergency medical condition. Depending on the patient's presenting symptoms, the medical screening examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical lab tests, CT scans, and other diagnostic tests and procedures. ... 8. The physician providing the medical screening shall physically examine the patient and, where necessary, to rule out any potential emergency medical condition in the range of the differential diagnosis for the patient, shall order such testing and further examination by the on-call physicians as is routinely available to the Emergency Department within the capabilities of the Medical Center. ..."

Review of Patient #3's DED record revealed a [AGE] year-old male that presented via ambulance transport to the DED North campus from an assisted living facility on 07/30/2015 at 1157 with a chief complaint of fall. Review of the ambulance trip report revealed "Staff stated that the patient was ambulating in the hallway with his walker when he tripped and fell causing an abrasion to his left shin and advised that he hit his head." Review of the triage note at 1157 recorded an acuity level of ESI 3 (urgent). Vital signs were recorded at 1201 of blood pressure (BP) 148/83, pulse (P) 80, respirations (R) 20 and 100% oxygen saturation. Notes recorded pain as "unable to assess." Review of a medical screening examination recorded at 1224 by MD #1 revealed the patient had an unwitnessed fall and reportedly hit his head with no loss of consciousness. The notes recorded the patient had baseline dementia, talked intermittently and walked with assistance with a walker. Review of the notes revealed the patient was on aspirin and no other blood thinners. The notes recorded the patient had altered mental status on arrival, but would wake up and speak to the staff. The physician recorded that the patient had an abrasion on his left lower leg. The physician documented the patient had an elevated blood sugar of 265. Review revealed the patient was moving all extremities, intermittently followed commands and denied pain. Review of the examination revealed the patient had full range of motion in all major joints and no deformity. Review revealed lab studies, EKG, x-ray of the pelvis, chest x-ray and CT of the head and spine were ordered and completed with all resulting in negative findings. Review of the DED physician's notes revealed the patient was resting comfortably on multiple repeat exams and was at his baseline dementia with no evidence of skull fracture, head bleed, spinal cord injury, acute myocardial infarction, urinary tract infection, pneumonia or sepsis. Review of the physician's notes revealed a final clinical impression of "fall, minor head injury, dementia, left lower leg abrasion." Review revealed the patient was discharged back to the assisted living facility and departed the DED at 1603.

Review revealed Patient #3 returned to the main campus DED (visit #2) on 08/02/2015 at 1136 (2 days, 19 hours and 33 minutes after prior departure from the DED) via ambulance transport. Review of the ambulance trip report revealed the patient was lying in the hallway upon arrival and complained of right leg pain. Review of the trip report revealed "This is a 96 yo (year old) M (male) c/o (complaining of) right leg pain secondary to being 'hit'. Upon our arrival, patient was lying right lateral recumbent, responsive to painful stimuli. ... No trauma noted to extremity. Patient lifted to stretcher. While securing patient with seat belts he began moaning and spoke (unintelligible words). ... While enroute to the hospital, the patient awoke and began crying. When asked what was wrong, patient stated that, 'He hit me on the leg.' When asked who, patient only stated that he knew 'him'. Patient was crying and difficult to console. Further review of the ambulance report recorded the patient had bandages to his left shin that appeared old. Review of the DED record revealed the patient was triaged at 1155 with an ESI level of 3 (urgent) and a chief complaint of fall and altered mental status. Review revealed vital signs recorded at 1155 of temperature (T) 97.9 degrees Fahrenheit, BP 130/69, P 81, R 16, 99% oxygen saturation. Nursing notes at 1158 recorded pain as "unable to assess accurately" and noted that the patient was talking, awake and alert. Review revealed MD #2 conducted a medical screening examination at 1235 documenting a chief complaint of possible fall and altered mental status. The DED physician's note recorded the patient had a small abrasion to his left shin and a history of Alzheimer's dementia. Review of the examination notes revealed the patient had "good range of motion in all major joints. No tenderness no palpitation or major deformities noted." Review revealed a CBC (complete blood count), Chemistry Panel, Urinalysis, CT of the head and x-ray of the left tibia and fibula were ordered and completed with negative findings. Review of the DED physician's notes revealed "ED Course and Medical Decision Making: Pertinent labs and imaging studies reviewed. [AGE] year old male with long-standing history of Alzheimer's dementia who present for a possible fall. Patient does have a small abrasion over his left anterior shin. He intermittently talks to me. On review of the electronic medical record, patient was recently seen for a very similar episode, also intermittently verbal with the physician. I suspect this is likely his baseline mental status. Computed tomography scan of the head was obtained which did not reveal any abnormality, x-ray of the leg did not reveal any fractures. Urinalysis did not revealed any signs of infection, there was some blood which I suspect likely from catheter insertion. Lab work was essentially unremarkable, creatinine stable. Tetanus status was undated while in the emergency room . I suspect the patient suffered a mechanical fall today. At this time I feel that the patient is stable for discharge to home, patient was given usual and customary return precautions and discharge instructions. Final Impression: Fall, initial encounter, Dementia, without behavioral disturbance." Record review revealed the patient departed the DED at 1716 via wheelchair with a caregiver.

Review revealed Patient #3 returned to the main campus DED (visit #3) on 08/02/2015 at 2015 (2 hours and 59 minutes after prior departure from the DED) via ambulance transport. Review of the ambulance trip report revealed the patient was sitting upright in a wheelchair in his room with family present upon arrival. Review of the ambulance report revealed the family stated that the patient fell earlier in the day and was evaluated at the DED. The notes recorded "Family states when the patient was evaluated at the hospital for the fall the patient was evaluated for pain on his left side due to abrasions being present, however at this time the patient is complaining of pain to his right hip and right lower extremity. Family states patient did not begin to complain of the right hip/extremity pain until after riding in a car to return to the facility and being placed in his wheelchair. Upon palpitation of the patient's right hip, the patient complains of pain. Unable to assess any rotation or shortening while patient in the sitting position. Patient was carefully lifted up under his shoulders and knees and lowered, still in the sitting position, onto the stretcher with his legs outstretched in front of him. Once in this position, the patient's shoes were removed. Patient's right lower extremity is found to be laterally rotated and to have approximately one inch of shortening. ... Patient has pain in the right lower extremity. ..." Review revealed the patient was administered Fentanyl (pain medication) 25 MCG (micrograms) intravenously at 1958 prior to arrival in the DED. Review of the DED record revealed the patient was triaged at 2015 as an ESI level 2 (urgent) with vital signs recorded as BP 143/88, P 104, R 17 and 100% oxygen saturation. Review of nursing notes recorded at 2033 revealed the patient's son was at the bedside and reported the patient was unable to bear weight on the right lower extremity when he was discharged earlier in the day. Review of MD #3's medical screening examination recorded at 2144 revealed a chief complaint of "fall, right leg shortening, external rotation, seen earlier for the left side." Review of the notes revealed "[AGE] year-old male presents to the emergency department for right leg shortening and pain. Evidently patient reportedly had fallen earlier and pain to left leg had a CT head that was negative and x-rays a left leg that were negative however evidently patient complained of pain to the right side now unable to bear weight." Review of the notes recorded shortening and external rotation were noted to the right lower extremity and pain with rotation of the hip. Review revealed an x-ray of the right hip and pelvis were ordered and completed. Review of the DED physician's notes revealed "ED Course, Labs, EKG: The patient arrived, history and physical examination was obtained. Patient has an obvious basocervical right femoral neck fracture extending into the intertrochanteric region. Patient will be admitted to orthopedics for further evaluation and treatment at this time." Review revealed the patient was admitted and departed the DED at 2316.

Review of the admission record revealed Patient #3 had an open reduction and internal fixation of the proximal femoral intertrochanteric fracture (surgical repair) performed on 08/04/2015. Review revealed the patient was discharged to a skilled nursing facility on 08/06/2015.

Telephone interview on 10/28/2015 at 1335 with RN #4 revealed she remembered Patient #3. RN #4 was assigned to the patient during the DED visit #2 on 08/02/2015 at 1136. Interview revealed the patient had presented after a fall at the nursing facility with altered mental status and dementia. The nurse stated it was hard to assess the patient. The nurse stated the patient was combative when the physician tried to manipulate his legs. The nurse stated "When the doctor did range of motion, he started kicking and he felt like that caused pain. I don't recall moaning or grimacing. He constantly laid on his side with his legs bent. I had to turn him. I didn't notice his leg being shortened more than the other leg." She stated the patient was able to do range of motion and it was difficult to assess his pain. The nurse stated the patient was "kicking" the physician when he was trying to assess the patient. The nurse stated she was away for a time and upon her return, the patient had orders for discharge. The nurse stated the patient left in a wheelchair with a caretaker and transport. The nurse stated she stood the patient up on the side of the bed and got him into a wheelchair. The nurse stated the patient didn't have any signs or symptoms of pain upon standing. Interview revealed the patient's son called back to the DED within one hour after departure stating that the patient was unable to walk and he was able to walk prior to the fall. The nurse stated she suggested the patient return to the DED. The nurse stated she found out the next day that the patient had returned and had a hip fracture.

Telephone interview on 10/29/2015 at 0900 with MD #2 revealed he was the DED physician for Patient #3 during DED visit #2 on 08/02/2015 at 1136. Interview revealed the physician had reviewed the patient's DED record and remembered the patient. The DED physician stated the patient had been seen a few days earlier for a fall and he had a history of dementia. The physician stated the patient presented without an obvious area of pain after an unwitnessed fall. MD #3 stated "There was an abrasion to the left leg, so I was thinking injury from a fall. I can't remember if I thought it was new. He was observed moving his joints, moved his knee, ankle, elbow, any joint that looked injured. He was moving his joints adequately. I can't remember. I don't think he was in much pain at all. I don't remember there being a caregiver or family member there." The physician stated he did not see any major deformity and no obvious fracture. The physician stated he couldn't remember if the patient did any weight bearing while he was in the DED and wasn't sure if he required assistance with ambulating. MD #3 stated the patient had no obvious shortening of the leg or rotation seen during the DED visit. The physician stated the patient "had a different complaint during my visit. He fell and had altered mental status. The next visit he had a broken hip." The physician stated a pelvic x-ray was not ordered due to there was no indication of a need to x-ray.

An interview was attempted with MD #3 (DED visit #3). He was unable to be contacted.

In summary, Patient #3 presented to the hospital's DED on 07/30/2015, 08/02/2015 at 1136, and 08/02/2015 at 2015. Review revealed the patient presented via ambulance after a fall at the nursing facility. Findings revealed the patient had pain in the right leg after the second fall and (MDS) dated [DATE] at 1136. Review revealed no x-ray of the pelvic or hip area obtained. Review revealed the patient was discharged home at 1716 and returned at 2015 (2 hours and 59 minutes later) with a fracture of the hip.