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CUMBERLAND MEDICAL CENTER 421 S MAIN ST CROSSVILLE, TN 38555 March 16, 2012
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


The Tennessee Bureau of Health Licensure and Regulation conducted a complaint investigation survey on March 16, 2012. It was determined that the facility failed to provide emergency room care for Patient # 6 and Patient #21 and that an Immediate Jeopardy is present and ongoing. The administrator was notified on May 2, 2012. The complaint number is TN 400.



Based on medical record review and interview, the facility failed to maintain a complete Transfer Certfication form for one patient (#6) and complete Condition of Admission forms for twenty-four (#2-25) of twenty-five sampled patients.

The findings included:

Patient #6 presented to the facility's emergency room on [DATE].

Medical record review (Hospital #1) of a Transfer Certfication - Physician form dated February 19, 2012, revealed,"...Notice of Risks of Transfer...Benefits: Further stabilization, evaluation, and treatment by ortho (orthopedic)...at (Hospital #2)...Time of MD (medical doctor) to MD discussion 1410 (2:10 p.m.)..."

Medical record review (Hospital #2) of a Transfer Certification - Physician form dated February 19, 2012, revealed, "...Notice of Risks of Transfer...Benefits: Further stabilization, evaluation, and treatment..." Continued review revealed no documentation regarding "by ortho" or "Time of MD to MD discussion."

Telehone interview with the facility's Director of Quality and Accreditation on March 15, 2012, at 12:30 p.m., revealed the Transfer Certification form was a duplicate form, and confirmed the medical record for Patient #6 was incomplete.


Medical record review of a Condition of Admission form revealed, "...THE UNDERSIGNED CERTIFIES THAT HE/SHE HAS READ THE FOREGOING, AND IS THE PATIENT, OR IS DULY AUTHORIZED BY THE PATIENT AS THE PATIENT'S GENERAL AGENT TO EXECUTE THE ABOVE AND ACCEPT ITS TERMS...Patient/Authorized Representative...Witness...Time..." Continued review revealed the forms for Patients #2 through #24 included no signatures of witnesses.

Interview with the Director of Medical Records on March 13, 2012, at 12:55 p.m., in a conference room, confirmed the facility failed to ensure medical records for sampled patients #2-#25 were complete.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on medical record review, review of an emergency call center recording, review of facility policy, review of facility Rules and Regulations, review of a facility physician roster, review of an On-Call Physician Schedule, review of a Scope of Practice for the facility's Orthopedic Hospitalist Program, and interview, the facility failed to provide an appropriate transfer for two patients (#6, #21) of nine patients reviewed of twenty-five sampled patients.

The findings included:

Patient #6 presented to the facility's (Hospital #1) emergency room (ER) on February 19, 2012.

Medical record review of a Triage Assessment Record dated February 19, 2012, at 11:58 a.m., revealed, "...Priority 2...(emergency rating 1-5 and 1 was highest emergency)...'caught a horse and it kicked me about 9:30 (a.m.), I fell backwards and I think it knocked my L (left) shoulder out of place and broke my leg'..."

Medical record review of an Emergency Provider Record dated February 19, 2012, revealed, "...Time Seen: 12:15 (p.m.) Room: Ortho (orthopedic)...chief complaint: injury to:...left shoulder...leg...in pain...Thigh/Hip tenderness...Attempt at reduction L shoulder...partially successful...transferred... stable..."

Medical record review of a left shoulder x-ray dated February 19, 2012, revealed, "...Complex fracture dislocation of the left humeral head and proximal humeral diaphysis (shaft of long bone). Secondary bone fragments..." Medical record review of a left femur x-ray dated February 19, 2012, revealed, "...Complex transverse comminuted fracture involving the mid femoral diaphysis with significant displacement and overriding of bone fragments..."

Medical record review of a Physician's Note and Order Form dated February 19, 2012, at 1:59 p.m., revealed, "Attempted sedation reduction L shoulder without success - Reduced but would not stay...Dr. (On-call Orthopedic Surgeon- Medical Doctor M.D. #2) said to transfer to (Hospital #2 - Level I Trauma Center) Diagnosis...L femur fx (fracture) L fx - dislocation shoulder. Discharge Instructions Transfer as above..."

Medical record review of a Transfer Certification - Physician form dated February 19, 2012, revealed, "...Benefits: Further stabilization, evaluation, and treatment by ortho...Physician Requests Transfer...my medical condition has been evaluated and explained to me by my treating physician who has recommended that I be transferred to (Hospital #3)...The potential benefits of such transfer, the potential risks...and the probable risks of not being tranferred have been explained to me and I fully understand them...The hospital does not have the capacity or capability of providing care, specialty physicians..." Medical record review revealed no documentation regarding M.D. #2's first name or address.

Review of an emergency call center recorded conversation between M.D. #1 and an orthopedic surgeon at Hospital #3, provided by Hospital #3, revealed the following: The patient was hemodynamically stable, the head, neck, and chest were clear, the injuries consisted of a midshaft femur fracture and a dislocated fractured shoulder. Continue review revealed M. D. #1 stated, "We don't take multiple trauma." Hospital #3's orthopedic surgeon stated, "...We don't either...If midshaft femur and shoulder it's not multiple trauma. Yea, we'll take (patient) if you don't have any orthopods there..."



Patient #21 presented to the facility's ER on March 6, 2012.
Medical record review of an Emergency Provider Record dated March 6, 2012, revealed, "Time Seen: (12:40 a.m.) Room: Ortho ...chief complaint: ...injury to: R (right) ankle ...transferred (Hospital #2) ..." Continued review revealed no documentation regarding consultation with an orthopedic on-call physician. Medical record review of an Emergency Department Order Form dated March 6, 2012, revealed, " ...Diagnosis MVC (motor vehicle crash) Open R (right) Ankle Fracture ...to (Hospital #2) Trauma Center."
Medical record review of a Transfer Certification - Physician form dated March 6, 2012, revealed, " ...Benefits: ...tx (treatment) by trauma team ..."
Review of facility Policy: Emergency Screening, Stabilization & Transfer (EMTALA) Policy Number: 678-04-007 most recently revised in October, 2010, revealed, "...Every patient will be provided within the hospital's capacity for emergency medical treatment...An appropriate transfer of the patient will be conducted if the hospial does not have the capability or capacity to provide the treatment necessary to stabilize the emergency medical condition..."

Review of facility Medical Staff Rules and Regulations amended December 19, 2011, revealed, "...The Emergency Department (ED) physician must notify the on-call physician...if he determines that the services of the on-call physician are needed...If the ED physician requests that the on-call physician come to the department, it is not the discretion of the on-call physician whether to respond or not...When there are five Orthopedic Surgeons 100% coverage will be required..."

Review of a facility physician roster provided by the Executive Director of Quality and Accreditation on February 12, 2012, revealed the facility employed five orthopedic surgeons and included M.D. #2 and M.D. #4.

Review of the facility's Physician On-Call Schedule dated February 19, 2012, revealed M.D. #2 was the orthopedic surgeon on call. Review of the facility's On-Call Schedule dated March 6, 2012, revealed M.D. #4 was the orthopedic surgeon on call.
Review of Scope of Practice for (name deleted) Orthopaedic Hospitalist Program provided by M.D. #2 on March 16, 2012, revealed, "...It should be noted that our orthopaedists are always available to evaluate any case to assess whether their program has the capability of taking care of that particular patient...All other traumatic/acute injuries will be assessed and treated...These will include: Proximal humerus and humeral shaft fractures, shoulder dislocations...Proximal femur fractures...Femoral shaft, supracondylar and other distal femur fractures..."

Telephone interview with ER M.D. #1 on March 15, 2012, at 2:23 p.m., revealed M.D. #1 contacted M.D. #2 on February 19, 2012, regarding the care of Patient #6. ER M.D. #1 stated, "...I told the on-call, 'Can you come help us with this case'. That's my practice.That is a request. We have to find the treatment the person needs. (M.D. #2) was on call and we had capacity. (M.D. #2) said that was multiple trauma and needed to sent to (Hospital #2 - a Level I Trauma Center)...I asked the orthopedic on the phone (Hospital #3) if he could accept, he said he could." M.D. #1 stated, "(Patient #6)...not emergency as far as stability (but) fractured femur can turn into shock...." Continued interview revealed M.D. #1 was unaware the physician's order and the transfer form had conflicting documentation regarding the receiving hospital, M.D. #1 was unaware the patient was not transferred to Hospital #1, and he stated, "That would be a problem, wouldn't it?"

Telephone interview with M.D. #2 on March 16, 2012, at 9:38 a.m., revealed he was notified Patient #6 had multiple long bone injuries and he stated, "...This patient is polytrauma...multiple trauma is out of our scope of practice...(Patient #6 had) dislocated shoulder fractured femur...(I) trained at a Level I trauma center. I have treated many of these patients in the past..." Continued interview confirmed M.D. #2 did not assess and/or treat the patient and the facility failed to provide an appropriate transfer for Patient #6 on February 19, 2012.

Telephone interview with M.D. #3 on March 16, 2012, at 1:55 p.m., revealed M.D. #3 treated Patient #21 on March 6, 2012. Continued interview revealed M.D. #3 spoke to M.D. #4 regarding the care of Patient #21. M.D. #3 stated, "(M.D. #4) was concerned patient had alcohol with ankle fracture and may have other issues ..." Continued interview confirmed the facility failed to appropriately transfer Patient #21 and M.D. #3 stated, " (Patient's) ankle could have been repaired (at facility). From physician's statement nothing precluded (prevented) treatment (at facility) ...no problem getting on-call to respond, is sometimes hesitant to treat, may be gun shy... framed that around (referred to) orthopedics."
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