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TEXAS VISTA MEDICAL CENTER 7400 BARLITE BLVD SAN ANTONIO, TX 78224 Oct. 12, 2011
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based upon review of emergency treatment record and interview with staff and review of policy a full medical screen was not conducted. This requirement was not met as follows:

Findings:

a. Reviewed emergency treatment record of patient #25, a [AGE] year old female who visited the emergency department on December 21, 2010 complaining of having suicidal ideations with a plan of running into oncoming traffic. Nursing assessments were conducted and during the physicians medical screening assessment the patient became agitated, verbally aggressive, combative and left the treatment room. The facility's Security services and San Antonio Police Department (SAPD) was called and was told that the patient eloped. San Antonio Police Department (SAPD) responded, confronted the patient and transported the patient off the grounds of Southwest General Hospital. There was no evidence that the psychiatric portion of medical screening on this patient was completed and proven that an emergency medical condition did not exist before the police escorted this patient off the grounds of Southwest General Hospital. The treatment record stated the patient's disposition as being "stabilized" and "left against medical advice (AMA)".

b. Interviewed Staff # 12, Attending emergency room Physician at 3:35pm on October 13, 2011 via telephone said the patient was discharged the day before from a psychiatric facility. The patient smelled of alcohol and was very loud and verbal. She said she wanted to be admitted again because she wanted different medications, she said she felt suicidal and wanted to run into oncoming traffic. He said he tried to do a medical screen on her and she became more verbal and loud and started saying that she knew the psychiatrist at Southwest General and that he was sexually inappropriate to her. She continued making sexual inappropriate allegations against the psychiatrist. He said he had ordered a urine drug screen on her. He spoke to the facility's on-call psychiatrist about the patient and her inappropriate sexual allegations against him. The psychiatrist said that he could not see this patient, if she made sexual allegations against him. He said that this attending psychiatrist was the only psychiatrist available at Southwest General. There were no attempts to have another psychiatrist screen the patient. The plan was to complete the medical portion of the screen and try to finish clearing her for medical and to give her reference and talk to her about a facility and resources that could provide chemical dependency treatment for her. Southwest General does not provide chemical dependency treatment. He said medically the patient was stable. He said when he told the patient that she could not be admitted to the psychiatric unit at Southwest General the patient became angry started yelling more and ran out of the treatment room. He said he called San Antonio Police Department and told them that the patient eloped. He said he went to see other patients and when the police came he spoke to them about what happened and they went to look for the patient. He said he heard they found her in the front of the hospital. Staff #12, MD said he did not see the patient again after she ran out of his office. The police did not bring her back to the treatment room. This requirement was not met when an appropriate medical screening examination was not provided to prove whether an emergency medical condition existed in this patient who came to the facility with a suicidal ideation with plan.

c. Reviewed Policy Treatment of Psychiatric Patient in the ED (including Psychiatric patient with violent and/or combative behavior) which states "All reasonable steps shall be taken to provide psychiatric patients with a medical screening examination and any further examination and necessary stabilization treatment within the scope of services of the staff and facilities of Southwest General hospital that may be required to identify and stabilize an emergency condition." Under involvement of San Antonio Police Department (SAPD) it states the "Emergency Department Staff shall take all reasonable steps to provide necessary stabilizing treatment to the patient who is determined to have an emergency condition before the patient is discharged to the custody of the police." It was never determined completely in this case whether or not an emergency condition still existed because a psychiatric assessment was never completed in this patient who came to the facility with suicidal ideation with plan.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based upon review of emergency treatment record, review of policy and interviews, an appropriate transfer was not conducted. This requirement is not met as follows:

Findings:

a. Reviewed emergency treatment record of patient #28, a [AGE] year old female who visited the emergency department at Southwest General on December 26, 2010 at 7:27pm complaining that she had nausea and started vomiting and in the process dislocated her jaw. She had a 10/10 on the pain scale. She was not having problems with airway and breathing or circulation. Her initial vital signs were within normal limits. She was seen by the physician at 7:30pm on December 26, 2011. The physician documented that a "medical screening evaluation was performed and that further evaluation was needed to rule out an EMC." The emergency physician further documented a procedure note: Jaw reduction. Consent obtained for further reduction and conscious sedation; gave 0 mcg Fentanyl, 20mg Etomidate; Zofran 8mg, and a mandible series x-ray was conducted. Right TMJ easily reduced with manual downward and posterior pressure. It was documented by physician "Instructed patient and father that we do not have an oral maxillofacial surgeon available at this facility. One is available at the University Hospital, and I instructed them to go directly to that facility." The main discharge instruction signed by the patient and the attending emergency room nurse stated "GO TO UNIVERSITY HOSPITAL TO FOLLOW UP WITH MAXILLA/FACIAL DOCTOR". The emergency physician's disposition of the patient documentation states "emergency medical condition is stabilized." The patient disposition type is "discharged ." "Special Instructions: Go to University Hospital to follow up with Maxilla/Facial doctor." Patient ready for discharge 12/26/2010 at 10:40pm. The ED physician again documented under ED Course notes.

"Instructed pt and father that we do not have an oral maxillofacial surgeon available at this facility.
One is available at the University Hospital and I instructed them to go directly to that facility. The patient is otherwise healthy and stable, so I do not believe an ER to ER transfer is necessary."

b. Reviewed emergency record from University Hospital showed [AGE] year old female with dislocated jaw who arrived at facility this facility on December 26, 2011 at 9:34pm ambulatory. It states the patient was sent from Southwest General with x-rays. The patient received tests, more x-rays, medication, conscious sedation and a consult from a facial physician while at University Hospital.

c. Reviewed policy Transfer Guidelines revised April 2011:

Under the subject "Transfers out of Southwest General Hospital" it states:
1. If the patient has a condition that requires a higher level of care, we attempt to locate a hospital, and the physician locates an accepting physician. The patient should be stable prior to transfer. ...
2. The reason(s) for the transfer must be documented in the patient's medical record and on the Memorandum of Transfer (MOT) form.

There was no evidence found that the emergency room staff at Southwest tried to contact any other hospitals that had an oral maxillofacial surgeon available at the facility. There was no evidence provided to prove that a Memorandum of Transfer (MOT) was generated from Southwest General Hospital to University Health system on this patient. The patient and her father were instructed directly by the emergency room physician to go directly to University Hospital because they have an oral maxillofacial surgeon. The patient did as directed by Southwest General Hospital emergency physician. The patient and her father drove themselves with the x-rays taken at Southwest General to the emergency room at University Health System.

c. In interviews with staff # 4, Director of Risk Management at 12:10pm on October 11, 2011 in the
administration conference room. All 3 patients were discussed in this interview. Staff #4 was sure that
there were no EMTALA violations conducted with patient #1 and patient #2. When he reviewed the
emergency treatment record for patient #28, [AGE] year old female it was indicated that he did not know what the physician was thinking about when he told the patient to go to University Hospital and not arrange a transfer.

d. Interviewed staff # 5, LVN, Emergency Department Operations Officer at 4:30pm on October 11,
2011 in the administration conference room. Reviewed the case of patient #28 with Staff # 5. Staff#5 reviewed the treatment record and acknowledged that the physician should have arranged a transfer in this case. He agreed that this was not a normal way of handling a patient and a transfer should have been arranged in this case to a facility that had the capability of having an oral maxillofacial surgeon since Southwest General does not have an oral maxillofacial surgeon, plastics or an ear, nose and throat doctor. Staff interviewed was not able to provide evidence of compliance with this requirement.

e. Interviewed Staff #13, Attending emergency room Physician via phone interview at 9:00am on October 19, 2011attending emergency physician who treated the patient #29, [AGE] year old female. He said that he conducted a thorough screen on the patient who came to the emergency room in pain after having a jaw dislocation that occurred after she had a bout of vomiting earlier that day. He said she was given pain medications, x-rays were taken that were normal. He said the patient was placed under conscious sedation and he tried to relocate her jaw at least 3-4 times. He said each time she would gag or yawn and the jaw would dislocate again. He said the patient was with her father during the visit. He said the patient was medically stable. He knew she needed to eventually see an oral maxillofacial specialist. Southwest General does not have oral maxillofacial specialist on call. He thought she was stable enough to be discharge but knew that she would eventually need to see a specialist for her problem. He gave her discharge instruction to go to University Hospital to see an oral maxillofacial specialist. He said both the patient and her father were agreeable with these instructions. Staff #13, MD explained that a jaw dislocation is not something that anyone would admit a patient as an inpatient but knew that it eventually needed to be taken care of within the next 2-3 days. He said he did not try to contact University Health System and arrange a transfer because he knew that this was not a transferrable case, it did not involve trauma so it did not fit the criteria for transfer. He thought it would be easier for her to see if she could see a specialist at University Hospital as an outpatient. His intention was to discharge and not transfer her.

e. Reviewed emergency treatment record of patient #25, a [AGE] year old female who visited the emergency department on December 21, 2010 complaining of having suicidal ideations with a plan of running into oncoming traffic. Nursing assessments were conducted and during the physicians medical screening assessment the patient became agitated, verbally aggressive, combative and left the treatment room. The facility Security services and San Antonio Police Department (SAPD) were called and was told that the patient eloped. San Antonio Police Department (SAPD) responded, confronted the patient and transported the patient off the grounds of Southwest General Hospital. There was no evidence provided to show that there was an attempt to transfer the patient who needed a psychiatric assessment portion of her medical screen to another psychiatrist for assessment because the on-call psychiatrist at Southwest General on date of visit to the emergency department December 21, 2011 was unwilling to see this patient in-order to conduct psychiatric portion of the medical screening at Southwest General. The treatment record stated the patient's disposition as being "stabilized" and "left against medical advice (AMA)".

f. Interviewed Staff # 12, Attending emergency room Physician at 3:35pm on October 13, 2011 via telephone said the patient was discharged the day before from a psychiatric facility. The patient smelled of alcohol and was very loud and verbal. She said she wanted to be admitted again because she wanted different medications she said she felt suicidal and wanted to run into oncoming traffic. He said he tried to do a medical screen on her and she became more verbal and loud and starting saying that she knew the psychiatrist at Southwest General and that he was sexually inappropriate to her. She continued making sexual inappropriate allegations against the psychiatrist. He said he had ordered a urine drug screen on her. He said he spoke to the psychiatrist about the patient and her inappropriate sexual allegations against him. The psychiatrist said that he could not see this patient, if she made sexual allegations against him. He said that this attending psychiatrist was the only psychiatrist available at Southwest General. There were no attempts to have another psychiatrist screen the patient. The plan was to complete the medical portion of the screen and try to finish clearing her for medical and to give her reference and talk to her about a facility and resources that could provide chemical dependency treatment for her. Southwest General does not provide chemical dependency treatment. He said medically the patient was stable. He said when he told the patient that she could not be admitted to the psychiatric unit at Southwest General the patient became angry started yelling more and ran out of the treatment room. He said he called San Antonio Police Department and told them that the patient eloped. He said he went to see other patients and when the police came he spoke to them about what happen and they went to look for the patient. He said he heard they found her in the front of the hospital. Staff #12, MD said he did not see the patient again after she ran out of his office. The police did not bring her back to the treatment room. A referral to another psychiatrist and appropriate transfer to another facility was not made for this patient who came to the facility with a suicidal ideation with plan.