HospitalInspections.org

1. Based on policy review, review of the hospital's By-Laws and Rules and Regulations, review of the Hospital's Quality records, medical record reviews and interview, the hospital failed to ensure all patients presenting to the Dedicated Emergency Department (DED) received an appropriate Medical Screening Examination (MSE), according to hospital policy and within the capabilities of the hospital to determine if a medial emergency existed and failed to ensure all emergency medical conditions were treated for 1 of 21 (Patient #21) sampled patients.

Refer to A2406

2. Based on policy review, review of the hospital's By-Laws and Rules and Regulations, review of the Hospital's Quality records, medical record review and interview, the hospital failed to provide further medical examination and treatment as required to stabilize the medical condition for 1 of 21 (Patient #21) sampled patients.

Refer to A2407

Based on policy review, review of the hospital's By-Laws and Rules and Regulations, review of the Hospital's Quality records, medical record reviews and interview, the hospital failed to ensure all patients presenting to the Dedicated Emergency Department (DED) received an appropriate Medical Screening Examination (MSE), according to hospital policy and within the capabilities of the hospital to determine if a emergency medical existed and failed to ensure all emergency medical conditions were treated for 1 of 21 (Patient #21) sampled patients.

The findings included:

1. Review of the hospital's policy, "Emergency Medical Treatment and Patient Transfer Policy" revealed, "...Definitions...Medical Screening Examination is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists...Such screening must be done within the Hospital's Capacity and Capability and available personnel...The Medical Screening Examination is an ongoing process and the medical record must reflect continued monitoring based on the patient's needs and continue until the patient is either Stabilized or Appropriately Transferred...MEDICAL SCREENING EXAMINATION... When an individual comes to the Emergency Department of the Hospital...and a request is made on the individual's behalf for a medical examination or treatment, an appropriate Medical Screening Examination, within the Capabilities of the department (including ancillary services routinely available in the emergency department) , shall be provided to determine whether an Emergency Medical Condition exists... a Medical Screening Examination is not an isolated event, it is an ongoing process..."

2. Review of the hospital's "Medical Staff By-Laws Rules and Regulations", revealed, "Screening...Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition. Generally, an "emergency medical condition" is defined as...a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual...Services available to Emergency Department patients shall include ancillary services routinely available to the Emergency Department..."

3. Medical record for Patient #21 revealed the patient presented to Hospital #1's Emergency Department (ED) on 2/18/12 at 10:44 PM with complaints of pain in multiple sites. The triage nurse documented at 11:50 PM the patient complained of back and neck pain and numbness in his right arm with a decrease in use. The patients pain was documented 10 on a scale of 1-10 with 10 being the most painful. The nurse documented the patient was wearing his own neck brace and reported he had not had a bowel movement in 3 days. The nurse also documented the patient stated he had been involved in a motor vehicle accident in July 2011 in which he sustained a neck fracture at Thoracic (T) 11 and T 12.

ED Physician #1 performed a MSE at 12:52 AM and documented his review of the nursing triage notes including the patient's rated pain of 10/10 at multiple sites. The ED physician documented the patient was positive for joint pain and extremity pain, had constipation and was depressed. The physical examination by ED Physician #1 revealed the neck appeared normal with no jugular vein distention present was supple with no bony tenderness or palpable adenopathy. ED Physician #1 documented the Musculoskeletal assessment revealed normal joint range of motion, no swelling or deformities. The Neurological assessment revealed the patient was alert and oriented and Cranial Nerves 2-12 grossly intact with no motor sensory deficits. The physician ordered an Acute Abdomen series, Complete Metabolic Panel (CMP), Complete Blood Count (CBC) and Urinalysis (UA).

The Imaging Report for the abdominal series dated 2/19/12 revealed, "...Impression: 1. Subsegmental atelectasis left lower lobe. Tiny pleural effusions 2. Fecal stasis 3. Air filled dilated loops of small bowel and colon. This may be related to ileus given the patient's paralysis. Follow-up recommended" The CBC results dated 2/19/12 revealed a white blood cell count of 16.47 (Normal Range 4.23-9.07). The CMP results dated 2/19/12 revealed Albumin 3.0 ( Normal Range 3.4-5.0), Phosphatese 434 (Normal Range 50-136) and Sodium Serum 128 (Normal Range 135-145). The UA results dated 2/19/12 revealed yellow cloudy urine positive for Nitrates and moderate amount of Leukocytes with 4 plus bacteria.

The patient was administered the following medications in the ED: Tylenol 650 milligrams (mg) on 2/19/12 at 4:24 AM, Toradol 160 mg intramuscular (IM), Norflex 60 mg IM, Percocet 5 mg 2 tablets and one bottle of mag citrate on 2/19/12 at 7:30 AM.

ED Physician #1 diagnosed the patient with a Urinary Tract Infection, Fecal Stasis and Chronic neck and back pain. The patient was discharged home with the following prescription medications: Ciprofloxacin 500 mg one pill twice a day for 14 days for UTI, Cyclobenzaprine 10 mg one pill three times a day as needed for muscular pain, Methylprednisone as directed and Tramadol 50 mg one every six hours as needed for pain.

ED physician # 1 did not perform tests to assess the patient for the initial complaints of numbness in his right arm with a noted decrease in use, or the Radiologists interpretation that the patient had paralysis. There was no further MSE performed.

The nursing discharge documentation dated 2/19/12 at 8:08 AM revealed the patient was discharged home with discharge instructions in stable condition. Pain at discharge was documented as 10 on a scale of 1-10, the patients pain was unchanged from his triage assessment.

During a telephone interview with Physician #1 on 6/30/15 at 3:00 PM, the surveyors asked for clarification regarding the imaging results of Patient #21's abdomen series dated 2/19/12. Specifically the surveyors asked about the note referencing the patient's paralysis. Physician #1 stated, "...paralysis is not something I'm going to see on an X-ray..." He stated that the technician , who is with the patient at time of X ray, is able to enter notes into the system that he can see on his computer screen. The physician stated the notes for Patient #21 read, "Patient is in a wheel-chair, right sided paralysis, multiple back surgeries at [Hospital #2] in a lot of pain." Physician #1 stated he documented Patient #21 paralysis based on the note entered by the technician.

4. Patient #21 returned to Hospital #1's ED on 2/19/12 at 11:26 PM via ambulance. Review of the Emergency Medical Services documentation revealed, "DISPATCHED ROUTINE RESPONDED PROMPTLY TO PT [Patient] RESIDENCE FOR C/O [complaints of] R [right] LEG WEAKNESS BACK PAIN, NECK PAIN. PT HAD MVC [MOTOR VEHICLE CRASH] 6 MONTHS AGO. FELL OUT OF RECLINER AROUND CHRISTMAS STARTED HAVING R LEG WEAKNESS 2 DAYS AGO. WAS SEEN IN...ER [emergency room] LAST NIGHT. DX [diagnosed] WITH UTI, CONSTIPATION. pt has 4 rx [prescriptions] from last night he has not had filled. pt mae [moves all extremities] well except for r [right] leg...Chief complaint NECK AND BACK PAIN Secondary Complaint R LEG WEAKNESS..."

The patient was triaged at 11:26 PM with a chief complaint of neck injury moderate- severe. The triage nurse documented, " Pt c/o [complains of] of unable to move R leg, denies numbness....Pt on back board, wearing his own neck brace" The patients pain was documented 10 on a scale of 1-10 with 10 being the most painful. The patient was immobilized after arrival and the nurse documented the patient had neuro-motor deficits. The nurse documented the patient had weakness on his right side and chronic symptoms to the neck and back.

ED Physician #2 performed an MSE at 11:39 PM and documented the patient was unable to move his right leg but no injury had occurred. He documented the patient had a neck injury 3 month prior. In the review of systems, ED Physician #2 documented Musculoskeletal- positive back pain, positive neck pain, positive extremity pain. The Neurological physical exam documentation revealed, "Mental status intact Oriented X 3 Normal sensory exam throughout motor weakness right leg, no sensory deficit..."

At 12:00 AM the patient was administered Toradol 60 mg IM for pain. ED Physician #2 diagnosed the patient with Chronic neck and back pain and ordered an injection for pain. ED Physician #2 documented the patient was discharged home stable, satisfactory and improved. The documented instructions from ED Physician #2 were "...Patient agrees to return to Emergency Department immediately if symptoms worsen or fail to improve. advised to see neurosurgeon today."

ED Physician #2 did not perform tests related to the patient's complaint of inability to move his right leg. The patient was discharged with no improvement in his pain documented a 10/10 on presentment and unchanged upon discharge.

The nursing discharge documentation dated 2/20/12 at 12:56 AM revealed the patient was discharged home and that his pain was unchanged.

During a telephone interview with Physician #2 on 7/1/15 at 12:58 PM the surveyors asked about the Medical Staff Peer Review he completed for the ED case dated 2/19/12. Physician #2 was provided a copy of the record and the Medical Peer Review form prior to the telephone interview for reference. Physician #2 stated, "...I felt like he [Patient #21] needed more evaluation than he got in the emergency Room...should have had more evaluation...maybe some X-rays..." Physician #2 stated the patient was unable to move his right leg and he felt it was good advice to see a neurosurgeon but with the patient's history he felt it may have been a little more urgent and maybe a referral should have been done. Physician #2 stated, "...so much was going on with this man [Patient #21] just to give him a sheet and tell him to see a neurosurgeon wasn't enough...couldn't move his right leg...need to establish reason he couldn't move his leg..."

During an interview with ED Physician #2 on 7/1/15 at 10:08 AM, he was asked if he recalled treating Patient #21 on 2/19/12. ED Physician #2 was provided a copy of the medical record to review. ED Physician stated as he recalled the patient came into the ED with compliant of neck pain from a previous injury. He stated that the patient had been treated in the ED the previous night by another physician. ED Physician # 2 was asked what kind of treatment he provided Patient #21. He stated, "...evaluated him, examined him...vital signs...heart and lungs...his vital signs were very stable...neuro exam..." He stated the patient had focal weakness in his right leg, a slight weakness that he thought was related to his on-going neck and back problem. ED Physician #2 stated he gave the patient pain medication Toradol and he thought that helped the patient. When asked what instructions he gave the patient at discharge, he stated it was an on-going problem and the patient still needed to see a neurosurgeon or neurologist, someone more specialized. When asked if the patient had an established neurosurgeon, ED Physician #2 stated he did not recall any names but he thought the patient had a neurosurgeon at another hospital. ED Physician #2 stated he thought the weakness was a focal weakness people in pain sometimes don't move their extremities well because of their pain. He stated because the patient reported no recent injury, he thought it was progressing from his previous injury (motor vehicle accident several months earlier). He further stated, "That is why I asked him to see his specialist to see if something else needed to be done..." ED Physician #2 was asked how he would treat an acute neck injury. He stated, "X- rays or get them transferred to a neurosurgeon for further evaluation and treatment...I would have consulted...on call neurologist...further work up would have been done if recent injury or fall...CT [computerized tomography] scan...X-rays...". ED Physician #2 further stated he did not feel it was an emergency situation, he felt it was related to his chronic neck and back pain.


5. Review of Patient #21's medical record from Hospital #2 revealed he presented to the ED on 2/20/12 at 2:13 PM with complaints of no feeling in both legs and both arms. The triage nurse documented at 3:04 PM the patient reported pain at 10/10 with a numb quality. The nurse documented that the patient was grimacing and moaning and his grips were weak bilaterally with weakness in the left and right from shoulders down and from waist down.

ED Physician #3 began the MSE at 4:25 PM and documented the patient presented to the ED with complaints of numbness and weakness of both upper and lower extremities, with onset one week ago. The patient reported that for the past week he could not feel anything in any of his extremities and was unable to walk. The physician documented the patient had, "...difficulty standing, the patient cannot stand, paresthesias of the left lower extremity, left upper extremity, right lower extremity, right upper extremity..."

ED Physician #3 further documented the patient had a fall 2 months ago from his recliner, the patient was seen at Hospital #2 and had a computerized tomogrphy (CT) scan that ruled out any fracture to his cervical spine.

The ED physician documented review of the patient's past medical history revealed the patient had an motor vehicle accident (MVA) 1 year ago and had numbness and weakness at baseline from that previous injury. The physician documented the patient's baseline nerological assessment revealed the patient was fully alert and oriented, had right and left side weakness, ambulated with assitance only.

The ED physician documented the patient's current symptoms were "paralysis or paresis" and "positive for gait disturbance, numbness and weakness".

ED Physician #3 ordered a CT Cervical Spine, Magnetic Resonance Imaging (MRI) Cervical Spine, MRI Thoracic Spine, MRI Lumbar Spine and a Neurology consult. The patient was administered Percocet for pain.

Results of the MRI of the Thoracic Spine Report dated 2/20/12 at 3:48 PM revealed, "...Impression...Constellation of findings there is concerning for hardware infection with secondary osteomyelitis, discitis, and paraspinal or phlegmon formation..."

Results of the CT of the Cervical Spine Report dated 2/20/12 at 4:23 PM revealed, "...Impression...Interval erosion of the C5 [cervical] through C7 vertebral bodies with posterior extension into the spinal canal causing stenosis and possibly affecting the cervical cord. Leading differential considerations include a vascular necrosis secondary to trauma and discitis/osteomyelitis...Staff Addendum...Extensive erosive/destructive changes involving C5 and C6 vertebrae as well as C7 to lesser extent...resulting in pathologic fractures. There is impaction of C5 and C6 with posterior bone fragments extending into the spinal canal as well as disruption of the posterior elements most pronounced at C6 on the right side..."

At 11:28 PM, ED Physician #3 documented, "Patient underwent CT scan of his neck that showed pathologic fracture of is C5, C6 and C7 vertabra with associated cord compression shown on the MRI scan..." Further documentation on 2/21/12 at 1:54 AM revealed, "Admit ordered for Neurosurgery...Preliminary diagnosis his Spinal Cord Injury...condition is serious, problem is chronic, symptoms have worsened..."

The Physician's Oders to Hospital #2's Surgical Intensive Care Unit dated 2/21/12 at 1:10 AM documented a diagnoses of C 5/6 fracture and Quadriplegia with a guarded condition.

6. Review of Hospital Quality records revealed a Medical Staff Peer Review was conducted by Physician #2 on 2/14/13 of Patient #21's ED visit dated 2/19/12. Review of the document revealed, "...Should have had a lumbar spine X ray, needed a better...Findings...Treatment Inappropriate..." The document was signed by Physician #2.

Based on policy review, review of the hospital's By-Laws and Rules and Regulations, review of the Hospital's Quality records, medical record review and interview, it was determined the hospital failed to provide further medical examination and treatment as required to stabilize the medical condition for 1 of 21 (Patient #21) sampled patients.

The findings included:

1. Review of the hospital's "EMERGENCY SERVICES DEPARTMENT PATIENT CARE" policy revealed, "...Emergency Services are available twenty-four (24) hours daily for ill or injured persons to be evaluated, advised and/or appropriately treated. Following initial care, the patient may be discharged, admitted to this hospital or transferred to another facility as indicated by individual circumstances and the judgment of the attending physician...Radiology services for Emergency Room patients are available 24 hours a day 7 days a week..."

Review of the hospital's "Emergency Medical Treatment and Patient Transfer Policy" policy revealed, "...Emergency Medical Condition means...A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain...) such that the absence of immediate medical attention could reasonably be expected to result in...Placing the health of the individual...in serious jeopardy...Serious impairment of bodily functions...Serious dysfunction of any bodily organ or part...Stabilized/Stabilization: With respect to an Emergency Medical Condition, to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility...Stable for Discharge: A patient is Stable for Discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions; or, the patient requires no further treatment and the treating physician has provided a written documentation of his/her findings..."

Review of the hospital's "Triage Assessment of Patients (5 Tier)" policy revealed, "...A licensed professional prior to registration will assess every patient arriving to the ED [emergency department] for care...Category III-Urgent: These patients require 2 or more resources for a disposition decision to be reached. The patient is stable for the interim but requires department resources...Category IV-Semi Urgent: Condition requires one resource for a disposition decision to be reached. These patients may safely wait for evaluation. Routine care is required. Care can be delayed for patients to be treated with more acute problems..."

2. Review of the hospital's "Medical Staff By-Laws Rules and Regulations" revealed, "...EMERGENCY MEDICAL SCREENING, TREATMENT, TRANSFER & ON CALL ROSTER POLICY...Stabilization...Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge..."

3. Medical record for Patient #21 revealed the patient presented to Hospital #1's Emergency Department (ED) on 2/18/12 at 10:44 PM with complaints of pain in multiple sites. The triage nurse documented at 11:50 PM the patient presented to the ED with complaints of back and neck pain and numbness in his right arm with a decrease in use. The patients pain was documented 10 on a scale of 1-10 with 10 being the most painful. The nurse documented the patient was wearing his own neck brace and reported he had not had a bowel movement in 3 days. The nurse also documented the patient was involved in an motor vehicle accident in July 2011 in which he sustained a neck fracture at Thoracic (T) 11 and T 12.

ED Physician #1 performed a MSE at 12:52 AM and documented he reviewed the nursing triage notes including the documented pain of 10 at multiple sites. The ED physician documented the patient was positive for joint pain and extremity pain, had constipation and was depressed. The physical examination by ED Physician #1 revealed the neck appeared normal with no jugular vein distention present was supple with no bony tenderness or palpable adenopathy. The Musculoskeletal assessment revealed normal joint range of motion, no swelling or deformities. Neurological assessment revealed the patient was alert and oriented and Cranial Nerves 2-12 grossly intact with no motor sensory deficits. The physician ordered an Acute Abdomen series, Complete Metabolic Panel (CMP), Complete Blood Count (CBC) and Urinalysis (UA).

The Imaging Report for the abdominal series dated 2/19/12 revealed, "...Impression: 1. Subsegmental atelectasis left lower lobe. Tiny pleural effusions 2. Fecal stasis 3. Air filled dilated loops of small bowel and colon. This may be related to ileus given the patient's paralysis. Follow-up recommended" The CBC results dated 2/19/12 revealed a white blood cell count of 16.47 (Normal Range 4.23-9.07). The CMP results dated 2/19/12 revealed Albumin 3.0 ( Normal Range 3.4-5.0), Phosphatese 434 (Normal Range 50-136) and Sodium Serum 128 (Normal Range 135-145). The UA results dated 2/19/12 revealed yellow cloudy urine positive for Nitrates and moderate amount of Leukocytes with 4 plus bacteria.

The patient was administered the following medications in the ED: Tylenol 650 milligrams (mg) on 2/19/12 at 4:24 AM, Toradol 160 mg intramuscular (IM), Norflex 60 mg IM, Percocet 5 mg 2 tablets and one bottle of mag citrate on 2/19/12 at 7:30 AM.

ED Physician #1 diagnosed the patient with a Urinary Tract Infection, Fecal Stasis and Chronic neck and back pain. The patient was discharged home with the following prescription medications: Ciprofloxacin 500 mg one pill twice a day for 14 days for UTI, Cyclobenzaprine 10 mg one pill three times a day as needed for muscular pain, Methylprednisone as directed and Tramadol 50 mg one every six hours as needed for pain.

There was no documentation the patient's EMC related to the numbness in his right arm or decrease in use of his right arm or the pain were stabilized prior to discharge. There was no documentation that the paralysis referenced by the Radiologist had been addressed by ED Physician #1.

The nursing discharge documentation dated 2/19/12 at 8:08 AM revealed the patient was discharged home with discharge instructions in stable condition. Pain at discharge was documented as 10 on a scale of 1-10, the patients pain was unchanged from his triage assessment.

During a telephone interview with Physician #1 on 6/30/15 at 3:00 PM, the surveyors asked for clarification regarding the imaging results of Patient #21's abdomen series dated 2/19/12. Specifically the surveyors asked about the note referencing the patient's paralysis. Physician #1 stated, "...paralysis is not something I'm going to see on an X-ray..." He stated that the technician , who is with the patient at time of X ray, is able to enter notes into the system that he can see on his computer screen. The physician stated the notes for Patient #21 read, "Patient is in a wheel-chair, right sided paralysis, multiple back surgeries at [ named another facility] in a lot of pain." Physician #1 stated the note from the technician was why paralysis was mentioned in his documentation.

4. Patient #21 returned to Hospital #1's ED on 2/19/12 at 11:26 PM via ambulance. Review of the Emergency Medical Services documentation revealed, "DISPATCHED ROUTINE RESPONDED PROMPTLY TO PT [Patient] RESIDENCE FOR C/O [complaints of] R [right] LEG WEAKNESS BACK PAIN, NECK PAIN. PT HAD MVC [MOTOR VEHICLE CRASH] 6 MONTHS AGO. FELL OUT OF RECLINER AROUND CHRISTMAS STARTED HAVING R LEG WEAKNESS 2 DAYS AGO. WAS SEEN IN...ER [emergency room] LAST NIGHT. DX [diagnosed] WITH UTI, CONSTIPATION. pt has 4 rx [prescriptions] from last night he has not had filled. pt mae [moves all extremities] well except for r [right] leg...Chief complaint NECK AND BACK PAIN Secondary Complaint R LEG WEAKNESS..."

The patient was triaged at 11:26 PM with a chief complaint of neck injury moderate- severe. The triage nurse documented, " Pt c/o [complains of] of unable to move R leg, denies numbness....Pt on back board, wearing his own neck brace" The patients pain was documented 10 on a scale of 1-10 with 10 being the most painful. The patient was immobilized after arrival and the nurse documented the patient had neuro-motor deficits. The nurse documented the patient had weakness on his right side and chronic symptoms to the neck and back.

ED Physician #2 performed an MSE at 11:39 PM and documented the patient was unable to move his right leg but no injury had occurred. He documented the patient had a neck injury 3 month prior. In the review of systems, ED Physician #2 documented Musculoskeletal- positive back pain, positive neck pain, positive extremity pain. The Neurological physical exam documentation revealed, "Mental status intact Oriented X 3 Normal sensory exam throughout motor weakness right leg, no sensory deficit..."

At 12:00 AM the patient was administered Toradol 60 mg IM for pain. ED Physician #2 diagnosed the patient with Chronic neck and back pain and ordered an injection for pain. ED Physician #2 documented the patient was discharged home stable, satisfactory and improved. The documented instructions from ED Physician #2 were "...Patient agrees to return to Emergency Department immediately if symptoms worsen or fail to improve. advised to see neurosurgeon today."

There was no documentation the patient was provided stabilizing treatment for his complaints of inability to move his right leg, back or neck pain. The facility failed to perform tests within it's capabilities to ensure the patient was stable before discharge. The patient rated his pain 10/10 upon presentation to the ED and at discharge the pain had not improved.

During a telephone interview with Physician #2 on 7/1/15 at 12:58 PM the surveyors asked about the Medical Staff Peer Review he completed for the ED case dated 2/19/12. Physician #2 was provided a copy of the record and the Medical Peer Review form prior to the telephone interview for reference. Physician #2 stated, "...I felt like he needed more evaluation than he got in the emergency Room...should have had more evaluation...maybe some X-rays..." Physician #2 stated the patient was unable to move his right leg and he felt it was good advice to see a neurosurgeon but with the patient's history he felt it may have been a little more urgent and maybe a referral should have been done. Physician #2 stated, "...so much as going on with this man [Patient #21] just to give him a sheet and tell him to see a neurosurgeon wasn't enough...couldn't move his right leg...need to establish reason he couldn't move his leg..."

During an interview with ED Physician #2 on 7/1/15 at 10:08 AM, he was asked if he recalled treating Patient #21 on 2/19/12. ED Physician #2 was provided a copy of the medical record to review. ED Physician stated as he recalled the patient came into the ED with compliant of neck pain from a previous injury. He stated that the patient had been seen in the ED the previous night by another physician. ED Physician # 2 was asked what kind of treatment her provided Patient #21. He stated, "...evaluated him, examined him...vital signs...heart lungs...his vital signs were very stable...neuro exam..." He stated the patient had focal weakness in his right leg, a slight weakness that he thought was related to his on-going neck and back problem. ED Physician #2 stated he gave the patient pain medication Torodol and he thought that helped the patient. When asked what instructions he gave the patient at discharge, he stated it was an on-going problem and the patient still needed to see a neurosurgeon or neurologist, someone more specialized. When asked if the patient had an established neurosurgeon, ED Physician #2 stated he did not recall any names but he thought the patient had a neurosurgeon at another hospital. ED Physician #2 stated he thought the weakness was a focal weakness that people in pain sometimes don't move their extremities well because of their pain and because the patient reported no recent injury, he thought it was progressing from his previous injury (motor vehicle accident 3 months earlier). He further stated, "That is why I asked him to see his specialist to see if something else needed to be done..." ED Physician #2 was asked how he would treat an acute neck injury. He stated, "X- rays or get them transferred to a neurosurgeon for further evaluation and treatment...I would have consulted...on call numerologist...further work up would have been done if recent injury or fall...CT scan...X-rays...". ED Physician #2 further stated he did not feel it was an emergency situation, he felt it was related to his chronic neck and back pain.

5. Review of Patient #21's medical record from Hospital #2 revealed he presented to the ED on 2/20/12 at 2:13 PM with complaints of no feeling in both legs and both arms. The triage nurse documented at 3:04 PM the patient reported pain at 10/10 with a numb quality. The nurse documented that the patient was grimacing and moaning and his grips were weak bilaterally with weakness in the left and right from shoulders down and from waist down.

ED Physician #3 began the MSE at 4:25 PM and documented the patient presented to the ED with complaints of numbness and weakness of both upper and lower extremities, with onset one week ago. The patient reported that for the past week he could not feel anything in any of his extremities and was unable to walk. The physician documented the patient had, "...difficulty standing, the patient cannot stand, paresthesias of the left lower extremity, left upper extremity, right lower extremity, right upper extremity..."

ED Physician #3 further documented the patient had a fall 2 months ago from his recliner, the patient was seen at Hospital #2 and had a computerized tomogrphy (CT) scan that ruled out any fracture to his cervical spine.

The ED physician documented review of the patient's past medical history revealed the patient had an motor vehicle accident (MVA) 1 year ago and had numbness and weakness at baseline from that previous injury. The physician documented the patient's baseline nerological assessment revealed the patient was fully alert and oriented, had right and left side weakness, ambulated with assitance only.

The ED physician documented the patient's current symptoms were "paralysis or paresis" and "positive for gait disturbance, numbness and weakness".

ED Physician #3 ordered a CT Cervical Spine, Magnetic Resonance Imaging (MRI) Cervical Spine, MRI Thoracic Spine, MRI Lumbar Spine and a Neurology consult. The patient was administered Percocet for pain.

Results of the MRI of the Thoracic Spine Report dated 2/20/12 at 3:48 PM revealed, "...Impression...Constellation of findings there is concerning for hardware infection with secondary osteomyelitis, discitis, and paraspinal or phlegmon formation..."

Results of the CT of the Cervical Spine Report dated 2/20/12 at 4:23 PM revealed, "...Impression...Interval erosion of the C5 [cervical] through C7 vertebral bodies with posterior extension into the spinal canal causing stenosis and possibly affecting the cervical cord. Leading differential considerations include a vascular necrosis secondary to trauma and discitis/osteomyelitis...Staff Addendum...Extensive erosive/destructive changes involving C5 and C6 vertebrae as well as C7 to lesser extent...resulting in pathologic fractures. There is impaction of C5 and C6 with posterior bone fragments extending into the spinal canal as well as disruption of the posterior elements most pronounced at C6 on the right side..."

At 11:28 PM, ED Physician #3 documented, "Patient underwent CT scan of his neck that showed pathologic fracture of his C5, C6 and C7 vertabra with associated cord compression shown on the MRI scan..." Further documentation on 2/21/12 at 1:54 AM revealed, "Admit ordered for Neurosurgery...Preliminary diagnosis is Spinal Cord Injury...condition is serious, problem is chronic, symptoms have worsened..."

The Physician's Oders to Hospital #2's Surgical Intensive Care Unit dated 2/21/12 at 1:10 AM documented a diagnoses of C 5/6 fracture and Quadriplegia with a guarded condition.

6. Review of Hospital Quality records revealed a Medical Staff Peer Review was conducted by Physician #2 on 2/14/13 of Patient #21's ED visit dated 2/19/12. Review of the document revealed, "...Should have had a lumbar spine X ray, needed a better...Findings...Treatment Inappropriate, but the adverse impact on the patient was minimal..." The document was signed by Physician #2.