Based on clinical record review, observation and staff interviews, the Hospital failed to implement preventive action to address the root causes that had been identified on 08/28/14, relating to an adverse patient event occurrence of 08/09/14. The findings include: An interview was conducted with the hospital Risk/ Quality Manager on 09/08/14 beginning at 10:45 AM, to review an adverse patient event which occurred on 08/09/14 concerning Patient #1. The manager stated a root cause analysis of the patient event was completed on 08/28/14 and the following concerns were identified: 1. A non-employee Agency Registered Nurse assigned to the patient care did not know how to call code blue during the event. 2. Enhance monitoring for patient at risk. 3. Security of the sharps box in patient rooms. 4. Code cart on 2nd floor missing Versed medication. 5. Short supply of Sisco/ Spectra link phone on the 2nd floor medical units. 6 A need to educate nurses on hospital emergency procedure and enhanced patient monitoring. The surveyor requesteed evidence to substantiate preventive action was implemented for the above identified concerns. The Quality Manager stated corrective action has not been developed or implemented as of 09/08/14.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, staff interview and policy review the Director or Nursing Services failed to ensure non-employee Registered Nurses have been oriented to the hospital emergency procedures. On 08/09/14, 2 of 2 Registered Nurses ( RN -A and RN -B ) providing patient care did not know the hospital emergency phone number to dial for medical and non medical emergencies. A root cause analysis identified on 08/28/14, a non-employee agency Nurse (RN-C) working in the hospital on [DATE] did not know how to call a Code Blue during a medical emergency involving a patient (#1). This failure presents a potential risk to patient safety. The findings include: Observation conducted on 09/08/14 beginning at 1:45 PM on a second floor Medical unit revealed two non- employee Registered nurses are working during the 7 AM - 7:30 PM shift. In an interview with RN-A on 09/08/14 at 2:00 PM, the nurse stated she had been working with the hospital affiliated agency since 2008. The surveyor asked the nurse to explain the hospital procedure to call an emergency code. The nurse stated she would leave the patient room and call 4444 from the nurses' station. Her other option would be to press the call bell and wait for another staff to come and assist. Immediately after the interview the RN informed the nurse manager she did not know the phone number to dial in an emergency. The nurse manager directed RN-A to the nurses' station and showed her the emergency number posted on a telephone at the nurses' station. In an interview with the Nurse Manager on 09/08/14 at 2:40 PM, the nurse Manager stated we dial * for rapid response and all hospital emergency codes. The nurse manager states each nurse is supposed to be assigned and carry a Sisco Link phone each shift. For the past 6 months only one Sisco Link phone is available on the unit and it is assigned to the charge nurse. The nurse manager states she has reported it to the hospital IT (information Technology). During an interview with RN-B on 09/08/14 at 2:15 PM, the nurse stated this was her first day back at this hospital. She stated she is employed by an agency that is an affiliate of the hospital. The nurse stated she received an initial orientation at the agency and a brief hospital orientation to the unit. When asked to explain the hospital emergency procedure and phone number to dial for an emergency code, the nurse stated she would dial 0 from the patient telephone in the room and tell the operator the location of the emergency. She stated I am not sure what the number is here, we do team nursing on this floor and I could ask the other RN I am working with. An interview was conducted with the hospital Risk/ Quality Manager on 09/08/14 beginning at 10:45 AM, to review an adverse patient event which occurred on 08/09/14 concerning Patient #1. The manager stated a root cause analysis (RCA) of the patient event was completed on 08/28/14. The clinical record of Patient #1 and the root cause analysis related to the event that occurred on 8/9/14 were reviewed. The RCA identified among other findings that the non-employee Agency Registered Nurse assigned to Patient #1's care on 8/9/14 did not know how to call a code blue during the event. The hospital policy /procedure # 5.11 titled Rapid Response, Code Blue policy dated 09/09/13 specified to bring a team of skilled clinicians together to a patient bedside to assess a patient's condition and determine if a higher level of care, Rapid Response or Code Blue is warranted. If a primary nurse, charge nurse or any other clinician identifies clinical help is necessary, they may call a rapid response. The Rapid response, Code Blue policy procedure #5.11 dated 9/09/13, did not include or specify the number to dial for Rapid Response and Code Blue.
Based on clinical record review, facility record review and staff interviews it was determined the facility failed to comply with 42 CFR 489.24(j)(2)(i). Review of facility license and service inventory list revealed Oral Maxillofacial Service(OMFS) is within the capability of and available at West Palm Hospital (WPH). Review of the Hospital Emergency Services Call List April through November 2012 reveals the On - Call physician for OMFS is also the On - Call physician for Plastic Surgery on the same days. The Oral Maxillofacial (OMFS) and Plastic Surgery listed on its license and Service Inventory list as within its capability 24 hours per day/7 days per week by direct staff or indirect parties with whom an agreement to provide that service exist. The facility failed to render Oral Maxillofacial Services for 3 of 20 sampled patients (Patient #2, #5 and #7). Please refer to deficient practice cited in this report at A2404 and A2409.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on reviews of medical records, on -call schedules, delineation of privileges, facility license and service inventory , medical staff rules and regulations and interviews, the facility failed to ensure that the Oral Maxillofacial Services on-call physicians on staff meet the needs of the hospital patients who are receiving services required with the resources available at the hospital including the availability of on- call physicians for 2 of 20 samples patients (# ' s 5, & 7) who required Oral Maxillofacial Services. Findings: The hospital ' s Medical Staff Rules and Regulations, revised 10, 2012 was reviewed. The Medical Staff Rules and Regulations revealed in part, I. emergency room ...2. Medical Staff coverage for the Emergency Department is assumed only by qualified members of the Medical Staff who are duly appointed by the Board following review of their delineation of privileges ...4. The Chief Executive Officer and the Medical Staff have adopted the following procedures for assigning emergency room coverage for primary care physicians and consultants: a. if the patient does not have a private practitioner, he/she will be assigned to the member of the staff on call in the service to which the illness or condition of the patient indicates treatment. The Core Privileges for Oral Maxillofacial (OMFS) and Plastic Surgery were reviewed with the Medical Director of the Emergency Department (ED) at 0910 hours on 11/9/12. The Delineation of Privileges for the Plastic Surgery: Core Privileges include admission, workups and performance of surgical procedures for patients presenting with both congenital and acquired defects of the body's soft tissue, including the functional and aesthetic management and the provision of consultations; treatment of skin neoplasm's, diseases and trauma;surgery of the breast; treatment of facial diseases and injuries, including maxillofacial structures; surgery of the hand and extremities; reconstructive microsurgery; reconstruction of congenial and acquired defects of the trunk and genitalia; complex wound healing and burn treatment; cosmetic surgery; endoscopic cosmetic surgery; and laser therapy for vascular and crustaceous lesions. The Medical Director of the ED verified on 11/9/12 at 0915 hours the Core Privileges for Plastic Surgery are the same as for Maxillofacial Surgery. Review of facility license and service inventory list revealed Oral Maxillofacial (OMFS) is within the capability of and available at West Palm Hospital (WPH). The Oral Maxillofacial (OMFS) and Plastic Surgery listed on its license and Service Inventory is listed as within its capability 24 hours per day/7 days per week by direct staff or indirect parties with whom an agreement to provide that service exist. Review of the WPH Emergency Services Call List April through November, 2012 reveals the On - Call physician for OMFS is also the On - Call physician for Plastic Surgery on the same days. The ED Director verified the specialities can perform the same services. Review of 2 sampled medical records and the Emergency Service Call schedules from the ED disclosed: 1) Patient # 7 was transferred to WPH on 8/3/12 from another hospital outside the county. The reason for transfer per the transferring hospital ED document is as follows: Medical Decision: Patient had an isolated injury to the left cheek. With multiple facial/orbital fractures. Patient had a CT(computerized tomography) scan of the head which was negative. The CT of facial bones which revealed multiple fractures and possible left infraorbital nerve injury which is consistent with exam clinically. Dr. N____plastic surgery covering for oral maxillofacial surgery (OMFS) at West Palm Hospital for possible Evaluation and possible repair and definitive treatment. The patient accepted by Dr. N____. Case discussed with Dr. B___ Emergency physician. Dr. B___accepting physician in the ED. Patient had worsening pain and was given 8 mg. of Morphine total. The ED physician documents he discussed the condition and treatment with the patient and available family after verbal consent from the patient. The Clinical Impression: Extensive facial fractures; Comminuted fracture through left; infraorbital wall; Left infraorbital nerve injury; Zygomatic arch fracture (cheek bone fractures); Lateral maxillary (Upper jaw fractures) sinus wall fracture; Anterior maxillary sinus wall fracture and Lateral orbital wall fracture Patient transported without consequence by EMS (Emergency Medical Services) to West Palm Hospital 8/3/12 at 0655 hours. The patient arrived in the ED at WPH at 0745 hours. The Triage Nurse writes patient to ER (emergency room ), a transfer from ________ Hospital for Maxillofacial injury, accepted by Dr. N____. The ED physician (at WPH) documents the time seen by Medical Provider as 0748 hours. The ED physician writes the patient was transferred here from ______ Hospital for Maxillofacial fractures (Upper jaw area fractures). The patient had CT which show comminuted fracture the Right infraorbital wall and foramen as well as zygomaticomaxillary fracture. Patient denies Headache, vomiting or visual changes. He complained of numbness to left side of face. Under the heading MDM-Trauma Minor/Fall Patient course: Patient transferred here because we have OMFS on call. Spoke with OMFS and will see patient as an outpatient. Consultation: Referral/Consultant Name: Dr. N_____. Consultant called: OMFS Consultant: Will see patient in his office. He instructs patient to keep HOB elevated, no blowing nose and start on Keflex. Disposition-Trauma Minor/Fall Clinical Impression: Fracture(s) (Multiple facial) Disposition: discharged home Active Problems - Blow out fracture of orbit (is a fracture of one or more of the bones surrounding the eyes). The OMFS on-call physician failed to come to the ED after being notified that patient #7 had arrived from the transferring hospital, awaiting possible repair and definitive treatment for his injuries, as discussed when the on call physician accepted patient #7 on 8/3/2012. The ED nurse documents the patient is discharged home at 0824 hours. The patient is instructed to follow up with Dr. N___ today. The medical record was reviewed with the ED Medical Director at 0910 hours. This writer inquired as to why the patient, who was accepted by the On - Call physician Dr. N____, was not seen by the On - Call physician. The Medical Director stated we will always accept the patient. After the evaluation if there is no emergency we send the patient home. This writer stated this patient was sent here from another county for possible evaluation, possible repair and definitive treatment and by virtue of the service capability listed on the license and On-Call coverage available on 8/3/12, requires WPH to provide that service. The medical director stated, It's inconvenient but it meets the standard of care in our community. There is an agreement dated 5/1/12 between West Palm Hospital and their sister facility to offer OMFS. The QA (Quality assurance) director and the ED Nurse Manager stated at 1240 hours that she does not know if the sister facility was called or if they were called why they did not accept patient #7. The EMTALA Log for August 2012 was sent yesterday (11/8/12) to storage, according to the ED Manager. At the time of the survey the facility was unable to provide evidence of the EMTALA Transfer Acceptance or Denial Form for patient #7. Review of the on-call schedule dated 8/3/2013 revealed that Dr. N was on call for Maxillo and Plastic The hospital failed to ensure that the OMFS on-call physician came to the ED to provide OMFS services required and available for patient #7 on 8/3/2012. 2) Patient #5 presented to ED on 11/1/12 at 12:00 a.m. The Triage nurse documents the following: Chief complaint, Tried to kill myself, I jumped off a bridge. The nurse documented the patient complained of a right elbow, jaw pain, a 4 centimeter (cm.) laceration to chin- not actively bleeding, lip laceration and suicide attempt. The patient is seen by the ED physician at 0004. The physician documents a Medical Screening Exam (MSE) as follows: Patient comes to the ER after trying to kill himself by jumping off a bridge. Patient ambulated here without difficulty. He states he was trying to kill himself. Complained of facial pain. The CT of the Brain - No acute intracranial abnormality seen; CT Cervical Spine- No acute fractures or malallignment of the cervical spine. The CT of Maxillofacial skeleton without contrast - Non- displaced fracture of the right mandibular ramus fracture and the lateral right ptergoid plate. Minimal displaced nasal bone fracture. No air fluid levels are present. Under the heading- MDM-Psychiatric Illness the ED physician documents the following : ED Course: CT of brain and CT of spine read as no injury. Facial bones study shows Non- displaced fracture of the right mandibular ramus fracture (Broken jaw) and ptergoid plate fractures (Facial fractures involving upper jaw bones) as well as several displaced teeth. Spoke with Dr. M___Trauma Service at ______ (county hospital) and he is accepting patient in transfer. The ED physician documents under Consultation: Referral/Consultant name: Dr. N___, ( On-Call physician for Maxillofacial/Plastic Surgery at WPH). Call returned: MD is a Plastic surgeon and advised patient to be seen by OMFS before being medically cleared for psych. There was no documented evidence in the medical record to indicate that on 11/1/2012 patient #5 was seen and evaluated by the on call OMS physician. A review of the on-call schedules verified that Dr. N was the OMFS physician on- call on 11/1/2012. The facility failed to ensure that the OMFS on call physician came to the ED to evaluate patient #5 on 11/1/2012 after being notified. The Plastic Surgeon was on call for OMFS at West Palm hospital on [DATE]. Disposition: - Psych. Illness; Clinical Impression: Primary Impression: Suicide attempt Additional Impressions: Facial Laceration, Fracture of the mandible, Fracture of tooth On the facility document titled: EMTALA Memorandum of Transfer, the physician documented the following: Medical Condition: Right Mandible fracture/subluxed teeth/Suicidal. Risk and Benefits for Transfer: Obtain level of care/services unavailable at this facility. Service: OMFS Patient Consent to Medically Indicated Transfer or Patient Request for Transfer: There is an X in the box adjacent the words I hereby Consent to Transfer to another facility. The words Baker Act is written in as the reason for transfer. The patient signs the document. Review of the Transfer Log under D/C Diagnosis a nurse documented Right Mandible Fx. Subluxed teeth/Baker Act. Reason for the Transfer: OMFS. EMTALA Transfer Acceptance or Denial Form: Problem or Diagnosis Right mandible fracture, subluxed teeth; Reason for Transfer: Needs specialized level of OMFS care. Disposition : Transferred to ______(county hospital); Disposition time: 0334 In an interview at the time of the review, the ED Nurse Manager contends that the patient was accepted as a Trauma patient. Review of the receiving hospital ED Record revealed at 0611 the Physician Assistant (PA) documented under ED Physician Notes: The need for follow-up as outpatient discussed with patient/guardian for definitive care and OMFS specialist, the need to transfer to another facility. To return to ED if symptoms worsen. The PA discussed the case with Dr. K____. The CT were reviewed. Okay for follow - up as outpatient. At 0453 the PA writes Psychiatric Baker Act (BA) procedures completed. The diagnosis Multiple mandibular fractures; Major Depression, Suicidal Ideation's and medically cleared. At 0845 hours the nurse documents the patient was transferred to another psychiatric facility.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on reviews of medical records, on call schedules, facility license, delineation of privileges, policies and procedures, and interviews the facility failed to provide an appropriate transfer by not providing further evaluation and medical treatment within its capacity to minimize the risks and transferring unstable individuals to a facility with the same level of care for 2 of 20 sampled patients requiring oral maxillofacial services (Patients #2 and 5). Findings are: The facility's policy titled EMTALA- FL Transfer Policy Policy # 5.10.2; effective 5/9/01 revised 5/31/12 was reviewed. The policy stated in part, b. A transfer will be an appropriate transfers if: i. The transferring hospital provides medical treatment within its capacity that minimizes the risk of the individuals health. 1) Review of the medical record revealed Patient # 2 (MDS) dated [DATE] at 1521 hours. The chief complaint: Hit in head with unknown object. The patient is seen by the ED physician at 1523. The physician documents a Medical Screening Exam (MSE) as follows: CT Scan - CT Cervical Spine without contrast - Negative non-contrast enhanced CT study of the cervical spine. No cervical spine fractures or subluxations seen. CT Scan -CT Brain without contrast - No acute intracranial abnormalities identified. CT Scan- Facial Bones without contrast 1531 hours. Comminuted Right zygomaticofrontal complex fracture involving lateral and inferior walls of right orbit with air within the extraconal post septal orbital fat and partial opacification of the right maxillary sinus. This is described by the ED Medical Director at 0915 hours on 11/9/12 as a Blow Out Fracture. ED Course: Patient course: stable , improved. Disposition -Head Injury: The ED physician documents the following in the ED record: Counseled patient /family regarding: diagnosis, imaging studies, need for transfer. Patient and girl friend said they cannot afford to follow up with a Maxillofacial Surgeon. Will transfer to _______(county hospital). On the facility document titled: EMTALA Memorandum of Transfer, the physician documented the following: Medical Condition: Orbit Fx. Multiple; Risk and Benefits for Transfer: Obtain level of care/services unavailable at this facility. The hospital's October 2012 Emergency Service call schedule was reviewed. Review of the call schedule verified that on 10/21/12 West Palm Hospital had on call OMFS/Plastics for patient #2. Review of the Transfer Log under D/C Diagnosis the ED physician wrote Multiple Facial Fx. Reason for the Transfer: Maxillofacial Surgery. On the EMTALA Transfer Acceptance or Denial Form: Problem or Diagnosis Multiple Facial Fx and Reason for Transfer: Maxillofacial/Trauma. At 1715 the ED physician calls the ED physician at ________ (county hospital). The Consultant accepts the transfer. Disposition Transferred to: _________(county hospital). Disposition time: 1720 hours. Review of the ED record from the receiving facility revealed the patient's stay in the ED at the county hospital was 1 hour and 15 minutes. The patient was discharged home at 2204 hours with instructions for follow - up. The patient was given a referral plan. 2) Patient #5 presented to ED on 11/1/12 at 12:00 a.m. The Triage nurse documents the following: Chief complaint, Tried to kill myself, I jumped off a bridge. The nurse documented the patient complained of a right elbow, jaw pain, a 4 centimeter (cm.) laceration to chin- not actively bleeding, lip laceration and suicide attempt. The patient is seen by the ED physician at 0004. The physician documents a Medical Screening Exam (MSE) as follows: Patient comes to the ER after trying to kill himself by jumping off a bridge. Patient ambulated here without difficulty. He states he was trying to kill himself. Complained of facial pain. The CT of the Brain - No acute intracranial abnormality seen; CT Cervical Spine- No acute fractures or malallignment of the cervical spine. The CT of Maxillofacial skeleton without contrast - Non- displaced fracture of the right mandibular ramus fracture and the lateral right ptergoid plate. Minimal displaced nasal bone fracture. No air fluid levels are present. Under the heading- MDM-Psychiatric Illness the ED physician documents the following : ED Course: CT of brain and CT of spine read as no injury. Facial bones study shows Non- displaced fracture of the right mandibular ramus fracture (Broken jaw) and ptergoid plate fractures (Facial fractures involving upper jaw bones) as well as several displaced teeth. Spoke with Dr. M___Trauma Service at ______ (county hospital) and he is accepting patient in transfer. The ED physician documents under Consultation: Referral/Consultant name: Dr. N___, ( On-Call physician for Maxillofacial/Plastic Surgery at WPH). Call returned: MD is a Plastic surgeon and advised patient to be seen by OMFS before being medically cleared for psych. There was no documented evidence in the medical record to indicate that on 11/1/2012/patient #5 was seen and evaluated by the on call OMS physician. A review of the on-call schedules verified that Dr. N was the OMFS physician on- call on 11/1/2012. The facility failed to ensure that the OMFS on call physician came to the ED to evaluate patient #5 on 11/1/2012 after being notified, as this resulted in an inappropriate transfer for patient #5. The Plastic Surgeon was on call for OMFS at West Palm hospital on [DATE]. Disposition: - Psych. Illness; Clinical Impression: Primary Impression: Suicide attempt Additional Impressions: Facial Laceration, Fracture of the mandible, Fracture of tooth On the facility document titled: EMTALA Memorandum of Transfer, the physician documented the following: Medical Condition: Right Mandible fracture/subluxed teeth/Suicidal. Risk and Benefits for Transfer: Obtain level of care/services unavailable at this facility. Service: OMFS Patient Consent to Medically Indicated Transfer or Patient Request for Transfer: There is an X in the box adjacent the words I hereby Consent to Transfer to another facility. The words Baker Act is written in as the reason for transfer. The patient signs the document. Review of the Transfer Log under D/C Diagnosis a nurse documented Right Mandible Fx. Subluxed teeth/Baker Act. Reason for the Transfer: OMFS. EMTALA Transfer Acceptance or Denial Form: Problem or Diagnosis Right mandible fracture, subluxed teeth; Reason for Transfer: Needs specialized level of OMFS care. Disposition : Transferred to ______(county hospital); Disposition time: 0334 In an interview at the time of the record review, the ED Nurse Manager contends that the patient was accepted as a Trauma patient. Review of the receiving hospital ED Record revealed at 0611 the Physician Assistant (PA) documented under ED Physician Notes: The need for follow-up as outpatient discussed with patient/guardian for definitive care and OMFS specialist, the need to transfer to another facility. To return to ED if symptoms worsen. The PA discussed the case with Dr. K____. The CT were reviewed. Okay for follow - up as outpatient. At 0453 the PA writes Psychiatric Baker Act (BA) procedures completed. The diagnosis Multiple mandibular fractures; Major Depression, Suicidal Ideation's and medically cleared. At 0845 hours the nurse documents the patient was transferred to another psychiatric facility. West Palm Hospital had the capacities and facilities to provide further medical examination and treatment for patient #2 on 11/21/12 and patient #5 on 11/1/12, as this resulted in the inappropriate transfers of these individuals.
Based on clinical record reviews and staff interviews, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services to determine whether or not an emergency medical condition exist for 1 of 20 sampled patients (#1). Please refer to the deficient practice cited in this report at A2406.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on clinical record reviews and staff interviews, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services to determine whether or not an emergency medical condition exist for 1 of 20 sampled patients (#1). The findings include: Review of the clinical record for patient #1 revealed the patient (MDS) dated [DATE] at 4:20 p.m. Documentation by the triage nurse on the Triage Encounter Record dated 3/27/2011 revealed in part, Chief Complaint,: GI (gastro-instestinal) Pain... Assessment...Patient presents to ER (emergency room ) with Epigastric pain times (for) 4 days, seen by PMD (Primary Medical Doctor) for same Friday.. . Priority level (Triage Level: evaluation to determine order of treatment) 3 The writer notes includes, patient presents to ER with epigastric pain, last 5 minutes then resolves, denies N/V/D (nausea/vomiting/diarrhea); last BM (bowel movement) today soft; denies urinary S&S (sign / symptoms) tolerating PO (oral) well. Current PO medications listed the patient on Metformin 100 (mg) milligrams twice daily and Metoprolol XL/ Toprol-Xl 100 twice daily. The patient also took the following medications only once daily: Folic Acid 1 mg; Prenatal Vitamins 1 tab, Losartan/HCTZ 100/ 25 mg , Nifedipine ER 90 mg Aspirin 81 mg and Allopurinol 200 mg. Additionally, the patient took Simvastatin/Zocar 80 mg. at bedtime . There were no allergies to drugs noted. The pain assessment on the Triage Record notes: Pain location: abdomen; Pain intensity: 2. The Physician Assistant documented on the Emergency Department Physician Medical Record (medical screening examination) notes includes: History of Present Illness - A [AGE] year old female with epigastric pain times (for) 2 days. This is a noted discrepancy with the information documented in the Triage Record as epigastric pain for 4 days. The note continues to specify, seen by primary MD for same; given suppositories for nausea; no N/V/D (nausea /vomiting/diarrhea); stool yellow. The time (duration of the pain) is indicated as intermittent. The quality of the pain is documented as an ache and cramping, pain worsened with meals. The severity of the pain is documented as being mild - severe, illegible note / 10. (Interview with the Physician Assistant (PA) later presented in this report identifies the illegible notation as 2.) Associated symptoms documented are: nausea, vomiting. The patient was not experiencing nausea / vomiting / diarrhea while in the ER being examined; however patient #1 did report experiencing the occurrences prior to visiting the ER as noted in the medical screening examination note documented by the PA under Associated Symptoms. Documentation also revealed that patient#1 had a past medical history of Hypertension, Diabetes, Coronary Artery Disease and Hypercholesterolemia (high cholesterol). The patient's surgical history included a hysterectomy, neck and back. the section titled Physical Exam indicated in part, ABDOM (Abdomen): Benign Abdomen. The medical screening exam note does not document the performance of any ancillary services such as laboratory diagnostic tests, x-ray, CT (computerized axial tomography scan is an x-ray procedure that combines many x-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body)abdominal scan etc. to determine if an emergency medical condition existed for patient #1. The medications Bentyl and Tagamet were prescribed for the patient with the notation to follow up with primary MD(medical doctor) tomorrow. Patient #1 presented to another acute care hospital on March 29, 2011 at 12:09 p.m. Review of the nurses triage notes indicated that patient #1 presented with complaint of I've been feeling nauseous and throwing up since Wednesday. Review of the history and physical dated 3/29/2011 indicated the patient presented to the ER with complaint of abdominal pain associated with vomiting. Documentation by the Emergency Department physician revealed that patient #1 reported that on Friday (3/25/2011), Initially she had vomiting which was brown in color so she was seen on Sunday (3/27/2011) at Columbia Hospital and was discharged home. Further review revealed that Laboratory tests were ordered, intravenous (IV) fluids were administered, CT of the abdomen, GI consult, Zofran (medication used to prevent nausea and vomiting) and pain medications were administered. The physical examination included ... Abdomen: mild to moderate tenderness located in the epigastric area. No rigidity, no rebound tenderness.. A review of the consultation report dated 3/29/2011 indicated in part, presents with 3-4 days of nausea and vomiting. An acute abdominal series was consistent with a possible distal small bowel obstruction. .. CT of the abdomen and pelvis was performed which showed only severe small bowel obstruction ...distal ileum as well as gallstones. Patient #1 was admitted to the hospital, and was taken emergently to surgery on 3/30/2011 and expired on [DATE]. During an interview, on 4/01/11 at 12 PM, with the director of the ER the director stated there was no evidence of an emergency medical condition for patient #1, and no IV fluids, no laboratory work, no CT scans, and no medications with narcotics so she was discharged home by herself. Interview on 4/01/11 at 12:30 PM with the triage nurse revealed he remembered patient #1. The nurse stated, the patient drove herself to the facility with a bag of medications. She stated that her tummy was burning at the doctor's office on Friday but the doctor found nothing to treat. She had asked the doctor for pain medication but the physician gave her Phenergan suppositories for nausea. She told the triage nurse she had no intention of putting them in, and that every time she eats it burns. The physician told her on Sunday to go to the ER. She told the triage nurse that she had never taken any medication for heartburn. The patient had a non toxic appearance. She did not mention her bowels, nausea, vomiting or diarrhea right away. She pointed to her epigastric area with her finger and said that when she eats she has a pain right there. It lasts 5 minutes and resolves. The triage nurse stated that patient #1 did not report a history of arthritis, sickle cell disease or any other disease for the medications that she brought. The patient did have a history of high blood pressure, high cholesterol, and diabetes and had those medications with her. Interview on 4/01/11 at 1:00 PM with the Physician Assistant (PA) who performed the medical screening examination on patient #1 in the ER revealed he remembered patient #1. The PA stated, the patient had seen the primary care physician and the physician gave the patient Phenergan suppositories for nausea. The patient asked the PA to give her a pain killer for the epigastric pain. She pointed to the location of the pain for her. She reported to the PA that she had no nausea, vomiting or diarrhea and that her stool had been yellow that morning. The PA said, the patient had no chest pain, or she would have been admitted immediately. The patient was very specific that her pain was epigastric and that she wanted pain medication. There was no indication for labs, EKG, X-rays or CT scans. During an interview with the medical director of the E.R., who was the ER physician who was the physician in the ER at he time patient #1 was in the ER, on 4/4/11 at 11:30 AM the medical director said the PA saw and examined the patient; the ER physician on duty must observe the patient before he/she cosigns the exam and care on the clinical record. He examined the patient and went over the clinical record with the PA. The medical director / ER physician said he found that the patient had stable vital signs with epigastric pain that subsided after 5 minutes after eating. He added, contrary to the Triage record and the PA medical screening exam note, the patient had no pain at the time of the ER visit, no acute abdominal symptoms, no rigidity of the abdomen.
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