HospitalInspections.org

Based on interview and record review, the facility's medical staff failed to ensure policies and procedures were developed and implemented for five of 21 sampled patients (Patients 3, 5, 13, 14, and 16), as follows:

1. The hospital failed to have sufficient rules and regulations, and policies and procedures regarding the use of Physician Assistants (PA) in the Emergency Department (ED), when it was not specifically stated in the Medical Staff Bylaws or Rules and Regulations, who was a Medically Qualified Professional (QMP) capable of performing a Medical Screening Exam (MSE), not specific as to the types of patients a PA could see in the ED, and not specifically stated as to how the supervising physician was going to monitor the progress of a patient who was being cared for by a PA. As a result, Patients 3 and 5 received care by a PA, without documentation of supervision, by the physician on duty. This further has the potential for confusion as to the types of patients seen by PA's as well as the acuity level of each patient, and could result in a decline in their medical condition.

2. The hospital failed to have a policy and procedure for how discharge decisions are coordinated and documented for psychiatric patients when services are coordinated with County Behavioral Health Services. This resulted in Patient 16's record having no evidence of the county decision that it was safe to discharge Patient 16 to home.

3. Patients 13 and 14 did not have documentation whether follow-up was needed or performed following their leaving the ED without being seen.

Findings:

1. 42 CFR 489.24(a)(1)(i) read, "The MSE must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of 482.55 concerning emergency services personnel and direction. The designation of the QMP should be set forth in a document approved by the governing body of the hospital. If the rules and regulations are approved by the board of trustees or other governing body, those personnel qualified to perform the MSE's may be set forth in the rules and regulations, or the hospital bylaws. It is not acceptable for the hospital to allow informal personnel appointments that could frequently change."

A review of Patient 3's record indicted she presented to the ED on 10/6/17, with complaints of being pregnant, lower abdominal pain, nausea and vomiting. Patient 3 was assigned a Triage acuity level (the first assessment by a nurse to determine the priority of their needs) of 3 (per facility Triage policy a Level 3 was potentially unstable, required two or more resources and vital signs may or may not be in the danger zone). PA 1 completed the MSE. After Patient 3 was discharged home, a supervising physician co-signed the record. Nothing in the record indicated PA 1 spoke to the supervising physician regarding the care of this patient, prior to discharge of Patient 3.

During an interview on 10/17/17 at 1:20 pm, the Director of Quality (DQ) confirmed there was no statement documented by PA 1 which indicated a conversation with the supervising physician prior to the discharge of Patient 3. DQ confirmed the supervising physician co-signed the record after Patient 3 was discharged.

A review of Patient 5's record indicated she came to the ED on 2/25/17, with complaints of being pregnant, with cramping, and bleeding. Patient 5 was assigned a Triage acuity level of 3. PA 2 completed the MSE. After Patient 5 was discharged home, a supervising physician co-signed the record. Nothing in the record indicated PA 2 spoke to the supervising physician regarding the care of this patient, prior to discharge of Patient 5.

During an interview on 10/16/17 at 2:50 pm, DQ confirmed there was no statement documented by PA 2 which indicated a conversation with the supervising physician prior to the discharge of Patient 5. DQ confirmed the supervising physician co-signed the record after Patient 5 was discharged.

DQ provided statistics which indicated PA's saw 28.4% of the ED patients over the past three months.

During an interview on 10/16/17 at 1 pm, the Medical Staff Director (MSD) stated there was nothing in the facility's policies and procedures, or Medical Staff Bylaws or Rules and Regulations, that specifically stated who was qualified to perform a MSE, or what patients, according to their Triage Acuity Levels, that PA's could examine.

On 10/17/17 at 10:30 am, PA 1 and PA 2's credentialing files and PA Standards/Privilege Lists were reviewed with MSD. MSD confirmed the files did not contain specific language indicating they were QMP's and there was nothing specific in writing as to what kinds of patients the PA's could see in the ED.

The PA Standards/Privilege List read, "The supervising physician has continuing responsibility to follow the progress of the patient and to make sure that the physician assistant does not function autonomously."

During an interview on 10/17/17 at 11:35 am, the ED Medical Director (EDMD) was referred to the above statement in the Privilege List and asked how the above was accomplished. EDMD stated the PAs would discuss the care of the patients with the supervising physicians and a note should be in the patient's record regarding this conversation. EDMD stated PA's examine and treat only Triage Level 3, 4, and 5 patients and do not treat patients with Triage Levels of 1 or 2. He stated this was a practice but it was not written in the Medical Staff Rules and Regulations or hospital policies.




26611


2. On 10/17/17, Patient 16's record was reviewed. Patient 16 presented to the ED on 9/13/17 at 2:34 am with suicidal ideations (thoughts). The record indicated at 5:49 am, a tele-psych (psychiatrist consultation via phone and video) consultation recommended Patient 16 be admitted for behavioral health services. The ED visit summary included a notation that the County Behavioral Health saw Patient 16 at 2:40 pm and determined Patient 16 was ready for discharge at 5:44 pm. Patient 16 was discharged home at 6:11 pm. Patient 16's record did not include documentation that explained the change in disposition from admit to instead home.

On 10/17/17 at 2:45 pm, the Director of the ED (DED) explained that Patient 16 had medical clearance and was waiting for the County Behavioral Health Services to evaluate Patient 16. DED stated the County does not always agree with the tele-psych recommendations. DED further stated the County does not always provide them with the documentation to make the discharge decisions clear in the medical record. DED was asked for the policy regarding the discharge and documentation process for the County involvement and she stated they did not have a policy.

3a. Patient 14 presented on 10/6/16 at 2:30 am pregnant with suicidal ideations. The triage (the first assessment by a nurse to determine the priority of their needs) note did not contain information about how many weeks pregnant. Patient 14 was noted to have left without being seen at 2:53 am. No follow-up was noted on Patient 14's record

3b. On 10/17/17, Patients 13's record was reviewed. Patient 13 presented to the ED on 9/12/17 at 3:41 am with a complaint of a possible medication ingestion error. Patient 13's record indicated she left prior to triage at 3:52 am. No follow-up was noted on Patient 13's record.

The hospital policy "Left before Triage, Left Without Being Seen, Elopement, Against Medical Advice," new on 3/1995 and last updated 4/2017, indicated that the ED physician/Midlevel in collaboration with the Charge Nurse shall determine appropriate follow-up action.

On 10/17/17 at 2:50 pm, DED stated the ED personnel do follow up on some patients but there is not a structured format for how they decide who gets followed-up on, and if that is documented in the patient record. DED also acknowledged the number of weeks of pregnancy should be recorded on the triage note.

Based on observation, interview, and record review, the hospital failed to ensure that adequate and qualified personnel were available to meet the anticipated Emergency Department (ED) needs for four of 21 sampled patients (Patient 10, 12, 15, and 16) as follows:

1. Nursing staff were not qualified by training to get a blood pressure for Patient 10, who had a LVAD (left ventricular assist device, a heart pump). This failure could result in a misdiagnosis.

2. Patient 16 had a period of approximately five hours without a nursing assessment. This failure could result in patients' changes in condition going undetected.

3. Registered Nurse (RN) D, did not have the same triage training as other ED RNs, and did not document a triage level for Patient 15. This failure could result in delays in getting needed services in a timely fashion and negatively impact patient health.

Triage is the sorting of patients in priority (levels 1 to 5) of the urgency of the their care using a Level 1 as the most life threatening and Level 5 as a visit that requires services consistent with a routine physician visit.

4. Patient 12's record indicated the ED physician saw Patient 12 and no record of this evaluation was available. This failure can lead to miscommunication regarding patient evaluation and result in a patient not being seen by a provider.

5. The ED did not have adequate staffing to ensure the environment was kept clean, and safe from accidental puncture wounds from an over-full sharps container. These failures placed patients and staff at risk for cross contamination and infection.


Findings:

1. On 10/16/17, Patient 10's record was reviewed. Patient 10 presented to the ED with a LVAD alarm indicating the LVAD may have a clot. Patient 10 was transferred to the hospital that inserted the LVAD for further work-up. Patient 10's record did not contain evidence of blood pressure measurements by the nurse caring for Patient 10, RN B.

In an interview on 10/16/17, when asked about how blood pressure is measured for LVAD patients, the Director of the ED (DED) provided documentation that was provided to the hospital regarding Patient 10's LVAD. A letter, dated 5/17/13, was sent to the ED Nursing Educator, that read, "This letter is to inform you that one of our patients (Patient 10) is being discharged into your community. We want to let you know because this patient has special healthcare needs. As a potential first responder, you may appreciate knowing in advance how to respond to potential emergencies concerning this patient. (Patient 10) has a ...LVAD or "blood pump." The device is implanted along-side the patient's native (own) heart. It takes over the pumping function of the sick or weakened heart so that the lungs, organs, and tissues get the oxygen-rich blood they need. The LVAD is considered a life sustaining device.... Additional in-service program and educational material are available if you or members of your staff would like additional training or information." DED also provided a document from their resource manual on the LVAD which read, "Use a Doppler (sound waves) to measure patient's blood pressure."

On 10/17/17, RN B's personnel file was reviewed and did not contain evidence of LVAD training.

In an interview on 10/17/17 at 2:30 pm, the ED Educator acknowledged no training had been recorded that ED nursing staff were educated on the care of an LVAD patient nor was a policy developed.

In an interview on 10/17/17 at 3:40 pm, DED acknowledged nurses should be knowledgeable of how to care for an LVAD patient, including how to get a blood pressure.

2. On 10/17/17, Patient 16's record was reviewed. Patient 16 presented to the ED on 9/13/17 at 2:34 am with suicidal ideations (thoughts). Patient 1 was triaged at a level 2 (serious or acute condition or injury that might endanger loss of life or limb or vision without treatment). Patient 16's record indicated that the last nursing assessment prior to the discharge assessment at 6:09 pm was conducted at 1:03 pm, approximately five hours prior.

The hospital policy "Assessment and Reassessment of Patients," dated 8/19/17, read under the section for the ED, "Reassessments and vital signs are performed as appropriate to the nature and severity of the patient's illness/injury, level of pain and treatment/medications given. At a minimum:... Level 2 at least every 15-30 minutes with the understanding that more frequent assessment is often indicated and will be expected until vital signs are stable. If vital signs are stable they must be measured every 30 minutes to every hour.... Level 5 at least every 4 hours."

In an interview on 10/17/17 at 2:45 pm, DED reviewed the record and acknowledged that Patient 16 was not reassessed according to policy.

3. On 10/17/17, Patient 15's record was reviewed. Patient 15 presented to the ED on 1/4/17 with complaints of vomiting and dehydration. Patient 15's record did not contain evidence of a triage level.

The hospital policy "Triage," dated 1/90, read, "upon arrival a RN will perform a brief targeted history and focused assessment to determine the appropriate ESI (triage) level.

On 10/17/17, ED RN D's personnel file was reviewed. ED RN D's file contained Triage training dated 7/14/15 but did not contain training that other ED RN's had in their files for "Triage for the Experienced Nurse" in 2017.

In an interview on 10/17/17 at 2:45 pm, DED acknowledged Patient 15's record did not contain a triage level and RN D did not have evidence of the most current training on triage.

4. On 10/17/17, Patient 12's record was reviewed. Patient 12 presented to the ED on 6/8/17 with complaints of stomach pains. Patient 12's record had a notation in the ED Visit Summary that indicated Patient 12 was with the physician at 3:08 am and that the patient left without being seen by the provider at 3:35 am. Patient 12's record did not contain any evidence of a medical screening exam.

In an interview on 10/17/17 at 3:25 pm, DED reviewed Patient 12's record and stated the physician's have scribes who document their examinations. DED further stated sometimes the scribes will indicate in the computer that the physician is with the patient prior to the physician actually arriving at the room to evaluate the patient. DED related that when the scribe indicated this event in advance, like for Patient 12, this creates an inaccurate record.

5. On 10/16/17 at 9:30 am, ED Rooms 1 and 2 were observed to have dirty floors and an over-full sharps container (used to dispose of syringes and needles).

In an interview on 10/16/17 when the Quality Director suggested the floors' condition was due to not being waxed, a damp paper towel was swiped over a 12 inch section of the Room 2 floor and revealed heavy dark black residue. In a concurrent interview, DED acknowledged the floor was dirty and the DED acknowledged the sharps container needed to be changed out for a new container.

The ED cleaning schedule and record of cleaning was reviewed. Room 1 and 2 floor cleaning with a damp mop was documented on 10/14/15. No cleaning for Rooms 1 and 2 (and other areas of the ED) was documented on 10/15/17. Floor buffing for Rooms 1 and 2 had not been completed since 3/2017, greater than six months prior.

The hospital policy "ED Room Cleaning," dated 2/2015, indicated all floors were to be cleaned daily and floors would be buffed weekly.

In an interview on 10/16/17 at 2:45 am, Environmental Service Worker (EVS) E stated one person was assigned to clean all the ED. EVS E stated she could not do it all and had to rely on the ED techs to help her with room turnover but the ED techs did not have access to equipment to clean the floors. EVS E further stated that the worker assigned to wax and buff the floors cannot keep up with the schedule. EVS E also reported that nurses will stop her from cleaning floors in certain rooms and that causes a build up of dirt. EVS E was informed about the above observation and then asked if Rooms 1 and 2 were truly cleaned on 10/14/17, she replied that the emphasis was on making sure the paperwork was complete.

In an interview on 10/16/17 at 3 pm, the Director of EVS (DEVS) acknowledged that it was not possible to keep up with the room turnover in the ED. DEVS stated she had advocated for more staff but still there was no plan for additional staff.

In an interview on 10/16/17 at 2:35 pm, the Chief Nursing Officer acknowledged that increased staff was needed to ensure a safe ED environment.

Based on observation, interview and record review, the facility failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) as evidenced by:

1. The facility failed to provide a medical screening exam (MSE) for Patient 1. (Refer to A 2406)

2. The facility failed to clearly post all EMTALA signs in the Emergency Department (ED) waiting room. (Refer to A 2402)

3. The facility failed to ensure the ED log included the names of all patients who presented for treatment as well as other inaccuracies including the patient complaint and discharge locations. (Refer to A 2405)

Based on observation, interview, and record review, the facility failed to clearly post signs for all persons using the Emergency Department's (ED) waiting room when seeking medical attention, with respect to the examination and treatment of Emergency Medical Conditions (EMC) including women in labor.

Findings:

A review of the facility's policy titled, "EMTALA - Compliance with the Emergency Medical Treatment and Active Labor Act, dated 2/2017, was reviewed. Under Signage it read: the facility "shall post signs conspicuously in lobbies, waiting rooms, admitting areas and treatment rooms where examination and treatment occurs in the form required by CMS (Centers for Medicare and Medicaid Services) that specifies the rights of individuals to examination and treatment for emergency conditions. Signs shall be posted in the Emergency Department, Labor and Delivery, ambulatory clinics and other locations where patients may present for emergency services."

On 10/16/17 at 9 am a tour of the ED was conducted with the Director of Quality (DQ), Chief Nursing Officer (CNO), and Director of ED. Doors for the public to use to enter the ED were observed to open into the waiting room. This area had no signs relating to the rights of individuals with EMCs and women in labor, who came to the ED for health care services, next to the entrance or elsewhere within the waiting room.

During an interview on 10/16/17 at 9:10 am, the CNO and DQ confirmed the signs were missing. They stated the signs may have been removed when the room was painted and not reposted.

Based on interview and record review, for those patients presenting to the hospital's Emergency Department (ED) the hospital failed to maintain a central log in which each patient presenting for emergency care was listed along with all of the information required by CFR 489.24 and hospital policy. The specific information missing from the ED log included the name for one of 21 sampled patients (Patient 1), the patients' presenting chief complaint (the medical problem which prompted the patient to come to the ED) was inaccurate for seven of 21 sampled patients (Patients 3, 4, 5, 7, 8, 14, and 16), and the disposition (admit, transfer, or discharge) location was inaccurate for one of 21 sampled patients (Patient 9). This failure had the potential to result in the facility's inability to accurately track the care given to each patient.

Findings:

A review of the facility's policy titled, "EMTALA - Compliance with the Emergency Medical Treatment and Active Labor Act, dated 2/2017, was reviewed. It read, under Central Log: Each department of the hospital that provides medical screening examination shall maintain a central log recording the following: patient's name, date of birth, sex, chief complaint, arrival time, triage time, registration time, MSE (medical screening exam) time, medical record/account number, mode of arrival, name of LIP (licensed independent provider) who provided the MSE, if admitted the name of the admitting LIP, and disposition of the patient including refusals of treatment, transfers, admitted, stabilized and transferred, or discharged.

1. During an interview on 10/12/17 at 1:55 pm, the admitting clerk supervisor (ACS) stated she had been working for about two weeks in the ED at the time of an incident on 10/4/17. She said a young woman who was obviously pregnant came in and sat in a wheelchair with her hands around her abdomen, moaning. She was accompanied by a young man and a middle aged woman who came up to the desk and said, my daughter is in labor. ACS stated she told them, Hospital B has OB services(obstetrics - care of women before, during, and after childbirth). The mother said Hospital B does OB, we should go to Hospital B. ACS stated she parroted what the mother had said, and said, go to Hospital B. ACS stated she did not ask the name of Patient 1 so she was unable to write it in the ED log.

2 a. A review of Patient 3's record indicated she came to the ED with complaints of being pregnant, lower abdominal pain, nausea and vomiting.

b. A review of Patient 4's record indicated she came to the ED with complaints of flank pain and was possibly pregnant.

c. A review of Patient 5's record indicated she came to the ED with complaints of being pregnant, with cramping and bleeding.

d. A review of Patient 7's record indicated she came to the ED with complaints of being pregnant and urinary symptoms.

e. A review of Patient 8's record indicated she came to the ED with complaints of being pregnant, bleeding, and painful urination.

During a concurrent interview and record review of the hospital's ED Log for Patients 3, 4, 5, 7, and 8, the Director of Quality (DQ) confirmed the documented reason for the visit, in the ED log, was, "pregnancy complications" as opposed to the specific reasons stated by the patients.



26611

3a. A review of Patient 14's record on 10/17/17 indicated she presented to the ED with suicidal ideations (thoughts) on 11/6/16.

The ED log indicated Patient 14's presenting complaint was "Eval."

3b. A review of Patient 16's record on 10/17/17 indicated she presented to the ED with suicidal ideations on 9/13/17.

The ED log indicated Patient 16's presenting complaint was "Eval."

In an interview on 10/17/17 at 2:45 pm, the Director of the ED (DED) reviewed Patient 14 and 16's records and acknowledged the log was not accurate for the presenting complaints for Patients 14 and 16.

4. A review of Patient 9's record on 10/16/17 indicated that Patient 9 admitted to the hospital for chest pains.

The ED log indicated that Patient 9 was transferred to another acute care hospital.

On 10/17/17 at 2:35 pm, DED reviewed Patient 9's record and acknowledged the log was inaccurate for Patient 9's disposition. The DED stated the ED did not have a process in place to monitor the accuracy of the ED log.

Based on interview and record review, the facility (Hospital A) failed to provide an emergency medical screening (MSE) to determine if an Emergency Medical Condition (EMC) existed, for one of 21 sampled patients (Patient 1), when Patient 1 presented to the Emergency Department (ED) in active labor and was told the hospital did not provide maternity (period during pregnancy and shortly after childbirth) services. Patient 1 then went to Hospital B where she underwent an emergency Caesarean section (C-section) for a breech presentation (position of the baby in which the feet or buttocks appear first during birth).

The facility also failed to implement their policies regarding Emergency Medical Treatment and Active Labor Act (EMTALA), and care of the OB (obstetrics - care of women before, during, and after childbirth) Patient in the ED.

This failure led to a delay in the assessment and treatment of Patient 1 potentially endangering her life and that of her unborn baby.

Findings:

The facility's "EMTALA - Compliance with the Emergency Medical Treatment and Active Labor Act" policy, dated 2/2017, was reviewed. It read: "Any individual who "comes to the hospital emergency department" requesting examination or treatment shall be provided with an appropriate Medical Screening Exam (MSE). This MSE will determine whether an individual has an actual Emergency Medical Condition (EMC). This exam should be done in a non-discriminatory way."

The facility's "Care of the OB Patient in the ED" policy, dated 4/2017, was reviewed. Under the "Policy" section it read: "Evaluate all women who present to the ED with obstetrical and pregnancy related medical complaints. Evaluate all women who are pregnant and who present with other than a pregnancy related complaint. Be in compliance with EMTALA. Provide safe transfer and transport of patient to other facilities requiring obstetrical services not available." Under the "Procedure" section it read: "Patients who are pregnant and present to the ED will be triaged by a Registered Nurse and will have a MSE provided by a physician and/or qualified medical provider. Appropriate work up and treatment will be provided as indicated by the medical evaluation using the resources available."

On 10/6/17 at 2:27 pm, the California Department of Public Health (CDPH) received a fax from the Director of Quality (DQ) at this hospital (Hospital A). DQ reported that Patient 1, who was in active labor, presented to their ED on 10/4/17, and was told by their registration clerk that Hospital A did not provide maternity services, so Patient A went to Hospital B.

On 10/6/17 at 3:32 pm, CDPH received a fax from the Manager of Regulatory Readiness (MRR) at Hospital B. MRR reported Patient 1 was refused care at Hospital A and directed to go to Hospital B, on 10/4/17. No medical exam was performed by Hospital A prior to sending Patient 1 by private vehicle to Hospital B.

A review of Patient 1's record from Hospital B indicated she presented to the facility on 10/4/17 at 5 pm. A medical screening exam was conducted immediately which indicated Patient 1 was having regular contractions. A bedside ultrasound (imaging method that uses sound waves to produce images of structures within the body) showed the baby to be in a breech position. The physician's impression was: active labor, proceed to C-section. Patient 1 was taken to the Operating Room at 5:21 pm and the baby was delivered with Apgar scores (a quick test done at one minute and repeated at five minutes which shows the physical condition of the baby ranging between 0 and 10, with 10 being the best condition possible) of eight and nine.

During an interview on 10/12/17 at 9:35 am, the Director of the ED (DED) stated she received a message from the ED Charge Nurse on 10/4/17, which informed her that the admitting clerk supervisor had sent a pregnant patient to Hospital B. DED stated the admitting clerks sat behind a desk with a window and would ask patients who come into the ED their name, date of birth, and what had brought them to the ED. DED stated, if a more experienced clerk had been working, she would have notified the nurse right away and brought the patient back into the treatment area.

During an interview on 10/12/17 at 1:55 pm, the admitting clerk supervisor (ACS) stated she had been working for about two weeks in the ED at the time of the incident on 10/4/17. She had previously worked in the business office. She said a young woman who was obviously pregnant came in and sat in a wheelchair with her hands around her abdomen, moaning. She was accompanied by a young man and a middle aged woman who came up to the desk and said, my daughter is in labor. ACS stated her first thought was that they were confused as to what hospital this was, since most pregnant patients go to Hospital B. ACS said she told them, Hospital B has OB services. The mother said, Hospital B does OB, we should go to Hospital B. ACS stated she parroted what the mother had said, and said, go to Hospital B. ACS said she did not ask the name of Patient 1. ACS stated a clinical staff nearby overheard what occurred and reported it to the Charge Nurse (CN) who discussed the incident with her shortly thereafter.

A statement from ACS, written on 10/4/17 was reviewed. This statement indicated on 10/4/17 between 4:30 and 5:30 pm, a young pregnant woman appeared in the lobby with an older woman and a young man. The older woman said, "my daughter is in labor." ACS said, "Oh Hospital B is the hospital who does OB. They have an OB ward." The woman said, "I thought this hospital did OB..we should go to Hospital B," and then repeated, "we should go to Hospital B." The entire family then whipped around and began heading out the door. ACS then repeated what the mother had said, and said, "yeah, go to Hospital B."

During an interview on 10/12/17 at 10 am, Registered Nurse (RN) A said she was on duty at the time of the incident and was sitting at the Rapid Assessment desk inside the ED. RN A said a patient "waddled" in and sat down in a wheelchair and her mom (she thinks) was with her. The mom came up to the window and she overheard ACS tell her, we don't have maternity services. After being told this, they walked out of the ED. RN A stated she did not intervene at the time because it all happened so quickly, but reported it to the charge nurse.

During an interview on 10/12/17 at 10:45 am, DQ confirmed the facility did not follow their policies regarding EMTALA and Care of the OB patient in the ED, and confirmed no MSE had been completed for Patient 1.