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Based on medical record reviews, interviews, and facility policy reviews, the facility's Governing Body failed to ensure medical staff followed hospital policy and procedures for two (#32 and #5) patients of fifty patients reviewed.

Refer to A 044 for the facility's failure to ensure medical staff followed hospital policy and procedures for two patients (#32 and #5).

Refer to A 115 for the facility's failure to protect one patient (#32) from harassment.

Based on medical record reviews, interviews, and facility policy reviews, the facility failed to ensure medical staff followed hospital policies and procedures for two (#32 and #5) patients of fifty patients reviewed.

The findings included:

Patient #32 presented to the Emergency Department (ED) on May 23, 2013, at 11:50 a.m., with a complaint of "laceration to left hand with a dye grinder blade."

Review of the Face Sheet revealed the patient was self-employed with no insurance coverage.

Review of Nurse's Notes dated May 23, 2013, revealed Patient #32 was triaged by Licensed Practical Nurse (LPN #1) and Registered Nurse (RN #1) at 11:54 a.m. Further review of the nurses notes dated May 23, 2013, at 11:54 a.m., revealed, "Laceration sustained to left hand is contaminated, 2.6 to 7.5 centimeters (cm) long, was sustained less than 30 minutes ago. Is bleeding moderately." Further review of the nurse's notes revealed, "12:00 pressure dressing applied. Ice pack applied."

Further review of the Nurse's Notes revealed the patient's pain was assessed at 12:01 p.m. as "8/10" (0-10 pain scale with 10 being the most severe, a score of 8 would indicate intense/very severe pain).

Review of Physician Documentation dated May 23, 2013, revealed Patient #32 was examined by a Physician Assistant (PA #1) at 12:59 p.m. and assessed as having "Deep laceration of the middle MP (the knuckle of the hand) region, superficial laceration of the 2nd MP region...positive for complete laceration extensor tendon of left middle finger." Further review of the Physician Documentation revealed Physician #2, "was called at 12:15 (pm)...regarding need to come to ED to see patient, and will see patient in the ED."

Further review of Nurses's Notes dated May 23, 2013, revealed intravenous (IV) access was obtained and Ancef (anti-biotic) one gram was given at 12:16 p.m.

Further review of Nurses's Notes dated May 23, 2013, revealed at 12:30 p.m., Physician #2 and PA #1 were "in to evaluate patient and speak with him about surgical process."

Further review of the Nurse's Notes dated May 23, 2013, revealed at 1:00 p.m., "went to see pt.(patient) asked him what the doctor said and he stated that he needed $2000.00 for doctor to do surgery...Discontinued IV...Bulk pressure dressing applied to patients hand to control bleeding per Dr...orders...bleeding has improved." Further review of the Nurse's Notes revealed at 1:14 p.m., "to bank by family member," and at 1:17 p.m., "...was told that pt has left on LOA (leave of absence) to go to bank to get money for surgery. Was told by Dr...that...CEO (Chief Executive Officer) approved for patient to go on LOA to go to bank..."

Further review of Nurse's Notes dated May 23, 2013, revealed at 1:43 p.m., "Patient back to ER (emergency room) and is in no apparent distress at this time."

Further review of Nurse's Notes dated May 23, 2013, revealed at 1:55 p.m., IV access was re-started, at 2:17 p.m., Physician #2 was with the patient, and 2:27 p.m., the patient left the ED (transferred to surgery).

Review of Consultation notes dated May 23, 2013, timed 4:05 p.m., and authenticated by Physician #2 on May 28, 2013, revealed, "Date of Consultation: 05/23/2013...Site...Emergency Room...History of Present Illness...sustained complex grinder injury to the dorsum (top) of the left hand with laceration in common extensors of left index and middle fingers...Plan: At this time was to the operating room for definitive treatment."

Review of the Operative Notes dated May 23, 2013, revealed, "Preoperative Diagnoses: Severe avulsion (forcible tearing of a body part by trauma) laceration on dorsum of left hand secondary to grinder injury with avulsion lacerations of the common extensors to the left index and middle fingers...Procedure: Repair of avulsion laceration to the common extensors to the left index and middle fingers and repair of complex avulsion laceration of dorsum left hand with application of...splint...plus sharp excisional debridement (cutting and removing) of necrotic (dead) tissue."

Review of Post-Operative notes dated May 23, 2013, revealed the patient was discharged home at 6:10 p.m.

Review of the medical record revealed a hand written note, on a blank piece of paper, dated May 23, 2013, no time documented, which stated, "...received $1000.00 toward...balance owed." Further review of this note revealed it was witnessed and signed by Financial Counselor #1 and Registrar #1.

Interview with RN #1 on January 16, 2014, at 11:00 a.m., in the emergency department eye examination room, revealed the RN remembered patient #32's visit to the ED on May 23, 2013. RN #1 stated, "I remember (physician #2) coming in to see the patient...I did not hear the conversation, the story is (physican #2) asked him if he had a certain amount of money for the procedure...I saw (patient #32) when he left to go get money...had a big bandage on his hand..."

Interview with RN #2 on January 16, 2013, at 3:10 p.m., in the ED eye exam room, confirmed the nurse remembered patient #32's visit to the ED on May 23, 2013. RN #2 stated she did not hear the conversation between Physician #2 and the patient, but was told by staff Physician #2 had told the patient to leave the ED and obtain money for surgery. RN #2 stated she asked the patient about this, and the patient told RN #2, Physician #2 wanted a certain amount (doesn't recall amount) of money for the physician before the surgery would be performed. RN #2 stated she told the patient "not to leave," left to contact the supervisor and the facility's CEO, and the patient left. RN #2 stated, " I was upset...the patient was gone when...I returned and I did not see him until after he returned to the ED."

During interview by telephone on January 16, 2014, at 6:45 p.m., patient #32 confirmed presenting to the ED on May 23, 2013, with a severe laceration to the left hand. The patient stated, "I cut half way through my left hand with a grinder, it cut three tendons, I was bleeding so bad." The patient stated Physician #2 looked at the injury, then asked the patient if he was insured. The patient stated he told Physician #2 "no I am unemployed". The patient stated the physician said the patient would have to get three to five thousand dollars before the physician would take the patient to surgery. The patient stated, "At first the doctor wanted three to five thousand dollars before the doctor would do surgery, but then decreased it to two thousand." The patient stated Physician #2, "told me I had 45 minutes to get $2000 dollars or...was going on vacation." The patient stated a friend drove him home, to the bank, approximately 12 miles, and the patient was only able to obtain $1000 in cash. The patient stated he returned to the ED with the money, gave the money to someone at the desk, and his surgery was performed shortly afterwards. The patient stated he felt like he had no choice other than paying the money as he was bleeding so badly.

Interview with Registrar #1, on January 21, 2013, at 11:20 a.m., in the facility's conference room, revealed the registrar remembered patient #32's visit to the ED, but did not remember the date. The registrar stated, "...I went to get (patient #32) to sign the AFR (Agreement of Financial Responsibility) form...I was in the room (physician #2) came in and told him (patient #32) he needed to pay $2000.00...told him, 'you get up out of that bed and go get the money now'...I was mortified...he (patient #32) came back with $1000.00..."

Patient #5 presented to the ED on December 24, 2013, at 10:21 a.m., for complaint of finger lacerations.

Review of the Face Sheet dated December 24, 2013, revealed patient #5 was "Disabled" and did not have insurance.

Review of Nurse's Notes dated December 24, 2013, revealed patient #5 was triaged at 10:22 a.m., and assessed as having amputated 2 fingers of the left hand with a table saw approximately 30 minutes earlier. The patient was assessed as having an acuity level of 2 (scale of 1-5, one being most critical), with a pain level of 7 (intense/severe pain) on a scale 0-10 (10 being the most severe pain). Continued review of nurse's note revealed, "Quality of pain is described as aching, sharp, shooting, stabbing, throbbing."

Continued review of a Nurse's Note dated December 24, 2013, revealed, "11:50 consult (Physician #2) hand surgeon at bedside for consult."

Review of Physician's Documentation dated December 24, 2013, at 12:32 p.m., revealed, "...Traumatic/jagged amputation of left hand index and middle finger...bleeding controlled...No ortho (orthopedic surgeon) or hand coverage available today...needs eval (evaluation) for wound care..."

Review of a Patient Transfer To An Outside Facility Form dated December 24, 2013, revealed patient #5 was transferred by private vehicle to Hospital #2 (a large medical center/university hospital approximately 76 miles from Hospital #1) for "Medical Necessity" and "Required Services not Available".

Review of Nurse's Notes dated December 24, 2013, revealed the patient left the ED at 12:49 p.m.

Review of medical records from Hospital #2 revealed patient #5 was admitted to the ED on December 24, 2013, at 2:36 p.m.

Review of physician's notes dated December 24, 2013, at 4:33 p.m., revealed Physician #6, a plastic surgery resident at Hospital #2, performed a "Completion Amputation of both Fingers" in the ED.

Further review of the ED record from Hospital #2 dated December 24, 2013, revealed patient #5 was discharged from Hospital #2 at 5:46 p.m.

Review of Hospital #1's Daily Call Schedule for December 24, 2013, revealed, "Plastics: Consult available 24/7 for plastics" and "Ortho" had Physician #3's name listed.

Interview with RN #3 on January 15, 2014, at 3:45 p.m., in the ED eye examination room, revealed the nurse remembered patient #5's visit to the ED on December 24, 2015. RN #3 stated Physician #2 was called by the ED physician and saw the patient. RN #3 stated witnessed Physician #2 with Patient #5 and heard part of their conversation. RN #3 stated physician #2 asked the patient about insurance and the patient told physician #2 he was uninsured. RN #3 then stated Physician #2 told the patient he could not treat him. RN #3, when asked to clarify that statement, stated, "first question was do you have a full time job and his second question was do you have insurance...he was saying this in front of the patient and his family..." RN #3 stated the physician then told the nurse, "not to put his name on the chart or anywhere..."

Patient #5 was interviewed by telephone on January 21, 2014, at 9:00 a.m. Patient #5 confirmed had presented to Hospital #1 on December 24, 2013, with a table saw injury to the left hand. The patient stated, "Cut off index and middle finger of left hand." The patient stated he did not remember everything because of being "in shock" from the injury. The patient stated he was seen by an ED physician shortly after arriving at the ED, and a second physician the patient was told was a hand surgeon examined the injury. The patient stated he did not remember any of the physician's names. The patient stated he remembered telling the physician, "we didn't have any insurance." The patient stated, "the doctor said he would help us but it would run us tens of thousands of dollars, we decided we wanted to go to (Hospital #2)...I mentioned that (Hospital #2) had helped us financially with another accident I had...I would have stayed...but I was afraid of being billed tens of thousands of dollars..." The patient stated his wife, who was present in the ED with the patient, transported him to Hospital #2 after discharge from Hospital #1.

Telephone interview with Patient #5's wife on January 21, 2013, at 9:20 a.m., confirmed the wife was present in the ED with the patient on December 24, 2013. The wife stated, "...the other doctor...I don't know who he was. He said he could do it but it would cost tens of thousands of dollars...it might be better for you to go to another facility that has a grant and he hated for us to be saddled with this bill...he said I am not going to put down that I saw you here..." The wife also stated, "we couldn't afford it...we might have stayed there if the doctor had not told us that...we felt like we didn't have a choice...he (the doctor) only looked at it and came out and talked to me." The wife stated she then drove the patient directly to Hospital #2.

Interview with Physician #1 on January 21, 2014, at 10:41 a.m., in the emergency department eye examination room, revealed the working on call schedule was kept at the secretary's desk. Further interview revealed the on call schedule for December 24, 2013, had been changed that morning. Physician #1 stated, "(Physician #3's name) was scratched through...said ortho was available until noon...don't know what happened to that one (the on call schedule with the name scratched through)...the ortho came through the ED and marked through on call schedule...(patient #5's) injury was more than what we do in the emergency department...would need to go to surgery...called (physician #2)...came in and looked at it...he wasn't going to be able to do it...he is never on call but always available for consult...he asked me before we went into the room does this guy work and I said yeah...I thought he did...he asked the guy are you going to be able to afford this...and then he (physician #2) said he had a family thing and had to go...the practice is we call (physician #2) if it is hands, then we call ortho, but ortho was off at noon that day..."

Interview with Physician #3, an orthopedic specialist at Hospital #1, on January 22, 2014, at 12:31 p.m., in the conference room, confirmed the physician was on call for orthopedic cases on December 24, 2013, all day. Physician #3 confirmed the printed on call schedule, which lists Physician #3 as on call for December 24, 2013, was correct and accurate. Physician #3 stated, "...we keep a master on call schedule in our office...if there is a change in the schedule we make a change on it and bring it to the ER (emergency department)...there is a designated place in the ER where it goes...I was on call the whole day...we don't do half days...I am aware of (patient #5)...no one called me...they should have called me; I could have taken care of it...he (physician #2) sent someone down the road and he shouldn't have...he should have taken care of (patient #5)...he said he went to see the patient to see if he could help the patient out...he knew it couldn't be done in the ER that it would need OR (operating room)...I was on call...I am board certified for hand surgery...I have told the ER I can do hands...if it is complex I will tell them..."

Interview with Physician #2, a surgeon at Hospital #1, board certified in plastic surgery, on January 16, 2014, at 8:30 a.m., in the conference room, revealed, "...I don't take call here...the ER (emergency room) guys often call me for advice or whatever...(patient #5's) type of injury could have been handled by any surgeon or orthopedist. The ER guys got used to calling me for hands...I was leaving for a family event...I was walking out the door and the ER guys asked me to take a look at it...It was distal fingertip injuries...was stable...it was not an injury that needed a hand specialist...The patient mentioned (hospital #2), which I believe was best for him...I didn't leave a note because I told him I wasn't going to charge...(physician #1) called me. I didn't ask him about money or insurance..."

Continued interview with Physician #2 revealed "...(patient #32) that was a situation where they (ER) called me...I did accept him...he was concerned about the cost...I went over and talked to the Administrator and said can we give him a break...they gave him a number (money amount) and he was going to go home and get money for the hospital not for me...I did his surgery...I had no financial stake in this guy...again I was not on call they just grabbed me...I was a hospital employee at that time...wrote a brief consultation note..."

Interview with the Director of Quality and Risk Management (DQ) on January 16, 2014, at 2:18 p.m., in the conference room, confirmed Physician #2 did send patient #32 from the ED on May 23, 2013, to obtain money for payment prior to performing the surgery. The DQ confirmed sending patients on a leave of absence to obtain money prior to surgery was against the hospital's policies and practices. The DQ stated, "There are no leave of absences from the ED."

Further interview with the DQ confirmed Physician #2 did see patient #5 in the ED on December 24, 2013, asked the patient questions about insurance and employment, and did not treat the patient. The DQ confirmed the ED physician did not follow the facility's policies.

Review of the facility's policy titled, A Patient's Bill of Rights and Responsibilities, revealed, "1. The Patient has the right to considerate and respectful care without regard to race, sex...or the source(s) of payment for his/her care."

Review of the facility's human resource's policy titled, Conduct, Performance, Management, and Discharge, effective date January 29, 2009, revealed, "...certain behaviors cannot be tolerated. Examples of behavior that will not be tolerated...Threatening, intimidating, or coercing others...Harassment or discriminiation..."

Review of facility policy titled Cases to be Transferred from the ED, dated July 2012, revealed, "No patient is to be arbitrarily transferred to another hospital if...can provide adequate care."

Review of the facility policy titled Emergency Medical Treatment and Labor Act, dated April 22, 2008, revealed, "If the on-call physician does not respond or the necessary sub-specialist is not available, the emergency department physician or his/her designee shall attempt to obtain the services of another appropriate specialist or sub-specialist from the hospital's medical staff..."

Based on medical record reviews, interviews, and review of facility policies, the facility failed to promote patient rights, and protect patients from harassment for one (#32) patient of fifty patients reviewed.

Refer to A-0145 for the facility's failure to prevent abuse and harrassment of one patient (#32).

Based on medical record review, interviews, and review of facility policies, the facility failed to prevent abuse and harrassment of one patient (#32) of fifty emergency patients reviewed.

The findings included:

Patient #32 presented to the Emergency Department (ED) on May 23, 2013, at 11:50 a.m., with a complaint of "laceration to left hand with a dye grinder blade."

Review of the Face Sheet revealed the patient was self-employed with no insurance coverage.

Review of Nurse's Notes dated May 23, 2013, revealed patient #32 was triaged by Licensed Practical Nurse (LPN #1) and Registered Nurse (RN #1) at 11:54 a.m. Further review of the nurses notes dated May 23, 2013, at 11:54 a.m., revealed, "Laceration sustained to left hand is contaminated, 2.6 to 7.5 centimeters (cm) long, was sustained less than 30 minutes ago. Is bleeding moderately." Further review of the nurse's notes revealed, "12:00 pressure dressing applied. Ice pack applied."

Further review of the Nurse's Notes revealed the patient's pain was assessed at 12:01 p.m. as "8/10" (0-10 pain scale with 10 being the most severe, a score of 8 would indicate intense/very severe pain).

Review of Physician Documentation dated May 23, 2013, revealed patient #32 was examined by a Physician Assistant (PA #1) at 12:59 p.m. and assessed as having "Deep laceration of the middle MP (the knuckle area of the hand) region, superficial laceration of the 2nd MP region...positive for complete laceration extensor tendon of left middle finger." Further review of the Physician Documentation revealed Physician #2, "was called at 12:15 (pm)...regarding need to come to ED to see patient, and will see patient in the ED."

Further review of Nurses's Notes dated May 23, 2013, revealed intravenous (IV) access was obtained and Ancef (anti-biotic) one gram was given at 12:16 p.m.

Further review of Nurses's Notes dated May 23, 2013, revealed at 12:30 p.m., Physician #2 and PA #1 were "in to evaluate patient and speak with him about surgical process."

Further review of the Nurse's Notes dated May 23, 2013, revealed at 1:00 p.m., "went to see pt.(patient) asked him what the doctor said and he stated that he needed $2000.00 for doctor to do surgery...Discontinued IV...Bulk pressure dressing applied to patients hand to control bleeding per Dr...orders...bleeding has improved." Further review of the Nurse's Notes revealed at 1:14 p.m., "to bank by family member," and at 1:17 p.m., "...was told that pt has left on LOA (leave of absence) to go to bank to get money for surgery. Was told by Dr...that...CEO (Chief Executive Officer) approved for patient to go on LOA to go to bank..."

Further review of Nurse's Notes dated May 23, 2013, revealed at 1:43 p.m., "Patient back to ER (emergency room)..."

Further review of Nurse's Notes dated May 23, 2013, revealed at 1:55 p.m., IV access was re-started, at 2:17 p.m., Physician #2 was with the patient, and 2:27 p.m., the patient left the ED (transferred to surgery).

Review of Consultation notes dated May 23, 2013, at 4:05 p.m., and authenticated by Physician #2 on May 28, 2013, revealed, "Date of Consultation: 05/23/2013...Site...Emergency Room...History of Present Illness...sustained complex grinder injury to the dorsum (top) of the left hand with laceration in common extensors of left index and middle fingers...Plan: At this time was to the operating room for definitive treatment."

Review of the Operative Notes dated May 23, 2013, revealed, "Preoperative Diagnoses: Severe avulsion (forcible tearing of a body part by trauma) laceration on dorsum of left hand secondary to grinder injury with avulsion lacerations of the common extensors to the left index and middle fingers...Procedure: Repair of avulsion laceration to the common extensors to the left index and middle fingers and repair of complex avulsion laceration of dorsum left hand with application of...splint...plus sharp excisional debridement (cutting and removing) of necrotic (dead) tissue."

Review of Post-Operative notes dated May 23, 2013, revealed the patient was discharged home at 6:10 p.m.

Review of the medical record revealed a hand written note, on a blank piece of paper, dated May 23, 2013, no time documented, which stated, "...received $1000.00 toward...balance owed." Further review of this note revealed it was witnessed and signed by Financial Counselor #1 and Registrar #1.

Interview with RN #2 on January 16, 2013, at 3:10 p.m., in the ED eye exam room, confirmed the nurse remembered patient #32's visit to the ED on May 23, 2013. RN #2 stated did not hear the conversation between Physician #2 and the patient, but was told by staff Physician #2 had told the patient to leave the ED and obtain money for surgery. RN #2 stated asked the patient about this, and the patient told RN #2, Physician #2 wanted a certain amount (doesn't recall amount) of money for the physician before the surgery would be performed. RN #2 stated told the patient "not to leave," left to contact the supervisor and the facility's CEO, and the patient left. RN #2 stated, "I was upset...the patient was gone when...I returned and I did not see him until after he returned to the ED."

During interview by telephone on January 16, 2014, at 6:45 p.m., patient #32 confirmed presenting to the ED on May 23, 2013, with a severe laceration to the left hand. The patient stated, "I cut half way through my left hand with a grinder, it cut three tendons, I was bleeding so bad." The patient stated Physician #2 looked at the injury, then asked the patient if he was insured. The patient stated he told Physician #2 "no I am unemployed." The patient stated the physician said the patient would have to get three to five thousand dollars before the physician would take the patient to surgery. The patient stated, "At first the doctor wanted three to five thousand dollars before the doctor would do surgery, but then decreased it to two thousand." The patient stated Physician #2, "told me I had 45 minutes to get $2000 dollars or...was going on vacation." The patient also stated, "they made me take the IV out of my arm...I was bleeding heavy...there was no dressing only a towel around it." The patient stated a friend drove him home, to the bank, approximately 12 miles, and the patient was only able to obtain $1000 in cash. The patient stated he returned to the ED with the money and gave the money to someone at the desk, who took the money, and his surgery was performed shortly afterwards. The patient stated he felt like he had no choice other than paying the money as he was bleeding so badly.

Interview with Registrar #1, on January 21, 2013, at 11:20 a.m., in the facility's conference room, revealed the registrar remembered patient #32's visit to the ED, but did not remember the date. The registrar stated, "...I went to get (patient #32) to sign the AFR (Agreement of Financial Responsibility) form...I was in the room (physician #2) came in and told him (patient #32) he needed to pay $2000.00...told him, 'you get up out of that bed and go get the money now'...I was mortified...he (patient #32) came back with $1000.00...I was standing right beside the poor man...his hand had a pretty big bandage...I was wondering how he was going to drive...never seen this before...gave me the money...I had to post it somehow...I don't know if it was for (physician #2) it was not for the hospital...I was surprised he (patient #32) went to get the money...I have worked here since 2006...this has never happened before...I had to call the supervisor to help..."

Interview with RN #2 by telephone, on January 27, 2014, at 10:20 a.m., revealed the RN did not identify Physician #2's behavior as being abusive.

Interview with Registrar #1 by telephone, on January 27, 2014, at 10:45 a.m., revealed the registrar did not identify Physician #2 as abusing or harassing Patient #32. The registrar stated, "I did not think it was abuse...I reported it to my supervisor."

Interview with the Director of Quality and Risk Management (DQ) on January 16, 2014, at 2:18 p.m., in the conference room, confirmed Physician #2 did send patient #32 from the ED on May 23, 2013, to obtain money for payment prior to performing the surgery. The DQ confirmed sending patients on a leave of absence to obtain money prior to surgery was against the hospital's policies and practices.

Interview with the DQ by telephone on January 29, 2014, at 11:30 a.m., revealed staff were required to report abuse or harassment of a patient by any facility staff, including a physician, immediately to their supervisor. The DQ stated staff were required to report any suspicion of abuse, and staff were told this during orientation. The DQ confirmed verbal intimidation or harassment by a physician would be considered abuse.

Review of the facility's policy titled, A Patient's Bill of Rights and Responsibilities, revealed, "1. The Patient has the right to considerate and respectful care without regard to race, sex...or the source(s) of payment for his/her care."

Review of the facility's human resource's policy titled, Conduct, Performance, Management, and Discharge, effective date January 29, 2009, revealed, "...certain behaviors cannot be tolerated. Examples of behavior that will not be tolerated...Threatening, intimidating, or coercing others...Harassment or discriminiation..."