HospitalInspections.org

Based on review of the medical record, policies/procedures and physician and staff interview it was determined that the facility failed to comply with 489.24 as required in the EMTALA (Emergency Medical Treatment and Active Labor Act) provider agreement.

Based on a review of facility documents and staff/physician interviews, the facility failed to maintain an on-call list that included the name of each physician on-call, as required. Specifically, the on-call lists for urology and cardiology did not contain the name of the physician on call each day, only the name of the practice groups and the phone numbers for the answering service for the practice groups. All other on-call lists for specialists did contain the names of specific physicians for each day.

The findings were:

On 7/19/11, the on-call lists of physicians and specialists for March-June, 2011 were reviewed and revealed that the on-call lists for urology and cardiology did not contain the name of the physician on call each day. The lists only contained the names of the practice groups and the phone numbers for the answering service for the practice groups. These findings were confirmed at approximately 2 p.m. on 7/19 by the clinical nurse specialist/interim director of the emergency department (ED). S/he stated that the on-call lists for these two groups typically listed only the group and the answering service for the group, not the name of each specific physician.

On 7/19/11 at approximately 1 p.m., the chief medical officer was shown the on-call calendars for urology and cardiology and was asked about compliance with the requirement that the on-call calendars or lists contain the names of specific physicians, not just of practice groups. S/he stated that maybe the ED had another list that had specific names and went to look for it.

On 7/19/11 at approximately 3:50 p.m., the director of quality improvement brought some papers that had the names of actual physicians on call for the urology and cardiology specialty groups for June and July, 2011 for urology groups and July-December, 2011 for the cardiology groups. S/he stated that the information was being provided in response to the previous questions to the chief medical officer about a specific on-call list or calendar that was being currently utilized by the hospital that contained the names of specific doctors, including urology and cardiology. After reviewing the newly provided on-call calendars, it was determined that the cardiology calendar still contained some days in which a cardiac clinic was on call with a legend at the bottom stating that the clinic's calendar should be checked for specific physicians. The director of quality improvement stated that the calendars of specific physicians on call had been provided to them today at their request. S/he stated that they had gotten away from requiring specific names on call lists because they found that the person on call frequently changed from when they received the calendar, so that they wasted time calling the wrong doctor through the answering services.

Based on review of facility documents and staff interview the facility failed to ensure that a central log was maintained that included the disposition of each patient seeking emergency care.

The findings were:

On 7/19/2011 at approximately 10:00 a.m., a "Log of ED [Emergency Department] patients for the past 6 months" was requested which was to contain "medical record number, age, diagnosis, physician, and disposition."

The facility provided to the surveyors four ledger-type notebooks that covered the time period requested. Upon review of the notebooks it was discovered that the books contained a label for each patient that presented to the ED. The label contained name, date of birth, and facility identification numbers. The next column contained generic codes for the presenting complaint for each patient, but was not consistently present for each entry. The next, and final, column contained information if the patient was admitted or transferred to another facility. Otherwise, the column was left blank.

On 7/19/2011 at approximately 1:00 p.m., the Director of Quality Improvement was notified of the missing data on in the notebooks. S/he was then requested to provide a computer printout for randomly selected weeks over the previous six months as s/he stated that the ED log was electronic.

The printout provided had spaces for the patient's name, admit date, discharge date, disposition, and diagnoses. In multiple entries, the disposition and/or diagnosis was blank.

On 7/19/2011 at approximately 3:30 p.m., the Director of Quality Improvement was notified of the missing data and that the printout did not contain all necessary information according to the regulation. S/he stated that the printout was not the ED Log and that the ED Log was the computer charting system. When asked to provide the ED Log for selected dates, s/he provided a computer printout for the selected dates.

A review of the ED Log provided revealed that, in the entries for the 27 days requested, fourteen entries were without the patient's discharge date/time and disposition.

On 7/21/2011 at approximately 2:35 p.m., the Director of Quality Improvement and the Quality Improvement Coordinator confirmed that the ED Log did not have the discharge date/time and disposition in the identified entries. The Director of Quality Improvement stated that the printout provided was the facility's ED Log for the regulation and that the facility would need to troubleshoot and find out how the data was missing to resolve the record keeping problem identified.