HospitalInspections.org

Based on document review and interview, the facility failed to follow the QSO-22-11-All Memorandum regarding the rate of compliance (81%).

Findings Include:

1. Review of policy titled: IU Health COVID-19 Vaccination Program, created 08/13/2021, indicated that IU Health personnel, privileged providers, volunteers, student learners and contracted vendors and workers who access IU Health facilities or affiliate locations will be fully vaccinated against COVID-19 and/or have an approved exemption.

2. Review of QSO-22-11-All Memorandum, revised 04/05/22, indicated that facilities failing to maintain compliance with the 100% standard may be subject to enforcement action.

3. Review of the facility's breakdown of compliance (see below):
Completed 171
Exemption 75
Non-compliant 59
Total Employees 305
Compliance equals 81%

4. During an interview on 5/27/22 at approximately 2:30 p.m. with A8, Human Resources Consultant and A9, Senior Human Resources Consultant, they verified knowledge of issue with the non-compliant number; that number is made up of travel staff, students, volunteers and contracted staff working inside the IU Health buildings and affiliates; and they confirmed that there is a process in place to start to reduce that number.

5. During an interview on 5/27/22 at approximately 4:30 p.m. with A13, Program Manager of Employee Health, he/she verified the facility's breakdown of compliance numbers listed above.

Based on document review and interview, it was determined that in 1 (Patient #1) of 21 medical records (MR) reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide a medical screening examination.

Findings Include:

1. See findings cited at 42 CFR 489.24, Medical Screening Exam (A2406).

Based on document review and interview, the facility failed to ensure a medical screening examination was completed for 1 of 21 patients presenting to the emergency department. (Patient #1)

Findings include;

1. Facility policy titled "Emergency Transfers (EMTALA) [Emergency Medical Treatment and Active Labor Act]" with an origination date of 11/28/2017 indicated the following: "...I. PURPOSE: All persons seeking emergency care...shall receive an appropriate Medical Screening Examination by qualified medical personnel to determine whether an emergency condition exists...II. SCOPE: This policy applies to all people who present...for emergency services, as well as patients in an emergency or unstable condition who request or require a transfer to another facility...V. POLICY STATEMENT: It is the policy...that all patients requesting emergency medical services receive an appropriate Medical Screening Examination (MSE) as required by the Emergency Medical Treatment and Active Labor Act ("EMTALA") and all Federal regulations and interpretive guidelines. All patients who have an emergency condition will be provided any necessary stabilizing treatment until stable and/or transferred in accordance with federal regulations to another hospital...5. Qualified Medical Person...means physician as set forth in the credentialing of all Emergency Medical Providers privileges. 6. As part of the MSE, the Qualified Medical Personnel will perform and document the history and physical assessment..."

2. Review of Patient #1's ambulance run sheet dated 3/26/22 indicated the following: "...DISPATCHED TO RESIDENCE FOR A...PT (Patient) WHO HAD FALLEN PER DISPATCH...UPON ARRIVAL, FOUND (Patient) SITTING ON (HIS/HER) WALKER UNRESPONSIVE WITH RESPIRATIONS OF 10 (per minute) AND SHALLOW BUT MOVING GOOD AIR..ONCE IN THE AMBULANCE PT REMAINED UNRESPONSIVE AND PT BEGAN WITH AGONAL RESPIRATION WITH A PULSE IN THE 30'S. PT IS VENTILATED WITH BVM (Bag Valve Mask) AND HIGH FLOW O2 (Oxygen). PT IS IMMEDIATELY INTUBATED...PT VITALS ARE ASSESSED AND PT IS HYPOTENSIVE AND IV IS ESTABLISHED...AND NORMAL SALINE AT A WIDE OPEN RATE. CARDIAC MONITOR IS APPLIED...AND TRANSPORT INITIATED TO (Facility #1) FOR PT STABILIZATION...(Facility #1) IS NOTIFIED VIA IHERN (Indiana Hospital Emergency Radio Network) AND INFORMED US THAT MD1 (Emergency Department Physician) WOULD MET US IN AMBULANCE BAY, UPON ARRIVAL AT (Facility #1) AMBULANCE BAY WE WERE MET BY (MD1) WHO STATED THAT SINCE PT IS INTUBATED AND HOSPITAL NOT HAVING VENTILATOR CAPILBILITIES THAT THE PT WOULD NEED TRANSFERRED ANY WAY. EVEN WITH PT BEING UNSTABLE WITH LOW BP (blood pressure) AND INTUBATED (HE/SHE) INSTRUCTED US TO CONTINUE ON TO (Facility #2) IN THE BEST INTEREST OF THE PT. ORDERS WERE GIVEN TO CONTINUE TO GIVE VERSED FOR SEDATION IF NEEDED AND TO GIVE FLUIDS FOR HYPOTENSION, EMERGENT TRANSPORT TO (Facility #2) IS CONTINUED AT 0122 HRS (hours). DURING TRANSPORT PT IS CONTINUALLY VENTILATED WITH BVM AND HIGH FLOW O2 AND FLUIDS INFUSING WIDE OPEN FOR HYPOTENSION. PT REMAINS HYPOTENSIVE THROUGHOUT TRANSPORT. PT IS RESEDATED TWICE DURING TRANSPORT..."

3. Facility #1 lacked documentation of medical record information for Patient #1 related to his/her emergency department visit on 3/26/22, which also included a lack of documentation of a medical screening examination for the patient.

4. During an interview on 5/27/22 at 3:32 p.m. with A3, Clinical Nurse/Quality Coordinator, he/she verified the lack of documentation of medical record information for Patient #1 related to his/her emergency department visit on 3/26/22. A3 verified the lack of documentation of a medical screening examination for Patient #1. A3 also verified that MD1, Doctor of Medicine/Emergency Department Physician did not ensure that Patient #1 was brought into the emergency department to have a medical screening examination and to be stabilized prior to being transported via emergency medical services to Facility #2.

5. During an interview on 5/27/22 at approximately 3:45 p.m. with A7, Accreditation/Regulatory Consultant, he/she verified that once the ambulance pulled onto Facility #1's property, at that point it was a request for a medical screening examination on behalf of the patient.