HospitalInspections.org

Based on observations, interviews, policy and procedure reviews, emergency department (ED) Physician on-call schedules, and review of a letter to the Chief of Staff, it was determined the facility failed to comply with 42 CFR 489.20(q) in regard to conspicuously posting a sign specifying an individuals rights to examination and treatment for an emergency condition. Observations during a tour of the emergency department (ED) on 12/14/11 at 9:30 AM revealed the required EMTALA signage was not posted in the waiting area of the ED. The facility failed to comply with 42 CFR 489.20(r)(2) and 42 CFR 489.24(j)(1-2) related to the Pediatric on-call Physicians to the ED meeting the needs (failed to admit to the facility) of one patient (#1) in the selected sample of 20. Additionally, the facility failed to follow their policy "Medical Coverage" related to patients, without an attending physician, being provided services from the on-call physician. A review of a letter dated July 12, 2011, to the facility's Chief of Staff, revealed Physicians #4, #5, and #6 requested a leave of absence from the hospital from 08/01/11 through 07/31/12. They would no longer have admitting privileges at the hospital. A review of the ED Medical and Pediatric on-call schedule revealed that on 12/07/11 Physician #1, who was a Pediatrician, was on-call to the ED to provide further evaluation and/or treatment to stabilize individuals. Record reviews and interviews revealed Patient #1 was sent to the ED, on 12/07/11, by Physician #4 (personal physician with no admitting privileges) for possible admission. Patient #1 had bilateral pneumonia and required oxygen therapy and IV antibiotics. Hospital A had the capacity and the capability to provide care for Patient #1. Patient #1 was transferred to Hospital B for admission due to Physicians #1 and #2 not admitting patients of Physicians #4, #5, and #6. Physician #3 (ED Physician) did not call Physician #1 to request admission because he had been informed by his supervisor that Physicians #1 and #2 would not admit Patients of Physicians #4, #5, and #6. Interviews with Physicians #1 and #2 and with the Chief Executive Officer of the clinic (clinic that Physicians #1 and #2 practice out of) confirmed they took call for the ED, but they would not admit the pediatric patients of Physicians #4, #5, and #6. The facility failed to comply with 42 CFR 489.24(r) and 489.24(c) in regard to the facility's bylaws and/or rules and regulations detailing who was determined qualified to conduct the medical screening examination (MSE) to determine if an emergency medical condition existed. Review of the bylaws and rules and regulations revealed "Only a licensed physician, nurse practitioner or physician assistant may perform a medical screening examination." Interview revealed OB patients who were 20 weeks gestation or greater, with OB related complaints, would be seen on OB by the Registered Nurse (RN) with consultation with the OB Physician. Review of the medical records of Patients #19 and #20, (2 of the selected sample of 20), confirmed the RN provided the assessment and monitoring of the OB patients presenting with OB complaints. The RN informed the OB Physician by telephone of the results of the assessment and monitoring and the Physician gave further instructions. The facility failed to include in the bylaws and/or rules and regulations that the OB RN could perform the MSE on obstetric (OB) patients, 20 weeks gestation or greater, with OB related complaints..

Refer to A 2402, A 2404, and 2406.

.

Based on observations and interviews, it was determined the facility failed to post a sign specifying the rights of individuals, to examination and treatment for emergency medical conditions and women in labor, in an area that was easily noticed by individuals whom were waiting for examination and treatment.

Findings include:

Observations during a tour of the emergency department (ED) on 12/14/11 at 9:30 AM revealed the required EMTALA signage was not posted in the waiting area of the ED.

Interview with the Chief Nursing Officer (CNO) on 12/14/11 at 9:30 AM verified there were no signs posted in the area individuals were waiting for examination and treatment (ED waiting room) containing the EMTALA required information. The CNO stated, the sign must have been removed during renovation three months ago and did not get put back up.

Based on interviews, record reviews, policy and procedure reviews, emergency department (ED) Physician on-call schedules, and review of a letter to the Chief of Staff, it was determined the facility failed to ensure that the Pediatric on-call Physicians to the ED met the needs (failed to admit to the facility) of one patient (#1) in the selected sample of 20. Additionally, the facility failed to follow their policy "Medical Coverage" related to patients, without an attending physician, being provided services from the on-call physician.

Findings include:

Review of the Nursing Services/ED policy and procedure "Medical Coverage" with the most recent revision date of January 2005 revealed the following: "A member of the Hospital's Medical staff shall be on call 24 hours a day to consult with the ED Physician. If the attending physician was unavailable, the patient shall be offered the services of the physician of his choice or the physician on call. Any patient seen in the ED without an attending physician shall be given the opportunity to avail himself of the services of a staff physician of his choice or the physician on-call at that time."

A review of the ED Medical and Pediatric on-call schedule revealed that on 12/07/11 Physician #1, who was a Pediatrician, was on-call to the ED to provide further evaluation and/or treatment to stabilize individuals.

A review of a letter dated July 12, 2011, to the facility's Chief of Staff, revealed Physicians #4, #5, and #6 were requesting a leave of absence from the hospital. They would no longer have privileges at the hospital from 08/01/11 through 07/31/12. Interview with the Chief Executive Officer on 12/14/11 at 8:15 AM revealed Physicians #4, #5, and #6 were granted a leave of absence effective 08/01/11. The leave of absence meant they no longer had admitting privileges at the hospital.

A review of the "Patient Progress Note" from the personal physician (Physician #4) of Patient #1, revealed Patient #1 was seen in the office on 12/07/11. Documentation revealed Patient #1 had "thick green mucus and diminished air sounds to bilateral lung bases." The oxygen saturation level before the nebulizer treatment was administered was 90% and it was 86% after the nebulizer treatment. Patient #1 was sent to the local ED. A review of the ED medical record of Patient #1 revealed he/she was a 7 year-old who presented with his/her guardian to the ED on 12/07/11 with pneumonia (diagnosed previously in Physician #4's office). Upon arrival to the ED, Patient #1's oxygen saturation level was 94% on room air. Examination and a chest x-ray revealed Patient #1 had "bilateral pneumonia." Review of the transfer forms revealed Patient #1 was transferred by ambulance to Hospital B for "Pediatric care." Patient #1 was a direct admit to Hospital B on 12/07/11. Review of Hospital B's History and Physical for Patient #1 revealed "Respiratory failure possibly related to pneumonia. Plan at this time is to continue patient on oxygen support, give nebulizer treatment and give IV fluids. Will start patient on Rocephin and Azithromycin."

Interview with Physician #3 (ED Physician) on 12/14/11 at 3:10 PM revealed he received a telephone call from Physician #4 (personal Physician of Patient #1) on 12/07/11 regarding Patient #1. Physician #4 indicated that Patient #1 was in her office, she felt that Patient #1 might need admission to the hospital, and she was sending him to the ED. When Patient #1 presented to the ED his/her oxygen level was low, the white blood cell count was elevated, and he/she was in need of oxygen. A chest x-ray revealed Patient #1 had bilateral pneumonia and it was determined that Patient #1 needed admission to the hospital. Physician #3 stated the hospital had the capacity and the capability to take care of Patient #1 if there was an admitting Pediatrician. Physician #3 did not call the Pediatrician on-call (Physician #1) to get Patient #1 admitted because he had been told by his supervisor (Physician #7) that Physicians #1 and #2 would not admit the patients of Physicians #4, #5, and #6. Therefore, he made arrangements to transfer Patient #1 to Hospital B.

Interview with Physician #7 (ED Medical Director) on 12/15/11 at 9:50 AM revealed he had conversations with Physician #2 and the Chief Executive Officer (CEO) of the clinic (clinic that Physicians #1 and #2 practice out of) regarding admissions of Pediatric patients. He was told by them that Physicians #1 and #2 would not admit the pediatric patients of Physicians #4, #5, and #6. They would admit their own patients and patients that were unassigned to a physician. Physician #7 stated he felt that patients of Physicians #4, #5, and #6 would be considered unassigned patients, when they presented to the ED, because those physicians had no privileges at the facility.

Interview with the CEO, of the clinic of Physicians #1 and #2, on 12/16/11 at 10:45 AM, revealed that Physicians #1 and #2 did not see or admit patients of Physicians #4, #5, and #6 when they presented to the ED. They did not have a formal agreement with Physicians #4, #5, and #6, therefore, their malpractice insurance would not cover them. The CEO stated he had made Physician #7 (ED Medical Director) aware that Physicians #1 and #2 would not be admitting the patients of Physicians #4, #5, and #6.

Interview with Physician #1 on 12/16/11 at 11:45 AM revealed that she was on-call to the ED on 12/07/11 for pediatrics. She did not receive a call from the ED concerning Patient #1. Physician #1 stated she did not know how she would have responded if she would have been called about admitting Patient #1, because her practice is not admitting the patients of Physicians #4, #5, and #6.

Interview with Physician #2 (partner of Physician #1) on 12/16/11 at 1:30 PM, revealed her practice was not admitting patients from Physicians #4, #5, and #6. When she was on-call, she was on-call for herself and Physician #1's patients, Physicians she had formal agreements with, and unassigned patients. Physician #2 stated that Physicians #4, #5, and #6 had not approached her practice about covering their patients when they needed admission to the facility. She stated when she had received calls from the ED concerning patients of Physicians #4, #5, and #6 needing admission, she informed the ED to call Physicians #4, #5, and #6, it was their responsibility to make arrangements for their patients when they needed admission.

Interview with Physician #4 (personal Physician of Patient #1) on 12/19/11 at 11:30 AM (attempts to reach Physician #4 during the investigation were unsuccessful, she returned the call after exit) revealed, she had sent Patient #1 to the ED on 12/07/11 for possible admission. Patient #1 was seen in her office and had low oxygen saturation levels. She wanted Patient #1 to go to the nearest ED for treatment and stabilization. Physician #4 stated she later received a call from Patient #1's guardian stating Patient #1 was transferred because Hospital A would not admit Patient #1. The guardian was upset because he/she did not have the money for gas to get to Hospital B, which was over 30 miles away. Physician #4 stated this was the first she was aware that Physicians #1 and #2 were refusing to admit her patients.

Based on interviews, record reviews, policy and procedures review, and bylaws and rules and regulations review, it was determined the facility failed to define in their bylaws and/or rules and regulations, who was qualified to perform the medical screening exam (MSE) on obstetric patients, to determine if an emergency medical condition (EMC) exists.

Findings include:

A review of the facility bylaws and rules and regulations revealed the bylaws detailed that all individuals presenting to the hospital, that requested examination or treatment would be triaged and receive a MSE within the capability of the Hospital's emergency department (ED). "Only a licensed physician, nurse practitioner or physician assistant may perform a medical screening examination." Review of the Obstetrics Department's (OB) policy and procedure "Admission to Postpartum beds," originated September 1996 with the most recent revision date of September 2007, revealed the following: "Pregnant women who are 20 weeks gestation or greater presenting to the ED with obvious obstetrical related complaints shall be seen by the obstetrical department for assessment and evaluation. Pregnant women presenting to the ED who are less than 20 weeks gestation or with non-obstetrical related complaints (regardless of gestation) shall be triaged by an ED nurse and seen in the ED. Consultation with the Obstetrician will be done if indicated." There was no evidence the information contained in the OB policy and procedure was included in the bylaws and/or rules and regulations or whether the OB policy had been approved by the governing body. Additionally, the OB policy and procedure did not specify the Registered Nurse could perform the MSE.

Review of the medical record of Patient #19 revealed she was 38 weeks gestation and presented to the facility on 12/11/11 with OB related complaints. Patient #19 was assessed and monitored on OB by a RN. The OB physician was notified by telephone of the condition of Patient #19 and the results of the assessment and monitoring. The OB Physician gave orders over the telephone to discharge home with follow-up in the Physician's office.

Review of the medical record of Patient #20 revealed she was 35 weeks gestation and presented to the facility on 10/15/11 with OB related complaints. Patient #20 was assessed and monitored on OB by a RN. The OB physician was notified by telephone of the condition of Patient #20 and the results of the assessment and monitoring. The OB Physician gave orders over the telephone to discharge home with follow-up in the Physician's office as scheduled.

Interview with the OB Supervisor on 12/15/11 at 1:10 PM revealed that OB patients that were 20 weeks or greater gestation, with OB related complaints would be seen on OB. The OB RN would examine the patient, place them on the monitor, and notify the Physician, who would give further orders. The Physicians did not come in to see the patient unless the RN requested them to.

Interview with the Medical Staff Coordinator on 12/15/11 at 4:15 PM confirmed the information regarding the OB RN performing the MSE, with consultation with the OB Physician, was not defined in the bylaws or rules and regulations. She stated she was unaware if the OB policy and procedure, permitting OB patients to be evaluated on OB, was approved through the governing body in Sept 2007.