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Based on observation during tour and interview with staff, it was determined the hospital failed to post the emergency medical transportation and labor act (EMTALA) rights in places likely to be noticed by all individuals.

Findings:

During tours of the emergency department (ED) and urgent care (UC) conducted on 03/23/10, at 1200 and 1730 hours and 03/24/10, at 0730 hours, EMTALA signage was located in the triage room. Patients bypassing the triage room would not see the signage. No other EMTALA signs were posted.

The Chief Nursing Officer (CNO) accompanying the Surveyor during the tours confirmed the location of the one sign and confirmed that not all patients enter the triage room upon arrival to the ED.

Based on observation, review of the ED log, and interview with staff, it was determined the hospital:

1. failed to maintain a central log of patients presenting to the hospital requesting emergency services; and

2. failed to document in the urgent care (UC) log, the disposition of the UC patients, to indicate whether the patients refused treatment, were transferred, admitted and treated, stabilized and transferred, or discharged.

Findings include:

1. All patients/persons enter the hospital through the main entrance and are greeted by a registration person who then directs them where to go. All patients requesting emergency services are triaged by an registered nurse (RN). The hospital has a dedicated emergency department (ED), and within the ED's dedicated space are two rooms used for "Urgent Care" (UC). The triage RN, after triage, will determine if a patient will be seen in the ED or the UC. The UC is utilized for the lower acuity patients and is staffed with Nurse Practitioners (NP) who conduct the medical screening examinations (MSE) and treat those patients. In the ED, physicians provide the MSE's.

The Surveyors requested the ED log for the past 6 months, 10/01/10 through current date (03/23/10). The log was in an electronic format and contained the following elements: patient name; medical record number; age; sex; date of services; arrival time; discharge time; attending primary care; chief complaint; disposition; mode of arrival; and triage level.

On 03/24/10, the Chief Executive Officer (CEO) was asked if all patients that enter the hospital requesting emergency services were on the ED log to include the patients that were triaged to the UC rooms. The CEO discovered that the UC patients were not listed on the original ED log presented to the Surveyors on the 03/23/10, and s/he was unaware the ED log was not complete.

2. The Surveyors requested the UC log and the hospital provided the log. The UC log was in an electronic format and contained the following elements: patient name; age; triage level; physician; and arrival date.

The UC log did not include the disposition of the UC patients.

Based on review of medical records, physician credential files, hospital policies and procedures, bylaws, medical staff rules and regulations, and observation during tour, it was determined the hospital:

1. failed to conduct an appropriate medical screening examination (MSE) to sufficiently rule out an emergency medical condition (EMC) on 02/06/10, for Pt #1 who presented to the ED for the third time with similar signs, symptoms and pain from the previous two visits;

2. failed to determine who was qualified by the hospital bylaws or rules and regulations to conduct a medical screening examination (MSE);

3. failed to require ED physicians #'s 1, 2, 3, 5, and 6 were qualified according to the hospital's credentialing requirements; and

4. allowed nurse practitioners (NP's) to conduct MSE's in the UC.

Findings include:

1. Patient (Pt) #1 presented to the ED on four different occasions: 01/16/10; 01/23/10; 02/06/10; and 02/08/10.

On 01/16/10, Pt #1 presented at 1344 hours to the hospital. During triage the patient complained of increasing weakness with dizziness, which started 1 day prior. Vital signs taken during triage at 1424 were: blood pressure (BP) 85/59; pulse (P) 81, respirations (R) 16; temperature (T) 98.8 Farenheit (F); and oxygen (O2) saturation (sat) 90%. The Pt was seen by Physician #7 who ordered lab work and intravenous (IV) fluids. The patient's white blood count was high at 15.0 (normal 4.0-11.0), neutrophil number high at 12.20 (normal 2.0-6.90), potassium low at 3.4 (normal 3.5-5.1), osmolality low at 272 (normal 275-300), calcium low at 8.2 (normal 8.8-10.5), total bilirubin high at 1.10 (normal .00-1.0), and magnesium was low at 1.5 (normal 1.8-2.4). The urinalysis was within normal limits. The patient was discharged at 1955. The physician documented the patient was improved and the clinical impression was "Hypotension, Hypo___(illegible), Pyretic." Discharge instructions included: "...Drink electrolyte drinks (Gatorade, Powerade)...Septra as directed...Dec (decrease) Diovan to keep BP top number (systolic) at 100-130...follow up with primary doc...next wk 5-7 days...." The patient left the ED at 1955.

Seven days later, on 01/23/10, Pt #1 presented to the ED at 1330 hours, with complaints of fever and diarrhea, for the past 2 days. Temperature on arrival was 99.5 F and the patient had taken Tylenol at 1200. Physician # 9 evaluated the patient and ordered a urinalysis, which was normal. The patient was discharged with the following instructions: "...F/U (follow up) with (primary care) doctor...any changes in your condition, come back to the ED as soon as possible...." No medications or treatments were provided on this visit. The patient left the ED one hour later at 1530.

Fourteen days later on 02/06/10, Pt # 1 presented to the ED at 0649 hours, with complaints of nausea, vomiting, fever, and severe upper back pain, which started 8 hours earlier. Vital signs during triage at 0700 included, T 98.6 F, P 68, RR 18, BP 145/92, O2 sat 95%. Physician # 1 ordered lab, xrays and a medication for nausea (Zofran). Lab results showed a white cell count elevated at 15.4 (normal 4.0-11.0), neutrophil count high at 11.10 (normal 2.00-6.90), and total bilirubin high at 1.20 (normal .00-1.00). The acute abdomen xray series revealed the following: "...Probable small area of scar or atelectasis at the left base without definite pneumonia...Consideration for ileus. Followup study recommended as clinically warranted...." The urinalysis showed the patient had 2+ blood (normal negative), 3+ protein (normal negative), and 0.2 urobilinogen (normal none). The patient was discharged at 0820 hours with the following instructions: "...Cipro and Phenergan as directed. Tylenol for fever, clear liquids 24 (hours) F/U PCP (primary care physician), return if worse...."

Approximately 32 hours later Pt #1 returned to the ED at 1535. The triage nurse noted the following complaints, "stomach ache, backache, nausea x 1 week, seen here for same finished Cipro." The symptoms started 1 week prior and pain is a level 10 (on a scale of 0-10 with 10 as the worst pain ever). ED Physician #2 evaluated the patient and ordered labs, urinalysis, and computerized tomography (CT) of the abdomen. The patient's white blood count was elevated at 18.0, and the CAT scan revealed "hydrops of the gallbladder which approximates 12 cm (centimeters), without adjacent inflammatory change or gallstones identified." Pt #1 received an IV with normal saline, Claf__ IV (antibiotic) and Demerol and Phenergan for pain and nausea. Physician # 2 transferred the patient to another acute care hospital for a surgeon referral. The hospital contacted two of the closest hospitals, both did not have beds. Pt #1 was transferred out of state to another acute care hospital.

Review of the medical record from the second acute care hospital revealed, Pt #1 was admitted to the hospital. A surgical consultation in the ED recommended a "...cholecystostomy tube...(for the acute cholecystitis) to decrease the inflammation and make the subsequent surgery easier...."

2. The hospital's bylaws, and medical staff rules and regulations, dated 12/08/09, were reviewed, and did not specify who may conduct a MSE.

3. The hospital's bylaws and medical staff rules and regulations approved 12/08/09, required: "...The Contracted Emergency Physicians Staff...Qualifications. The Contracted Emergency Department Physicians Staff shall consist of those practitioners who...are qualified allopathic and/or osteopathic physicians whose sphere of practice in the Hospital is rendering Emergency Room patient care and...have clinical privileges as are approved by the Governing Board...Rules and Regulations...Forms...Application forms and any other prescribed forms required by these Bylaws for use in connection with staff appointment, reappointment, delineation of clinical privileges, corrective action, notices, recommendations reports and other matters shall be subject to adoption by the Governing Body after considering any recommendation from the Medical Executive Committee...."

The hospital provided a form titled La Paz Regional Hospital Medicine Service Emergency Medicine Delineation of Privileges. The Director of IT (formerly the Director of Medical Staff Services) verified on 03/24/10, that this form is the form that is currently in use and has been approved by the medical executive committee and governing board. This form required: "...Minimum Threshold Criteria...In order to be eligible to request clinical privileges for both initial appointment and reappointment a practitioner must meet the following minimum threshold criteria: Education: M.D. or D.O. Formal Training: Applicants requesting privileges in Emergency Medicine must be board certified or board eligible in Emergency Medicine OR board certified in Internal Medicine of Family Medicine AND have at least 3 years experience in Emergency Medicine in a comparable or larger ER OR have at least 3 years experience at a hospital of similar volume and complexity of cases and be recommended by the Emergency Department head of such hospital and the LPRH current Emergency Medicine Director and/or staff physicians...."

The hospital has a contract for emergency department physicians, the contract required: "...Each Emergency Physician's Staff Privileges and membership on the medical staff will be contingent upon, among other things, the Emergency Physician's compliance with the Hospital's medical staff bylaws, rules and regulations (collectively, the 'Hospital's Policies')...."

Physician #1's, who evaluated and discharged Pt #1 on 02/06/10, credential file was reviewed. The file contained the emergency medicine delineation of privileges form which required: "...Applicants requesting privileges in Emergency Medicine must be board certified or board eligible in Emergency Medicine OR board certified in Internal Medicine of Family Medicine...." The form was signed by the Credentialing Committee Chair, Chief of Staff, and Board of Directors Chair, indicating Physician #1 had met the requirements.

However, the hospital produced documentation that Physician #1 was board certified in Occupational Medicine.

ED Physician #2, Medical Director for the ED, did not have board certification or eligibility in emergency medicine, or board certification in family practice or internal medicine.

ED Physicians #3, 5, and 6 did not have board certification or eligibility in emergency medicine, or board certification in family practice or internal medicine.

The CEO explained during an interview on 03/24/10, that she felt that the physicians did not need to have board certification or be board eligible, and they needed to meet the requirements in the bylaws that required an allopathic or osteopathic medical license only; and they did not need to meet the requirements on the emergency medicine delineation of privileges, even though this form was currently being used and had been approved by the medical executive board and governing board.

ED Physicians #'s 1, 2, 3, 5, and 6 were not qualified according to the bylaws to practice emergency medicine, therefore, could not perform a MSE.

4. This hospital has a dedicated emergency department (ED). Within the ED's dedicated space, there are two rooms are used for the "Urgent Care" (UC). The triage registered nurse (RN), after triage, will determine if a patient will be seen in the ED or the UC. The UC is utilized for the lower acuity patients and is staffed with Nurse Practitioners (NP) who conduct the medical screening examinations (MSE) for those patients.

The hospital's policy titled EMTALA Compliance, last revised on 04/09, required: "...The Emergency Department Physician will provide a medical screening examination to all persons who come to the Hospital's property requesting emergency services...Personnel qualified to conduct a medical screening examination at LPRH are the Emergency Department Physicians and/or the attending physicians...."

Patients #21 and #31 were triaged then admitted to the UC where the NP was observed conducting the medical screening exams, during a tour of the ED on 03/23/10. The hospital's bylaws, rules and regulation did not specify who is qualified to conduct MSE's. The hospital's EMTALA Compliance policy indicated that only ED or attending physicians could conduct a MSE.

Based on review of medical records, transfer forms, policies and procedures, and interview with staff, it was determined the hospital failed to document the medical records that were sent with 4 of 13 patients (Pts # 14, 22, 23, and 24) requiring transfers to other hospitals.

Findings include:

The hospital's policy titled EMTALA Compliance, last revised 04/09, required: "...General Transfer Requirements...The Hospital shall send to the receiving facility all medical records available at the time of transfer...."

The ED log for 10/2009 through 03/23/10 was reviewed. A sample of 13 patients indicating that they had been transferred were reviewed. Of those patients 4 patients' transfer sheet did not indicate that medical records were sent at the time of transfer.

The Chief Nursing Officer (CNO) verified on 03/24/10, that the transfer sheets were missing the portion that indicated which medical records were sent for Pts # 14, 22, 23, and 24 and could not confirm they sent the records per policy.