HospitalInspections.org

Based on review of patient records, hospital policies and procedures and staff interviews, the hospital failed to comply with all requirements of 489.24.

Refer to citations and examples at:

A 2402 (489.20 (q)) Posting of Signs-the hospital failed to ensure that signs identifying the rights of individuals to examination and treatment for emergency medical conditions and women in labor were posted in Emergency Department waiting area.

A 2404 (489.20(r)(2)On Call Physicians-the hospital failed to have a member of the medical staff available on site or on call to further evaluate and provide treatment to stabilize a patient with an emergency medical condition for 2 of 2 patients reviewed.

A 2406 (489. 24(r) and 489.24(c) and 489.24 (j)(2)(i)) Medical Screening Exam - the hospital failed to ensure that Emergency Room Registered Nurses who performed Medical Screening Exams (MSE) had completed the required training activities to meet Medical Screening Exam Certification Standards as required by approved hospital policy; failed to ensure that RNs applied policy protocols to conduct MSEs and document the results; and failed to have language in the Medical Staff Bylaws and approved by the Governing Body specifying who was determined qualified to provide patient MSE.

A 2409 (489.24(e)(1-2)) Appropriate Transfer-the hospital failed to ensure that staff completed an appropriate transfer of an unstable patient for 1 of 2 unstable patients transferred by a Registered Nurse when the hospital was on "Diversion Status" and there was no medical provider available on-site or on-call: No receiving hospital or physician had accepted the patient prior to transfer; no medical record information from the hospital was sent to the receiving hospital; and no medical provider was available to determine the risks/benefits of transfer, or sign a Consent for Transfer form.

Based on observation and staff interview, the hospital failed to ensure that signs identifying the rights of individuals to examination and treatment for emergency medical conditions and women in labor were posted in the Emergency Department waiting area.

Findings:

A tour with administrative staff on 4/29/2015 at 2 p.m. of the hospital Emergency Room and waiting area revealed that required signage notifying individuals of their rights to treatment were not posted in the waiting area. The required signage (in a form as specified by the Secretary) was seen in the ER Treatment room, but not where patients, family members, or other visitors wait and would be able to see and read their rights under Federal law.

Administrative staff agreed the required signage was not posted in the waiting area.

Based on record review, review of hospital policies, observation, and staff interview, the hospital failed to have a member of the medical staff available on site or on call to further evaluate and provide treatment to stabilize a patient with an emergency medical condition for 2 of 2 patients reviewed who were evaluated and transferred with an emergency medical condition following an initial medical screening exam by a designated Registered Nurse (Patients #6 and #8).

Findings:

Interview with administrative and nursing staff on 4/29/2015 revealed that 2 physician assistants employed by the hospital had resigned their positions--1 in December, 2014, and 1 in January, 2015. At the time of this investigation, the hospital was unable to fill the open shifts and on-call positions. On-call shifts after normal business hours of Monday through Friday 8 a.m. to 5 p.m.(when a medical provider was available) were left unfilled by the 2 remaining medical staff members--the medical director and the Advanced RN Practitioner (ARNP). Review of on-call schedules and other hospital records showed unfilled on-call shifts began on 3/17/2015 and continued through April and into May.

The hospital policy #728-0018, "Medical Screening Exam Protocol" was reviewed. The policy gave the protocol for medical screening examination by designated RN staff in the ER. Protocol required, "...information about the chief complaint, the patient's vital signs, mental status assessment, general appearance, and a focused physical exam related to the patient's complaint." The protocol also listed exclusion criteria that, "A determination that an Emergency Condition Does Not Exists is excluded if there is..." and listed 8 symptoms or conditions (including nurse's discretion based on clinical judgement). Presence of chest pain was criteria to identify an Emergency Medical Condition.

Patient #6 walked into the ER complaining of chest pain on 4/16/2015 at 5:05 p.m. Per policy, an emergency medical condition existed for this patient because of the presence of chest pain. There was no member of the medical staff on site or on call at that time. Record review showed the patient was provided a medical screening exam by the designated RN.

The designated RN provided an assessment, an EKG, and established an intravenous line. However, there was no member of the medical staff available to provide further evaluation, orders, or stabilizing treatment prior to transferring the patient by ambulance to another area hospital. The RN documented that the patient was transferred by ambulance in stable condition, but there were no vital signs documented as directed in the above policy. The RN documented that labs were drawn and communicated to the receiving physician, but there were no lab results on the chart.

Patient #8 was a diabetic patient brought by ambulance to the hospital grounds on 4/13/2015 at about 2:40 a.m. with symptoms of dangerously low blood sugar. There was no member of the medical staff on site or on call at that time.

Record review showed the patient was lethargic and weak; diaphoretic and non verbal, unable to respond to questions or commands. Blood sugar on arrival was 19 (normal is 60-90). The designated RN provided an emergent, focused exam with the patient who remained in the ambulance. The RN established an intravenous line with normal saline and administered one syringe of IV Dextrose to alleviate the low blood sugar. The blood sugar was rechecked 5-6 minutes later and was 137. The patient was then able to respond coherently and, "...was transported to Tri-State (Hospital)per his/her request."

There was no member of the medical staff available to provide further evaluation, orders, or stabilizing treatment prior to transferring the patient in the ambulance to another area hospital. There were no medical provider orders obtained prior to administering the emergency treatment.

Staff interview on 4/30/2015 verified that documentation of specific and information required by the Hospital's protocol was missing, and physician orders were not secured prior to the transfer.

Based on staff interview, review of hospital policy, review of Medical Staff Bylaws, and review of nursing staff employee files, the hospital failed to ensure that Emergency Room Registered Nurses who performed Medical Screening Exams(MSE) had completed the required training activities to meet Certification Standards to perform MSEs as specified in approved hospital policy for 4 of 4 RNs reviewed; potentially could have contributed to an adverse outcome for 2 of 2 patients reviewed who were discharged to home without discharge instructions (Patients #5 and #7); and failed to ensure that Medical Staff Bylaws, approved by the Governing Body, contained the information of who was determined qualified to conduct a MSE.

Findings:

Failure to Train Staff

Interview with chief administrative and nursing staff on 4/29/2015 revealed that all patients coming to the hospital Emergency Room when the hospital was on "Diversion Status" (and no medical provider was available on-site or on-call), would be seen by a Registered Nurse who had been designated to perform Medical Screening Exams(MSE) to rule out an Emergency Medical Condition.

The hospital policy, #723-0022 "Medical Screening Examination Certification Standard for Qualified Registered Nurse (QRN)" last review 12/11/2013, specified training standards for certification of nursing staff and the proficiencies required prior to being permitted to perform a MSE without the direct supervision of a Medical Provider (Physician, Advanced RN Practitioner or Physician Assistant). In addition to being certified in Trauma Nurse Core Certification (TNCC) and Advanced Cardiac Life Support (ACLS), requirements included to: watch a training video with a study guide; complete a written test; and complete 10 encounters in the ER under the direct supervision of a Preceptor or Medical Provider Staff and perform a MSE with 100% accuracy. The Medical Director was to review all competency documentation.

To maintain the certification, the "QRN" was to meet mandatory in-service participation, maintain 95% or better ER documentation standard, and maintain 100% MSE documentation standard.

Review of 4 files of RNs who provided MSEs to patients showed 4 of 4 were ACLS and TNCC certified, but failed to evidence any documentation that the additional specified standards had been met, or that documentation of ER and MSE patient records had been audited for compliance with standards.

Interview with the hospital's Medical Director on 5/4/2015 revealed that he had not been involved in any of the qualifying activities described. Interview with the Administrator on 5/4/2015 and the Chief Nursing Officer on 5/5/2015 revealed that the documentation of the initial approvals or on-going maintenance requirements( including audits of MSE patient records for compliance with standards) could not be located.

Failure to Document according to Documentation Standards

Interview with nursing staff on 5/7/2015 revealed that the hospital did not have or know what the documentation standards were that were referred to in the policy. Staff were unsure what the source was (such as the national Emergency Nurses Association)
for the training materials described in policy #723-0022, "MSE Certification Standard for qualified Registered Nurse (QRN).

Review of records of patients who came to the ER during "Diversion Status" revealed inconsistent documentation in the medical screening exams and provision of discharge instructions that could have potentially contributed to an adverse outcome for 2 of 2 patients reviewed that were discharged to home (Patients #5 and #7).

Patient #5 - per record review, was a 13 year old who came to the ER with a parent on 4/10/2015 at 5:02 p.m. after having a motorcycle accident in the mountains. The patient complained of pain in the right elbow, rating it 6 out of 10 and was not able to rotate the arm laterally. The designated RN "did a focused assessment" and placed the arm in a sling. The patient and parent were offered assistance to seek further medical treatment at another hospital, but refused and, "...decided to go back to their cabin and wait until morning to see how the patient was feeling then."

The hospital policy, #728-0018 "Medical Screening Exam Protocol" read at item #2, "Every patient presenting to the hospital ER, must receive an appropriate MSE...including ancillary services routinely available (Radiology, Lab, etc.) to determine if an emergency medical condition exists."

No X-ray was provided for this patient to rule out a fracture or a compression injury which placed the patient at risk for compartment syndrome (which potentially could lead to limb amputation).

Further, the policy defined Stabilization on pg 7: "Under the statute, to stabilize an emergency medical condition means to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility..."

The designated RN failed to follow hospital policy to: document vital signs on arrival or upon discharge; document the presence or absence of pulses in the affected arm; or obtain an X-ray to rule out fracture. There was no evidence that the designated RN provided discharge instructions to educate and alert the patient and parent of the signs and symptoms to watch for and when to seek additional medical services to prevent further injury or harm.

Patient #7-per record review, was a 3 year old who came to the ER with parents on 4/26/2015 at 6:07 p.m. with a forehead laceration after having a fall "playing superman." The designated RN documented that the child walked in and, "the child was crying on admit, but laughing during exam." The RN provided a neuro check and found no redness or bruising of the face or forehead. An ambulance was offered for transfer to another hospital, but the parents, "Opted to have the (nurse) perform first aid."
The RN documented treatment to cleanse the laceration and applied steri strips. Vital signs were documented and within normal limits. There was no evidence that the designated RN provided discharge instructions to educate and alert the parents to signs and symptoms to watch for related to a potential head injury, and to seek additional medical services to prevent harm.

Failure to Set Forth Qualified Staff in Bylaws Approved by the Governing Body

Review of Medical Staff Bylaws revealed that there was no language directing who was determined to meet the requirements to conduct patient medical screening exams.

Interview with the administrator on 4/29/15 revealed that the hospital's policy #728-0018 "Medical Screening Exam Protocol" included in item #1, "The GCHD (Garfield County Health District) Board of Commissioners recognizes the Registered Nurses working in the GCHD ER as qualified medical personnel (AMP) able to perform the MSE." The language was not included in the Bylaws.