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Based on review of policies, procedures, medical records, medical staff bylaws, rules, regulations, and interview with staff, it was determined the Governing Body failed to ensure the hospital met the conditions of participation for emergency services as evidenced by:

482.12(f)(1) Tag 0092
failure to comply with the requirements of Condition of Participation for Emergency Services 482.55 by not meeting the needs of patients in accordance to standards of practice: and

482.12(a)(5) Tag 0049
failure to ensure sure that the medical staff is accountable to the governing body for the quality of care provided to patients:

a. the Medical Staff Bylaws, Rules and Regulations for 2011 did not determined who was qualified to perform a medical screening examination (MSE) indicating if a patient has an emergency medical condition (EMC);

b. the Medical Staff Bylaws, Rules and Regulations for 2011 and 2012, did not define the criteria and qualifications for a physician to supervise the ED;

c. the Governing Body failed to identify a physician be in the hospital and immediately available to supervise the care given to ED patients;

d. the Governing Body did not require reports regarding the quality of care provided to ED patients; and

e. the Governing Body failed to require the hospital meet the requirements of of the Condition of Participation for Emergency Services 482.55.

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to meet the requirements for the Condition of Participation for the Governing Body.

Based on review of medical records, medical staff bylaws, rules, regulations, ED patient log, and staff interview, it was determined the hospital failed to be responsible for the quality of medical care provided to ED patients as evidenced by:

482.22(c) Tag 0353
the hospital's failure to enforce the medical staff bylaws, rules and regulations pertaining to:

a. maintaining medical records for 3 of 22 ED patients (Pts #'s 8, 13 and 15);

b. ensuring a physician documented orders for 4 of 4 patients receiving medications (Pts #'s 2, 7, 11 and 16); and

c. ensuring the physician documented assessments, a history of present illness, and a physical examination (Pts #'s 1, 3, 5, 9, 10, 14, 17, 18 and 20).

The cumulative effects of these deficient practices resulted in the hospital's failure to meet the conditions of participation for Medical Staff Services.

Based on review of policies, procedures, personnel files, facility documents, medical records, observations on tour, medical staff bylaws, rules, regulations, ED patient log, physician credential files, and interviews with staff, it was determined the hospital failed to meet the emergency needs of patients within acceptable standards of practice as evidenced by:

482.55(a)(2) Tag 1103
the hospital's failure to integrate emergency services with laboratory, radiology, surgical services, medical surgical services, and the intensive care services of the hospital;

482.55(a)(3) Tag 1104
the hospital's failure to establish written policies and procedures governing medical care provided in the emergency department;

482.55(b)(1) Tag 1111
the hospital's failure to ensure the emergency services were supervised by a qualified member of the medical staff, twenty-four hours a day, seven days a week, that met the requirements of 482.55 conditions of participation for emergency services: and

482.55(b)(2) Tag 1112
the hospital's failure to ensure that there were adequate medical and nursing personnel qualified in emergency care, 24 hours per day, seven days a week that met the requirements of 482.55 conditions of participation for emergency services:

a. the hospital failed to determine qualifications for physicians supervising the ED; and

b. Six of 9 House Supervisors did not have the required training to work in the ED and competencies were not verified by the hospital (Personnel #'s 4, 6, 13, 14, 17, 18, and 20).

The cumulative effects of these deficient practices resulted in the hospital failing to meet the condition of participation for emergency services.

Based on review of Medical Staff Bylaws, facility documents, and staff interviews, it was determined the hospital failed to ensure that the medical staff is accountable to the governing body for the quality of care provided to emergency department (ED) patients as evidenced by:

1. the Medical Staff Bylaws, Rules and Regulations for 2011 did not determine who was qualified to perform a medical screening examination (MSE) indicating if a patient has an emergency medical condition (EMC);

2. the Medical Staff Bylaws, Rules and Regulations for 2011 and 2012, did not define the criteria and qualifications for a physician to supervise the ED;

3. the Governing Body failed to identify a physician be in the hospital and immediately available to supervise the care given to ED patients;

4. the Governing Body did not require reports regarding the quality of care provided to ED patients; and

5. the Governing Body failed to require the hospital meet the requirements of of the Condition of Participation for Emergency Services 482.55.

Findings include:

1. Review of the Medical Staff Bylaws, Rules and Regulations approved 2011, revealed they did not include who was qualified to perform a MSE.

The DQM confirmed this finding on 04/05/12.

2. Cross Reference tag A1111 for information regarding physician qualifications and criteria to supervise the ED.

3. Cross Reference tag A1111 for information regarding the requirement for a physician to be in the hospital immediately available to supervise ED patients.

4. Review of the Medical Staff Bylaws revealed: "...Basic responsibilities of Medical Staff membership...provide his/her patients with continuous care that meets the generally recognized professional level of quality and efficiency...abide by all applicable laws and regulations of governmental bodies and agencies...abide by the Bylaws and Rules, and all other lawful standards and policies of the Medical Staff and the Hospital...responsibilities...to provide effective mechanisms to monitor and evaluate the quality of patient care and the clinical performance of all individuals with Medical Staff or AHP Privileges within the Hospital, and to ensure that all Practitioners provide care at a consistent level of quality...."

Review of the policy titled Physician Performance Improvement Process, Including Focused and Ongoing Professional Practice Evaluation required: "...purpose of the policy is to standardize the process for conducting focused professional practice evaluations (FPPE) and ongoing professional practice evaluations (OPPE) using MEC-approved Performance Review Criteria...MEC in consultation with the Quality Council and/or Governing Board approves Hospital Performance criteria that are used to assess the quality of medical care at the Hospital...."

Review of the Medical Staff PR (peer review) Executive Session minutes, revealed that House Physician issues were never discussed related to ED patient quality of care.

Review of the MEC minutes from January through October 2011 revealed discussions about the numbers of patients seen in the ED and transfers to other hospitals. The July 2011 MEC minutes identified an issue in the ED with incomplete dates, missing times and patient signatures on some charts.

Review of the Critical Care Committee Summary minutes for May through August 2011 revealed Emergency Services Report which identified discussions about the numbers of patients seen/ transferred. There was no discussion documented about the monitoring or evaluation of Quality of Care provided in the ED.

The Director of Quality Management confirmed in an interview on 4/10/12 at 1500 hours, that the MEC minutes and the Critical Care Committee minutes revealed discussions about ED patient numbers. The hospital did not identify any problems with the delivery of the ED services provided to patients.

5. Cross Reference tag 1100 regarding the hospital's failure to meet the emergency needs of patients within acceptable standards of practice.

Based on review of policies and procedures, medical records, observation on tour and interview with staff, it was determined the hospital failed to comply with the requirements of Condition of Participation for Emergency Services 482.55 by not meeting the needs of patients in accordance to standards of practice.

Findings include:

Cross Reference Tag A 1103 regarding the hospital's failure to integrate emergency services with laboratory, radiology, surgical services, medical surgical services, and the intensive care services of the hospital.

Cross Reference Tag A 1104 regarding the hospital's failure to establish written policies and procedures governing medical care provided in the emergency department.

Cross Reference Tag A 1111 regarding the hospital's failure to ensure the emergency services were supervised by a qualified member of the medical staff, twenty-four hours a day, seven days a week, that met the requirements of 482.55 conditions of participation for emergency services.

Cross Reference Tag A 1112 regarding the the hospital's failure to ensure that there were adequate medical and nursing personnel qualified in emergency care, 24 hours per day, seven days a week that met the requirements of 482.55 conditions of participation for emergency services.

Based on review of medical records, medical staff bylaws, rules, regulations, ED patient log, and staff interview, it was determined the hospital failed to enforce the medical staff bylaws, rules and regulations as evidenced by failing to:

1. maintain medical records for 3 of 22 ED patients (Pts #'s 8, 13 and 15);

2. ensure a physician documented orders for 4 of 4 patients receiving medications (Pts #'s 2, 7, 11 and 16); and

3. ensure the physician documented assessments, a history of present illness, and a physical examination (Pts #'s 1, 3, 5, 9, 10, 14, 17, 18 and 20).

Findings include:

1. The Medical Staff Rules and Regulations for 2011 and 2012 required: "...Medical Records. 1. The practitioner shall be responsible for the timely completely (sic) of an accurate and legible medical record for each patient...The contents of the shall be pertinent and current...."

Patient #8 presented in the ED on 05/05/11 at 1325 hours. The notes indicated the patient's complaint included "feet hurt need pain pill, antibiotics, thinks he has tuberculosis, transferred to (name of acute care hospital)." The hospital did not have a medical record for Pt #8.

Patient #13 presented in the ED on 02/02/11 at 1415 hours, with a complaint of "feels like something in R eye, eye wash station." The hospital did not have a medical record for Pt #13.

Patient #15 presented in the ED on 09/25/10 at 0400 hours, with a complaint of Chest Pain. Notations in the ED patient log include: "...VS (vital signs), Nitro, ASA (aspirin), EKG (electrocardiogram)...(name of acute hospital) ER via PMT (name of ambulance). The hospital did not have a medical record for Pt #15.

The DQM confirmed on 04/06/12 at 1140 hours, that the hospital did not have medical records for Pts #'s 8, 13 and 15.

2. The Medical Staff Rules and Regulations for 2011 and 2012 required: "...All...outpatient orders for medication, treatment procedures...shall be recorded in the medical record...

Review of the following ED patient records revealed the following records did not have physician orders for treatments or medications provided to patients:

Patient #2 received an Intravenous (IV), Oxygen (O2), and an Aspirin (ASA).

Patient #7 received an IV in the left hand.

Patient #11 received Tylenol 650 milligrams (mg) orally (PO).

Patient #16 received two doses of Nitroglycerin subliquinal, and ASA PO.

3. The Medical Staff Rules and Regulations for 2011 and 2012 required: "...The medical record shall include...chief complaint; history of present illness, past medical history...inventory by body systems; the report of the physical examination; a provisional diagnosis with treatment plan...condition on discharge...."

The following patient records did not have physician documentation which included the chief complaint, a history of the present illness, past medical history, inventory of body systems, and a physical examination:

Cross Reference tag A1111 for further patient information.

Patient #1's medical record did not include documentation of a physical examination by the physician.

Patient #3's medical record contained a physician signature only. No information was documented by the physician.

Patient #5's medical record did not have documentation by the physician. The patient was discharged home after the nurse assessed the patient and called the ED physician.

Patient 9's medical record did not include any documentation by the physician other than a signature on the transfer form.

Patient 10's medical record did not include documentation by the physician.

Patient 14's medical record did not include documentation by the physician.

Patient 17's medical record did not include documentation by the physician.

Patient 18's medical record did not include documentation by the physician.

Patient 20's medical record did not include documentation by the physician.

The DQM confirmed the findings in the medical records on 04/05/12.

Based on review of policies and procedures, facility documents, medical records, observation on tour and interview with staff , it was determined the hospital failed to integrate emergency services with laboratory, radiology, surgical services, medical surgical services, and the intensive care services of the hospital.

Findings include:

Review of policy and procedure titled Emergency Room Services revealed: "...in the event of an emergency, the affected person will be treated and stabilized within the ability of the facility and when needed, admitted or transported via paramedics to the nearest emergency department providing a higher level of care...patient will be seen by the physician...make decisions and give orders regarding treatment, admission, transfer and/or release...."

Review of Laboratory "posted" hours and personnel schedule revealed, hours of operation are Monday through Friday, 0600 A.M. to 5:30 P.M., Saturday and Sunday, 6:00 A.M. to 3:00 P.M., and holidays 6:00 A.M. to 3:00 P.M.

There were no posted hours for Radiology.

Observation on tour revealed posted signs with hours of operation only on the day shift up to 5:30 PM. Both departments are closed during the evening and night shift.

The DQM stated on interview 4/3/12 at 1515 hours, that there are no laboratory or radiology staff on site for the off shifts, and

a. The hours and personnel schedule for Radiology are Monday through Friday 8:00 A.M. to 4:00 P.M., Saturday and Sunday 8:00 A.M. to 12:00 noon and on call at all other times

b. On off hours both the laboratory and radiology departments have a 30 minute window to respond to needs of ED patients when their departments are closed.

c. no X-rays have ever been ordered for ED patients and the only lab that has been done in their ED is a blood glucose fingerstick. She explained that no patients have ever been admitted to the hospital's Intensive Care Unit (ICU), medical surgical unit (Med/Surg), or to the Surgical Services area of the hospital.

Review of 22 out of 22 medical records revealed that no laboratory or radiology tests were ever ordered for patients in the ED as part of the MSE to determine if the patient had an EMC.

The Chief Clinical Officer confirmed in an interview on 4/6/12 at 1220 hours, that there is no process in place and or no written defined procedures to order blood work or X Ray films for patients needing both services in the Emergency department.

Based on review of Medical Staff Bylaws, policies and procedures and interview with staff, it was determined the hospital failed to establish written policies and procedures governing medical care provided in the emergency department.

Findings include:

Review of the medical staff bylaws signed and dated 3/22/2011, revealed: "...Clinical decisions...identifying the health care needs of a patient is the basis for clinical care...policies and procedures relating to patient clinical needs are available on request to patients, clinical staff, LIPs, and Hospital personnel.

Review of policies and procedures revealed one Emergency department policy titled Emergency Room Services. There are 3 revisions to the policy 7/07, 8/07 and 2/12. The Emergency room service policy required: "...the out-patient is assessed for presence of Life Threatening or Non LifeThreatening Event...Life Threatening Event determined...Call 911 stabilize and treat...call receiving facility with assessment and report...follow Emtala procedures for the transfer...give report to Paramedics...Non- Life Threatening Event Determined...Evaluate need for continued care at a higher level of care...Provide treatment to manage the emergency medical condition...if patient is being transferred to a higher level of care, follow EMTALA (Emergency Medical Treatment and Labor Act) procedures...."

Director Of Quality Management confirmed in an interview conducted on 4/4/12 at 0855 hours, that the policy titled Emergency Room Services is the only policy available for the ED that addresses medical care provided. She confirmed the hospital does not have an EMTALA policy/procedure referenced in the Emergency Room Services policy.

Based on review of medical records, ED patient log, hospital bylaws, rules, regulations, physician credential files, hospital documents, and staff interviews, it was determined the hospital failed to ensure the emergency services were supervised by a qualified member of the medical staff, who was immediately available in the hospital twenty-four hours a day, seven days a week, that met the requirements of 482.55 conditions of participation for emergency services.

Findings include:

Prior to 03/28/12, the Medical Staff Bylaws, Rules and Regulations did not include a determination of who was qualified to supervise the Emergency Services. On 03/28/12, the governing body approved new medical staff rules and regulations which included: "...When a person presents themselves to the Emergency Services at the Phoenix campus, an RN who has training and competency to conduct a MSE (medical screening examination) will do so. The RN will then proceed to call a physician to give a full report and receive orders. On days, the RN will use the Emergency Call List. During evening hours the RN will involve the House Physician...."

The hospital directed the Surveyors to the hospital bylaws section below as the requirements/qualifications for a physician to supervise the emergency services.

Review of the hospital bylaws approved by the Governing Board 03/22/11, included: "...Emergency Privileges...Individual Emergency...In the case of an individual emergency as defined in this Section, any Physician, dentist or podiatrist Member of the Medical Staff, to the degree permitted by his/her license, education and training -- regardless of Medical Staff status or lack of it--shall be permitted and assisted to do everything possible to prevent serious permanent harm to an individual, using every available facility of the Hospital necessary including the calling for any consultation necessary or desirable...."

The Surveyors requested the Medical Staff criteria that established qualifications that a medical staff member must possess in order to be granted privileges for the provision of emergency services. The hospital provided a credentialing form that the House Physicians use to request privileges. The physicians could request the following privileges: Abdominal paracentesis; anoscopy; arterial cannulation/arterial puncture; arthrocentesis; central line insertion; chest tube placement; control epistaxis; I&D abscesses; Intubation; IV anesthesia; local anesthesia; lumbar puncture; management of cardiac emergencies; management of extremity strains, sprains, and muscular injuries; management of superficial localized burns; other airway management; preliminary x-ray interpretation; regional anesthesia; removal of foreign body by minor incision, speculum or forceps, repair of simple lacerations, temporary pacing; temporary splinting of dislocations and fractures thoracentesis; venous cannulation; ventilator management; and Level IV Emergency Service: Determine if an emergency exists, render life saving first aid and make appropriate referral to the nearest organization that is capable of providing needed service.

The hospital considered the Level IV Emergency Service "request for privileges" as criteria delineating qualifications as an ED physician. If the physician was approved for the Level IV Emergency Services they were then qualified to supervise the emergency department and conduct medical screening examinations. No qualifications were defined by the medial staff.

Review of 8 physician credential files revealed the 4 House Physician files contained approval for Level IV Emergency Services and the non House Physician files did not include privileges for supervising the ED.

The DQM verified on 04/04/12, that all of the House Physicians who provide hospital coverage at night have been privileged for Level IV Emergency Services. She explained the House Physicians are like hospitalists, and confirmed the Non House Physicians did not have additional privileges granted by the hospital for supervising the ED.

If an emergency patient arrives between the hours of 0630 and 2000 hours, the staff is to call the on call physician to see the ED patient. If that physician is not in the hospital making rounds the staff are to page overhead for any physician in the building to see the ED patient. The DQM, on 04/05/12, confirmed this is the practice for the ED patients and she verified that there is not a physician in the hospital, immediately available, at all times to care for emergency patients.

The Lead House Physician's credential file indicated he was not approved for the following procedures: Chest Tube Placement; Control of epistaxis; I&D abscesses; IV anesthesia; Lumbar puncture; Management of extremity strains, sprains, and muscular injuries; Temporary pacing; and Temporary Splinting of dislocations and fractures. He was approved for the Level IV Emergency Services.

On 04/05/12, the DQM explained the emergency services provided to patients depended on the expertise of the on call ED and House Physician. The care may be different for each patient depending on the physician's credentials.

The hospital did not have written criteria delineating the qualifications of a medical staff member to provide supervision of the emergency services and did not have a supervising physician in the hospital immediately available for ED patients, twenty four hours a day, seven days a week.

Review of the ED patient log was conducted. The past 22 ED records were reviewed.

Review of ED patient medical records revealed:

Patient #1:Presented to the ED on 03/25/12, with a complaint of nausea, abdominal pain, left upper quadrant and left lower quadrant. A registered nurse (Personnel #5 ) assessed the patient. The ED physician (Physician #2) documented the following: "Young male with ulcerative colitis presented for abd. pain. Transfer to (Name of acute care hospital) hospital. Ambulance was offered. Pt refused and called his wife to take him to ER. Hemodynamically stable."

Patient #2:
Presented to the ED on 01/20/11, with a complaint of chest pain, feels like "something is sitting on her chest." The patient was assessed by a RN (Personnel #15). No physician documentation is in the medical record. The nurse started an intravenous (IV) line, administered oxygen (O2) at 2 liters (L). The nurse called 911 and sent the patient to an acute care hospital. No physician evaluated the patient and ordered the IV or O2. The ED did not have protocols or standing orders for the nurses.

Review of the receiving hospital's medical record included the following documentation: "...The following Life or Limb Threatening Differential Diagnosis were considered: Myocardial Infarction; CAD; Pulmonary Embolus; Thoracic Aorta Dissection (TAD); Pneumothorax; AAA; Myocarditis; Pericarditis; Pericardial Effusion; Pneumonia; Mediastinitis...01/20/2011...13:25...."

Patient #3:
Presented to the ED on 11/15/11, with a complaint of lower back pain. RN Personnel #5 assessed the patient. The patient was transferred to an acute care hospital. No physician documentation is on the medical record. The transfer documentation included a verbal order from Physician #2 to transfer the patient to another acute care hospital. Physician #2 signed the medical record without documenting any notes or signing the transfer certification form.

Review of the receiving hospital's medical record indicated the patient was admitted with diagnoses of: back pain; renal insufficiency; tachycardia; diverticulitis and hypertension.

Patient #4:
Presented to the ED on 01/27/12, with a complaint of nausea, vomiting, diarrhea for 2 days. RN Personnel #16, assessed the patient and called 911 for transfer to another acute care hospital. The RN documented: "...Dr (name) notified of transfer and he agrees...." No laboratory tests or treatments were initiated for this patient.

Review of the receiving hospital's medical record indicated the patient was admitted with a Mallory-Weiss tear, intractable vomiting, and dehydration.

Patient #5:
Presented to the ED on 01/20/12, with a complaint of diarrhea six times and vomiting three times. RN Personnel #5 assessed the patient and called physician #2 who ordered the patient to be discharged home and go to an ER if fever, headache, abdominal pain or further vomiting. The physician did not evaluate the patient.

Patient #6:
Presented to the ED on 08/13/11, with a complaint of pain in the right leg after a fall. The physician documented the following: "Alert and Oriented. Heart: Regular, Lungs: clear, Abd: soft, Ext(remities): Pain in R thigh...Patient stable for transfer to ER for further evaluation." The patient was transferred to another acute care hospital.

Review of the receiving hospital's medical record indicated the patient had leg pain with "fractured hardware."

Patient #7:
Presented to the ED on 07/07/11, with a complaint of sharp pain in the right lower quadrant of the abdomen. The patient said he drank 1 beer to kill the pain, but it didn't work. Vital signs upon arrival included: blood pressure (BP) 174/88, pulse (P) 120, respirations (R) 20, temperature (T) 98.0 Fahrenheit (F). The patient reported vomiting one time earlier in the day. The RN started an IV on the patient. The patient was transferred to another acute care hospital. The physician did not evaluate the patient. The nurse documented a verbal order from the physician for transfer.

Patient #8:
Presented to the ED on 05/05/11, at 1325 hours, with complaints of feet hurting, needing pain pills, antibiotics, and the patient thought he had Tuberculosis. Notations in the ED log indicated the patient was transferred to another acute care hospital. The hospital did not have a medical record for this patient.

Patient #9:
Presented to the ED on 04/11/11, with complaints of needing psychiatric help, after using $200-$300 dollars for cocaine. Nursing documented the patient reported struggling financially and was falling apart and had a "hard time breathing." The nurse documented the patient was not at risk for self harm or elopement. The physician did not document in the medical record other than to sign the certification for transfer, which had been dated and timed by the nurse. The DQM verified she could not be certain when the physician signed the transfer form or that the physician ever evaluated the patient.

Patient #10:
Presented to the ED on 03/29/11, with complaints of bilateral lower back pain starting on 03/28/11 and progressively getting worse. The patient's past medical history included bladder, prostate, lymph node cancer, with removal of the bladder, and prostate. The patient had a ureterostomy for 1.5 years. Nursing documented calling the ED physician at 1750. The ED physician called back at 1805 and ordered the patient to be transferred to another acute care hospital. The patient refused to be transferred and the nurse signed the patient out against medical advice. No laboratory tests were performed on the patient. Vital signs included: BP 154/101, P 83, R 20, T 97.2, pain 8 on a scale of 0 to 10, with 10 the worst pain ever.

Patient #11:
Presented to the ED on 03/29/11, with complaints of hitting the back of his head and reported "feeling weird," the room was spinning. A physician evaluated the patient, ordered Tylenol and observed the patient for 1 hour and sent the patient home. No neurological examination was documented. A Glasgow Coma Scale of 15 was documented.

Patient #12:
Presented to the ED on 03/11/11, with complaints of back pain with burning and tingling in his feet with difficulty walking. The patient reported his legs felt weak. Past medical history included back surgeries in 1995, and 1997. The physician documented to transfer the patient for "pain control." The patient was transferred to another acute care hospital.

Patient #13:
Presented to the ED on 02/02/11, with complaints of the feeling like something is in her right eye. The hospital did not have a medical record for this patient.

Patient #14:
Presented to the ED on 10/13/10, with complaints of a stiff back. The patient refused vitals signs and treatment. The patient left without treatment.

Patient #15:
Presented to the ED on 09/25/10, with complaints of chest pain. According to notes in the ED log the patient received Nitroglycerine, Aspirin, Morphine and an EKG. The patient was transferred to another acute care hospital. The hospital did not have a medical record for the patient.

Review of the receiving hospital's medical record revealed the patient was admitted to the hospital with the following diagnoses: Chest Pain; Atrial Fibrillation.

Patient #16;
Presented to the ED on 09/02/10, with complaints of shortness of breath and chest pain. The patient's past medical history included a pericardial effusion. The patient's pain level was reported as a 7. The patient received Nitroglycerin and the pain was at a 5 level. The patient received an Aspirin and was transferred to another acute care hospital. A physician did not evaluate the patient or write orders for the medications given to the patient.

Review of the receiving hospital's medical record indicated the patient received an EKG, chest x-ray (CXR) and determined he did not have an emergency medical condition.

Patient #17:
Presented to the ED on 08/09/10, with complaints of pain to the genital area with swelling for 4 days. Nursing assessed the patient and called a physician who verbally ordered the patient to be transferred to another acute care hospital.

Patient #18:
Presented to the ED on 07/0910, with complaints of burning with urination with discharge from the urinary meatus. The physician did not document in the medical record except to sign the certification for transfer to another acute care hospital.

Patient #19:
Presented to the ED on 06/02/12, with complaints of dizziness and feeling faint. The patient reported being 10 weeks pregnant. The physician evaluated the patient and transferred the patient to another acute care hospital. No laboratory tests were performed on the patient.

Patient #20:
Presented to ED on 05/25/10, with complaints of chest pain radiating from the sternum to the back. The past medical history includes congestive heart failure, pacer, and hypertension. Documentation included the patient used street drugs and was on Methadone. An EKG was obtained and the report included: "...Sinus Tachycardia with occasional premature ectopic complexes, left atrial enlargement, nonspecific intraventricular block, inferior infarct, age undetermined...." A physician did not evaluate the patient. The patient was transferred to another acute care hospital. No treatment was initiated for the patient.

Review of the receiving hospital's medical record indicated the patient was admitted with the following diagnoses: Chest Pain; Congestive Heart Failure; Substance Abuse; and Human Bite.

Patient #21:
Presented to the ED on 05/23/10, with complaints of midsternal chest pain with dizziness. Past medical history included a mechanical heart valve, heart attack 8 years prior, and on coumadin. A physician evaluated the patient. The EKG report included: "Undetermined Rhythm, Inferior--Posterior infarct, age undetermined." The patient was transferred to another acute care hospital. The patient did not receive any treatment.

Patient #22:
Presented to the ED on 04/04/12, with complaints of kidney stones and left lower quadrant abdominal pain. Nursing assessed the patient and two physicians evaluated the patient. The patient received an IV, Morphine for pain and was transferred to another acute care hospital. The Surveyors were on site when this patient arrived and requested to observe the care of the patient.

On 04/05/12, the DQM confirmed the above information, and lack of 3 medical records in the findings as identified above.

Based on review of medical staff bylaws, rules, regulations, facility documents, physician credential files, personnel files, RN House Supervisor schedule, and interview with staff, it was determined the hospital failed to ensure that there were adequate medical and nursing personnel qualified in emergency care, 24 hours per day, seven days a week, as evidenced by:

1. the hospital failed to determine qualifications for physicians supervising the ED; and

2. Six of 9 House Supervisors did not have the required training to work in the ED and competencies were not verified by the hospital (Personnel #'s 4, 6, 13, 14, 17, 18 and 20).

Findings include:

1. Cross reference Tag (A 1111) for information regarding supervision of care in the ED by qualified personnel.

2. On 03/28/12, the governing body approved new medical staff rules and regulations which included: "...When a person presents themselves to the Emergency Services at the Phoenix campus, an RN who has training and competency to conduct a MSE (medical screening examination) will do so. The RN will then proceed to call a physician to give a full report and receive orders. On days, the RN will use the Emergency Call List. During evening hours the RN will involve the House Physician...."

The DQM explained on 04/04/12, that the House Supervisors are notified when a patient arrives to the ED. The House Supervisor takes the Code Cart from the 4th floor medical/ surgical area down to the first floor triage area when an ED patient arrives. The House Supervisors assess the ED patients and are required to take "Critical Thinking In Defensive Triage."

Review of the House Supervisors personnel files for Personnel #'s 4, 5, 6 and 7, revealed the files contained no documentation of training or competencies for the ED. On 04/05/12, the DQM identified that the hospital provided a class for the House Supervisors that would qualify them to work in the ED. The name of the class was "Critical Thinking In Defensive Triage." She verified the hospital has had one training class to date.

The hospital provided the attendance sheet for this triage class which indicated there were 3 House Supervisors that attended the training on 06/01/11. The hospital has 9 House Supervisors working for the hospital currently. Of those 9 House Supervisors, 3 have attended the "Critical Thinking In Defensive Triage" class.

The DQM confirmed on 04/04/12, that the hospital considered the "Critical Thinking In Defensive Triage" as training for the nurses to conduct the medical screening examinations for ED patients.

The hospital provided a document that identified the House Supervisors that currently work for the hospital and the names of RN's that have worked in the past 2 years.

The Chief Clinical Officer confirmed in an interview on 04/04/12, that 6 of 10 House Supervisors did not take the required triage class to work in the ED.

Review of ED patient medical records revealed:

Patient #2:
Presented to the ED on 01/20/11, with a complaint of chest pain, feels like "something is sitting on her chest." The patient was assessed by a RN (Personnel #15). No physician documentation is in the medical record. The nurse started an intravenous (IV) line, administered oxygen (O2) at 2 liters (L). The nurse called 911 and sent the patient to an acute care hospital. No physician evaluated the patient and ordered the IV or O2. The ED did not have protocols or standing orders for the nurses.

Documentation in the medical record indicated RN #15, a Nurse Manager, assessed the patient. This RN did not have documentation of training to work in the ED.

Patient #10:
Presented to the ED on 03/29/11, with complaints of bilateral lower back pain starting on 03/28/11 and progressively getting worse. The patient's past medical history included bladder, prostate, lymph node cancer, with removal of the bladder, and prostate. The patient had a ureterostomy for 1.5 years. Nursing documented calling the ED physician at 1750. The ED physician called back at 1805 and ordered the patient to be transferred to another acute care hospital. The patient refused to be transferred and the nurse signed the patient out against medical advice. No laboratory tests were performed on the patient. Vital signs included: BP 154/101, P 83, R 20, T 97.2, pain 8 on a scale of 0 to 10, with 10 the worst pain ever.

Documentation in the medical record indicated RN #6, a House Supervisor, assessed the patient. This RN did not have documentation of training to work in the ED.

Patient #20:
Presented to ED on 05/25/10, with complaints of chest pain radiating from the sternum to the back. The past medical history includes congestive heart failure, pacer, and hypertension. Documentation included the patient used street drugs and was on Methadone. An EKG was obtained and the report included: "...Sinus Tachycardia with occasional premature ectopic complexes, left atrial enlargement, nonspecific intraventricular block, inferior infarct, age undetermined...." A physician did not evaluate the patient. The patient was transferred to another acute care hospital. No treatment was initiated for the patient.

Documentation in the medical record indicated RN #7, a House Supervisor, assessed the patient. This RN did not have documentation of training to work in the ED.

The DQM confirmed the above findings on 04/04/12, for each of the patients.