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Based on staff interview and review of medical records, incident reports, and Medical Staff Rules, it was determined the CAH failed to ensure emergency care necessary to meet the needs of its patients was provided. This resulted in delays in the provision of care to patients. Findings include:

Refer to C207 as it relates to the CAH's inability to ensure practitioners were available by telephone and in person to treat emergency patients.

The cumulative effect of these systemic failures prevented patients from receiving emergency care in a timely manner.

Based on staff interview and review of medical records, incident reports, and Medical Staff Rules, it was determined the CAH failed to ensure a practitioner was immediately available by telephone and available on site within 30 minutes for 2 of 21 emergency patients (#10 and #21), whose records were reviewed. This delayed treatment and placed patients with serious medical conditions at risk of further deterioration. Findings include:

1. Patient #10's "EMERGENCY ROOM ADMISSION" form documented a 68 year old male who presented to the ER at 1:05 AM on 11/19/10. He complained of chest and back pain and numbness of his left leg. His blood pressure was 166/98 at that time. His pulse was 45. His respirations were 14. His oxygen saturation rate was 97%. The nursing note at 1:05 AM on 11/19/10 stated he was short of breath and receiving oxygen but did not state how much. The nursing note at 1:10 AM stated Physician A, the on call provider tasked with examining the patient within 30 minutes [see example #4], was contacted and orders for medications, an electrocardiogram, laboratory tests, and X-rays were given. At 1:50 AM, the physician had not yet arrived. The nurse documented trying to call Physician A at that time because Patient #10 rated his pain at 10 of 10. The note stated the nurse left a message on the Physician A's telephone. At 1:55 AM, the nurse documented calling Physician A again with no answer. The note stated Patient #10 was leaving the hospital against medical advice. A nursing note at 2:00 AM on 11/19/10 stated Physician A arrived at that time. Patient #10 was still in the hospital. The "EMERGENCY PHYSICIAN RECORD" was dated 11/19/10 and erroneously timed 1:05 AM (the time was incorrect as the physician did not arrive at the hospital until 2:00 AM). The "EMERGENCY PHYSICIAN RECORD" documented an examination of Patient #10, noting no respiratory distress and normal breath sounds. The physician record stated Patient #10's electrocardiogram showed atrial fibrillation with slow ventricular response. The physician record documented the clinical impression as "Back pain, GERD."

Physician A wrote orders for Patient #10 to be admitted for observation at 2:45 AM on 11/19/10. At 5:10 AM, the nurse documented Patient #10 was found unresponsive and required ventilatory assistance by bagging. Patient #10 was transferred to an acute care hospital at 5:30 AM. A physician note, dated 11/19/10 at 5:38 AM, stated "ASSESSMENT: Probable aspiration with hypoxic event."

The RN who cared for Patient #10 was interviewed on 3/21/11 at 11:05 AM. She stated she called Physician A at 1:10 AM and received orders for an electrocardiogram, laboratory, and X-ray tests. She stated Patient #10's pain was increasing. She said she tried to call Physician A twice but he did not answer either call. She stated Patient #10 became frustrated when the physician did not come to the CAH. She said he got dressed and was ready to leave for another hospital when the physician arrived. Then the patient decided to stay at the CAH.

Physician A was interviewed on 3/18/11 beginning at 11:10 AM. He stated he did not know why it took him 50 minutes to arrive at the hospital. He stated he lived 7 miles away. He said he may have fallen back asleep. He also stated he did not know why the nurse was unable to reach him by telephone.

The physician was not immediately available by telephone and did not arrive at the hospital within 30 minutes after he was called.

2. Patient #21's "EMERGENCY ROOM ADMISSION" form documented a 51 year old male who presented to the ER at 3:45 AM on 12/24/10. He complained of shortness of breath, stating he was having an "Asthma Attack" and was unable to catch his breath. The "EMERGENCY ROOM ADMISSION" form documented his blood pressure was 101/80 at 3:50 AM. His pulse was 133. His respirations were 24 and his oxygen saturation rate was low at 84%. Physician A was notified of the patient's arrival and orders for treatment were received. Physician A came and admitted Patient #21 for observation.

"SUPPLEMENTARY NURSES NOTES" documented Patient #21 slept a while. At 7:50 AM, the notes stated he ate breakfast and had another breathing treatment. Following this, the nurse started to write the time of a new note but did not complete it. She documented speaking with Physician A and informing him of Patient #21's elevated cardiac enzymes, which had been drawn that morning. Physician A stated he would be in to review the laboratory test results. The nurse then documented Patient #21 had respiratory distress, a decreased pulse rate of 58, and decreased oxygen saturation rate although the number was not documented. The note further stated "work of breathing [increased]. diaphoretic. Dr [Physician A] called. No answer, transfer to ER via bed. [Monitor] applied; EKG, Life Flight launched. Dr [Physician A] called no answer. 0830 [Receiving doctor at receiving hospital] informed of situation. Lovenox and aspirin given. [Heart rate] 57. [Increased] WOB. 112/53 R 36. 0845 HR 138. [Electrocardiogram per doctor at receiving hospital. Results and laboratory test results faxed to that physician. 0913 Lost Rivers Medical Center physician with patient.] Morphine 2 mg given IV. Unable to obtain BP [with] manual cuff. Albuterol [nebulizer treatment] given. 0930 P 56 manual, weak, thready. O2 saturation 82%. 0925 130 HR." The notes stated Life Flight paramedics arrived at 9:25 AM. The notes stated the paramedics intubated Patient #21 and he suffered a cardiac arrest. Cardiopulmonary resuscitation was started. Patient #21 was transferred to the receiving hospital via helicopter at 10:15 AM. The medical record from the receiving hospital stated Patient #21 arrived at the Receiving hospital at 10:55 AM with CPR in progress. It stated CPR was discontinued and he was pronounced dead at 11:20 AM on 12/24/10.

Physician A dictated a 'HISTORY AND PHYSICAL" on 12/24/10 at 10:20 AM. The dictation stated Patient #21's pulse had been restored after he arrested. The note stated he was given a clot busting medication and loaded into the helicopter for a flight to an acute care hospital. The note stated Patient #21 "...was in critical condition but was somewhat stable at the time [of transfer]." Physician A wrote that Patient #21's diagnosis was myocardial infarction.

The RN who cared for Patient #21 was interviewed on 3/22/11 at 10:15 AM. She stated she called Physician A at approximately 8:15 AM with the laboratory results. She stated she reached him and he stated he would be in to review the report. She stated she did not know the time specifically but shortly after talking with the physician, she found Patient #21 in respiratory distress. She said she called Physician A but he did not answer the phone. She stated she took Patient #10 to the ER to treat him. She stated since she could not reach the CAH physician, she called Life Flight at a regional medical center. She said she then tried to call Physician A again and again he did not answer. She said she then spoke with the ER physician at the regional medical center and got orders to treat Patient #21. She stated Physician A arrived in the ER at 9:13 AM on 12/24/10 and the helicopter arrived at 9:25 AM. The nurse stated she had called Physician A on several other occasions and had not been able to reach him. She was not able to be more specific about other times she had called the physician and had not been able to reach him.

Physician A was interviewed on 3/18/11 beginning at 11:10 AM. He stated he did not know why the nurse was unable to reach him by telephone. He stated he may have gone to do chores on his ranch and did not take his telephone with him.

The physician was not immediately available by telephone and did not arrive at the hospital within 30 minutes after he was called.

3. An incident report, dated 11/30/10, stated Physician A did not report to the hospital in a timely manner on 11/19/10 to treat Patient #10. On 1/06/11, the Director of Quality Improvement wrote on the "QAPI" section of the incident report "as of 1/06/11 no other occurrences reported." During an interview on 3/18/11 at 10:35 AM, the Director of Quality Improvement stated she did not have an incident report related to the delay in treatment of Patient #21 and was not aware of the delay.

The hospital failed to monitor other incidents when physicians failed to respond in a timely manner.

4. Medical Staff Rules, dated 5/24/10, stated "Emergency Call...All patients presenting to the ER will be seen by the on-call provider within 30 minutes after notification." This did not happen for the above cases.

The Administrator was interviewed on 3/18/11, beginning at 11:05 AM. He stated, following the incident involving Patient #10, he reviewed the Medical Staff Rules with the physician who treated Patient #10 and counseled him regarding the importance of responding to the hospital in a timely manner. The administrator stated he was not aware of the lack of response to Patient #21 so he had not taken action in that case.

The hospital failed to ensure physicians answered telephones and responded to emergencies in a timely manner.

Based on patient and staff interview and review of clinical records and CAH policies, it was determined the CAH failed to ensure complete and accurately documented records for 9 of 21 sample patients (#3, #5, #10, #13, #14, #16, #17, #18 and #21) whose records were reviewed. The CAH also failed to ensure complete ER registry entries for 5 of 6 months (October 2010, December 2010, January 2011, February 2011, and March 2011) involving 9 patients (#22, #23, #24, #25, #26, #27, #28, #29, and #30). This resulted in a lack of clarity about the course of patient care. It had the potential to interfere with coordination of patient care. Findings include:

An undated CAH policy, "CHARTING, GENERAL RULES," included the following points:

> All charting must be accurate, neat, honest, and legible.
> Charting should be brief, concise, accurate, complete, and meaningful.
> Each time an attending physician or house staff visits should be recorded.
> All symptoms or changes in condition of patients should be recorded.
> When a mistake is made, mark a single line through the error and indicate an error was made, and sign your initials.

In the examples that follow, the charting policy was not followed.

1. Patient #10's "EMERGENCY ROOM ADMISSION" form documented a 68 year old male who presented to the ER at 1:05 AM on 11/19/10. He complained of chest and back pain and numbness of his left leg. The nursing note at 1:05 AM on 11/19/10, stated he was short of breath and receiving oxygen but did not state the flow rate. The "SUPPLEMENTARY NURSES NOTES," dated 11/19/10 at 2:35 AM, stated Patient #10 was given Zantac and Zofran for nausea. Subsequent notes did not state if these medications were effective. Patient #10 received Morphine at 2:50 AM, 3:50 AM, and 4:50 AM. The response to these medications was not documented. At 5:10 AM, the nurse documented Patient #10 was found unresponsive and required ventilatory assistance by bagging. The nursing note documented giving Patient #10 Narcan, a narcotic antagonist, at 5:15 AM. A response to this drug was not documented.

A physician's "EMERGENCY ROOM NOTE," dated 11/19/10 at 5:38 AM, stated Patient #10 "...vomited and then went blue and quit breathing. The nurses quickly got him to the floor and started bagging him. He fairly quickly started to breathe again and pinked up. He had an oropharyngeal tube in (a tube to keep his airway open). The patient's head was quite blue, his heart rate never stopped. It continued in the 50s to 100 in atrial fibrillation, but the patient was disoriented and did not remember anything. He was bagged for approximately 20 minutes before we contacted Dr. [name at the receiving hospital] and he accepted transport to [the receiving hospital] by ambulance." The reason for this mode of transportation for this critically ill patient was not documented.

The distance between the two hospitals was 72 miles, according to Google Maps, queried on 3/23/11 at 11:00 AM.

The physician who treated Patient #10 was interviewed on 3/18/11, beginning at 11:10 AM. He stated the local ambulance crew were volunteers and did not include paramedics. He stated he did not remember why he sent Patient #10 by local ground ambulance rather than summoning a Life Flight helicopter that was staffed by paramedics. He said maybe the weather was bad and maybe the receiving hospital sent an ambulance to meet the local ambulance half way between the two hospitals but he could not remember.

The medical record from the receiving hospital stated Patient #10 arrived there at 6:40 AM on 11/19/10 with ambulance personnel performing CPR. The receiving hospital continued resuscitation efforts until 6:57 AM when CPR was discontinued and Patient #10 was pronounced dead.

CAH staff did not completely document the care provided to Patient #10.

2. Patient #21's "EMERGENCY ROOM ADMISSION" form documented a 51 year old male who presented to the ER at 3:45 AM on 12/24/10. He complained of shortness of breath, stating he was having an "Asthma Attack" and was unable to catch his breath. The "EMERGENCY ROOM ADMISSION" form documented the physician was notified of the patient's arrival and orders were received at 4:00 AM. A nebulizer breathing treatment was administered at 4:04 AM. The nurse did not document Patient #21's response to the nebulizer breathing treatment. The "EMERGENCY PHYSICIAN RECORD" was dated 12/24/10 at 3:45 AM, although this time was not correct as the physician did not arrive until 4:23 AM, according to the "EMERGENCY ROOM ADMISSION" form. The physician record documented the breathing treatment "helped" but did not explain what this meant. The same physician note stated the Patient #21's respirations had prolonged expirations, accessory muscle use, retractions, decreased air movement, and wheezes. Patient #21 was admitted for observation.

"SUPPLEMENTARY NURSES NOTES" documented Patient #21 slept a while. At 7:50 AM, the notes stated he ate breakfast and had another breathing treatment. The nurse started to write the time of a new note but did not complete it. She documented speaking with the physician and informing him of Patient #21's elevated cardiac enzymes. The physician stated he would be in to review the laboratory test results. She then documented Patient #21 had respiratory distress, a decreased pulse rate of 58, and a decreased oxygen saturation rate although the number was not documented. The note further stated "work of breathing [increased]. diaphoretic. Dr [name] called. No answer, transfer to ER via bed. [Monitor] applied; EKG, Life Flight launched. Dr [name] called no answer. 0830 [Receiving doctor and receiving hospital] informed of situation." Events between 7:50 AM and 8:30 AM were not timed.

The nurse who cared for Patient #21 was interviewed on 3/22/11 beginning at 10:15 AM. She confirmed the documentation.

CAH staff did not completely document the care provided to Patient #10.



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3. Patient #3 was a 49 year old female who presented to the ER on 1/03/11 at 5:30 PM with a cough and bloody sputum. An "EMERGENCY ROOM ADMISSION" report, documented orders for lab work and a chest x-ray. It also documented moving Patient #3 to "ER hold" and a plan to transfer her to an acute care hospital the following morning.

Patient #3's condition at discharge was not documented by the physician in ER records. There was also no documentation to indicate Patient #3 had been advised to transfer by ambulance but had refused.

Patient #3 was interviewed by telephone on 3/18/11 at 10:20 AM. She stated the hospital had offered her an ambulance for transfer to the receiving hospital. However, she said she did not want to go by ambulance because she did not have insurance and did not want to pay $150.00. She stated she was doing better at the time of the transfer and she felt comfortable being driven to the receiving hospital in a private vehicle, that it was her choice.

A hospital policy, "EMTALA," stated the patient had a right to refuse appropriate transfer. In such cases, the hospital would document the refusal, explain to the patient the benefits and risks, and take reasonable steps to obtain the individual's written informed refusal. If the individual refuses to sign a written informed refusal, the hospital will document the foregoing, including the steps it took to obtain the individual's written informed refusal. There was no documentation Patient #3 had refused appropriate transfer.

Patient #3's physician was interviewed on 3/17/11 at 3:55 PM. She stated she knew Patient #3 well. She recalled Patient #3 coming into the ER coughing up blood, and subsequently ordering lab and x-rays and contacting another physician from a receiving hospital to accept her for transfer the following morning. The physician stated she slept at the hospital and checked on Patient #3 about 4:00 AM on 3/18/11. This assessment was not documented. She stated she considered Patient #3 stable at the time of her assessment. She explained Patient #3 did not want to go in an ambulance to the receiving hospital because she did not have any insurance. The physician acknowledged she did not document her assessment of Patient #3 at 4:00 AM or having offered the ambulance for transfer and Patient #3's subsequent refusal.

The CAH staff did not completely document the communication with Patient #3 or all care provided to Patient #3.

4. Patient #16 was a 69 year old female with chest pain who arrived via ambulance at the ER on 1/02/11 at 7:30 AM. The "EMERGENCY PHYSICIAN RECORD," dated 1/02/11, did not document Patient #16's condition at the time of transfer to a receiving facility, whether stable or unstable. The form, "TRANSFER TO ANOTHER HEALTH CARE FACILITY," dated 1/02/11, contained Patient #16's signature and the physician's signature. There were no times or dates next to either signature to indicate when they were signed.

During an interview on 3/18/11 at 9:30 AM, the Director of Medical Records reviewed Patient #16's record and confirmed the missing information.

Signatures were undated.

5. A hospital policy, "Emergency Room - Register," stated an emergency room register would contain information, including (but not limited to) the physician's name and the disposition of the case.

The ER register was reviewed from October, 2010 to March, 2011. Entries that follow were incomplete or crossed out without corresponding initials and/or explanation.

a. Patient #22's name was logged into the ER register on 10/20/10 at 9:40 PM. The entry was crossed out, without initials. The word "error" was visible. A disposition was not documented.

b. Patient #23's name was logged into the ER register on 10/29/10. The time was not documented. The entry was crossed out, without initials or the word "error." The disposition was not documented.

c. Patient #24's name was logged into the ER register on 12/15/10. The time was not documented. The entry was crossed out, without initials or the word "error." The disposition was not documented.

d. Patient #25's name was logged into the ER register on 1/17/11. The time was not documented. The entry was crossed out, without initials or the word "error." The disposition was not documented.

e. Patient #26's name was logged into the ER register on 1/31/11 at 7:20 AM. The disposition was not documented.

f. Patient #28's name was logged into the ER register on 2/21/11 at 10:50 AM. The disposition was not documented.

g. Patient #27's name was logged into the ER register on 3/03/11 at 10:30 AM. The disposition was not documented.

h. Patient #29's name was logged into the ER register on 3/03/11 at 10:30 AM. The disposition was not documented.

i. Patient #30's name was logged into the ER register on 3/03/11 at 10:50 AM. The physician's name, disposition, and time of disposition were not documented.

During an interview on 3/18/11 at 8:45 AM, the Director of Medical Records reviewed the ER registry. She initially stated she did not know why the 4 entries (Patients #22, #23, #24, and #25) were crossed out. She confirmed the incomplete entries on #25, #26, #27, #28, #29, and #30.

A few moments later, after researching the crossed out entries, she offered explanations. Patient #22 had been an outpatient rather than an ER patient. Patient #23 had not actually come to the ER but had been admitted to the hospital without going through the ER. Patient #24's information had been accidentally entered twice. Patient #25 had not actually come to the ER and she thought perhaps an ambulance had called ahead but did not arrive.

ER registry entries were incomplete. Correction of errors were incomplete.

6. Patient #5 was a 39 year old male who arrived at the ER on 1/25/11. A time of arrival of 4:15 PM was documented and then crossed out. There were no initials as to who changed the time. A second time of 6:15 PM was entered.

During an interview on 3/18/11 at 9:30 AM, the Director of Medical Records reviewed Patient #5's record. She stated the error should have been initialed.

The correction of an error was incomplete.



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7. Patient #14 was a 39 year old male who presented to the ER on 2/13/11 at 2:45 PM for care primarily related to shortness of breath, decreased level of consciousness and low blood pressure. Patient #14 was transferred by Life Flight to another hospital for specialty care. The clinical record did not contain information regarding the risks, benefits, or consent for transfer. In addition, the physician did not document Patient #14's condition prior to transfer.

In an interview on 3/18/11 at 11:10 AM, the physician confirmed the clinical record did not contain a transfer form which contained the risks, benefits, and consent for transfer. The physician further stated a transfer form was filled out for Patient #14, but he did not know why it was not in the record.

A hospital policy titled "Transfer of Patients to Another Facility" (6/26/03) states "The following guidelines are available to assist in the continuity of patient transfers." The referring physician completes the transfer form. The RN is to obtain signed consent for transfer. There were no physician transfer or consent forms in the clinical record.

The clinical record was incomplete.

8. Patient #13 was a 16 year old male who presented to the ER on 11/25/10 at 10:59 PM for care primarily related to abdominal pain. In a review of the clinical record, it was found that Patient #13 was discharged from the ER to home without documentation of his condition prior to discharge. In an interview on 3/17/11 at 4:35 PM, the physician confirmed Patient #13's condition prior to discharge was not documented.

The clinical record was incomplete.

9. Patient #18 was a 27 year old male who presented to the ER on 1/08/11 at 12:45 AM for care primarily related to severe abdominal pain. On the "EMERGENCY ROOM ADMISSION" form, Patient #18 was documented as being discharged at "1330" (1:30 PM). In an interview on 3/17/11 at 9:25 AM, the Director of Medical Records reviewed the clinical record and stated the discharge time was incorrectly written and should have been 1:30 AM.

The clinical record was inaccurate.

10. Patient #17 was a 63 year old female who presented to the ER on 1/09/11 at 10:55 PM for care primarily related to shortness of breath. On the "EMERGENCY ROOM ADMISSION" form under "Vital Signs," O2 saturations were scribbled out without the documenter's initials. The error was unreadable due to the way it was changed.

In an interview on 3/17/11 at 9:25 AM, the Director of Medical Records stated that the O2 saturation was not properly corrected as it was changed without the use of one line to cross out the error with the documenter's initials next to the line.

The error was not crossed out with one line and then initialed according to hospital documentation standards. The clinical record was incorrectly changed.