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Based on review of facility documents, on-call schedules, and staff interviews (EMP), it was determined that the facility failed to have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control.

Findings include:

Review of the " UPMC Bedford Memorial Department of Emergency Medicine, Rules and Regulations," dated 08, 208 [sic], revealed " ... The call roster currently contains sections for: Primary Care: General Medicine-Hospitalist, Obstetrics, Pediatrics; Other: Anesthesiology, Cardiology; Surgery and Surgical Subspecialties: ENT [Ear Nose Throat], General Surgery, Ob-Gyn [Obstetrics Gynecology], Ophthalmology, Oral-Maxillofacial, Orthopedic Surgery; Medical Imaging; Pathology; Podiatry; and Urology ... The use of specialized consultation and transfer will adhere to hospital policy and meet the requirements of existing statute. No patient will be transferred without being accepted for transfer by the receiving attending physician and institution. If a patient is transferred, the EDP/ED-PE must complete the appropriate Transfer Form (s). In the case of the transfer form(s) being completed by and ED-PE, the form (s) will be co-signed by the on-duty EDP. Transfer agreements have been made with other hospitals in order to comply with EMTALA when the need arises to expeditiously transfer an unstable patient ... ."
Review of "UPMC Policy and Procedure Policy: HS-LE000: Legal Subject: Emergency Medical Treatment And Active Labor Act (EMTALA) Date: March 31, 2011 I. Policy: It is the policy of UPMC to comply will all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 USC 1395dd. II. Purpose: The purpose of this policy is to set forth hospitals' requirements under EMTALA. III. Scope: This policy applies to all domestic UPMC hospitals. Each hospital may develop its own procedures for implementing this policy, provided that such procedures are consistent with the policy ... 5. Following the Medical Screening Exam, a patient may be transferred if requested by the patient or their representative, after being notified of the risks and benefits of the transfer. If the hospital determines that it does not have appropriate medical and/or staffing resources to properly stabilize the patient, transfer to an appropriate facility may be made if a physician certified in writing that the medical benefits of the transfer are expected to outweigh the risks of transfer; or if a QMP certifies in writing that the benefits of transfer are expected to outweigh the risks of transfer, and such certification is co-signed by a physician. When a patient is transferred the consent of the receiving hospital to accept the transfer must be first obtained and documented in the medical record. In the case of transfer from UPMC facility, the UPMC facility shall send to the receiving facility, copies of all pertinent medical records available the time of transfer, and affect the transfer through qualified personnel and transportation equipment ... Each UPMC hospital's Emergency Department [ED] shall maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an Emergency Medical Condition. Physicians on-call are required to personally attend to the patient when requested to do so by the treating physician ... 13. Each UPMC hospital shall maintain policies and procedures to (a) respond to situations in which a particular specialty physician is not available or if on-call physician is not able to respond due to circumstances beyond his or her control; and (b) provide that emergency services are available if the hospital elects to permit its on-call physicians to schedule elective surgery during the time that they are on call or permit physicians to participate in simultaneous on-call service ... ."

1) A review of MR1 revealed the patient presented post motor vehicle accident with left arm deformity, and confirmed fracture and foreshortening of the radius and ulna and a distal fracture of the radius. Physician documentation in the medical record revealed that the Orthopod was out of town. Documentation in the medical record indicated that the patient was medicated for pain, and a splint was applied. The patient was provided with X-rays and stated that the patient was traveling home and going right to the ER [Emergency Room] to be evaluated. The physician documented that they did not believe at this time, patient needs to have surgery emergently ... ."
2) Review of the On-Call Schedule for Orthopedics for June 17, 2011, revealed the physician was "semi-available," but not on call.
3) Interview was conducted with EMP6 on June 28, 2011, at 1:28 PM. EMP6 was queried in regard to Emergency Department policy and procedure to direct staff on the process of what to do in the event that an on call specialist is unavailable. EMP6 confirmed that there is no ED policy and procedure to assist staff in the event a specialist physician is unavailable. EMP6 stated, "I do not know of that being in any of our bylaws [ED Bylaws], but it could be in the specialist bylaws. When required to take call, they are very good about it. We have no problem with coverage. If a specialist is unavailable, the staff would call a referral hospital."

Based on review of facility documents, review of closed medical records (MR), and staff interviews (EMP), it was determined that the facility failed to maintain a central log on each individual who comes to the dedicated emergency department, as defined in 489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged.

Findings include:

Review of "Review of "UPMC Policy and Procedure Policy: HS-LE007, Legal Subject: Emergency Medical Treatment And Active Labor Act (EMTALA) Date: March 31, 2011 I. Policy: It is the policy of UPMC to comply will all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 USC 1395dd. II. Purpose: The purpose of this policy is to set forth hospitals' requirements under EMTALA. III. Scope: This policy applies to all domestic UPMC hospitals ... 12. Each hospital facility shall maintain a central log in the Emergency Department identifying each individual that seeks emergency medical treatment at that facility, and indicate whether they refused treatment, or whether they were transferred, admitted, or discharged. These logs shall be retained for three (3) years. 13. Each UPMC hospital shall maintain policies and procedures to (a) respond to situations in which a particular specialty physician is not available or if on-call physician is not able to respond due to circumstances beyond his or her control; and (b) provide that emergency services are available if the hospital elects to permit its on-call physicians to schedule elective surgery during the time that they are on call or permit physicians to participate in simultaneous on-call service. Off Campus Locations 1. For off-campus sites that do not meet the definition of a Dedicated Emergency Department, the site personnel should activate their local EMS process and render appropriate assistance. 2. A log of all emergency events will be maintained at each off campus site and a copy submitted to the Hospital Compliance Officer, or designee, on a quarterly basis. ... ."

Review of the "UPMC Bedford Memorial Department of Emergency Medicine, Rules and Regulations," dated 08, 208 [sic], revealed, " ... A control register log will be maintained in the ED. An entry will be made for any patient who utilizes the services of the ED. All times will noted in military time. The log will contain, at a minimum, the following information on each patient visit: patient identification data, date and time of arrival, time seen by physician, time of disposition, disposition, final ED diagnosis, name of treating physician, and any consultants, etc, triage level, charge level, diagnostic studies, by department ... 4. Patient Care. Upon presentation to the ED, patients will be triaged by the nursing staff ... ."

Review of Department Of Emergency Services Policy and Procedure "Title: OB Patients Presenting To The Emergency Department, Date Issued 9/1996, Reviewed: ... 2/10 ... Procedure: 1. Any pregnant female presenting at 16 weeks gestation or later and is reporting vaginal bleeding, ruptured membranes, or contractions is taken immediately to the OB Department for evaluation. 2. The Emergency Department Staff will contact the OB Department with the patient's name, OBMD, chief complaint, and date of confinement."

1) A review of the OB "Register of Visits" dated May 1, 2011, to June 27, 2011, revealed no documented evidence if a patient was scheduled or unscheduled when presenting to the OB department. Further observation of the Register of Visits revealed that the register did not indicate whether the patients were transferred, stabilized and transferred, or discharged.

Interview with EMP8 confirmed the above findings.

2) Review of the scheduled appointment log book for outpatient testing was reviewed. During an interview with EMP8, on June 27, 2011, at approximately 02:00 PM, revealed "This is an incomplete log book, we cannot tell who was emergent and who was scheduled. The nurses do not always enter the patients into the log book."

3) Review of the OB "Register of Visits" dated June 1, 2011, to June 27, 2011, revealed that 98 patients presented to the OB department. The register revealed that seventeen of the ninety-eight patients were admitted to the unit. Of the ninety-eight patients, the register did not reveal if the patients were scheduled or unscheduled in presenting to the unit. The register was also inconsistent in documentation of "reason" of why the patient presented.

Interview with EMP8, Unit Manager on June 27, 2011, at approximately 11:00 AM, revealed, "We have no policy on the log book. We just keep it for us. We cannot pull up a log of patients on the computer. There is no way to tell where they (patients) came from. You can't tell if they were in the emergency department. We register them here."

4) The facility determined and it was confirmed by EMP 2, that on May 2011, 40% of the patients that presented to the OB department were unscheduled visits. In June 2011, 30% of the patients that presented to the OB department were unscheduled visits.

EMP2 confirmed the above findings and revealed "We [staff] went through every medical record on the register to determine if it was scheduled or unscheduled."

Based on review of facility documents, closed medical records (MR) and staff interviews (EMP), it was determined that the facility failed to provide an appropriate medical screening examinations for two of ten OB medical records (MR) reviewed (MR2, MR3).

Findings include:

Review of "UPMC Policy and Procedure Policy: HS-LE000: Legal Subject: Emergency Medical Treatment And Active Labor Act (EMTALA) Date: March 31, 2011 I. Policy: It is the policy of UPMC to comply will all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 USC1395dd. II. Purpose: The purpose of this policy is to set forth hospitals' requirements under EMTALA. III. Scope: This policy applies to all domestic UPMC hospitals. 3. Medical Screening Exam (MSE) is an appropriate exam within the capacity of the hospital to determine whether an emergency medical condition exists. ... 5. Qualified Medical Person ("QMP") is defined as a licensed physician or other appropriately qualified individual as determined by each hospital in their respective by-laws or rules and regulations. V. Procedure 1. If an individual seeking emergency medical care comes to the hospital's Dedicated Emergency Department, physicians or other Qualified Medical Person (QMP) shall offer a shall offer a Medical Screening Exam to such person. ... ."

1) Review of MR 2 dated March 25, 2011, revealed no documented evidence of patient receiving a medical screen from physician. Further review of MR2 revealed, " ... Complaint "I've had on-going GB [Gall Bladder] issues with this pregnancy, and it really hurts now. I am to see Dr.[surgeon] General Surgeon, from Summit Health next week for my GB and couldn't wait. I had an US [Ultrasound] done last week of my GB, and my doctor is sending me to the surgeon" ... Orders Received Yes ... Phoned Dr. ... with pt update. Strip reactive, has some slight uterine irritability which pt does not feel. As baby appears fine on strip. Dr. ... advised pt to go to ... regular OB dept, for them to help facilitate ... seeing the surgeon ASAP. ... Discharge Instructions ... go there now Follow-UP at: Chambersburg Hospital."

Interview with EMP8 on June 28, 2011, at 1:50 PM confirmed the above findings of MR2 and revealed "There is no documentation that the physician saw this patient."

2) Review of MR3 dated May 19, 2011, revealed no documented evidence of a medical screen from a physician. Further review of MR3 revealed "Obstetric Evaluation Summary ... To: 208 D By: Walk ... From X Home ... Evaluation, Procedure(s): ... X Unscheduled X NST ... Indication(s): MVA today ...Notes: MVA 1040 today - was stopped to yield onto the bypass another car hit her from the rear, no injury to self or vehicle, denies any contracts. 1330 Infant very active ... no contractions seen. Dr called - orders obtained to D/C home ... initials of EMP22. ... Orders ... NST v/o Dr. .../EMP22 D/C home to be seen in office tomorrow. T/O Dr. ... /EMP22. ... ."

Interview with EMP8 on June 28, 2011 at 2:00 PM confirmed the above findings of MR3 and revealed, "there is no medical screening by a physician."

Based on review of facility documents, closed medical records (MR), and staff interviews (EMP), it was determined the facility failed to execute an appropriate transfer for two of 33 patients who had presented to the Emergency and Obstetrics Department, for treatment. (MR1, MR2)

Findings:

Review of "UPMC Policy and Procedure Policy: HS-LE000: Legal Subject: Emergency Medical Treatment And Active Labor Act (EMTALA) Date: March 31, 2011, I. Policy: It is the policy of UPMC to comply will all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 USC1395dd. II. Purpose: The purpose of this policy is to set forth hospitals' requirements under EMTALA. III. Scope: This policy applies to all domestic UPMC hospitals. Each hospital may develop its own procedures for implementing this policy, provided that such procedures are consistent with the policy ... 5. Following the Medical Screening Exam, a patient may be transferred if requested by the patient or their representative, after being notified of the risks and benefits of the transfer. If the hospital determines that it does not have appropriate medical and/or staffing resources to properly stabilize the patient, transfer to an appropriate facility may be made if a physician certified in writing that the medical benefits of the transfer are expected to outweigh the risks of transfer; or if a QMP certifies in writing that the benefits of transfer are expected to outweigh the risks of transfer, and such certification is co-signed by a physician. When a patient is transferred the consent of the receiving hospital to accept the transfer must be first obtained and documented in the medical record. In the case of transfer from UPMC facility, the UPMC facility shall send to the receiving facility, copies of all pertinent medical records available the time of transfer, and affect the transfer through qualified personnel and transportation equipment ... 13. Each UPMC hospital shall maintain policies and procedures to (a) respond to situations in which a particular specialty physician is not available or if on-call physician is not able to respond due to circumstances beyond his or her control; and (b) provide that emergency services are available if the hospital elects to permit its on-call physicians to schedule elective surgery during the time that they are on call or permit physicians to participate in simultaneous on-call service ... ."

Review of Administrative policy and procedure "Title: Transfer Policy/Procedure (Also See HS-LE007 EMTALA) Date Issued 11/91, ... Section General, Policy G34 ... Revised: ... 12/10 Policy: It is the policy of UPMC Bedford Memorial to comply with all applicable laws and regulations when initiating an interfacility transport of a patient. UPMC Bedford Memorial follows the UPMC Health System Policy HS-LE007. This policy address the UPMC Bedford Memorial specific procedures. Procedures: 1. Initiation of a patient transfer - The decision to transfer a patient is the ultimate responsibility of the physician. The patient should ideally be stable at the time of transfer. On recognizing the need for transfer: A) The physician will: 1) Determine the receiving hospital and verify a receiving physician. 2) Exchange clinical information with the receiving physician. 3) Determine the necessary level of medical care and life support equipment necessary during transfer. 4) Determine time frame for and order classification of transfer based on time elapsed from order given to patient leaving: a) Emergent (immediate) b) Urgent (within 1-2 hours), or c) Non-urgent 5. Determine and order mode of transfer: a) ALS or BLS Ground ambulance, or b) Helicopter 6) Explain the risks and benefits of transfer to the patient and family. Complete the physician section of the Transfer Form. B) The primary RN, charge RN, or his/her designee will: 1) Notify the agency of transport along with a report on all transfers. Emergency and Urgent Transfers a) Land Transfers-Call ambulance; Call County control at ... b) Helicopter - verify that arrangements have been confirmed. Non-Urgent Transfers a) Call ambulance; Call county Control if unable to secure an ambulance. B) Coach is called for non-urgent when appropriate. 2) Verify that the Transfer Form is completed. 3) Ensure the entire current chart is copied to send with the patient. 4) Verify time and bed availability with admissions office of receiving facility. 5) Give verbal report to transport staff. 6) Call report to nursing unit receiving the patient prior to their arrival. 7) Ensure all pre-transfer orders are carried out. 8) Notify the Nursing Supervisor. II Documentation of patient transfer - A) Physician documentation must include: 1) Informed risks and benefits of transfer, benefits must outweigh the risks except in a patient initiated transfer. 2) Chief Complaint, History & Physical, working diagnosis, and current status note. 3) Documentation of discussions with patient and/or family. 5) Transfer order 6) Ambulance Medical Necessity Form. 7) Physician section of the Transfer Form. B) Primary or Charge RN documentation must include: 1) Treatment given to patient and the patient's response. 2) Completion of the nursing section of the Transfer Form. 3) Documentation of report being called to nursing unit. 4) Continued to monitor and document changes in the patient's condition until the moment of transfer. ... D) Physician Not Present At Time of Transfer 1) Physician must discuss the risks/benefits with the patient or responsible party. 2) A verbal order for transfer may be taken from the physician if and only if: a) The discussion with the patient/family has taken place via telephone, and b) The physician is not present in the institution. 3) The verbal order section on the Transfer from must be completed by nursing. 4) The physician ordering transfer must co-sign the order. 5) Forms may be faxed per policy. E) Nondiscrimination A participating hospital that has specialized capabilities or facilities shall not refuse to accept an appropriate transfer of a patient who requires such specialized capabilities. There will be no delay of medical screening or transfer order to inquire about the individual's method of payment or insurance status. Should an institution refuse to accept such a patient the institution shall be reported within 72 hours and as per HS-LE007."
1) A review of the patient's medical records from UPMC Bedford (MR1) and York Hospital (MR 34) was completed.
MR1 revealed the patient presented post motor vehicle accident with left arm deformity, and confirmed fracture and foreshortening of the radius and ulna and a distal fracture of the radius. Physician documentation in the medical record revealed that the orthopod was out of town. Documentation in the medical record indicated that the patient was medicated for pain and a splint was applied. The patient was provided with xrays and stated that the patient was traveling home and going right to the ER [Emergency Room] to be evaluated. The physician documented that they did not believe at this time, patient needs to have surgery emergently.

Review of MR34, dated June 17, 2011, through June 18, 2011, revealed, "ED Phys Note: ... Time seen 6/17/2011 8:03 PM, seen with [OTH1] ... Arrival mode: Private vehicle ... Additional Information: Chief complaint from Nursing Triage Note: Chief Complaint, 6/17/2011 7:07 PM Chief complaint: Pt states restrained driver involved in MVC in Bedford, PA. ... Pt seen in ER in Bedford. Xrays with pt. Pt states L arm fx and requiring surgery. Pt states L arm pain 10/10. ... History of Present Illness ... Additional history: Pt was at UPMC Bedford this afternoon s/p MVC. [Pt] was unable to see an orthopedist s/p L arm fracture and was told that [MR34] may follow-up with [MR34] local trauma hospital today. [MR34] fracture was not reduced and was splinted. ... Addendum Teaching-Supervisory Addendum Brief ... Notes: Patient in MVC in Western Pennsylvania. Seen in ED at UPMC Bedford and x-rays show multiple fractures of the left arm. Apparently no orthopedic surgeon there so patient d/c to drive back to York to see orthopedics. Segmental fxs, of radius and ulnar fx as well. Patient with no orthopedic preference. ... Pt reports [MR34] has a comminuted fracture of the L forearm and there was no orthopedist available to treat [MR34]. Therefore, pt was splinted without reduction and given percocet at discharge with instructions to follow-up with [MR34] local trauma center.

Telephone interview with EMP24 on June 30, 2011, at 10:40 AM, revealed, "[Patient] had a bad fracture. Our Orthopod was out of town. I told the Orthopod that [patient] would need surgery but it was not emergent. [Patient] said they were going to go to [patient's] own hospital or ED. I didn't diagnose an open fracture. If it was, it would have required antibiotics and would need fixed. There could have been a tiny open fracture that I missed, that would require more to be done. We discussed [patient] going to a trauma center, but after reviewing everything, [patient] was discharged stable knowing that they would need more attention to the arm."

Telephone interview with EMP13 on June 30, 2011, at 11:10 AM, revealed, " ... He contacted the ortho specialist in [patient's] area. [Patient's] main concern was that [patient] wanted to go back home to [patient's] area. The patient stated that [patient] wanted to go back home because they were on the way home when the accident happened. I don't recall any conversation about going to a trauma center. ... [Patient] was discharged from our emergency room with the understanding that [patient] was going straight to [patient's] hospital. We gave [patient] specific instructions that [patient] needed to be seen.

Telephone interview with EMP26 on June 30, 2011, at 12:45 PM, revealed , "... [Patient] was discharged after that as far as I know. I thought [EMP24] said something about a trauma center. The daughter, I guess it was the daughter, didn't want to go to Johnstown and wanted to go closer to home. The patient was a little out of it because of the pain.

2) Review of MR2 dated March 25, 2011, revealed no documented evidence of patient
receiving a medical screen from physician. Further review of MR2 revealed " ... Complaint: "I've had on-going GB issues with this pregnancy, and it really hurts now. I am to see Dr.[surgeon] General Surgeon, from Summit Health next week for my GB and couldn't wait. I had an US done last week of my GB, and my doctor is sending me to the surgeon" ... Orders Received Yes ... : Phoned Dr. ... with pt update. Strip reactive, has some slight uterine irritability which pt does not feel. As baby appears fine on strip. Dr. ... advised pt to go to ... regular OB dept, for them to help facilitate ... seeing the surgeon ASAP. ... Discharge Instructions ... : go there now Follow-UP at: Chambersburg Hospital."

Interview with EMP8 on June 28, 2011 at 1:50 PM confirmed the above findings of MR2 and revealed "There is no documentation that the physician saw this patient."