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Based on review of the document "DELINEATION OF PRIVILEGES EMERGENCY MEDICINE" the hospital failed to ensure the approved privileges of emergency department providers for 2 of 6 providers (#2 and #8).

Findings include:

Review of documentation titled "DELINEATION OF PRIVILEGES EMERGENCY MEDICINE", revealed "...NAMED HOSPITAL...Please indicate requested privileges by placing your INITIALS in the appropriate request boxes. Check marks, lines with arrows, or indicators other than you (sic) initials are not acceptable and will be returned....EMERGENCY MEDICINE PRIVILEGES...Privileges include being able to assess, work-up, and provide initial treatment to patients who present in the Emergency Room with any illness, injury, condition, or symptom. An emergency room practitioner is expected to provide those services necessary to ameliorate minor illness, injury, provide stabilizing treatment to patients in order to determine if more definitive services are necessary....2. Specifics for Reappointment:...D. Pattern of Current Medical Practice:...A summary (Quality Profile ) of practitioner's practice will be submitted to the Credentials Reviewer and Chief of Staff. The Quality Profile shall include the following data:...1. Number of Special Request Procedures...The Emergency Department Medical Director will provide an evaluation of the practitioner and make a recommendation regarding reappointment to the Medical Staff. The Medical Staff will make recommendation regarding reappointment to the Board of Directors, The Board of Directors will make the final determination of approval of denial of reappointment...."

1. Review of the "DELINEATION OF PRIVILEGES EMERGENCY MEDICINE" for Staff #2, a Family Nurse Practitioner, revealed a five column table with the following headings sequenced (arranged in a particular order): "REQUESTED, APPROVED, APPROVED With CONDITIONS, DENIED" fifth column heading is blank. Review revealed under the requested column Staff #2 initials are in all seventy blocks requesting privileges for "...Management of Patients with:...Minor lacerations...Minor respiratory illness...Initial evaluation/management of:...Acute psychiatric illness...Acute respiratory illness...Multiple trauma victims...Emergency Procedures...Local anesthesia...Emergency thoracostomy...Other: SPECIFY". Further review of "APPLICANT CERTIFICATION" revealed "I, the undersigned, hereby certify that I possess the necessary skills and expertise to justify the granting of those privileges requested on the foregoing pages...." Review revealed Staff #2's printed name, signature and date of 11/16/15... RECOMMENDATION...The medical staff recommends that the clinical privileges requested be granted...." Review revealed the line provided for recommendation, the Chief of Staff signature and date are blank. Review revealed that staff #2 did not have privileges to provide patient care in the ED.

Interview on 08/08/2016 at 0955 with Staff #7 stated that she understood that Staff #2 did not have privileges to provide patient care in the ED.

2. Review of the "DELINEATION OF PRIVILEGES EMERGENCY MEDICINE" for Staff #8, a Physician Assistant, revealed a five column table with the following headings sequenced (arranged in a particular order): "REQUESTED, APPROVED, APPROVED With CONDITIONS, DENIED" fifth column heading is blank. Review revealed under the requested column Staff #8 initials are in all seventy blocks requesting privileges for "...Management of Patients with:...Minor lacerations...Minor respiratory illness...Initial evaluation/management of:...Acute psychiatric illness...Acute respiratory illness...Multiple trauma victims...Emergency Procedures...Local anesthesia...Emergency thoracostomy...Other: SPECIFY". Further review of "APPLICANT CERTIFICATION" revealed "I, the undersigned, hereby certify that I possess the necessary skills and expertise to justify the granting of those privileges requested on the foregoing pages...." Review revealed Staff #8's printed name, signature and date of 11/16/15... RECOMMENDATION...The medical staff recommends that the clinical privileges requested be granted...." Review revealed the line provided for recommendation, the Chief of Staff signature and date are blank. Review revealed that Staff #8 did not have privileges to provide patient care in the ED.

Interview on 08/08/2016 at 0955 with Staff #7 stated that she understood that Staff #8 did not have privileges to provide patient care in the ED.

Based on policy and procedure review, observation and staff interview the facility staff failed to check expiration dates on supplies used for the patient care on the inpatient unit and in the emergency department.

Review on July 21, 2016 of Policy and Procedure "Expired Supplies" (revised November, 2012) revealed, PURPOSE: To ensure the rapid turnover of supplies and prevention of handling expired items. POLICY: It is the policy of ... to monitor the expiration of sterile and dated items for rapid turnover. Expired stock is not to be used under any circumstances. PROCEDURE: An integral part of maintaining a close inventory control is the process of monitoring expires sterile supply items. An important aspect of inventory control is to return goods that are not being used. Expiration dates must be monitored on a regular basis so that items nearing expiration can be identified and used promptly if possible. If it is impossible to use the item before its expiration date, purchasing should be notified promptly so that credit can be obtained for the items. I credit cannot be obtained and the item cannot be used, the MDS sheet should be consulted if applicable to determine how to handle the disposal of the item. The item should be disposed of promptly. Any similar stock items held elsewhere in the hospital should be found and removed from stock. It is the responsibility of each department to monitor supplies in their department for expiration dates. Expired stock is not to used under any circumstance.

1. Observation on July 18, 2016 at 1615 during a tour on the Medical Surgical unit revealed a work room within the nurses station. Observation revealed two bottles of glucometer control solution with use by dates of May 21, 2017. Observation revealed the solution was open, but they were not labeled with and opened date. Observation revealed a crash cart across from the nurses station. Observation revealed LifePak pediatric patches with expiration date July 28, 2016. Observation in the supply closet on the Medical Surgical unit revealed a row of cabinets with wound dressing supplies. Observation revealed nine (9) Aquacel 4 X 5 dressings with expiration dates of April 2016 and seven (7) Aquacel 4 X 5 dressings with expiration dates of February 2016. Further observation in the supply closet revealed a supply cart with a blue cover. Observation revealed one (1) 4.5 fluid ounce Fleets Enema (laxative) with an expiration date of April 2016 and three (3) 4.5 fluid ounce Fleets Enemas with expiration dates of May 2016. Observation revealed two (2) Care Fusion AirLife Tracheostomy care Kits with expiration dates of August 2014. Further observation revealed one (1) MedChoice Suction Catheter Kit with a expiration date of April 2015. Observation revealed expired supplies on the nurses station available for immediate use during patient care.

Interview on July 18, 2016 during tour with Staff #9, the Medical-Surgical Nuesr Manager, revealed, the glucometer solution is good if unopened until May 31, 2016. Interview revealed, the glucometer solutions should be dated with the date opened and it expires thirty (30) days after the bottle is opened. Further interview revealed, the supplies were expired and had not been checked. Interview revealed supply management was a shared duty between the nursing unit and supply chain. Interview revealed the expired supplies would be discarded, The interview confirmed the observation finding.

Interview on July 20, 2016 at 1040 with Staff #7, the Chief Nursing Officer, revealed she was made aware that multiple supplies were expired. Interview revealed there was no process in place for checking floor supplies for expiration dates. Further interview revealed a process would be created for checking the treatment areas and crash carts for expired supplies. Further interview revealed a process would be created for checking the crash cart for expired supplies. The interview confirmed the observation finding.

Interview on July 20, 2016 at 1310 with Staff #3, a Pharmacist, revealed the pharmacy staff is responsible for replenishing and checking the medications stocked on the crash cart. Interview revealed the pharmacy staff do not check patient care supplies for expiration dates. Interview revealed the pharmacy checks the crash carts montly and documents medication with impending expiration dates on a sticker affixed to the front of the crash cart.


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2. Observation on 07/20/2016 at 0915 during a tour of the ED (Emergency Department) revealed the clean utility room with patient nutrients stored in the cabinet. Observation revealed two bottles of Ensure with expiration date "June 2016", two bottles of Pediatric Electrolyte with expiration date of "05/2016", one Jevity 1.2 Cal with an expiration date "April 2016" and two Similac Newborn bottles with an expiration date "April 2016". Observation of the ED's trauma room 4 revealed on an in the locked pediatric Braslow cash cart five pediatric defibrillator pads with an expiration date of "2015-10-18", three pediatric emergency systems IV (Intravenous), two pediatric emergency System Intubation with an expiration date of "2014/05", one LMA Size 1 mask (children) 2.5 with an expiration date of "April/2007" LMA Infant/Child 2.0 with an expiration date of "11/2006" and Tracheal Tube 4.5 with an expiration date of "2008/01". Observation of the ED trauma room and the sterile supply cart revealed four Pleur-evac (chest drainage system) with an expiration date of "2015-08" Observation revealed expired supplies in the ED for immediate use for patient care.

Interview on 07/20/2016 during tour with Staff #7 revealed the supplies she was made aware that multiples supplies were expired. Interview revealed there was not a process in place for checking the supplies on the pediatric braslow cart. Further interview revealed the braslow cart will be dismantled due to other available supplies. Interview revealed a process will be created for checking the ED trauma room and the sterile supply cart. The interview confirmed the observation.

Based on policy and procedure review, Telemedicine agreement, review of Telepsychiatry Services Agreement, medical record review and staff interview the hospital failed to provide a behavioral health provider evaluations for 1 of 4 IVC (Involuntary Commitment) patient per policy (Patient #12).

The findings include:

Review on 07/21/2016 of the policy and procedure "Behavioral Patient Pending Transfer to Psychiatric Facility",...effective date 1-11-2016 revealed "...Purpose: To provide holistic care to the Behavioral Health patient that warrants observation while awaiting placement for further evaluation...Policy: (Named hospital) will provide quality care of the Behavioral Health Patient that has the potential to inflict harm to self and others by providing direct observation and continuity of care....Procedure: 1. Patient will be placed in room 150 for direct observation while awaiting placement. 2. Emergency room nurse is to call report to the receiving nurse on the Med-Surg Unit. 3. Med-Surg nurse is to verify that a provider has written for the Psychiatric consult....15. Provider is to write and clarify orders upon receipt of recommendations from Psychiatric Specialist. 16. Med-surg nurse is to give report to the receiving facility when patient is prepared for transfer....19. Upon recommendation from Behavioral health provider, the provider at (Named hospital) will either discharge the patient on the 7th day or repetition the magistrate for new commitment papers. if the magistrate deems it necessary, he will give the new paperwork or if not, we will discharge the patient from the hospital services." Review of policy and procedure titled "...Management of Suicidal Patient", revision date 10/11/12 revealed "...PURPOSE: To take specific precautions and provide frequent observations of a patient that has the potential of inflicting self harm....PROCEDURE: 1. If the patient is medically stable, the patient should be transferred to the appropriate psychiatric facility per transfer policy....5. Psychiatric consultation is strongly recommended....6. A room search should be performed to ensure a safe room. Patient should be moved to room 150 (if available) or any other available room near the nurse's station to allow direct visualization...."

Review of (Named hospital) Telemedicine "AGREEMENT" revealed "...University shall establish the Program to provide professional psychiatry services using telemedicine for mental health intervention for patients who present in the emergency department or in Hospital with a mental health or substance abuse issue. University shall make available to Hospital a Physician and /or Advanced Level Practitioner psychiatric provider (hereinafter collectively referred to a "Provider"), who is qualified by experience, education and training, to provide medical services seven (7) days per week to assure timely intervention for patients served by the Program as determined by University and Provider....TERM. The term of this Agreement shall commence as of April 1, 2014, and shall continue in full force and effect until June 30, 2014. Thereafter, this Agreement shall automatically renew for successive one (1) year terms unless the Agreement is terminated as provided herein. Unless otherwise provided herein, either party shall have the right to terminate this Agreement, at anytime during initial term or any renewal term, without cause, upon the giving of thirty (30) days' notice in writing to the other party...."

Review of the "Telepsychiatry Services Agreement" revealed "...This letter is in follow-up to our prior communications regarding the Telepsychiatry Services Agreement (the "Agreement") dated April 1, 2014. As you are aware, physician services to your facility were being provided by our Contractor,...Unfortunately,..has ended its relationship with (Named providing company) and will no longer provide services after December 12, 2015. We are currently working to identify and credential other providers to serve your facility. However, we expect that there will be a break in our ability to provide services under the Agreement for some period of time while we bring new providers on board, Additionally, as we bring new providers on board, our days of service may be limited temporarily to weekday (Monday through Friday) coverage only....You have graciously agreed that this above-described break in service will not be considered a breach of the Agreement, provided that we are able to secure new providers on or before June 30, 2016. We would ask that you acknowledge this understanding by signing attached and returning to us. ....On behalf of (Named Hospital), I understand that there will be a break in (Named providing company) ability to provide physician services under the Telepsychiatry Services Agreement dated April 1, 2014. I also understand that once (Named providing company) resumes providing services, the days of service may be limited temporarily to weekday (Monday through Friday) coverage only. By signing below, Hospital agrees that the foregoing will not constitute a breach of the Agreement provided that (Named providing company) is able to resume providing weekday physician services by June 30, 2016...."

Closed medical record review of "Emergency Department Nursing Record" revealed on 05/09/2016 at 2105 patient #12 presented to the ED (Emergency Department), by the EMS (Emergency Medical Services - professional healthcare providers who provide care prior to and during transport of patients to healthcare facilities), mother and the police, for an intentional drug overdose. The patient #12 was placed into the ED room 4 and the PRIMARY ASSESSMENT: revealed that the patient has a history of a cutting and eating disorder and IVC (Involuntary Commitment - process used through the court system to obtain health care, usually for patients that demonstrate the potential to hurt themselves or someone else). Continued review of medical record revealed patient #12 was placed on telemetry (monitoring the electrical activity of the heart). Review of the "EMERGENCY PHYSICIAN RECORD", by Staff #1, revealed that patient #12 took medication from three bottles, because her boyfriend's mother would not let her speak to him. The medication taken consisted of the following: "Hydroxyzine (medication used to treat anxiety) 10 mg (milligram- unit of measure), Escitalopram (medication used to treat depression) 10 mg and Trazodone (medication used to treat depression and anxiety) 50 mg". Further record review revealed that the patient #12 was tearful, crying and would not talk to the care givers. The physical exam revealed "depressed mood,...tearful,... non-communicative" and an "Outer Right Hip multiple superficial Linear cutting Abrasions". Record review revealed that the patient #12 was "cleared medically for psychiatric referral by Staff #1. Record review revealed that the patient #12 's mother petition to have her IVC'd and the IVC petition was granted on 05/09/2016 at 2307. Record review revealed that on 05/10/216 at 0830, the patient #12 was transferred from the ER room 4 to the Med Surg-Unit floor room number 150 (a designated, out patient, room located on the med surg unit specifically for ED patients waiting for bed placement to another facility). Record review revealed that the patient #12 was IVC'd from 05/10/2016 through 05/16/2016, while waiting for bed placement at a psychiatric facility a total of seven days. Review revealed that search for an inpatient bed placement was made daily, by named facility, to five different facilities resulting in no bed available or delay. Further review of "(Named Hospital) Progress Record" revealed on 05/16/16 at 1124 Staff #2 documented "Pt (Patient) seen & (and ) examined. Sitting up on bed, denies c/o (complaint of) No voices, no S/H (Suicidal/Homicidal) ideations, no desire to self harm. Contracts for safety to call for help if feelings return. Will f/u (follow up)" with "psychiatrist." Record review revealed that patient #12 did not have a psychiatric evaluation while IVC'd and prior to being discharged home.

Closed medical record review of "Emergency Department Nursing Record", EMERGENCY PHYSICIAN RECORD" and "...EXAMINATION AND RECOMMENDATION TO DETERMINE NECESSITY FOR INVOLUNTARY COMMITMENT" documentation revealed on 05/18/2016 at 1710 patient #12 presented to the ED with the "law enforcement under IVC papers." Record review revealed a diagnosis of ODD (Oppositional Defiant Disorder - usally associated with children or teenagers exhibiting angry, rebellious hurtful behavior toward a person or persons in authority), depression (mental illness that effects a persons mood) and anxiety (feeling of overwhelming worry or unease). Review of "...PROGRESS..." by Staff #3 at 1715 revealed "...Pt denies suicidal or homicidal ideations. States she is doing really well...Denies telling anyone she was suicidal in the last 24" hours"...No obvious cut marks to arms or skin. No bruises or injury noted. Pt had good eye contact, pleasant and cooperative. Social services here" with "pt and spoke with mother on the phone. I also spoke with mother on phone who agrees with pt coming home....IVC papers reversed. Pt taken home by law enforcement" on 05/18/2016 at 1750. Further record review revealed discharge instructions were given and included follow up tomorrow with social worker and a follow up with a psychiatrist. Record review revealed that patient #12 did not have a psychiatric evaluation while IVC'd and prior to being discharged home. Record review revealed that patient #12 did not have a psychiatric evaluation while IVC'd and prior to being discharged home.


Interview with Staff #5, the Chief Medical Staff, on 05/21/2016 at 1315 revealed that all mid-level providers, in the ED, are contract employees and hired using the named hospital's process. The staff is hired after being interviewed by Staff #5 and review of credentials. Further interview revealed that the ED staff is able to handle anything in the ED and not just psychiatric patients. Interview revealed that Staff #5 definition of Behavioral health provider is a Psychiatrist (medical doctor who specializes in the treatment of mental illnesses) or a Psychologist (a doctor who specializes in the treatment of mental illnesses - not a medical doctor). Interview revealed that patient #12 did not have a psychiatric evaluation while IVC'd and prior to being discharged home.

Interview with Staff #7, the Chief Nursing Officer, on 05/21/2016 at 1315 revealed that the policy titled "Behavioral Patient Pending Transfer to Psychiatric Facility" requires a recommendation from a Behavioral health provider. Staff #7 confirmed "our policy is not consistent with our practice." Interview revealed that patient #12 did not have a psychiatric evaluation while IVC'd and prior to being discharged home.

Interview with Staff #3 on 07/20/2016 at 1205 revealed that Staff #3, a Family Nurse Practitioner, remembers the patient #12. Continued interview revealed that named facility does not IVC children. Staff #3 stated the youngest patient was the 13 year old, who's IVC papers ran out but the mother agreed to take the patient home. Interview revealed that IVC patients present with police or guardian with paperwork for a patient to be IVC'd. Interview revealed that an IVC patient is medically cleared before they can go to a psychiatric facility. Further interview revealed once the patient is cleared medically, the named facility began searching for placement immediately. Continued interview revealed that if bed placement is unavailable, the IVC patient is placed on the medical surgical unit for observation under an ED provider. Interview revealed that all of the ED providers psychiatric training is limited to medical school. Staff #3 stated that the IVC patient on the med-surg floor is evaluated by an ED provider. Interview revealed that there are two options when an IVC patient is placed on the named facility's medical surg unit. 1. The patient is evaluated by an ED provider up to seven days while waiting for bed placement. If bed placement is not available within seven days, the IVC has to be requested and granted for the patient to remain in the named facility's care. 2. The patient is discharged home. Interview revealed that discharging a patient home is what the patient says when asked if they are suicidal or homicidal. Staff #3 stated if the patient says yes, the petition for IVC would continue or another request made if IVC is run out. Staff #3 stated the patient has to have family support to be discharged home. Interview revealed that appointments are made prior to discharging the patient home in the daytime. If the discharge occurs at night time the discharge instructions are explained and given to follow up with a psychiatrist. Further interview revealed that patients that do not have an established psychiatrist are given a card for the local mobile crisis team for follow-up. Interview revealed that patient #12 did not have a psychiatric evaluation while IVC'd and prior to being discharged home.

Interview with Staff #6 on 05/21/2016 at 0900 revealed Staff #6, the Chief Executive Officer, acknowledged that the "Telepsychiatric Services Agreement" documentation was received on 2-4-2016 and signed and dated by Staff #6 on 2-10-16. Staff #6 acknowledged the time frame in which psychiatric providers would be available to the named hospital but she did not return a response to the providing company. Interview revealed that staff #6 made a telephone call to the (Named providing company) this morning (07/21/2016) for follow-up information. Staff #6 stated she left a voice mail. Interview revealed that the (Named hospital) did not have a Behavioral Health Provider to provide psychiatric evaluations. NC00117390