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The Hospital failed to be in compliance with the Condition of Participation of Compliance with Federal, State and Local Laws as evidenced by:


Based on record reviews, contract reviews and interview the hospital failed to be in compliance with 42 CFR ? 412.22 (e)(1)(v)(A) which requires hospitals to perform the basic functions specified in ? 482.21 (QAPI), ? 482.22 (Medical Staff), ? 482.23 (Nursing Services), ? 482.24 (Medical Records), ? 482.25 (Pharmacy Services), ? 482.26 (Radiology Services), ? 482.27 (Laboratory Services), ? 482.30 (Utilization Review), ?482.42 (Infection Control), ? 482, 43 (Discharge Planning) and ? 482.45 (Organ Procurement) through the use of employees ,or under contracts or other agreements with entities other than a) the hospital occupying space in the same building or of the same campus or b) a third entity that controls both hospitals. This was evidenced by Lafayette General Medical Center (LGMC) signing a contract to provide, and then providing laboratory and blood gas services, radiology & imaging services, medical staff services, emergency and code blue services, pharmacy services, and telemetry services to hospital "a".

Findings:

42 CFR ? 412.22 (e)(1)(v)(A) requires hospitals to perform the basic functions specified in ? 482.21 (QAPI), ? 482.22 (Medical Staff), ? 482.23 (Nursing Services), ? 482.24 (Medical Records), ? 482.25 (Pharmacy Services), ? 482.26 (Radiology Services), ? 482.27 (Laboratory Services), ? 482.30 (Utilization Review), ? 482.42 (Infection Control),?482, 43 (Discharge Planning) and ? 482.45 (Organ Procurement) through the use of employees, or under contracts or other agreements with entities other than a) the hospital occupying space in the same building or of the same campus or b) a third entity that controls both hospitals.

Review of the "Purchased Services Agreement", dated 10/1/11, and presented to the surveyor as the most current agreement between acute care Hospital LGMC and long term acute care Hospital "a". This agreement revealed LGMC would provide laboratory and blood gas services, radiology and imaging services, medical staff services, emergency services and code blue response, pharmacy services, and telemetry services to Hospital "a".

This agreement further stipulated that LGMC would respond to any code blue or emergency situations in Hospital "a" with LGMC physicians and hospital "a" support staff handling the emergency and code blue situations.

Review of the Code Blue Log from Hospital "a" revealed there was a "code blue" in hospital "a" on 09/13/12 and on 09/17/12, and an emergency intubation on 09/16/12. Review of this log revealed that LGMC medical staff responded to these 2 code blues and intubated the patient.

In an interview on 10/11/12 at 11:05 a.m. with S5MD, who was on duty in the ER of Lafayette General Medical Center, he stated that the ERMD who is on duty at LGMC ER does respond to Emergencies in hospital "a".

In an interview on 10/11/12 at 11:05 a.m. with S6MD, who was on duty in the ER of Lafayette General Medical Center, he stated that the ERMD who is on duty at LGMC ER does respond to Emergencies in hospital "a".

During another interview on 10/11/12 at 11:55 a.m. with S3CMO he stated that he does recall seeing a physician, S5MD, intubating a patient (#2) in hospital "a" on 09/16/12. S3CMO stated that before this he was not aware that physicians from contracted ER group responded to emergencies in hospital "a". S3CMO stated that it is OK for LGMC ER physicians to respond to hospital "a" emergencies as it is "only one floor away" and does not understand why that is regulatory. S3CMO reviewed documentation from the medical record of 2 patients (#1, #2) (patients in the HWH) and agreed that the LGMC ER physician on duty at Lafayette General Medical Center attended a Code Blue in hospital "a" on 09/13/12 at 11:39 a.m. (S7MD) and 09/17/12 at 0540 (5:40 a.m.) (S8MD). S3CMO stated that the ERMD from the contracted ER physicians group leaving the ER to attend a Code Blue in another hospital could affect services provided in the ER at LGMC.

In an interview on 10/11/12 at 12:05 p.m. with S4MD, Medical Director of the ER at LGMC and Medical Director of the contracted ER physicians Group "a", he stated that it was OK for the ERMD on duty in the ER of LGMC to leave the ER to attend an emergency in hospital "a". S4MD further stated that he was not aware of any regulation regarding the ERMD responding to emergencies at a hospital within another hospital.

Review of a document titled "(contracted ER physicians group "a")" revealed it was an ER Physician schedule for September 2012. The following physicians were listed on the schedule: September 13, 2012 10 a.m. - 9 p.m. shift: Dr. (S7MD); September 16, 2012 7 a.m. - 7 p.m. shift: Dr. (S5MD) (emergency intubation performed in hospital "a"); and September 16,, 2012 8 p.m. - 7 a.m. shift: Dr. (S8MD). Review of the Code Log for Operators revealed there was a Code Blue in hospital "a" on 09/13/12 at 11:45 a.m. and 09/17/12 at 0541 (5:41 a.m.).