HospitalInspections.org

Based on staff interview, physician on-call schedule review, facility daily report review and policy/procedure review the facility failed to provide a practitioner with training and experience in emergency care to be immediately available by telephone/radio and on site within 30 minutes during January, February and March of 2022, requiring the facility to place the Emergency Department on diversion and failing to meet the needs of patients for 37 of 180 shifts: January 1 - 7:00 a.m. - 7:00 p.m. (a.m.) shift; February 11, 13, 19, 20, 21, 22, 24, 25, 26, 27, 28 - both a.m. and 7:00 p.m. - 7:00 a.m. (p.m.) shift; February 14 and 23 p.m. shift; March 3, 5, 13, 14, and 23 for both a.m. and p.m. shifts. March 28 a.m. shift and March 29 p.m. shift.

Findings Include:

Interview on 03/17/2022 at 11:05 a.m. with Director of Nursing (DON) revealed the facility places the Emergency Department (ED) on diversion if they do not have a physician/practitioner available on-site in the ED or on-call and available by phone/radio and on-site within 30 minutes.

Interview on 03/17/2022 at 11:20 a.m. with DON revealed "when we are on diversion we have a staff member, usually an LPN (Licensed Practical Nurse), working at the ED desk to let anyone coming to the ED for care know the facility does not have a physician available." The DON stated, "depending on their acuity we may call an ambulance for transport to another facility." Interview confirmed the facility does not document individuals requesting service on diversion days in the ED daily log because care is not provided.

Interview on 03/17/2022 at 12:45 p.m. with Chief Administrative Officer (CAO) revealed she is responsible for scheduling practitioners for the ED. CAO confirmed, "if I did not have practitioner coverage for the ED, the department would be placed on diversion and the ambulance service would be notified of the dates and times of diversion."

Interview on 3/17/2022 at 1:10 p.m. with Chief Executive Officer (CEO) confirmed the facility's ED would go on diversion if they did not have qualified practitioners available to staff the department.

Interview on 03/17/2022 at 2:30 p.m. with Chief Administrative Officer and Chief Nursing Officer confirmed individuals coming to the facility for ED services on diversion days are not documented in the ED daily log.

Review of the facility's physician/practitioner schedules for January, February, and March of 2022 revealed dates of diversion due to Medical Staffing Issues (no qualified practitioner available or on-call) for the following diversion dates in 2022: January 1 - 7:00 a.m. - 7:00 p.m. (a.m.) shift; February 11, 13, 19, 20, 21, 22, 24, 25, 26, 27, 28 - both a.m. and 7:00 p.m. - 7:00 a.m. (p.m.) shift; February 14 and 23 p.m. shift; March 3, 5, 13, 14, and 23 for both a.m. and p.m. shifts. March 28 a.m. shift and March 29 p.m. shift.

Review of the Facility's Daily Log reveals the facility had a "0" Census on the days of diversion: January 1 - 7:00 a.m. - 7:00 p.m. (a.m.) shift; February 11, 13, 19, 20, 21, 22, 24, 25, 26, 27, 28 - both a.m. and 7:00 p.m. - 7:00 a.m. (p.m.) shift; February 14 and 23 p.m. shift; March 3, 5, 13, 14, and 23 for both a.m. and p.m. shifts. March 28 a.m. shift and March 29 p.m. shift.

Review of facility's Emergency Department "Staffing" policy, policy #ED-78, no effective date or revised date, approved by Medical Staff and Board of Trustees, states "Emergency Department will staff licensed personnel 24 hours a day. One Registered Nurse who is ACLS certified, and Emergency Department experienced per shift; Appropriate personnel to meet quality patient care; One board certified Emergency Department physician per shift."

Review of facility's "Diversion Policy" 2021-2022, no policy number, no effective date or revised date, states " ... DIVERSION CATEGORIES-The following are acceptable pre-hospital diversion categories ...Medical staffing issues - Due to staffing shortages resulting from the pandemic, the emergency department is not available for incoming patients and therefore will be diverted to the next closest facility. All EMS services will be notified and documented ...".

During Exit Conference on 03/17/2022 at 3:04 p.m. survey findings were discussed, and no further documentation was submitted for review.

Based on interview, staffing record review, and policy review the facility failed to ensure qualified Physician/Practitioner coverage on-site or on-call, that is sufficient to provide the essential services for the Emergency Department (ED), twenty-four hours per day to meet the needs of their patients in a safe manner in accordance with acceptable standards of practice for 37 of 180 shifts on one (1) of one (1) day of survey: 2022 dates January 1 - 7:00 a.m. - 7:00 p.m. (a.m.) shift; February 11, 13, 19, 20, 21, 22, 24, 25, 26, 27, 28 - both a.m. and 7:00 p.m. - 7:00 a.m. (p.m.) shift; February 14 and 23 p.m. shift; March 3, 5, 13, 14, and 23 for both a.m.
and p.m. shifts. March 28 a.m. shift and March 29 p.m. shift.

Findings Include:

Cross Refer to C-0882/486.618(a) for the facility's failure to ensure qualified staffing for the Emergency Department.

During Exit Conference on 03/17/2022 at 2:10 p.m. survey findings were discussed, and no further documentation was submitted for review.

Based on staff interviews, Physician/Practitioner On-call Schedule review, daily logs, and policy/procedure review the facility failed to ensure qualified Physician/Practitioner coverage in the Emergency Department (ED) on-site or on-call, that was sufficient to provide the essential services for the ED, twenty-four hours per day to meet the needs of their patients in a safe manner in accordance with acceptable standards of practice for 37 out of 180 shifts in January, February, and March of 2022: Dates in 2022, January 1 - 7:00 a.m. - 7:00 p.m. (a.m.) shift; February 11, 13, 19, 20, 21, 22, 24, 25, 26, 27, 28 - both a.m. and 7:00 p.m. - 7:00 a.m. (p.m.) shift; February 14 and 23 p.m. shift; March 3, 5, 13, 14, and 23 both a.m. and p.m. shifts. March 28 a.m. shift and March 29 p.m. shift.

Findings Include:

Interview on 03/17/2022 at 11:05 a.m. with Director of Nursing (DON) revealed the facility places the Emergency Department (ED) on diversion if they do not have a qualified physician/practitioner available for on-site or on-call coverage.

Interview on 03/17/2022 at 12:45 p.m. with Chief Administrative Officer (CAO) revealed she is responsible for scheduling practitioners for the ED. CAO confirmed, "if I did not have practitioner coverage for the ED, the department would be placed on diversion and the ambulance service would be notified of the dates and times of diversion."

Review of the facility's Physician/Practitioner Schedules for January, February, and March of 2022 revealed dates of diversion due to Medical Staffing Issues (no qualified practitioner available or on-call) for the following diversion dates in 2022: January 1 - 7:00 a.m. - 7:00 p.m. (a.m.) shift; February 11, 13, 19, 20, 21, 22, 24, 25, 26, 27, 28 - both a.m. and 7:00 p.m. - 7:00 a.m. (p.m.) shift; February 14 and 23 p.m. shift; March 3, 5, 13, 14, and 23 for both a.m. and p.m. shifts. March 28 a.m. shift and March 29 p.m. shift.

Review of the Facility's Daily Log reveals the facility had a "0" Census on the days of diversion: January 1 - 7:00 a.m. - 7:00 p.m. (a.m.) shift; February 11, 13, 19, 20, 21, 22, 24, 25, 26, 27, 28 - both a.m. and 7:00 p.m. - 7:00 a.m. (p.m.) shift; February 14 and 23 p.m. shift; March 3, 5, 13, 14, and 23 for both a.m. and p.m. shifts. March 28 a.m. shift and March 29 p.m. shift. A qualified physician was not on site at the facility; however, a qualified physician/practitioner was not scheduled for availability by phone/radio or available to be on-site with-in 30 minutes.

Review of facility's Emergency Department "Staffing Policy," policy #ED-78, no effective date or revised date, approved by Medical Staff and Board of Trustees, states "Emergency Department will staff licensed personnel 24 hours a day. One Registered Nurse who is ACLS certified, and Emergency Department experienced per shift; Appropriate personnel to meet quality patient care; One board certified Emergency Department physician per shift."

Review of facility's "Diversion Policy" 2021-2022, no policy number, no effective date or revised date, states " ... DIVERSION CATEGORIES-The following are acceptable pre-hospital diversion categories ...Medical staffing issues - Due to staffing shortages resulting from the pandemic, the emergency department is not available for incoming patients and therefore will be diverted to the next closest facility. All EMS services will be notified and documented ...".

During Exit Conference on 03/17/2022 at 3:04 p.m. survey findings were discussed, and no further documentation was submitted for review.

Based on staff interviews, Emergency Department Daily Log review, Facility Daily Log review, Physician/Practitioner Schedule review, and policy/procedure review the facility failed to maintain a central log on each individual who "comes to the emergency department (ED)," as defined in 489.24(b) on one (1) of one (1) day of survey.

Findings Include:

Interview on 03/17/2022 at 11:05 a.m. with Director of Nursing (DON) revealed the facility places the Emergency Department (ED) on diversion if they do not have a physician/practitioner available to staff the ED or be on-call.

Interview on 03/17/2022 at 11:20 a.m. with DON revealed "when we are on diversion we have a staff member, usually an LPN (Licensed Practical Nurse), working at the ED desk to let anyone coming to the ED for care know the facility does not have a physician available." She also stated, "depending on their acuity we may call an ambulance for transport to another facility." Interview confirmed the facility does not document individuals requesting service on diversion days in the ED daily log because care is not provided.

Interview on 03/17/2022 at 12:45 p.m. with Chief Administrative Officer (CAO) revealed she is responsible for scheduling practitioners for the ED. CAO confirmed, "if I did not have practitioner coverage for the ED, the department would be placed on diversion and the ambulance service would be notified of the dates and times of diversion."

Interview on 3/17/2022 at 1:10 p.m. with Chief Executive Officer (CEO) confirmed the facility's ED would go on diversion if they did not have practitioners available to staff the Emergency department.

Interview on 03/17/2022 at 2:30 p.m. with Chief Administrative Officer and Chief Nursing Officer confirmed individuals coming to the facility for ED services on diversion days are not documented in the ED daily log.

Review of the facility's Physician/Practitioner schedules for January, February, and March of 2022 revealed dates of diversion due to Medical Staffing Issues (no qualified practitioner available or on-call) for the following diversion dates in 2022: January 1 - 7:00 a.m. - 7:00 p.m. (a.m.) shift; February 11, 13, 19, 20, 21, 22, 24, 25, 26, 27, 28 - both a.m. and 7:00 p.m. - 7:00 a.m. (p.m.) shift; February 14 and 23 p.m. shift; March 3, 5, 13, 14, and 23 for both a.m. and p.m. shifts. March 28 a.m. shift and March 29 p.m. shift.

Review of Emergency Department daily logs dated January 1, 2022 - March 16, 2022, revealed the facility has no documented evidence of recording individuals (potential patients) coming to the ED on diversion days in the daily ED log.

Review of the facility's "EMTALA Policy," effective dated 12/28/21, revealed " ...The Hospital must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE ...".

During Exit Conference on 03/17/2022 at 3:04 p.m. survey findings were discussed, and no further documentation was submitted for review.