HospitalInspections.org

Based on observations, review of Emergency Department (ED) policies, medical records, and Medical Staff Bylaws Rules and Regulations, the critical access hospital (CAH) failed to follow their policies and procedures and did not conspicuously post in the emergency department (ED) signs notifying individuals of their rights to receive care; and failed to provide medical screening examinations (MSE) within its capabilities to determine if an emergency medical condition existed for 6 of 43 records (#14, #34, #39, #41, #42, and #43) selected for review from July 2014 to March 2015. The Critical Access Hospital (CAH) reported 264 Emergency Department (ED) patient visits in the last six months.

The CAH's failure to follow their policies and place signs in areas as required denied individuals entering the ED with knowledge of their rights for health care services; and the CAH's failure to have and follow consistent policies and procedures for providing adequate medical screening examations placed patients at risk for inadequate emergency care.

Findings include:

1. Review of the CAH's policy/procedure titled "Emergency Department General Policy" indicated: "...Signage will be available to all patrons regarding Kiowa District Hospital's emergency responsibility and participation in Medicaid..."

Observation of the ED which included a waiting room, admitting area, trauma room, isolation room, and ED entrance revealed only one sign placed in a corner of the trauma room which could not be seen by all individuals presenting for, or awaiting for care in the ED. Refer to tag C2402 for details.


2. Review of the CAH's Medical Staff Bylaws Rules and Regulations (2015) directed: "...A medical screening exam is to be performed by a Physician, Physician Assistant (PA) or Advanced Registered Nurse Practitioner (ARNP) to determine if an Emergency Medical Condition exists..."

Review of the CAH's emergency department policy titled "Medical Screening Exam" directed the on-call provider to perform the medical screening exam for patients who present to the ED requesting medical treatment or evaluation.

Review of a second policy titled "Emergency Department Chain of Command" directed: PROCEDURE "1) All patients presenting to the Emergency Department for care will have a nursing assessment completed by the Registered Nurse (RN) on duty to determine whether an Emergency Medical Condition exists. 2) The on call practitioner is required to see all patients who present to the Emergency Department and complete a medical screening exam..." This policy was inconsistent with the CAH's Medical Staff Bylaws Rules and Regulations and its Medical Screening Exam policy and procedure.

Review of closed medical records revealed that the CAH failed to follow their Medical Staff Bylaws Rules and Regulations and their Medical Screening Exam policy and did not provide six patients (#14, #34, #39, #41, #42, and #43) who presented to the ED seeking treatment with an examination by an on call provider to determine if an emergency medical condition existed. Refer to tag C 2406 for details.

The Critical Access Hospital (CAH) reported 264 Emergency Department (ED) patient visits in the last six months. Based on observation, review of ED policies, and staff interview, the CAH failed to post signs that specify the rights of individuals with an emergency medical condition (EMC) and women in labor who come to the ED for health care services in a place or places likely to be noticed by all individuals entering the ED, admitting area, waiting room, isolation room, and treatment room areas. The CAH's failure to place signs in the required areas denied individuals entering the ED, admitting area, and/or treatment area with an EMC and women in labor knowledge of their rights for health care services.

Findings include:

1. Review of the CAH's policy/procedure titled "Emergency Department General Policy" reads in part, "...Signage will be available to all patrons regarding Kiowa District Hospital's emergency responsibility and participation in Medicaid..."

Observation of the ED area during a tour on 3/23/15 at 1:35pm revealed one small sign (approximately 8.5" X 11") with small lettering which specified the rights of individuals with Emergency Medical Conditions and women in labor posted on a wall in a corner of the trauma room. Patients entering the ED through the emergency entrance, other side of the trauma room, isolation room, waiting room, and admitting area, could not see or read the sign.


In an interview on 3/23/15 at 1:35 PM, the Director of Nursing (DON) acknowledged the small sign in the trauma room was the only available sign for patients entering the entire ED area.

Based on medical record review and staff interviews, the Critical Access Hospital (CAH) failed to provide medical screening examinations (MSE) within its capabilities to determine if an emergency medical condition existed for 6 of 43 records (#14, 34, 39, 41, 42 and 43) selected for review from July 2014 - March 2015. The CAH reported 264 emergency department (ED) patient visits in the last six months.

Findings include:

Review of the CAH's policy titled "Emergency Department Chain of Command" which reads in part, PROCEDURE "1) All patients presenting to the Emergency Department for care will have a nursing assessment completed by the Registered Nurse (RN) on duty to determine whether an Emergency Medical Condition (EMC) exists. 2) The on call practitioner is required to see all patients who present to the Emergency Department and complete a medical screening exam..."

Review of the CAH's policy titled "Medical Screening Exam" which reads in part, the on-call provider is required to do the medical screening exam for a patient who presents to the ED requesting medical treatment or evaluation.

Review of the CAH's Medical Staff Bylaws Rules and Regulations (2015) directed: "...A medical screening exam is to be performed by a Physician, Physician Assistant (PA) or Advanced Registered Nurse Practitioner (ARNP) to determine if an Emergency Medical Condition exists..."

Tour of the Emergency Department (ED) revealed the CAH used the ED isolation room as an outpatient treatment room.

In an interview on 3/26/15 at 10:45 AM, the Director of Nursing (DON) confirmed that the isolation room in the ED (if available) or one of the patient rooms near the nurses' station can be used for outpatient services. There are no signs posted specifying the location of the outpatient department and the CAH does not have any set hour/days of the week for outpatient services. The patients can come at any time to receive outpatient services. Only patients receiving routine medications or treatments are scheduled on the outpatient calendar with specific dates/times. The on call Doctor makes a decision if the patient appears unscheduled as to whether they are treated as an ED patient or as an outpatient. Staff A further explained they do not have a formal list of specific procedures/treatments they provide as outpatient services but some of them are intravenous therapy, wound dressing changes, injections, wound-vac (therapy which promotes healing through negative pressure) care, urinary catheter insertions and/or changes, enemas, and porta-catheter (an implanted device to access a vein)/central line flushes.

1. Review of the closed medical record showed that Patient #14 presented to the ED on 3/2/15 at 8:24 AM complaining of severe migraine pain accompanied with a prescription from physician H untimed, dated 3/2/15 for Toradol (non-narcotic pain medication) 60 mg (milligrams) injection, Phenergan (anti-nausea medication) 50 mg injection, and Kenalog (a steroid used for its anti-inflammatory properties) 40 mg. Registered Nurse (RN) F documented the patient's vital signs and that she was alert and oriented to person, place, and time. Additionally, RN F documented that she administered Toradol 60 mg (milligrams) in the right hip muscle at 8:30 AM, Phenergan 50 mg injection in the left hip muscle at 8:31 AM, and Kenalog 40 mg in the right arm muscle at 8:44 AM. Further documentation by RN G indicated the patient tolerated the medication well and that discharge instructions were reviewed with the patient ' s spouse. RN G documented that patient # 14 still complained of pain prior to discharge at 9:06 AM.

The medical record did not contain evidence that patient # 14 received an appropriate medical screening examination by a qualified medical professional (QMP) as required by the CAH ' s medical staff bylaws to determine the cause of her headache, or any other abnormalities associated with headache pain, or the effects of administering the three pain relieving medications, or determined whether or not an emergency medical condition existed.

Review of the physician on call list for 3/2/15 showed Physician H was on call and available to come to the ED to provide medical screening examinations and stabilizing treatment if required.
Review of the CAH ' s Outpatient Calendar for March 2015 did not show that patient #42 had an appointment scheduled on 3/2/15 or for any day in March 2015.

2. Review of the closed medical record showed that Patient #34 presented to the ED on 3/3/15 at 7:20 PM complaining of generalized pain. Licensed Practical Nurse (LPN) E documented the patient rated her pain 7 on a scale of 0-10, with 10 being the worst pain ever felt and that the patient described her pain as "aching." At 7:25 PM LPN E documented she notified physician B. Further documentation showed LPN E administered Toradol 60 mg by injection into patient #34 ' s right hip at 7:25 PM and that the patient received the following discharge instructions: "Call or return to ER (Emergency Room) if pain worsens." LPN E discharged patient #34 at 7:48 PM. Patient #34 signed a "Refusal to Stay Recommended Time Post Injection" form on 3/3/15 (time unknown) indicating a Registered Nurse or Physician explained the risks in not waiting 20 minutes after the injection "so that my vital signs may be retaken and I can be reassessed for any untoward effects of the injection that I was given."

The medical record did not contain evidence that patient # 34 received a medical screening examination by a QMP as required by the CAH ' s medical staff bylaws to determine the cause of her headache, or any other abnormalities associated with headache pain, or that a QMP explained the risks of not waiting for reassessment following injection of the pain relieving medications, or determined whether or not an emergency medical condition existed.

In an interview on 3/26/15 at 10:00 AM, the Director of Nursing (DON) stated that only physicians and mid-level practitioners (Physician Assistants (PAs) and Advanced Registered Nurse Practitioners (ARNPs) are designated as qualified medical personnel (QMP) and may perform medical screening examinations.

Review of the physician on call list for 3/3/15 showed Physician H was on call and available to come to the ED to provide medical screening examinations and stabilizing treatment if required.

In an interview on 3/26/15 at 11:30 AM, Physician B acknowledged documentation in the medical record indicated patient #34 presented to the ED but did not receive a medical screening examination by a QMP.

3. Review of the closed medical record showed that Patient #39 presented to the ED on Saturday 2/7/15 at 1:10 PM complaining of a burning pain in the upper left chest. The patient stated they saw the physician earlier this week for same pain. LPN C documented a set of vital signs and notification to Physician B. LPN C administered a GI cocktail (a liquid medication of Maalox (antacid) maximum strength oral suspension, 10ml (milliliters), Donnatal (treats intestinal cramping) elixir (16.2mg(milligrams)/5ml)10ml, and Viscous Xylocaine (used to treat burning sensation) 2% (100mg/5ml) 10ml) on 2/7/15 at 1:25 PM. Further documentation revealed patient #39 stated he felt much better, Heartburn Education sheet reviewed with patient and he left the ED by private vehicle at 1:40 PM.

The medical record did not contain evidence that patient # 39 received a medical screening examination by a QMP as required by the CAH ' s medical staff bylaws to determine if his pain was due to a heart problem or other symptoms associated with chest pain to determine whether or not an emergency medical condition existed.

Review of the CAH's Outpatient Calendar for February 2015 did not show that patient #39 had an appointment scheduled for 2/7/15 or for any other day in February 2015.

In an interview on 3/24/15 at 4:55 PM LPN C acknowledged she remembered this patient and that he was treated as though he were an outpatient. LPN C explained the patient came into the hospital's ED complaining of left upper chest pain like he had before earlier that week and the Dr. ordered him the same medicine.

In an interview on 3/24/15 at 4:55 PM, Physician B explained that he knew patient # 39 well and that the patient had ongoing problems with acid reflux. Physician B stated he had seen patient #39 earlier in the week at the clinic and gave the patient a GI cocktail.

4. Review of the closed medical record showed that Patient #41 came into the CAH's ED on 1/27/15 at 4:06 AM complaining of a migraine headache rating her pain 8 on a scale of 0-10, with 10 being the worst pain ever felt. Registered Nurse (RN) G documented a set of vital signs and notified physician B (on call) at 4:09 AM. RN G administered Toradol (non-narcotic pain medication) 60mg (milligrams) injection into the patient's right thigh and Phenergan (anti-nausea medication) 50mg injection into the patient's left thigh at 4:15 AM. Further documentation showed at 4:35 AM patient #41 feeling better, with headache pain now rated 3. RN G discharged patient #41 at 4:50 AM from the ED with instructions to follow up with the clinic.

The medical record did not contain evidence that patient # 41 received an appropriate examination by a QMP as required by the CAH ' s medical staff bylaws to determine the cause of her headache, or any other abnormalities associated with headache pain, or whether or not an emergency medical condition existed. Additional review of the medical record showed Physician staff B documented an ED note dated 1/27/15 at 7:57 AM, that read in part: I have examined the patient. I have reviewed the medical record. ...Diagnosis: headache. Impression: Migraine is doubtful. Most likely a tension headache. Plan: she responded well to Toradol and Phenergan. She is to call the clinic later this morning if her headache returns.

In an interview on 3/26/15 at 11:30 AM, Physician B explained that he knew the patient and had seen her frequently for migraine headaches. Physician B stated he had seen patient #41 in the clinic the day before for a headache. Staff B confirmed he did not come to the ED to examine the patient on 1/27/15. Physician B stated he wrote the note in the electronic medical record only for their use in the clinic; it was not meant to be a part of this chart. Staff B explained they input the note for the clinic chart to keep track of the visits the patient makes.

5. Review of the closed medical record showed that Patient #42 arrived to CAH's ED on 1/9/15 at 9:10 PM (Friday) complaining of abdominal pain. RN G documented patient # 42 stated that she has lower back pain that radiates around to the front: feels like labor pains. She cannot keep food down. RN G documented that patient # 42 ' s bowel sounds were decreased (a sign that intestinal activity has slowed) and that her abdomen was distended and tender when applying deep pressure. Further documentation showed patient # 42 reported feeling nauseous and had been vomiting since 5:00 PM. Patient # 42 rated her pain a 10 on a scale of zero to ten, with ten being the worst pain ever felt. RN G further documented that she notified physician B at 9:50 PM on 1/9/15 regarding patient #42's assessment. Physician B stated that this visit should be treated as outpatient therapy. RN G documented that she administered Phenergan 25mg injection in the patient's right hip muscle at 9:53 PM and administered Toradol 60mg by injection in the patient's left hip muscle at 10:00 PM. RN G documented that patient # 42 tolerated the medication and gave the patient education on nausea prior to discharge at 10:05 PM.

The medical record did not contain evidence that patient # 42 had any lab tests or diagnostic tests or received a medical screening examination including evaluation of her abdominal pain by a QMP to determine whether or not an emergency medical condition existed.

Review of the CAH ' s Outpatient Calendar for January 2015 did not show that patient #42 had an appointment scheduled on 1/9/15 or for any day in January 2015.

In an interview on 3/26/15 at 9:10 AM, Physician B explained that he knew patient # 42 as she comes in frequently with pain because of her medical condition. Physician B stated that the patient should have been treated as an outpatient. Physician B did not explain why the patient did not receive an examination by a QMP.

6. Review of the closed medical record showed that Patient #43's presented to ED on 2/27/15 at 1:57 PM (Friday) complaining of an inability to urinate since a procedure he had to remove something from his ear earlier in the morning at another hospital. LPN C documented an Emergency Admission Assessment on 2/27/15 at 2:23 PM that read (in part): Genitourinary Bladder is distended ..Voiding (another word for emptying the bladder) patterns include retention. LPN C inserted a 16 French (measures the size of the catheter) Bard indwelling Foley catheter on 2/27/15 at 2:10 PM. LPN C documented on 2/27/15 at 2:30 PM that the patient had 650 cc (milliliters) of pale yellow urine and she replaced the Foley bag with a leg bag and provided the patient and daughter catheter and leg bag care instructions. LPN C further documented that she reviewed discharge instructions on 2/27/15 at 2:35 PM with the patient and daughter to return to the clinic on Monday to have the catheter removed. Documentation in the record showed that the patient was discharged on 2/27/15 at 2:45 PM.

The medical record did not contain evidence that patient # 43 received a medical screening examination by a QMP to evaluate his inability to urinate or to determine whether or not an emergency medical condition existed. Patient # 43's record did not contain an order from the physician to place a urinary catheter. LPN C documented in "Comments" under the Emergency Admission Assessment on 2/27/15 at 4:16 PM that "chart should have been outpatient" and Effective on 2/27/15 at 4:27 PM the status of the Emergency Admission Assessment was marked "Erroneous.".

Review of the CAH's Outpatient Calendar for February 2015 did not show that patient #43 had an appointment scheduled on 2/27/15 or for any day in February 2015.

In an interview on 3/26/15 at 9:20 AM, the DON explained that the Emergency Admission Assessment is marked as erroneous because the patient should have been seen as an outpatient not an ED patient. The DON explained the patient had initially been identified as an ED patient.

In an interview on 3/26/15 at 9:20 AM, Administrative staff D confirmed that LPNs cannot perform assessments.

In an interview on 3/26/15 at 9:20 AM, Physician B explained the patient had called ahead and stated that they were having trouble urinating after they had a procedure on their ear earlier that day. Staff B explained he knew the patient who went back and forth from the clinic to the hospital and knew the patient was coming to the hospital. Physician B did not explain why the patient, who presented to the ED requesting care did not receive an examination by a QMP.

In an interview on 3/25/15 at 10:45 AM, the DON acknowledged the CAH does not have outpatient policies/procedures with set criteria for staff to follow.










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