HospitalInspections.org

Based on document review and staff interview it was determined the facility failed to ensure emergency services are provided in accordance with acceptable standards of practice. This failure has the potential to negatively impact all care provided to patients in an emergency situation.

Findings include:

1. The policy, "Trauma Alert/Response", last approved 06/15, was provided for review. Section II 'Trauma Response Alert Members' states, in part: "ED Physician, ED Nurse, Recorder (CNA or ED RN/LPN), Respiratory Therapist (RT), Phlebotomist, Radiology Technician, and Nursing Supervisor House Charge, Nurse Manager and/or Medical Charge Nurse are all members of the trauma response alert team...." Section VII states, in part: "Responsibilities of the Trauma Response Members: Section A. The ED Physician: 1. Serves as team leader for the Trauma Team; 2. The ED physician assumes the primary care of the patient and decides priority of diagnostics and therapy."

2. Review of the medical record for Patient #1 revealed the Emergency Department (ED) physician did not serve as team leader for the Trauma Team during a pediatric code for the patient. He allowed a paramedic, who is not an employee of the facility, to supervise the pediatric code while he was sitting at a desk not more than six (6) feet from the trauma room where the code was occurring.

3. The policy, "Code M-Set Activation, Responders, & Responsibilities with Cardiopulmonary Arrests", last approved 10/15, was provided for review. Section E. 'Emergency Department Physician's Responsibilities' states, in part: "1. The Physician should avail himself/herself to Code M-SET emergency resuscitations. 2. Assume responsibility for resuscitation following ACLS or Pediatric Advanced Life Support (PALS) guidelines unless otherwise dictated by circumstances arising in any particular case. 3. Assist with intubation; order medications; defibrillates as needed."

4. Further review of the medical record for Patient #1 revealed the paramedic was allowed to intubate the pediatric patient when the ED Physician was available and qualified to perform the procedure. The nursing staff and the paramedic had to follow the PALS protocol for administering medications to the pediatric patient as the physician did not make himself readily available to give direction to the trauma team.

5. An interview was conducted with paramedic #1 on 10/20/15 at 9:30 a.m. He stated: "I was helping with the resuscitation efforts with the patient and the baby started having agonal respirations which meant imminent respiratory arrest. I said the patient is going to need intubated right now. One of the nurses had to go and find the physician so they could ask about the intubation. The physician came into the room and said, 'Yeah, he will probably need intubated.' I went ahead and intubated the patient. I felt like we were on our own during this code; we really had no direction from the physician."

6. An interview was conducted with Registered Nurse #1 on 10/20/15 at 11:40 a.m. She stated: "The paramedics just happened to be at the hospital to pick up another patient for transfer and when they heard the mom saying her baby was not breathing they jumped in to help us. I told the physician several times the baby was not breathing and needed to be intubated; he was on the phone and I had to write the question on a post it note to ask him. He just nodded his head yes and never got up from the desk to come into the room with the patient. I went in and told the paramedic to intubate the baby. Through the whole code I had to constantly track down the physician to try and get some type of order from him for what to do. I don't think I should have to continuously tell the physician on a post it note the patient is not breathing and needs intubated. He is the physician and we needed more direction from him than what we got during the code. He was not in charge of the code; the paramedics were running the code."

7. An interview was conducted with the ED Clinical Manager on 10/20/15 at 2:50 p.m. She stated: "The expectation is the ED Physician will be the team leader during a code if available and will direct the other trauma team members with medications, intubation etc. There is a phone in the trauma room to use in emergency situations so I'm not sure why he stayed at the desk in the nurse's station and didn't actively engage with the staff during the code. He really put the trauma team in a bad situation because they needed direction from the physician." She concurred with the findings.

Based on document review and staff interview it was determined the facility failed to follow their own written policies by allowing two (2) paramedics, who were not employed at the hospital, to actively engage in a pediatric code in the emergency department (ED). This failure has the potential to negatively impact the care given to all patients in an emergency situation.

Findings include:

1. The policy, "Relationship with EMS", last approved 5/15, was provided for review and states, in part: "Hampshire Memorial Hospital receives patients from and transfers patients via recognized community rescue squads and ambulance services. Statement of Procedure: 3. EMS authority over patient care ends with the arrival to the emergency department."

2. Review of the medical record for Patient #1 revealed both paramedics were an active part of the pediatric code in the ED even though there was a member of the medical staff available (ED Physician) to lead the trauma team in the code.

3. A phone interview was conducted with Paramedic #2 on 10/21/15 at 1:40 p.m. He stated: "I was at the hospital to pick up a patient for transfer to another facility when the mom came out of the room saying her baby was not breathing. My partner and I went over to see if we could help and we had to start resuscitation efforts with the patient. I was bagging the patient and the physician was at the desk on the phone with another facility. He never came in the room but a few times and we received no direction from him during the code. It was the strangest situation I have ever been in; usually the physician is leading the code and giving orders to the rest of the code team, not the paramedics."

4. An interview was conducted with the ED Clinical Manager on 10/20/15 at 2:50 p.m. She stated: "The paramedics were here and helped out because they had no choice; the physician was not running the code or giving the team any direction as to what to do. They were really put in a bad situation because the physician did not engage in the pediatric code but the expectation is the paramedic's authority over patient care ends with the arrival to the emergency department." She concurred with the findings.

Based on document review and staff interview it was determined the facility failed to ensure staff complied with the regulations for EMTALA at §489.20 and §489.24. The facility failed to provide necessary stabilizing treatment to an individual with an emergency medical condition (see tag C 2407).

Based on document review and staff interview it was determined the facility failed to provide stabilizing treatment within the capabilities of the staff and facilities available at the hospital by allowing two (2) paramedics, who were not employed at the hospital, to actively engage in a neonate code in the emergency department (ED). This deficient practice was identified in one (1) of twenty (20) records reviewed (Patient #1). This failure has the potential to negatively impact the care given to all patients in an emergency situation.

Findings include:

1. The policy, "Trauma Alert/Response", last approved 06/15, was provided for review. Section II 'Trauma Response Alert Members' states, in part: "ED Physician, ED Nurse, Recorder (CNA or ED RN/LPN), Respiratory Therapist (RT), Phlebotomist, Radiology Technician, and Nursing Supervisor House Charge, Nurse Manager and /or Medical Charge Nurse are all members of the trauma response alert team...." Section VII states, in part: "Responsibilities of the Trauma Response Members: Section A. The ED Physician: 1. serves as team leader for the Trauma Team; 2. The ED Physician assumes the primary care of the patient and decides priority of diagnostics and therapy."

2. Review of the medical record for Patient #1 revealed the ED Physician did not serve as team leader for the Trauma Team during a neonate code for the patient. He allowed a paramedic, who is not an employee of the facility, to supervise the neonate code while he was sitting at a desk not more than six (6) feet from the trauma room where the code was occurring.

3. The policy, "Code M-Set Activation, Responders, & Responsibilities with Cardiopulmonary Arrests", last approved on 10/15, was provided for review. Section E. 'Emergency Department Physician's Responsibilities' states, in part: "1. The Physician should avail himself/herself to Code M-SET emergency resuscitations. 2. Assume responsibility for resuscitation following ACLS or Pediatric Advanced Life Support (PALS) guidelines unless otherwise dictated by circumstances arising in any particular case. 3. Assist with intubation; order medications; defibrillates as needed."

4. Further review of the medical record for Patient#1 revealed the paramedic was allowed to intubate the pediatric patient when the ED Physician was available and qualified to perform the procedure. The nursing staff and the paramedic had to follow the PALS protocol for administering medications to the pediatric patient as the physician did not make himself readily available to give direction to the trauma team.

5. The policy, "Relationship with EMS", last approved on 5/15, was provided for review and states, in part: "Hampshire Memorial Hospital receives patients from and transfers patients via recognized community rescue squads and ambulance services. Statement of Procedure: 3. EMS authority over patient care ends with the arrival to the emergency department."

6. Review of the medical record for Patient #1 revealed both paramedics were an active part of the neonate code in the emergency department even though there was a member of the medical staff available (ED Physician) to lead the trauma team in the code.

7. An interview was conducted with Paramedic #1 on 10/20/15 at 9:30 a.m. He stated: "I was helping with the resuscitation efforts with the patient and the baby started having agonal respirations which meant imminent respiratory arrest. I said the patient is going to need intubated right now. One of the nurses had to go and find the physician so they could ask about the intubation. The physician came into the room and said, "Yeah, he will probably need intubated." I went ahead and intubated the patient. I felt like we were on our own during this code; we really had no direction from the physician."

8. An interview was conducted with Registered Nurse #1 on 10/20/15 at 11:40 a.m. She stated: "The paramedics just happened to be at the hospital to pick up another patient for transfer and when they heard the mom saying her baby was not breathing they jumped in to help us. I told the physician several times the baby was not breathing and needed to be intubated; he was on the phone and I had to write the question on a post-it note to ask him. He just nodded his head yes and never got up from the desk to come into the room with the patient. I went in and told the paramedic to intubate the baby. Through the whole code I had to constantly track down the physician to try and get some type of order from him for what to do. I don't think I should have to continuously tell the physician on a post-it note the patient is not breathing and needs intubated. He is the physician and we needed more direction from him than what we got during the code. He was not in charge of the code; the paramedics were running the code."

9. A phone interview was conducted with Paramedic #2 on 10/21/15 at 1:40 p.m. He stated: "I was at the hospital to pick up a patient for transfer to another facility when the mom came out of the room saying her baby was not breathing. My partner and I went over to see if we could help and we had to start resuscitation efforts with the patient. I was bagging the patient and the physician was at the desk on the phone with another facility. He never came in the room but a few times and we received no direction from him during the code. It was the strangest situation I have ever been in usually the physician is leading the code and giving orders to the rest of the code team, not the paramedics."

10. An interview was conducted with the ED Clinical Manager on 10/20/15 at 2:50 p.m. She stated: "The expectation is the ED Physician will be the team leader during a code if available and will direct the other trauma team members with medications, intubation etc. The paramedics were here and helped out because they had no choice. There is a phone in the trauma room to use in emergency situations so I'm not sure why he stayed at the desk in the nurse's station and didn't actively engage with the staff during the code. They were really put in a bad situation because the physician was not giving the team any direction as to what to do but the expectation is the paramedic's authority over patient care ends with the arrival to the emergency department." She concurred with the above findings.