HospitalInspections.org

Based on review of facility documents, personnel files (PF) and interview with staff (EMP), it was determined the facility failed to implement personnel policies regarding the Emergency Medical Treatment and Active Labor Act (EMTALA) training in six of seven Emergency Department nursing personnel files reviewed (PF2, PF7, PF13, PF17, PF19, and PF21) and 14 of 14 Patient Access Representative (PAR) personnel files reviewed (PF1, PF4, PF5, PF8, PF9, PF10, PF11, PF12, PF14, PF15, PF16, PF17, PF18, and PF20).

Findings include:

Review of facility policy and procedure "Policy and Procedure Guidelines," dated approved February 13, 2013, revealed "Purpose: To provide guidelines for development, review, and approval of policies and procedures developed within the Geisinger Heath System. ... It is the policy of the Geisinger Health System to standardize the policy and procedure format and establish an electronic review and approval process to comply with regulatory standards and requirements. ... General Guidelines ... 9. Policies and procedures are reviewed on an annual basis upon the last review date. ... 15. Communication and updates will also be shared with staff involved in the policy and procedure via this website. An e-mail will be sent as an alert noting an update has been posted to the website. ..."

Interview with EMP19 on July 31, 2013 at approximately 2:30 PM confirmed it was the responsibility of the Emergency Department employee to review the Emergency Department (ED) policies and procedures annually as part of their annual performance review.

Review on July 30, 2013 of "GWVMC (Geisinger Wyoming Valley Medical Center) Performance Improvement Program," dated approved January 9, 2013, revealed "Purpose: To continuously improve the performance of important functions, processes and outcomes through measurement and evaluation using current performance improvement models. This is in concert with Geisinger's mission to enhance quality of life through an integrated health service organization based on a balanced program of patient care, education, research and community service. It is also supportive of Geisinger's commitment to the pursuit of high quality care and the welfare and safety of our patients, employees, medical staff and visitors. ... Program Goals and Objectives: 1. To assure compliance with all external regulatory bodies. ... 3. To improve patient safety and to create a culture in which employees detect and help correct unsafe systems as part of their daily work responsibility. ... 4. To educate, facilitate, coach and innovate continuous improvement methods across GWVMC. ..."

1) Interview with EMP3 on July 31, 2013, at approximately 10:45 AM stated a binder titled "EMTALA Guidelines" was provided to all new emergency room nurses in the Orientation Binder. EMP3 stated the EMTALA Guidelines binder was present in the emergency room. The facility was not able to produce the binder for review.

2) Interview with PF13 on July 31, 2013, at approximately 11:15 AM revealed PF13 was unable to define or voice an understanding of EMTALA. Further interview with PF13 revealed they were unable to recall if EMTALA training was discussed or offered during orientation or during the ED's yearly inservice reviews. PF13 was unable to confirm if a policy addressing EMTALA was accessible to the ED staff.

3) Interview with EMP17 on July 31, 2013, at approximately 11:30 AM during the observation tour of the ED revealed EMP17 was unable to define or voice understanding of EMTALA. Further interview with EMP17 revealed they were unable to recall if EMTALA training was discussed or offered during orientation or during the ED's yearly inservice reviews. EMP17 was unable to confirm if a policy addressing EMTALA was accessible to the ED staff.

4) Interview with EMP18 on July 31, 2013, at approximately 11:45 AM during the observation tour of the ED revealed EMP18 was unable to define or voice understanding of EMTALA. Further interview with EMP18 revealed they were unable to recall if EMTALA training was discussed or offered during orientation or during the Emergency Department's yearly inservice reviews.

5) Review on July 30, 2013, and July 31, 2013, of PF2, PF7, PF13, PF17, PF19 and PF21 revealed no documentation of EMTALA training during orientation to the Emergency Department or annual review of Emergency Department policies and procedures.

Interview with EMP4 on July 31, 2013 at approximately 1:00 PM confirmed there was no documentation in PF2, PF7, PF13, PF17, PF19 and PF21 for education of EMTALA training during orientation or annual review of Emergency Department policies and procedures.

Interview with EMP4 on July 31, 2013 at approximately 10:45 AM noted the former Nursing Manager was responsible for educating the nursing staff about the EMTALA requirements. EMP4 confirmed there was no documentation EMTALA education was provided to PF2, PF7, PF13, PF17, PF19 and PF21.

6) Review on July 30, 2013, and July 31, 2013, of PF1, PF4, PF5, PF8, PF9 and PF10, PF11, PF12, PF14, PF15, PF16, PF17, PF18, and PF20 revealed no documentation of EMTALA training during orientation to the Emergency Department or annual review of policies and procedures for these Patient Access Representatives.

Interview with EMP5 on July 31, 2013, at approximately 12:30 PM confirmed there was no documentation of EMTALA training for the Patient Access Representatives at orientation or annually.

Based on review of facility documents, medical records (MR), and interview with facility staff (EMP), it was determined the facility failed to ensure an abnormal x-ray report was reviewed by the ordering practitioner and stabilizing treatment provided for bilateral pneumonia for one of 26 medical records reviewed (MR1).

Findings include:

Review on July 30, 2013, of the facility's "Rules and Regulations of the Medical Staff," dated last reviewed March 2011, revealed "... Section 20.1 Medical Records 20.1-24 ... The physician has the responsibility to keep the patient, and where appropriate, his immediate family, appraised of his condition, any major changes, proposed treatment plan and any other pertinent information."

Review on July 30, 2013, of MR1 revealed the patient presented to the emergency room on July 14, 2013, at 14:44 with the complaint of "chills." During this presentation, a chest x-ray was ordered. The results of this x-ray revealed bilateral pneumonia per the radiologist. Documentation revealed MR1 eloped from the emergency room at 17:00. There was no documentation of follow up regarding the positive chest x-ray finding.

Further review revealed MR1 returned to the emergency room on July 14, 2013, at 20:58 with the complaint of cold symptoms and sweating. The patient also reported diarrhea and vomiting. Documentation revealed the patient was medically screened and discharged from the emergency room. There was no documentation in MR1's second presentation to the emergency room that treatment was provided for the positive chest x-ray finding of bilateral pneumonia or that the patient was informed of the chest x-ray finding. MR1 was admitted to another facility the following day with the diagnosis of bilateral pneumonia that resulted in an inpatient stay.

Interview on July 30, 2013, with EMP1 confirmed there was no documentation in MR1 that the positive radiology finding were reviewed or treated by the emergency room practitioner (OTH1) during the two presentations to the emergency department. EMP1 confirmed there was no treatment ordered for the positive chest x-ray finding of bilateral pneumonia. EMP1 confirmed OTH1 was not available for interview at the time of the survey.

Interview on July 31, 2013, with OTH2 revealed the presenting symptoms on the second emergency room visit were more gastrointestinal. OTH2 noted the electronic medical record would show the studies ordered for the second presentation, not the studies from the first presentation, which included the chest x-ray showing bilateral pneumonia. OTH2 confirmed the presenting complaints on the second visit were not respiratory, noted the patient's lung sounds were clear, and OTH2 did not order a chest x-ray

Interview with OTH3 on July 31, 2013, confirmed there were problems with results of radiology studies when there was an elopement. OTH3 described it as a "glitch" in the system. OTH3 confirmed that because MR1 eloped, the patient was never assigned a physician. OTH3 confirmed the x-ray was read by radiology, and there was no documentation the report was reviewed by the physician.

Based on review of facility documents, medical records (MR), and interview with facility staff (EMP), it was determined the facility failed to ensure an abnormal x-ray report was reviewed by the ordering practitioner and the information provided to the patient, resulting in a delay in treatment for a bilateral pneumonia for one of 26 medical records reviewed (MR1).

Findings include:

Review on July 30, 2013, of the facility's "Rules and Regulations of the Medical Staff," dated last reviewed March 2011, revealed "... Section 20.1 Medical Records 20.1-24 ... The physician has the responsibility to keep the patient, and where appropriate, his immediate family, appraised of his condition, any major changes, proposed treatment plan and any other pertinent information."

Review on July 30, 2013, of MR1 revealed the patient presented to the emergency room on July 14, 2013, at 14:44 with the complaint of "chills." During this presentation, a chest x-ray was ordered. The results of this x-ray revealed bilateral pneumonia per the radiologist. Documentation revealed MR1 eloped from the emergency room at 17:00. There was no documentation of follow up regarding the positive chest x-ray finding.

Further review revealed MR1 returned to the emergency room on July 14, 2013, at 20:58 with the complaint of cold symptoms and sweating. The patient also reported diarrhea and vomiting. Documentation revealed the patient was medically screened and discharged from the emergency room. There was no documentation in MR1's second presentation to the emergency room that treatment was provided for the positive chest x-ray finding of bilateral pneumonia or that the patient was informed of the chest x-ray finding. MR1 was admitted to another facility the following day with the diagnosis of bilateral pneumonia that resulted in an inpatient stay.

Interview on July 30, 2013, with EMP1 confirmed there was no documentation in MR1 that the positive radiology finding were reviewed or treated by the emergency room practitioner (OTH1) during the two presentations to the emergency department. EMP1 confirmed there was no treatment ordered for the positive chest x-ray finding of bilateral pneumonia. EMP1 confirmed OTH1 was not available for interview at the time of the survey.

Interview on July 31, 2013, with OTH2 revealed the presenting symptoms on the second emergency room visit were more gastrointestinal. OTH2 noted the electronic medical record would show the studies ordered for the second presentation, not the studies from the first presentation, which included the chest x-ray showing bilateral pneumonia. OTH2 confirmed the presenting complaints on the second visit were not respiratory, noted the patient's lung sounds were clear, and OTH2 did not order a chest x-ray

Interview with OTH3 on July 31, 2013, confirmed there were problems with results of radiology studies when there was an elopement. OTH3 described it as a "glitch" in the system. OTH3 confirmed that because MR1 eloped, the patient was never assigned a physician. OTH3 confirmed the x-ray was read by radiology, and there was no documentation the report was reviewed by the physician.