HospitalInspections.org

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Based on an interview and record review, the facility failed to maintain an adequate on call list when:

1. The on call list for June and July for 2015 still contained the pediatrics group, not the individual physicians, even though the contract for the group covering pediatrics was canceled 6/30/15.

2. There was no specific MD names listed for the hospitalist. Instructions were to call the operator.

Findings:

During record review on 7/28/15, of the facility's policy and procedure, " on call physicians" undated, indicated, " the on call physician list for the emergency department will include specific physician names and phone numbers for all services provided."

During record review on 7/28/15, the on call list included the pediatric grouping, BAP (Bay Area 's Pediatrics), not individual doctors names or phone numbers.

During an interview on 7/28/15, at 3:04 PM, Emergency Department Director, stated, " I spoke with JoAnne (previous manager of the emergency department) and the current Medical Staff Director. The on call list was not done and they (previous manager and current medical staff director) had not gotten back to me why it wasn't done (to have doctors names and phone numbers). I wanted it to be like the July list."

During an interview on 7/29/15, at 9:30 AM, Emergency Department Director stated, " I spoke with the current medical staff director about BAP contract being canceled on 6/30/15. We no longer have OB/GYN or maternity. We have no pediatric service in the hospital. The doctors would consult with the receiving hospitals pediatric doctor."

During an interview on 7/30/15, at 10:15 AM, the Medical Staff Director, stated, "If I had known, I would have changed the on call schedule. Then I finally knew when the ED Director told me at the beginning of July."

During a concurrent interview on 7/30/15, at 10:15 AM, the Emergency Department Director, stated, " the on call list does need to be corrected."

Based on interview and record review, the facility failed to maintain their central log when 6 of 34 sampled patient records had incorrect dispositions (Patients 35, 39, 40, 55, 56, 60).

Findings:

1. Patient-35 was in the ED on 5/24/15 with a chief complaint of joint pain. The ESI was a level 5. Documentation by the ED nurse at triage stated: "Joint pain, pt. left w/o VS or DCI after MD advised him he would not be giving him opiates." According to the medical record, vital signs were not taken and the physician did not examine the patient. The disposition in the medical record and the ED central log stated the patient was an "elopement".

During an interview on 7/29/15 at 1:43 PM, the ED Director stated there was no policy and procedure for patient disposition definitions. But the ED Director stated, the definition of "elopement" would mean a patient was taken into the treatment room and be examined by a physician but leaves on his own without anyone knowing or seeing the patient go. The ED Director stated the definition for "Left Without Being Seen" would mean a patient may have been triaged and was not examined by a physician.

During an interview on 7/30/15 at 12:10 PM, the ED Director agreed Patient-35's disposition was not an elopement but should have been "Left Without Being Seen" or LWBS.

2. Patient-39 was in the ED on 6/11/15 with a chief complaint of shortness of breath. The ESI was a level 3. When the physician examined the patient, the MD documented the following: "Chief Complaint: Pt. states about 4 days ago noted what he thought was an ingrown hair on the back of the scrotum. Since then is increasing progressively in size, is very painful and tender, and this AM he noted fever. Also has noted pain spreading to the left inguinal area though no swelling there...". Subsequently, the physician determined the patient needed specialized care beyond the capability of the ED. The MD documented: " Pt. advised that this may not be a simple abscess as it appears the base of the penis is involved and is my feeling that he needs urological evaluation before any procedure is undertaken..., Pt. concurs with transfer and requests (Facility-B) where he gets regular care. Refuses ambulance transfer. Risks explained and still refuses. Wife will drive...".

The patient disposition in the medical record and the ED central log documented the patient as a "Transfer".

The facility's policy and procedure titled, "Transfer of Individuals With Emergency Medical Conditions", revised 9/14, page 5 of 16, documented the following: "G. Individuals Determined to Have an Emergency Medical Condition But Refuse to Consent to Treatment or Transfer... 1(c)... A patient who has refused further medical examination and treatment shall be considered a discharge against medical advice and appropriate policies covering this type of discharge shall be followed...".

During an interview on 7/30/15 at 12:10 PM, the ED Director agreed the patient disposition should have been an "AMA".

3. Patient-40 was seen in the ED on 6/11/15 with a chief complaint of high blood pressure and low pulse and was brought in by ambulance from the facility's skilled nursing facility. The ESI was a level 4. After the physician's assessment and after the course of time, the patient's condition normalized without additional treatment or procedures, it was determined the patient could be returned to the same skilled nursing facility.

The medical record and ED central log documented the patient's disposition as a "Transfer". During an interview on 7/30/15 ay 12:10 PM, the ED Director agreed the patient disposition should not have been a transfer but instead should have been a "Discharge".

On another interview on 7/30/15 at 9:05 AM, the ED Director stated she started audits on 7/16/15 by having the licensed nurses check the central logs for completeness and accuracy after the end of each shift and to have them initial the logs to verify that the audits were done by them. In turn, the ED Director visually checked the nurses' audits. Record review of the facility's Plan of Correction dated 5/18/15 showed their action plan as the following on pages 6 and 7 of 28: "The ED RN will print the central log and validate its accuracy at the end of each shift for four weeks, then every 24 hours for two weeks, and then monthly thereafter. Any discrepancies or omissions are to be corrected at the time. The ED Director/designee will review and validate the accuracy of the central logs every week for four weeks and monthly thereafter....". The completion date of this action plan was 7/17/15. There was no evidence that previous audits were being conducted prior to the ED Director's initiation of her own audit plan on 7/16/15. The ED Director stated she had been in contact with the interim Medical Director (MD-4) regarding the audits.

During this same interview, the ED Director stated she would collect the audit data and present the information to the PI Committee August 2015. Also, she stated the new Medical Director (MD-5) who will start 08/01/15 will be involved with the ED audits.




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4. Patient-55 was in the ED on 7/8/15 presented for evaluation of abdominal pain and abdominal distention. The ESI was a level 3.

During record review dated 7/8/15, at 17:56 (5:56 p.m.) " patient data sheet" indicated, "... Acute bowel obstruction."

During record review dated 7/8/15, at 17:56, the ED central log, indicated," disposition transfer."

During record review dated 7/8/15, at 21:32 (9:32), Dr. notes indicated," he (patient-55) refuses ambulance transport and is with a friend who says he will take him there directly. "

During an interview on 7/30/15, at 12: 10 PM, the ED director agreed patient - 55's disposition was not a transfer but should have been" left AMA."

5. Patient-56 was in the ED on 7/10/15, at 10:38 AM, with a complaint of numbness in his feet and arms. The ESI was a level 3.

During record review dated 7/10/15, at 10:38 AM, the ED central log, indicated," disposition transfer."

During record review dated 7/10/15, at 11:07 AM, " patient data sheet" indicated,"..." Extremity Paresthesias."

During record review dated 7/10/15, at 11:10 AM, Dr. notes indicated," patient-56 agrees to transfer to further evaluate, but refuses ambulance transport."

During an interview on 7/30/15, at 12:10 PM, the ED director agreed patient - 56's disposition was not a transfer but should have been" left AMA."

6. Patient - 60 was in the ED on 7/12/15, at 20:46 PM (8:46 PM), with the complaint of" rolled right ankle." The ESI was a level 3.

During a record review dated 7/12/15, at 20: 46 (8:46 PM),the ED central log , in the column titled" first urgency", did not display the first urgency, which should contain the severity level.

During a record review of facility's policy and procedure," maintenance of the central log", undated, indicated, on page 3," setting up EMTALA/central log...7. first urgency."

Based in interview and record review, the facility failed to obtain AMA consents for patients who refused ambulance transport to a receiving hospital for 2 of 34 sampled patients (Patients 43 and 65).

Findings:

1. Patient-43 was seen in the ED on 6/16/15 with a chief complaint of head injury 5 days previous from a fall from the roof of a car onto concrete slab. The patient's mother brought her in for further evaluation of head swelling with a "soft spot". The ESI was a level 3.

The ED physician discussed the case with the trauma doctor at Facility-D who agreed to accept the patient in transfer for evaluation. But the patient's mother refused ambulance transport. The ED physician documented: " Mother... refuses ambulance transport, so will sign out AMA and drive child there herself".

The medical record revealed transfer consent forms that stated the patient would be transported by private vehicle but there was not an AMA consent form.

The facility's policy and procedure titled, "Transfer of Individuals With Emergency Medical Conditions", revised 9/14, page 5 of 16, documented the following: "G. Individuals Determined to Have an Emergency Medical Condition But Refuse to Consent to Treatment or Transfer... 1(c)... A patient who has refused further medical examination and treatment shall be considered a discharge against medical advice and appropriate policies covering this type of discharge shall be followed...".

The facility's policy and procedure titled, "AMA (Against Medical Advice)Patients Signing Out", revised 3/12, page 2 of 2, documented the following: " 6. The patient shall be requested to sign the form 'Leaving Hospital Against Advice'. This form shall be kept in the patient's medical record".

During an interview on 7/28/15 at 11:28 AM, MD-3 stated if a patient refused a transfer with an ambulance, the patient's disposition would be an AMA and would document the reasons for patient's refusal.

During another interview on 7/30/15 at 12:10 PM, the ED Director agreed the AMA form should have been completed for Patient-34.





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2. Patient-65 was in the ED on 7/26/15, at 21:50 PM (9:50 PM),with a head injury from a fall from a bicycle. The ESI was a level 2.

During record review dated 7/26/15, at 23:13 PM (11:13 PM)," patient data sheet", indicated," patient left AMA MD explained all risks and patient insisted that he leave to go home."

During the same record review (as stated above), discharge instructions, indicated,"AMA form 2..." This medical record revealed no AMA form.

During an interview on 7/30/15, at 12: 10 PM, ED director, stated," I don't see the AMA form."