HospitalInspections.org

Based on record review and interviews, the facility failed to review clinical privileges for current board certification for 4 (S2, 6, 8, and 15) out of 12 (S2, S6 - S16) physicians. This failed practice has the likelihood of a patients' care being directed by a physician without current certifications.

Findings are:

A. Record review of the facility's "Medical Staff Bylaws" dated 10/18/2019, Section 2 "Qualifications for Membership (A) states, "All applicants for Medical Staff membership shall be American Board certified or qualified by the appropriate residency-training program to sit for the appropriate board examination or confirm equivalent years of training and experience."

B. Record review of S2's (Chief Medical Office) credential file revealed, no documentation of a current board certification.

C. Record review of S6's (Physician) credential file revealed, no documentation of a current board certification and an Advanced Trauma Life Support certification that expired on 11/18/2020.

D. Record review of S8's (Physician) credential file revealed, no documentation of a current board certification, Advanced Cardiovascular Life Support certification and an Advanced Trauma Life Support certification that expired on 07/18/2020.

E. Record review of S15's (Physician) credential file revealed, no documentation of a current board certification and an Advanced Trauma Life Support certification that expired on 07/16/2020.

F. On 03/24/2021 at 3:00 pm during interview with S2 (Chief Medical Officer) confirmed, that S2, 6, 8, and 15 did not have current board certifications.

Based on record review, observation, and interview, the facility failed to document in its COVID-19 (an infectious disease) policy to screen staff members (a system to test individuals for sign or symptoms of COVID-19) to prevent the transmission of the COVID-19 virus within the facility. This failed practice could increase transmission rate of COVID-19 within the facility.

Findings are:

A. Record review of "COVID 19 Operations Bulletin #23" date 01/22/21 revealed, "As of Monday, January 25, 2021, the facility will no longer be screening employees as they enter the building."

B. During an observation on 03/25/21 of 3 staff members entering the building confirmed that the facility was not screening staff for COVID-19 symptoms.

C. On 03/25/21 at 3:00 pm during interview with S1 (Chief Nursing Officer) confirmed, that employees are not screened prior to entering the facility. S1 also stated that facility stop screening because the facility had not had any employee that were positive for COVID-19 for the past couple of months.

D. Record review of "Centers for Disease Control and Prevention website" dated updated 02/23/21 revealed, "Screen and triage everyone entering a healthcare facility for signs and symptoms of COVID-19."

Based on interviews and record reviews, the facility was not in compliance with the Emergency Medical Treatment and Labor Act (EMTALA) by failing to provide prompt screening and determination of a medical emergency as evidenced by the following:

A. The facility failed to provide a Medical Screening Exam. See tag 2406

Based on Interviews and Record Reviews, the facility failed to provide a Medical Screening Exam (initial evaluation of a person, intended to determine the presence of a medical emergency) required under the Emergency Medical Treatment and Labor Act (EMTALA) for 2 (P1 & P9) out of 19 patients selected based on having a disposition other than admission to the facility.

The findings are:

A. On 03/24/2021 at 9:12 am, interview with P1's family member indicated that on 01/25/2021 P1 presented to the facility's Emergency Room (ER) for a concern of a suspected infection to the right eye. P1's family member continued stating that P1 returned stating that S4 (non clinical staff member) took P1's registration information and chief complaint but stated that the facility did not see eye complaints. P1's family member emphasized that P1 did not receive a medical screening exam or was assessed by any clinical staff but was told to wait in the parking lot in their car by a non-clinical staff member. P1's family member filed a grievance to the facility and states they only received a letter indicating that the grievance was filed.

B. Record Review of P1's Chart from 01/25/2021 revealed:

1. ED/Outpatient Admission Summary Sheet indicates reason for visit as right eye pain and that P1 entered ED at 10:19 am

2. No triage assessment done

3. No evidence of a medical screening done by medical doctor

C. On 03/24/2021 at 2:35 pm, interview with S4 (non clinical staff member) reported that their duties include verifying a patient that presents to be seen by checking their name, date of birth, address, primary care provider, and chief complaint. S4 states that after that is done they would go to the treatment area to notify the nurses that a patient is ready to be triaged. S4 confirmed that a non-clinical staff member's responsibility is not to defer patients to seek care elsewhere.


D. On 03/24/2021 at 2:50 pm, interview with S3 (Registered Nurse) reported that once the ER non clinical staff member notifies the nurses that a patient is ready to be triaged the nurse will come and promptly triage them. S3 indicates that COVID 19 (infectious respiratory disease) based restrictions do not allow patients to wait in the waiting room. The process for waiting is that patients will present and be triaged or quickly assessed by a nurse and then, if deemed stable enough, referred to wait in the personal vehicle for room availability. S3 highlighted that the ER non clinical staff member should not defer patients to wait in their personal vehicles before a nurse has deemed them stable enough to.

E. On 03/24/2021 at 3:45 pm, interview with S5 (non clinical staff member) confirmed that s/he were the clerk that registered P1's ER visit on 01/25/2021. S5 reported that their process as clerk was to verify patient's name, date of birth, primary care provider, and chief complaint. S5then would instruct the patient to wait in their car for a room to become available before going to the treatment area to notify the nurses. S5 confirmed that the nurses do not always assess patients prior to them being sent to wait in their cars. S5 confirmed that they were not trained on how to identify medical emergencies or signs of deterioration. S5 confirmed to be that s/he instructed P1 to wait in the car without having clinical staff evaluate the patient.


F. Record Review of facility's grievance from 01/25/2021 revealed:

1. Complainant concerns included poor communication and unprofessionalism by staff.

2. Investigative plan recommends: "the clerk needs EMTALA training to assist with the new position as the ER clerk. We [the facility] have EMTALA in our learning platform RELIAS (online educational platform for staff training)."

3. Corrective actions indicate that staff will receive education and training.

4. Contributing causes: facilities established protocol/procedure was not followed, staff not educated/trained, and inappropriate behavior resulting in ineffective communication.


G. Record Review of S5's RELIAS education transcript from 10/06/20 to 03/12/21 revealed:

1. No evidence of completion or enrollment in any EMTALA based educational training.


H. Record Review of P9's Chart from 12/17/2020 revealed:

1. ED/Outpatient Admission Summary Sheet indicated the reason for visit was shortness of breath and that P9 entered ED at 12:58 pm.

2. No triage assessment done.

3. No evidence of a medical screening done by medical doctor.

4. No documentation of attempts to evaluate P9 by clinical staff.


I. Record Review of facility's "Medical Screening Exam/EMTALA" policy effective since 02/10/2003 revealed:

1. "All persons seeking emergency care shall receive an appropriate Medical Screening Examination to determine whether an emergency medical condition exists."

J. Record Review of facility's "Emergency Room Triage" policy effective since 04/2007 revealed:

1. All patients will be evaluated by the triage nurse upon arrival to the Emergency department .

K. Record Review of facility's "Emergency Room Standards of Practice" policy effective since 11/2006 revealed:

1. The registered nurse determines the level of care needed by the patient which facilitates patient flow through the emergency care system.