HospitalInspections.org

Findings were:

1. Cross refer to A2403 as it relates to failure of the facility to establish a medical record for a patient presenting to the Emergency Department and transferred to another facility.

2. Cross refer to A2405 as it relates to failure of the facility to put the patient's name in the central log for a patient presenting to the Emergency Department via Emergency Medical System transport.

3. Cross refer to A2406 as it relates to failure of the Emergency Department physician to perform an appropriate medical screening.

4. Cross refer to A2407 as it relates to failure of the facility to provide stabilizing treatment for a patient, and failure to identify in the Medical Staff Bylaws/Rules and Regulations those individuals qualified to perform medical screenings..

5. Cross refer to A2409 as it relates to failure of the facility to effect an appropriate transfer.

Based on review of policies and procedures, physician and staff interviews, it was determined that the facility failed to establish a medical record, for a trauma patient, presenting to the emergency department (ED), on 6/27/10, by an Emergency Medical Services (EMS) ambulance.

1. During an interview on 7/22/2010 at 6:00 p.m, physician #1 stated that he/she was responsible for coverage of the ED on 6/27/10 from 6:00 p.m. until 6/28/10 at 6:00 a.m. The physician recalled that radio contact was made with the Emergency Medical Services(EMS) staff which took place during his /her shift on this date. According to the physician, the EMS staff informed the physician that the ambulance was in route to the facility with a trauma patient. The patient had been involved in a high speed motor vehicle collision. The EMS staff described the patient's injuries as multiple trauma involving the head, chest, and lower extremity. While in communication with the EMS staff, the physician checked with the ED secretary to determine if on-call physician coverage was available for orthopedics and general surgery. Orthopedic coverage was not available. The physician related that the EMS staff described the patient as stable. The physician stated that he/she felt that it was in the best interest of the patient to be transported to a trauma center where the patient would have access to specialized care (neurosurgery, orthopedic and thoracic surgery). He/she advised the EMS staff to transport the patient to another hospital where trauma services would be available. The physician continued to say that the EMS staff failed to hear the advice to divert and within a few minutes the ambulance arrived at the facility's ED. The physician met the EMS's staff outside at the ambulance entrance to the facility.

The physician confirmed that he/she did not have contact with the patient and that physical assessment, medical screening and stabilizing treatment were not provided. The physician questioned the EMS staff and was informed that the patient remained stable. The physician advised the EMS staff to transport the patient to another hospital where trauma services were available. The physician also confirmed that there was no discussion related to the risk and benefits of the transfer, and the receiving hospital was not contacted to arrange for acceptance of the patient.

2. A review of the facility's policy entitled "EMTALA - Transfer Policy", last approved 4/09 revealed that the transferring hospital must send to the receiving hospital copies of all medical records related to the emergency medical condition (EMC) which are available at the time of transfer. Medical and other records related to the individuals transferred to or from the hospital must be retained in their original or legally reproduced form in hard copy, microfilm, microfiche, optical disks, computer disks, or computer memory for a period of 5 years from the date of transfer. Documentation sent to the receiving hospital must include:
- Copies of the available history, all records related to the individual's EMC, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the individual or the certification of a physician or a qualified medical person (QMP).
-The name and address of any on-call practitioner who refused or failed to appear within a reasonable amount of time to provide necessary stabilizing treatment;
-The individual's vital signs which should be taken immediately prior to transfer and documented on the Memorandum of Transfer Form.
- Copies of available records must accompany the individual; and
- Copies of other records not available at the time of transfer must be sent as soon as practical after the transfer.

3. During an interview on 7/20/2010 at 6:30 p.m., employee #3, who was the acting charge nurse in the ED on the night shift -7:00 p.m. to 7:00 a.m. on 6/27/10, confirmed that the physician was the only person from the ED to have contact with the EMS staff and that a medical record was not established for the patient.

Based on review of policies and procedures, the emergency department (ED) central logs, and staff interview, it was determined that the facility failed to to maintain a central log on each individual who came to the Emergency Department (ED) seeking treatment.

1. During an interview on 7/22/2010 at 6:00 p.m., physician #1 acknowledged that he/she was responsible for coverage of the ED on 6/27/10 from 6:00 p.m. until 6/28/10 at 6:00 a.m. The physician recalled radio contact with the Emergency Medical System (EMS) staff, which took place during his /her shift on this date. The EMS staff informed the physician that the ambulance was in route to the facility with a trauma patient. The patient had been involved in a high speed motor vehicle collision. The EMS staff described the patient's injuries as multiple trauma involving the head, chest, and lower extremity. While in communication with the EMS staff, the physician checked with the ED secretary to determine if on-call physician coverage was available for orthopedics and general surgery. Orthopedic coverage was not available. The physician related that the EMS staff described the patient as stable. The physician stated that he/she felt that it was in the best interest of the patient to be transported to a trauma center where the patient would have access to specialized care (neurosurgery, orthopedic and thoracic surgery). He/she advised the EMS staff to transport the patient to another hospital where trauma services would be available. According to physician #1, the EMS staff did not hear the advice to divert and within a few minutes the ambulance arrived at the facility's ED. The physician met the EMS staff outside at the ambulance entrance to the facility.

The physician confirmed that he/she did not have contact with the patient and that a physical assessment, a medical screening and stabilizing treatment were not provided. The physician questioned the EMS staff and was informed that the patient remained stable. The physician advised the EMS staff to transport the patient to another hospital where trauma services were available. The physician also confirmed that there was no discussion related to the risk and benefits of transfer, and the receiving hospital was not contacted to arrange for acceptance of the patient.

2. Review of facility policy, entitled "Central Log Policy", last approved 2/09, revealed that the hospital will maintain a Central Log containing information on each individual who comes to the ED seeking assistance, whether he or she refused treatment, was refused treatment, or whether he or she was transferred or discharged.

3. The central log was reviewed for 6/27/10. The log lacked documentation related to a trauma patient presenting to the Emergency department requiring transfer to another facility.

4. During an interview on 7/20/2010 at 6:30 p.m., employee #3, the acting charge nurse in the ED on the night shift - 7:00 p.m. to 7:a.m. - on 6/27/10, confirmed that the patient's name was not obtained and no entry was made in the central log related to his/her presentation to the hospital.

Based on review of Medical Staff By-laws/Rules and Regulations, policies and procedures, physician and staff interviews, it was determined that the emergency department (ED) physician failed to provide a medical screening, for a trauma patient presenting to the ED, on 6/27/10, by Emergency Medical Services(EMS) ambulance. The Medical Staff Bylaws/Rules and Regulations lack documented evidence of who was determined to be qualified to perform medical screenings.

1. During an interview on 7/22/2010 at 6:00 p.m., physician #1 stated that he/she was responsible for coverage of the ED on 6/27/10 from 6:00 p.m. until 6/28/10 at 6:00 a.m. The physician recalled that radio contact was made with the Emergency Medical Services (EMS) staff which took place during his /her shift on this date. The EMS staff informed the physician that the ambulance was in route to the facility with a trauma patient. The patient had been involved in a high speed motor vehicle collision. The EMS staff described the patient's injuries as multiple trauma involving the head, chest, and lower extremity. While in communication with the EMS staff, the physician checked with the ED secretary to determine if on-call physician coverage was available for orthopedics and general surgery. Orthopedic coverage was not available. The physician related that the EMS staff described the patient as stable. The physician stated that he/she felt that it was in the best interest of the patient to be transported to a trauma center where the patient would have access to specialized care (neurosurgery, orthopedic and thoracic surgery). He/she advised the EMS staff to transport the patient to another hospital where trauma services would be available. According to the physician, the EMS did not hear the advice to divert and within a few minutes the ambulance arrived at the facility's ED. The physician met the EMS staff outside at the ambulance entrance to the facility.

The physician confirmed that he/she did not have contact with the patient and that a physical assessment, a medical screening and stabilizing treatment were not provided. The physician questioned the EMS staff and was informed that the patient remained stable. The physician advised the EMS staff to transport the patient to another hospital where trauma services were available. The physician also confirmed that there was no discussion related to the risk and benefits of the transfer, and the receiving hospital was not contacted to arrange for acceptance of the patient.

2. Review of the Medical Staff Bylaws, Rules and Regulations revealed that physicians were to adhere to the facility's policies and procedures. Review of facility's policy entitled "EMTALA - Medical Screening Exam and Stabilization Policy", last approved 4/09, revealed when an individual comes to a dedicated emergency department (DED) and a request is made on his or her behalf for an examination or treatment for a medical condition, or a prudent layperson observer would believe that the individual presented with an emergency medical condition (EMC), an appropriate medical screening examination (MSE), within the capabilities of the hospital's DED (including ancillary services routinely available and the availability of an on-call physicians), shall be performed by an individual qualified to perform such examination to determine whether an EMC exists, or with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. If an EMC is determined to exist the individual will provide the necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as required by EMTALA.

If ambulance personnel contact the hospital by telephone or telemetry communication and inform the hospital that they want to transport the individual to the hospital for examination and treatment, the hospital may deny access to the individuals when it is in diversionary status because it does not have the staff or facilities to accept any additional emergency individuals at that time. Caution: If the ambulance staff disregards the hospital's instructions and brings the individual on to hospital property, the individual has come to the emergency department and the hospital must perform an appropriate MSE. Should a hospital which is not in diversionary status fail to accept a telephone or radio request for transfer or admission, the refusal could represent a violation of Federal or State requirements.

3. During an interview on 7/19/2010 at 1:00 p.m., the ED Director at 1:00 p.m. confirmed that the ED was not on diversionary status on 6/27/10.

4. Review of the Medical Staff Bylaws/Rules and Regulations revealed a lack of documentation as to who were the individuals that were determined qualified to perform an appropriate medical screening.

5. During an interview on 7/20/2010 at 2:00 p.m., the Assistant Administrator confirmed that medical screening was not addressed in the current Medical Staff Bylaws/Rules and Regulations but was addressed and implemented by policy. The interviewee provided written documentation that revealed the Medical Staff Bylaws/Rules and Regulations were in the process of revision. A proposal has been made for revision of the Medical staff Rules and Regulations to include persons qualified to perform a medical screening. The Medical Staff and Board of Trustees were expected to approve the revision on 8/3/10.

The following corrective action has been taken or will be taken by the Administration of Fairview Park:

A. This incident has been referred for review pursuant to Fairview Park's peer review by process and handling in accordance with Fairview Park's medical staff bylaws.

B. The ED Medical Director counseled the ED physician regarding this incident and pointing out the EMTALA regulations applicable to the incident and EMTALA implications of the ED physician's action. The ED Medical Director emphasized: 1) the EMTALA regulation regarding when a patient has come to the ED and the two hundred and fifty yard rule; 2) the importance of performing an appropriate medical screening examination; 3) documentation of the medical screening exam; 4) stabilizing the patient to the full extent of the facilities capabilities; and 5) appropriately transferring and appropriately documenting the transfer of the patient to a receiving facility.

C. The ED Medical Director sent a communication to all EmCare ED physicians reminding them of the importance of EMTALA regulations and requesting that each physician complete the online EmCare EMTALA training offered by EmCare.

D. Fairview Park reviewed this incident with EmCare and has requested EmCare not to assign any ED physician to work at Fairview Park's ED unless the ED physician has completed an EMTALA training course since becoming an employee of EmCare.

E. The ED physicians will complete two separate EMTALA training courses, one offered by EmCare and the other offered through The Sullivan Group.

Based on review of the Medical Staff By-laws/Rules and Regulations Regulations, policies and procedures, physician and staff interviews, it was determined that the facility failed to provide stabilizing, treatment for a trauma patient presenting to the ED, on 6/27/10, by Emergency Medical Services (EMS) ambulance.

1. During an interview on 7/22/2010 at 6:00 p.m., physician #1 acknowledged that he/she was responsible for coverage of the ED on 6/27/10 from 6:00 p.m. until 6/28/10 at 6:00 a.m. The physician recalled that radio contact was made with the Emergency Medical Services (EMS) staff which took place during his /her shift on this date. The EMS staff informed the physician that the ambulance was in route to the facility with a trauma patient. The patient had been involved in a high speed motor vehicle collision. The EMS staff described the patient's injuries as multiple trauma involving the head, chest, and lower extremity. While in communication with the EMS staff, the physician checked with the ED secretary to determine if on-call physician coverage was available for orthopedics and general surgery. Orthopedic coverage was not available. The physician related that the EMS staff described the patient as stable. The physician stated that he/she felt that it was in the best interest of the patient to be transported to a trauma center where the patient would have access to specialized care (neurosurgery, orthopedic and thoracic surgery). He/she advised the EMS staff to transport the patient to another hospital where trauma services would be available. According to the physician, the EMS staff did not hear the advice to divert and within a few minutes the ambulance arrived at the facility's ED. The physician met the EMS staff outside at the ambulance entrance to the facility. The physician confirmed that he/she did not have contact with the patient and that a physical assessment, a medical screening and stabilizing treatment were not provided. The physician questioned the EMS staff and was informed that the patient remained stable. The physician advised the EMS staff to transport the patient to another hospital where trauma services were available. The physician also confirmed that there was no discussion related to the risk and benefits of the transfer and the receiving hospital was not contacted to arrange for acceptance of the patient.

2. Review of the Medical Staff Bylaws, Rules and Regulations revealed that physicians were to adhere to the facility's policies and procedures. Review of facility policy, entitled "EMTALA - Medical Screening Exam and Stabilization Policy", last approved 4/09, revealed when an individual comes to a dedicated emergency department (DED) and a request is made on his or her behalf for an examination or treatment for a medical condition, or a prudent layperson observer would believe that the individual presented with an emergency medical condition (EMC), an appropriate medical screening examination (MSE), within the capabilities of the hospital's DED (including ancillary services routinely available and the availability of on-call physicians), shall be performed by an individual qualified to perform such examination to determine whether an EMC exists, or with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. If an EMC is determined to exist the individual will provide necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as required by EMTALA.

3. During an interview on 7/20/2010 at 6:30 p.m., employee #3, the acting charge nurse in the ED on the night shift -7:00 p.m. to 7:00 a.m. - on 6/27/10 confirmed that the physician was the only person from the ED to have contact with the EMS and that stabilizing treatment was not provided for the patient by the ED staff.

Based on review of the Medical Staff By-laws/Rules and Regulations Regulations, policies and procedures, physician and staff interviews, it was determined that the facility failed to effect an appropriate transfer, for a trauma patient presenting to the ED on 6/27/10 by Emergency Medical Services (EMS) ambulance.

1. During an interview on 7/22/2010 at 6:00 p.m., physician #1 stated that he/she was responsible for coverage of the ED on 6/27/10 from 6:00 p.m. until 6/28/10 at 6:00 a.m. The physician recalled radio contact was made with the Emergency Medical Services (EMS) staff which took place during his /her shift on this date. The EMS staff informed the physician that the ambulance was in route to the facility with a trauma patient. The patient had been involved in a high speed motor vehicle collision. The EMS staff described the patient's injuries as multiple trauma involving the head, chest, and lower extremity. While in communication with the EMS staff, the physician checked with the ED secretary to determine if on-call physician coverage was available for orthopedics and general surgery. Orthopedic coverage was not available. The physician related that the EMS staff described the patient as stable. The physician stated that he/she felt that it was in the best interest of the patient to be transported to a trauma center where the patient would have access to specialized care (neurosurgery, orthopedic and thoracic surgery). He/she advised the EMS staff to transport the patient to another hospital where trauma services would be available. According to the physician, the EMS staff did not hear the advice to divert and within a few minutes the ambulance arrived at the facility's ED. The physician met the EMS staff outside at the ambulance entrance to the facility. The physician confirmed that he/she did not have contact with the patient and that a physical assessment, a medical screening and stabilizing treatment were not provided. The physician questioned the EMS staff and was informed that the patient remained stable. The physician advised the EMS staff to transport the patient to another hospital where trauma services were available. The physician also confirmed that there was no discussion related to the risk and benefits of the transfer, and the receiving hospital was not contacted prior to transfer to arrange for acceptance of the patient.

2. Review of the Medical Staff Bylaws, Rules and Regulations revealed that physicians were to adhere to the facility's policies and procedures. Review of the facility's policy entitled "EMTALA - Transfer Policy" revealed if an individual (or the individual's designated representative) "comes to the emergency department" of a hospital requesting (or a prudent layperson would assume the individual would be requesting) medical care and an EMC is identified, the hospital must provide an appropriate medical screening examination (MSE) and either
- further medical examination and treatment, including hospitalization if necessary as required to stabilize the medical condition within the capabilities of its staff and facilities; or
- a transfer to another more appropriate or specialized facility after provision of treatment necessary to minimize the risks to the health of the individual or in the case of a pregnant woman, the unborn child.

Individuals may be transferred to another facility only if (1) the patient requires a higher level of care than the transferring facility offers and (2) the individual requests the transfer. Before any transfer may occur, the transferring hospital must first provide to its capacity and capability, medical treatment to minimize the risks to the health of the individual or unborn child. Individuals may request to be transferred. Any transfers resulting from a request of an individual to another medical facility of an individual with an EMC must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual's behalf and must be accompanied by a physician order with the appropriate physician certification as required under EMTALA and/or .

The transferring hospital must call the receiving hospital to verify that the receiving hospital has available space and qualified personnel for the treatment of the individual being transferred and must have agreed to accept the transfer and provide appropriate treatment. The transferring hospital must document its communication with the receiving hospital, including the request date, time and the name of the person accepting the transfer.

The transferring hospital must also ensure that the following are sent to the receiving hospital related to the EMC which are available at the time of transfer:
- Copies of available records must accompany the individual; and
- Copies of other records not available at the time of transfer must be sent as soon as practical after the transfer.
A physician must sign an express written certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the unborn child, from being transferred.

3. During an interview on 7/20/2010 at 6:30 p.m., employee #3, the acting charge nurse in the ED on the night shift -7:00 p.m. to 7:a.m. on 6/27/10 confirmed that the receiving hospital was not contacted regarding the transfer of the patient.