HospitalInspections.org

Based on medical staff rules and regulations, policy reviews, medical record reviews, and physician interviews the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

The hospital failed to ensure on call physicians will respond to emergency needs by failing to specify requirements for on call physician response time in minutes.

~ Cross refer to §489.24(j) Availability of On-Call Physicians - Tag A2404

The hospital's qualified medical professional failed to provide physician documentation of an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 5 sampled Obstetrical patients (#16) who presented to the hospital's DED.

~ Cross refer to §489.24(r) and §489.24(c) Medical Screening Examination - Tag A2406

The hospital failed to to ensure an IVC patient (Patient #8) was appropriately transferred by failing to list specific benefits and risks and failing to document the time of certification to ensure the patient was stable for transport.

~ Cross refer to §489.24(e) Transfer - Tag A2409

Based on review of Medical staff rules and regulation, policy review, and staff interview the hospital failed to ensure on call physicians will respond to emergency needs by failing to specify on-call physician response time in minutes.

Findings revealed:

Review of Medical Staff Rules and Regulations revealed "...17. Available to Respond to Call Members of the Admitting Medical Staff who are on call for patients in the hospital or who are on specialty call for the ED must be available to respond to call within a reasonable period of time, depending on prevailing circumstances, after being notified that his/her presence is needed because of an emergency. ..." Review did not reveal the response time defined in minutes or reveal a definition of a reasonable period..

Review of hospital policy, "Medical Staff Specialty Call Schedule," revealed "...PROCEDURE A. The on-call specialty physician for the Emergency Department must come in if requested by the ED physician. B. The on-call specialty physician is not required to interrupt critical care to a patient that requires his/her personal management to respond to the ED if requested. However, he/she should respond immediately after caring for the specific patient, if so requested by the ED Physician. C. If requested by the ED Physician, it is not acceptable for the on-call specialty physicians to delay coming to the ED until the end of office hours, unless the ED physician agrees that such a delay is appropriate. ..." Policy review did not reveal response time specified in minutes

Review of hospital policy "Availability of Physicians Emergency On-Call Schedule" revealed "Procedure....the physician must have a back-up plan in the event the physician is called while performing elective surgery and is unable to respond to an on-call request in a reasonable time. ..." Review of policy did not reveal a response time defined in minutes or a definition of reasonable time.

Interview with Administrative Staff #1, on 10/26/2017 around 1400 revealed the hospital had not defined a required response time in minutes for on-call physicians. Interview revealed response time is stated as a "reasonable time".

Based on hospital policy review, closed DED (Dedicated Emergency Department) medical record reviews, physician and staff interviews, the hospital's DED failed to provide physician documentation of an appropriate Medical Screening Examination (MSE) to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 5 sampled Obstetrical patients who presented to the hospital for evaluation and treatment (Patient #16).

Findings included:

Review of hospital policy, "Medical Screening Exam," revealed "...Obstetrical patients determined to be greater than twenty (20) weeks gestation complaining of pregnancy related symptoms will be sent from triage to the obstetrical unit for a medical screening exam. The medical screening exam will be performed by an appropriately trained registered nurse who has completed the OB Triage/MSE competency, is certified in neonatal resuscitation... and has a minimum of six months obstetrical experience. ..." Policy review did not reveal when a physician was required to complete the MSE.

Review of hospital policy, "OB Triage Nursing Assessment," revealed "...The obstetrical patient of 20 weeks gestational age or greater, presenting with labor or pregnancy-related symptoms, will be assess by a nurse(s) on the OB unit who are qualified to do a medical screening examination. The OB nurse may conduct a medical screening examination in the absence of direct evaluation by a physician, consistent with federal regulations as per the Emergency Medical Treatment and Labor Act (EMTALA)....The OB physician on-call is responsible for any care or treatment of any OB patient that presents to [Unit name] to be triaged. A registered nurse qualified to do a medical screening exam will assess the OB patient's need for appropriate nursing care based on the patient's obstetrical history and complaints....The OB physician on call should be informed promptly if any of the following are present or suspected....And/or an abnormal/indeterminate FHR [fetal heart rate] pattern...If for any reason the nurse feels the need for the obstetrician to come in and assess the patient, she will communicate this to the physician over the phone. The patient will not be discharged home until the MD....has assessed the patient in person. ..." Policy review did not reveal other requirements for when a physician must complete the MSE.

Medical record review of Patient #16, on 10/25/2017, revealed the patient, a 20 year old pregnant female at 27 weeks gestation, who was sent from the physician's office on 07/13/2017 for further evaluation for fetal tachycardia. Record review revealed Patient #16 arrived to Labor and Delivery at 0950 and indicated "...Received....for further monitoring for fetal tachycardia....Fetal tachycardia (200-210) picked up with auscultation by NP: EFM [electronic fetal monitor] unable to evaluate FHR. Will monitor with physician to follow."Review of the "Standard Notes Log" for Patient #16 revealed a fetal heart rate (FHR) of 136 bpm (beats per minute) at 1035, 252 bpm at 1040, and 210 bpm at 1112. Review revealed a note at 1240 on 07/13/2017 that the obstetrician was at the bedside "...to observe FHR with US [ultrasound]," and "[Physician #4 Name] discussed pt.[patient] and fetal tachycardia with [Physician #6] at [Name of Medical Center]. Plan made for pt. to go into prenatal assessment there for evaluation. ..." Further review revealed a note at 1320 on 07/13/2017 which indicated "Discharge instructions completed with pt. and family member...pt. to go to [Name of Medical Center/Admissions], to go to 4th floor/prenatal assessment for evaluation per [Physician #6 Name]. Discharged ambulatory with family member." Review failed to reveal documentation Physician #4 completed a MSE or documented consultation related to follow-up care and consideration of transfer vs. discharge. Review did not reveal any documentation by Physician #4.

Review of Medical Record from Facility D revealed Patient #16 was seen for "Primary diagnosis: Encounter for antenatal screening of mother Reason for visit: Referred by [Name of Physician #4]" on 07/13/2017. Review revealed the patient was evaluated at the "[Name] UNIVERSITY PHYSICIANS Prenatal Assessment Center at [hospital name]. Review of "OBSTETRICS REPORT", dated 07/13/2017 at 1541, revealed "Service(s) Provided Basic OB >/= 14 weeks, 1 fetus Biophysical profile without NST ...Indications Fetal arrhythmia affecting pregnancy, antepartum Encounter for antenatal screening of mother 27 weeks gestation of pregnancy ....Comments Reactive NST with normal FHR baseline Impression Single intrauterine pregnancy.... Cephalic presentation. Normal limited anatomy. Normal fetal heart rate noted during entire scan. No SVT seen. Posterior placenta without evidence of previa. Normal amniotic fluid. Normal fetal growth. Recommendations Follow-up ultrasounds as clinically indicated. ..."

Interview with RN #1 on 10/25/2017 at 1545 revealed the RN cared for Patient #16 and assisted the physician with arrangements for the patient to go for more testing at the outside facility. "I asked if the patient was being transferred, RN #1 stated, and he (Physician #4) said no, and said it was more like an outpatient follow up, and he had talked to the doctor." RN #1 revealed "We often send patients down for comprehensive testing. ..." Interview revealed "I did stress the importance of going down to have the test." Interview revealed RN #1 made sure "She wasn't going to drive, and made sure there was someone to drive her." Further interview revealed RN #1 had believed Physician #4 would write a note about the evaluation, testing, and follow up plan.

Interview with the Manager #1, on 10/26/2017 at 0955 revealed the manager remembered Patient #16' s visit on 07/13/2017, and remembered that Physician #4 did a full exam on the patient, had been "very thorough, and had "discussed options" with the patient.

Interview with a physician leader, Physician #5, on 10/25/2017 at 1630 revealed the physician would expect in an ideal world that a note would be written about the plan and assessment done.

Telephone interview with Physician #4 on 10/26/2017 at 1415 revealed the physician remembered seeing Patient #16 on 07/13/2017 and recalled that Patient #16' s fetus was experiencing episodes of abnormally fast heart rates above 200 beats per minute. Interview revealed the physician spoke with a "high risk antenatal specialist," Physician #6, about the case. Physician #4 determined that the elevated fetal heart rate was real and should be evaluated by an antenatal specialist with access to more advanced testing methods. Physician #4 stated they discussed the timing of further testing, and Physician #6 did not want to put off an evaluation to a later date since if the fetal heart rate were to accelerate to over 200 for more an extended period there was the possibility of health consequences for the fetus. Interview revealed Physician #4 had done a medical screening exam for both Patient #16 and the fetus, and had not believed there was an urgent problem at the time of discharge from the facility. Physician #4 revealed he did not know why notes were not available in the record, stated he should have written notes, and did not recall if he had hand written them or entered them in an electronic record.

Based on policy and procedure review, DED medical record reviews, and physician and staff interviews, the hospital failed to provide appropriate transfer by failing to document specific benefits and risks associated with transfer or the time of certification to ensure the patient was stable for transport for 1 of 3 transferred patients (Patient #8).

The findings include:

Review of policy and procedure titled, "Transfer of Patient to Another Acute Care Facility," revealed "...The physician must certify in writing that based on reasonable risks and benefits expected from the provision of appropriate medical care at another facility outweigh the increase risks to the individual's medical condition from such a transfer....The physician must complete the 'Physician's Certificate of Transfer' and document the Benefits and Risks associated with the transfer. ..."

1. DED record review revealed Patient #8 arrived to Hospital A's DED by EMS on 09/22/2017 at 1949. Review of Triage Assessment, dated 09/22/2017 at 1949, revealed a chief complaint of overdose from Metoprolol and Losartan [medications that decrease Blood Pressure] and consuming alcohol, "bourbon". Review showed vital signs at 1954 were Pulse [P] 104, Respiratory Rate [RR] 16, Pulse Ox 98% on room air, and Blood Pressure [BP] 165/106. Review of Physician notes revealed an abdominal mass was confirmed by CT and Ultrasound. and revealed BP's dropped some overnight but remained stable and on 09/23/2017 at 0731 BP was up to 140/63. Further review of BP revealed reading of 196/89 on 09/23/2017 at 1653 and 212/101 at 2222. On 09/24/2017 at 0002, record reviewed indicated the was 146/84, at 0800 was 208/95, at 1812 was 190/85, and was 222/159 at 2300. Further review of BP's revealed on 09/25/2017 at 0051 BP was 134/76, and at 0800 was 195/95. Physician documentation from Physician #2, on 09/25/2017, no time, revealed Patient #8 had been accepted to Hospital B for inpatient psychiatric care. Review revealed Physician #2's documentation for transfer listed vital signs from 0803, which included the 195/95 BP. Further review of the Physician Departure Note revealed "...Additional Instructions: you have a large pelvic mass which is concerning for cancer it is imperative that you followup with GYN doctor Disposition....OTHER PSYCHIATRIC HOSPITAL Disposition Date: Sep 25, 2017 Disposition Time: 11:33....Condition: Stable. ..." Review did not reveal evidence of additional physician documentation. Review of vital signs revealed a BP at 1230 of 182/80. Record review did not reveal any further discussion of the Blood Pressure the physician. Review of a form titled, "PATIENT TRANSFER DOCUMENT [Attending Physician CHECK and COMPLETE Appropriate Sections]," revealed a top section of the form labeled "PHYSICIAN INITIATED TRANSFER (Physician's Certificate of Transfer)." Further form review revealed directions for the physician to certify that the benefits of transfer outweighed the increased risks to the medical condition risk from the transfer and for the physician to specify the benefits and risks. Form review failed to reveal any specific benefits or risks documented by Physician #2. Further review revealed Physician #2 signed the form but did not record the date or time of the certification. DED record review revealed Patient #8 was transferred to Hospital B by the Sheriff's Office at 1249.

Review of Patient #8's medical record at Hospital B revealed a Triage start time of 1615 and a first BP check of 223/95 with a statement the patient's heart rate was "fluctuating considerably". Further review revealed a BP recheck of 184/81. At 1650, record review showed a verbal order to transfer Patient #8 to the DED at Hospital C by EMS.

Interview, on 10/25/2017 at 1025, with Physician #2, who transferred Patient #8, revealed there is no medical provider on the transport, patients go out with law enforcement. Interview revealed Patient #8 was medically clear for transfer. Physician #2 stated that even with the hypertension and abdominal mass, the patient would have been discharged except for the psych condition. Further interview revealed ED physicians fill out the transfer forms. With IVC patients, Physician #2 stated, the physician tells patients they are being transferred for psych care, stating the service is not available at this hospital. Interview revealed Physician #2 followed the transfer process, but "missed the form". Interview revealed Physician #2 should have documented the benefits and risks of transfer, as well as date and time, of the certification.

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