HospitalInspections.org

Based on document review and staff interview, it was determined that the facility failed to ensure that individual physicians are identified on the facility's on-call list.

Findings include:

1. Upon request to Staff #8, an Emergency Department (ED) manager, on 12/6/2021 at 11:31 AM, the on-call list for 12/6/21 was provided for review. The on-call list identified for Labor and Delivery AM (Day Shift), OB-GYN (Obstetrics-Gynecology) Clinic, and General Surgery as physician groups, not individual physicians.

2. The On-Call schedule for the past six (6) months (June 2021 to December 2021) was provided for review. The following providers had physician groups listed for on-call and not individualized physicians: Labor and Delivery, HOPE (Hematology Oncology Physicians of Englewood), Neurosurgery, and Surgery (including Bariatric, General, and Pediatric).

3. An interview with Staff #1, an administrator, and Staff #8 identified that the process of the on-call list should be updated by the secretary in the morning daily to reflect individual physicians, but it had not been completed on 12/6/2021 by 11:31 AM. Staff #1 and Staff #8 also confirmed the process of on-call with physician groups. If a physician group is listed on the on-call list, then the secretary of the ED would call the group to get the physician's name and number of the individual on-call. The secretary would then have to call that physician for the ED referral/consult.

4. An interview with Staff #5 on 12/7/2021 at 1:37 PM confirmed the above findings. Staff #5 agreed that there could be a potential delay in treatment when a physician group is named and not the individual physician to be contacted directly.

5. Upon request to Staff #1 on 12/6/2021 at 1:12 PM and to Staff #5 on 12/7/2021 at 1:37 PM, the facility was unable to provide a documented policy and procedure for the maintenance of the on-call physician list and the process of utilizing an on-call physician group in order to minimize a delay in treatment of a patient.

Based on document review, staff interview, and review of policy and procedure, it was determined that the facility failed to ensure the Emergency Department (ED) central log is maintained.

Findings include:

Reference: Facility policy, titled, "Triage Emergency Medical Screening Treatment and On-Call Policy", states, "...F. Other EMTALA (Emergency Medical Treatment and Labor Act) Requirements 1. Central Log - a log must be maintained on each individual who presents to the ED and L&D (Labor and Delivery) Unit, or to any location of the hospital for emergency treatment... The Central Log must include the patient's name; the medical record number; the date and time of arrival; the names of the ambulance provider and mobile intensive care unit provider, if applicable; the chief complaint or medical diagnosis; time discharged; the name(s) of the QMP (Qualified Medical Person) who provided the MSE (Medical Screening Examination); the name(s) of the treating QMP; the disposition of each individual - whether the patient refused treatment; whether the patient was transferred, admitted and treated, stabilized and transferred, or discharged; and the condition of the patient at discharge...".

1. On 12/6/2021 at 10:22 AM, the ED department central logs were requested of Staff #1, an administrator, for the following dates: 6/4/2021, 7/16/2021, 8/13/2021, 8/31/2021, 9/19/2021, 10/12/2021, 10/30/2021, 11/19/2021, 11/24/2021, and 12/3/2021.

2. On 12/6/2021 at 12:00 PM, the ED central logs were provided and reviewed. The central logs were missing the following elements: the patient's medical record (MR) number, the names of the ambulance provider (if the patient came in by ambulance), the time of discharge from the ED if the patient was admitted, multiple entries of missing patient disposition, multiple areas of missing physician provider names.

3. The above findings were confirmed with Staff #1, an administrator, at the time of discovery. An interview with Staff #1 on 12/6/2021 at 12:34 PM revealed that the central logs are pulled from the electronic records system that the facility uses. The facility was unable to provide evidence of the process for monitoring the central logs for completeness and accuracy.

A. Based on review of one (1) of one (1) medical record of a patient with a suicidal attempt (#1), staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure patients receive an appropriate medical screening exam (MSE).

Findings include:

Reference: Facility policy titled, "Triage Emergency Medical Screening treatment and On-Call Policy" states, "... A Hospital must provide to any person who comes seeking emergency services, an appropriate medical screening examination ... Triage: ... To provide guidelines for triage of individuals in the E.D. (Emergency Department), to determine and assign clinical priority of care ... LEVEL II Emergent: situations serious ... Targeted medical screening will take place within 5 to 60 minutes. ... Examples include ... suicidal or homicidal patients ..."

1. Upon review of Medical Record #1, the following was noted:

a. The patient presented to the Emergency Department (ED) on 8/13/2021 at 10:25 PM with a complaint of "Suicidal Attempt."

b. The patient was triaged at 10:28 PM and classified as Level II Emergent.

c. The patient left the ED AMA (Against Medical Advice) at 10:45 PM.

d. The patient did not have an MSE that was completed by a qualified medical professional.

2. The above findings were confirmed with Staff #5 and Staff #8 on 12/8/2021 at 10:20 AM.


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B. Based on review of policy and procedure and staff interview, it was determined that the facility failed to ensure that a patient presenting to the Emergency Department (ED) is treated without delay for an emergency medical condition.

Findings include:

Reference: Facility policy titled "Triage Emergency Medical Screening Treatment and On-call" states, "...-A Hospital must provide to any person who comes seeking emergency services, an appropriate medical screening examination sufficient to determine whether he or she has an emergency medical condition... Access to the Hospital for emergency medical care means: that the individual requesting examination or treatment is on Hospital property..... non-hospital owned ambulances (i.e., volunteer first aid squads) physically on Hospital grounds.....2. Emergency Medical Screening and Stabilization A. Screening 1. Any individual who presents to the Emergency Department requesting an examination or treatment for an emergency medical condition shall be triage, and provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition..... 2. No patient will be discharged home or transferred to another facility without being seen and evaluated by an attending or Emergency Department Physician or Physician assistant.....B. Screening - Labor & Delivery (L&D) 1. All qualified providers in the Labor and Delivery Suite may also complete the medical screening for patients in active labor....."

1. An interview with Staff #4, an administrator, on 12/7/2021 at 1:35 PM identified that the facility had a self-reported potential EMTALA (Emergency Medical Treatment and Labor Act) violation and was still in the process of conducting an internal investigation and interviews with staff.

2. An interview on 12/7/2021 at 1:40 PM, with Staff #2, a nurse manager, revealed that on 11/19/2021, a physician had called the Maternal Child Health (MCH) Unit to report that a patient, who was at twenty-four (24) weeks gestation, was directed to come to the facility to been seen due to complaints of cramping. Staff #2 confirmed that the patient was not seen on the MCH unit on 11/19/2021.

3. Staff #2 and Staff #4 confirmed that the patient had arrived at the facility via ambulance on 11/19/2021, but the ambulance was directed in the ambulance bay by Staff #31, charge nurse of the ED, to take the patient to the regional perinatal center (RPC). The patient was not given a medical screening examination (MSE) at the facility before being directed to another facility.

4. Upon request to Staff #3, a risk manager, on 12/9/2021 at 11:00 AM, the facility was unable to provide written documentation of the investigation and interviews regarding the EMTALA event for review. Staff #3 verbally confirmed the following:

a. It remained unclear why Staff #31 met the ambulance in the ambulance bay to divert the ambulance to the (RPC).

b. Staff #31 did not speak with a physician to get an order to divert the ambulance to the RPC.

c. There was no official confirmation between the facility and the ambulance staff to confirm the identity of the patient.

d. Staff #31 had notified the MCH unit the patient was incoming, but did not notify the MCH unit that the patient had arrived and was told to go to the RPC.

e. It remained unclear if any report was endorsed to the RPC from the facility regarding the incoming patient.

A. Based on review of one (1) of one (1) medical record of a patient with a suicidal attempt (#1), staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure all patients who meet the criteria for Critical Watch receive that level of observation.

Findings include:

Reference: Facility policy titled, "Patient Levels of Observation" states, "... The use of levels of observation is needed to provide each patient with the optimal level of safety ... Critical Watch: The highest level of observation requiring one-to-one staff with direct observation, close proximity, and monitoring of an individual patient. ... Criteria for this level of observation ... Suicidal ideation ..."

1. Upon review of Medical Record #1, the following was noted:

a. The patient presented to the Emergency Department (ED) on 8/13/2021 at 10:25 PM with a complaint of Suicidal Attempt.

b. The patient was triaged at 10:28 PM and classified as Level II Emergent.

c. The patient was not placed on a Critical Watch.

d. The patient left the ED AMA (Against Medical Advice) at 10:45 PM without having a Medical Screening Exam.

2. Upon interview on 12/8/2021 with Staff #10, Staff 25, Staff #26, and Staff #27 (all ED nurses who are experienced with triage) stated that if a patient came in with a complaint of "Suicide Attempt" and tried to leave before having a Medical Screening Exam, they would call security and put the patient on a Critical Watch.

3. The above findings were confirmed with Staff #5 and Staff #8 on 12/9/2021 at 1:00 PM.

B. Based on review of three (3) of three (3) medical records of patients that left without the consent of the Emergency Department (ED) Physician (#1, #6, #7), review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure that patients presenting to the ED who choose not to continue treatment are properly dispositioned.

Findings include:

Reference: Facility policy titled, "Refusal of Advised Medical Care" states, "... It is the policy for [name of hospital] that a patient leaving any area ... without the consent of the attending physician / ED Physician ... must sign a properly executed Refusal of Advised Medical Care form. ... Documentation of the circumstances surrounding the refusal to sign the form must be noted on the form. The risks given to the patient or the patient's guardian of refusing either the proposed treatment or leaving the Medical Center must be documented on the form. ... If the patient is found missing from his/her room and a "Refusal of Advised Medical Care" form was not completed, the Security Department is to be notified. ... If the patient is not located, the Patient Care Director shall telephone the patient's residence to determine if the patient returned home. If the patient is found not to be at home (via telephone) the Security Officer in charge, shall telephone the appropriate Police Department ... The Security Officer in charge shall prepare a full report. ..."

1. Upon review of Medical Record #1, the following was noted:

a. The patient presented to the ED on 8/13/2021 at 10:25 PM with a complaint of "Suicidal Attempt."

b. The patient was triaged at 10:28 PM and classified as Level II Emergent.

c. The patient left the ED at 10:45 PM.

d. The "Refusal of Advised Medical Care Form" was not signed by the patient and/or caregiver and was not filled out completely.

(i) The circumstances surrounding the patient's and/or caregiver's refusal to sign the form was not noted on the form.

(ii) The risks given to the patient for refusing either the proposed treatment or leaving the Medical Center was not documented on the form.

2. Upon review of Medical Record #6, the following was noted:

a. The patient presented to the ED on 9/19/2021 at 6:52 PM with a complaint of "Burn to lower abdomen."

b. The patient was triaged at 6:53 PM and classified as Level IV Semi-urgent.

c. The patient left the ED at 8:35 PM without notification to the staff.

(i) Security was not notified, in accordance with facility policy.

(ii) The Patient Care Director did not telephone the patient's residence to determine if the patient returned home, in accordance with facility policy.

(iii) The Security Officer in charge did not telephone the appropriate Police Department or prepare a full report, in accordance with facility policy.