HospitalInspections.org

The Condition of Participation of Organizational Structure was out of compliance.

Findings included:

The Critical Access Hospital Governing Body (Board of Trustees) failed to ensure full responsibility for governing the Critical Access Hospital's total operation and that the Medical Staff was accountable to the Governing Body for the quality of equitable care provided to Emergency Services patients.

Refer to TAG: C-0241.

Based on records reviewed and interviews the Critical Access Hospital Governing Body (Board of Trustees) failed to ensure full responsibility for governing the Critical Access Hospital's total operation and that the Medical Staff was accountable to the Governing Body for the quality of equitable care provided to Emergency Services patients.

Findings included:

1.) Based on records reviewed and interviews the Critical Access Hospital failed to ensure that the Hospital provided Emergency Services necessary to meet the needs of its Emergency Department patients in accordance with acceptable standards of practice.

The American Academy of Emergency Medicine (AAEM) Mission Statement indicates that the Academy supports fair and equitable practice environments necessary to allow the specialist in emergency medicine to deliver the highest quality of patient care.

The Institute of Medicine (a nonprofit organization devoted to advance and disseminate scientific knowledge to improve human health) defined quality as having six domains: safe, effective, patient-centered, timely, efficient, and equitable. The Institute of Medicine defined equitable as providing care that did not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status (The United States Department of Health & Human Services at https://www.ahrq.gov/talkingquality/measures/six-domains.html).

The Surveyors interviewed the Chief of Emergency Medicine on 9/13/19 at 12:29 P.M. The Chief of Emergency Medicine said that he accepted the position of Chief of Emergency Medicine in 2016. The Chief of Emergency Medicine said that he replaced Emergency Physician #1 as Chief. The Chief of Emergency Medicine said that Emergency Room Physician #1 operated a Concierge medical practice for several years prior to his arrival and that Emergency Room Physician #1 and Emergency Room Physician #2 were both partners in the Concierge practice (a relationship between a patient and a primary care physician in which the patient pays an annual fee or retainer) while remaining credentialed and privileged as Martha's Vineyard Hospital (MVH) full time Emergency Room Physicians. The Chief of Emergency Medicine said that the Concierge practice was called Lifeguard Medical Group. The Chief of Emergency Medicine said that he did not monitor the Emergency Room Physician #1 and Emergency Room Physician #2's involvement in Lifeguard Medical Group and stayed clear. The Chief of Emergency Medicine said that he did not get involved in their practice. The Chief of Emergency Medicine said that both Emergency Room Physicians #1 and #2 brought their Lifeguard Medical Group patients into the Critical Access Hospital Emergency Department, registered the patients, then examined the patient & treated the patient utilizing Critical Access Hospital staff nurses and Hospital supplies. The Chief of Emergency Medicine said that he was not aware of how the Lifeguard Medical Group billed for the practice but the Critical Access Hospital considered it an Emergency Department visit. The Chief of Emergency Medicine said that the practice was allowed because both Emergency Room Physician #1 and Emergency Room Physician #2 were credentialed by the Critical Access Hospital. The Chief of Emergency Medicine acknowledged that Lifeguard Medical Group patients, who pay a fee for service to the Lifeguard Medical Group, could be seen before other patients who have been in the waiting room longer (for that same ailment or chief complaint) because Lifeguard Medical Group patients were accompanied by their Critical Access Hospital credentialed physician, while other patients waited for emergency evaluations and treatments by the Emergency Department physician who was scheduled to work that day in the Emergency Department.

Review of the website titled Lifeguard Medical Group, dated 9/24/19 at http://www.lifeguardmg.com/index.html., indicated a Concierge Medical Service of on-call Personal Emergency Physicians that provided urgent and emergency medical services to their clients 24 hours a day, 7 days a week, from Memorial Day weekend through Columbus Day, to personally meet their client (patient) in the Emergency Department (of the Critical Access Hospital) to help care for any medical issues that arise. The Lifeguard Medical Group Website indicated Member fees ranged from $10,000 to $125,000, including a Deluxe Plan that offered coverage to all household visitors or employees, as well as family members.

The Surveyors interviewed Nurse #1 on 9/13/19, at 1:00 P.M. Nurse #1 said that he/she was aware of Lifeguard Medical Group patients arriving and being treated in the Emergency Department by Emergency Room Physician #1 and Emergency Room Physician #2. Nurse #1 said that Lifeguard Medical Group patients receive preferential treatment because they are brought right back into the Emergency Department and receive care right away by the Lifeguard Medical Group physicians. Nurse #1 said that he/she had witnessed this multiple times. Nurse #1 said that it was difficult for nurses because it was unclear who was placing the orders and which Physician was in charge of the patient's care.

The Surveyors interviewed Nurse #2 on 9/13/19, at 2:00 P.M. Nurse #2 said that he/she had witnessed Lifeguard Medical Group patients being treated by Lifeguard Medical Group physicians many times in the Emergency Department. Nurse #2 said that he/she was unaware of which physician was in charge of the patient when this occurred.

The Surveyors interviewed the Chief Executive Officer (CEO) on 9/17/19 at 11:00 A.M. The CEO said that she was aware of the Lifeguard Medical Group and it was not affiliated with the Critical Access Hospital in any way. The CEO said that she made it clear with Emergency Room Physician #1 that all Lifeguard Medical Group patients were Martha's Vineyard Hospital (Critical Access Hospital) patients when they presented to the Critical Access Hospital Emergency Department. The CEO said that the Critical Access Hospital's expectations were that only the scheduled Martha's Vineyard Hospital Emergency Department physician was to examine or treat patients in the Emergency Department. The CEO said that non-scheduled physicians should not be treating Martha's Vineyard Hospital patients in the Emergency Department. The CEO said that all patients received the same care and go through the same triage evaluation process. The CEO said that the Critical Access Hospital did not provide preferential treatment to any patients.

The Surveyors interviewed the Chief Nursing Officer (CNO) on 9/17/19, at 2:00 P.M. The CNO said that all patients in the Emergency Department were registered and triaged in the same manner. The CNO said that no patients received preferential treatment. The CNO said that she was aware of the Lifeguard Medical Group but when their patients arrived at the Hospital they were seen by a Martha's Vineyard Hospital Emergency Physician scheduled that day. The CNO said that Lifeguard Medical Group physicians who were not scheduled do not examine their patients.

The Surveyors interviewed Emergency Room Physician #1 on 9/18/19, at 9:08 A.M. Emergency Room Physician #1 said that he worked full time as an Emergency Room Physician for MVH and he was the founder of the Lifeguard Medical Group. Emergency Room Physician #1 said that, while working for the Lifeguard Medical Group and not scheduled to work at MVH, he had brought his patients into the Emergency Department and provided emergency care for them. Emergency Room Physician #1 acknowledged that a Lifeguard Medical Group patient could be seen before other patients in the waiting room if they had similar ailments but not if the waiting room patients were more ill. Emergency Room Physician #1 said that he has not cared for patients not belonging to Lifeguard Medical Group during these Emergency Room visits. Emergency Room Physician #1 acknowledged that his pay for service patients have been escorted to MVH Emergency Department rooms, treated by off duty MVH physicians, cared for by on duty MVH nursing staff, and discharged by off duty MVH physicians. Emergency Room Physician #1 said that he personally drove Patient #1 (a Lifeguard Medical Group member) to the Hospital, escorted Patient #1 into the Hospital and performed Patient #1's initial emergency medical exam and assigned himself as the attending physician caring for Patient #1. Emergency Room Physician #1 said that Patient #2 was also a member of Lifeguard Medical Group and was recently treated in the Emergency Department. Emergency Room Physician #1 acknowledged that his pay for service patients can be treated before non-fee paying patients if they have the same chief complaint because he was a credentialed emergency room physician and privileged to practice at MVH.

Review of Patient #1's medical record indicated that Patient #1 arrived on 8/22/19, at 11:13 P.M. Review of the physician schedule indicated that Emergency Room Physician #1 was not scheduled to work this shift. Patient #1's medical record indicated that Patient #1 arrived to the Emergency Department complaining of chest pain. Emergency Room Physician #1 assigned himself as the attending in charge of Patient #1 at 11:19 P.M. Patient #1's emergency medical screening exam was signed by Emergency Room Physician #1 on 8/23/19, at 12:03 A.M. Patient #1 was diagnosed with a myocardial infarction (Heart Attack) and transferred to an outside hospital for treatment.

Review of Patient #2's medical record indicated that Patient #2 arrived to the Emergency Department on 9/9/19, at 4:31 P.M., via ambulance. Patient #2's medical record indicated that Patient #2 fell and hit his/her head and sustained a head injury. Patient #2's medical record indicated that he/she was initially assigned to Emergency Room Physician #3 (a non Lifeguard Medical Group member) at 4:31 P.M. Patient #2's medical record indicated that at 6:33 P.M., Emergency Room Physician #2 (Lifeguard Medical Group physician not scheduled to work that shift) placed a medical order for a Computerized Tomography (CT) scan. Patient #2's medical record indicated that at 6:45 P.M. Emergency Room Physician #2 was assigned as the attending physician in charge of Patient #2's care. Review of Patient #2's medical record indicated that he/she was discharged by Emergency Room Physician #2 at 7:08 P.M. Emergency Room Physician #2 completed Patient #2's medical record on 7:31 P.M.

2.) The Critical Access Hospital provided no clear interview information, policie(s), procedure(s) or Quality Assessment Performance Improvement activities or documentation that indicated the Governing Body was apprised of the Medical Staff evaluation of patient care Emergency Services provided in the Critical Access Hospital to ensure that the quality of Emergency Service care did not vary in equity (fairness) because of a high-profile patient, member of the Concierge Medical Service, socio-economic status.

The Bylaws of the Medical Staff, dated 9/17/2019, indicated that Emergency Medicine was a clinical department of the Critical Access Hospital. The Bylaws of the Medical Staff indicated functions of the Emergency Department Chairperson included the responsibility for monitoring and evaluating all clinical and administrative activities within the Emergency Department, unless otherwise provided for by the Critical Access Hospital.

Board of Trustees (Governing Body) Meeting Minutes, dated 7/2018 through 5/2019, Emergency Services Meeting Minutes, dated 18/2018 through 8/2019, and Medical Quality Improvement Meeting Minutes, dated 9/2018 through 5/2019 indicated no documentation (notes, comments, discussion) regarding the Critical Access Hospital and Lifeguard Medical Group.

The Critical Access Hospital provided no Governing Body Meeting Minutes to indicate that the Governing Body was involved in the day-to-day operation of the Critical Access Hospital Emergency Service and was fully responsible for its operations.

4.) Based on records reviewed and interviews the Critical Access Hospital Governing Body failed to ensure the Medical Staff established policies and procedures governing the medical care provided in the Emergency Services regarding high-profile patients that were members of the Concierge Medical Service based on the ongoing monitoring conducted by the Medical Staff or the Critical Access Hospital Quality Assessment activities.

The Bylaws of the Medical Staff, dated 9/2019, indicated that the Emergency Department Chairperson was responsible for the development and implementation of policies and procedures that guide and support the provision of Emergency Services.

The Job Description titled Director of the Emergency Department (Emergency Service), dated 7/28/16, indicated that the Director of Emergency Services (Emergency Services Chairperson) was responsible to provide leadership for the Emergency Service to provide Emergency Services for all patients that presented to the Emergency Department and coordination and evaluation for Emergency Services activities (including regarding the Critical Access Hospital and Lifeguard Medical Group patients quality of equitable care).

The Administrative Policy Manual, undated, indicated a Table of Contents. The Administrative Policy Manual indicated no policy or document regarding the Emergency Service Scope of Service regarding the Critical Access Hospital and Lifeguard Medical Group patients.

The Emergency Department Nursing Policy & Procedure Index, undated, indicated the Emergency Service policy and procedure Table of Contents. The Index indicated no policy(s) or procedure(s) regarding the Critical Access Hospital and Lifeguard Medical Group patients.

The Critical Access Hospital provided no operating policies or procedures to fully reflect its responsibilities in the provision of Emergency Services to the high-profile patient members of the Concierge Medical Service that presented to the Critical Access Hospital Emergency Service.