HospitalInspections.org

Based on a review of Emergency Medical Services Documents, ED Log, OB Logs, Medical Records, CAH Medical Staff Bylaws, Medical Staff Rules and Regulations, and staff interviews it was determined the CAH failed to ensure all patients who presented to the ED were entered into the ED log, refer to A2405-A. The CAH failed to ensure an OB log was designated to identify those patients who presented to the OB department for emergency services, refer to A2405-B. The CAH failed to ensure patients that presented to the ED were provided with a Medical Screening Examination, refer to A2406-A. The CAH failed to ensure the MSE was conducted by a qualified practitioner in accordance with its Medical Staff Bylaws, Rules and Regulations for patients who presented to the OB department for a MSE, refer to A2406-B.

A. Based on a review Emergency Medical Services documents, ED log, and staff interview, it was determined in 1 of 20 (Pts #1) records reviewed, in which the patient presented to the ED, the CAH failed to ensure all patients that presented to the ED were included in the ED log.
Findings include:

1. The Emergency Medical Services form dated 4/8/13 was reviewed for Pt #1. The form indicted that Pt #1 presented to the CAH's Emergency Department on 4/8/13.

2. The ED log for October 2012 thru March 2013 was reviewed on 4/17/13 thru 4/18/13. There was no documentation to indicate Pt #1 was entered onto the ED log on 4/8/13.

3. During a staff interview, conducted with the Director of Quality and Risk Management and the EDON on 4/18/13 at 11:00 AM, it was verbalized that the ED log was not completed per policy as Pt #1 was not entered onto the ED log.

B. Based on a review of the OB logs and staff interview, it was determined the CAH failed to ensure an OB log was designated to identify those patients who presented to the OB department for emergency services. This has the potential to affect 100% of the patients who present to the OB department to obtain a MSE, which currently delivers an average of 13 babies per month and an undetermined number of OB patients who presented to the OB department for a MSE and were subsequently discharged back home.
Findings include:

1. The OB logs were reviewed 4/17/13 thru 4/18/13. There were three logs, one for those who presented and delivered; one daily log; and one for patients in an outpatient and/or observation status. However, there was no way to differentiate who presented for outpatient/observation or direct admit versus those who presented requesting emergency services and in need of a MSE.

2. During a staff interview conducted with the Director of OB on 4/17/13 at 2:00 PM, the OB director was asked to describe how the logs identify how the patient presented to the OB unit as to whether it was for emergency services. The OB director stated "I would have to go back and pull each record to determine what the presentation to the unit would be and if a medical screening was done and by whom".

A. Based on a review of Emergency Medical Services documents, medical record review from receiving hospital, and staff interview, it was determined in 1 of 20 (Pts #1) patients who presented to the ED the CAH failed to ensure patients that presented to the ED were provided with a MSE.
Findings include:

1. The Emergency Medical Services form dated 4/8/13 was reviewed. The form indicated that Pt #1 presented to the CAH's Emergency Department on 4/8/13 and that the physician basically refused to see Pt #1. There was no documentation to indicate Pt #1 was seen or provided a MSE after arrival to the CAH.

2. The medical record of Pt #1 from the receiving hospital was reviewed on 4/18/13. Documentation indicated Pt #1 arrived via ambulance on 4/8/13 at 4:46 PM. Documentation on the "Emergency Room Note" from the receiving hospital indicated Pt. #1 was triaged at 4:50 PM on 4/8/13 and seen by the physician at 5:06 PM. Pt. #1 was treated and discharged. There was no documentation in the medical record at the receiving hospital to indicate Pt #1 had been to or received a MSE at Gibson Community Hospital.

3. A phone interview was conducted on 4/17/13 at 11:25 AM with the EMS (E#13) in regards to Pt #1. E#13 stated "I pulled up on the pad outside the ER and went in and talked to the nurse (E#2). E#2 said they don't have psych capabilities... I asked Physician E#1 "What's the deal" and Physician E#1 said they don't have psych and that we should take Pt #1 to ... I questioned him as to whether Physician E#1 was going to medically clear this Pt (Pt #1) and Physician E#1 shrugged..." EMS (E#13) verbalized that Pt #1 was not seen by the ED Physician.

4. A staff interview was conducted with RN (E#10) on 4/17/13 at 1:30PM with the In-house Counsel, Director Quality & Risk Management, and the EDON present. RN (E#10) was present on the day 4/8/13. RN (E#10) stated that (EMS E#13) "came into the ER but without the Pt. He stopped and talked to (RN E#2) and then talked to the (Physician E#1). The EMS (E#13) said that "they were stuck between a rock and a hard place and that the Pt. had to come to Gibson which was the closest facility." EMS (E#13) continued to argue about trying to divert on the radio. EMS (E#13) left out the back door. I went to check on them (EMS) because I thought they were bringing the Pt. (Pt #1) in and they (EMS) were gone."

5. A staff interview was conducted with the ED Physician (E#1), who is also the Medical Director of the ED, on 4/17/13 at 11:40 AM with the In-house Counsel, ED Director, Director Quality & Risk Management, and the EDON present. In regards to Pt #1, ED Physician (E#1) verbalized "he (EMS E#13) approached me, made eye contact, looked at name, said he (EMS E#13) was told by billing service to bring the Pt (Pt #1) here and I told him (EMS E#13) that the Pt. (Pt #1) should be taken to appropriate facility that had those services (psych). At no point was there any report given of any instability. The nurse followed him out to receive the Pt (Pt #1) but he (EMS E#13) had gotten in the rig and left." The ED Physician (E#1) confirmed that he did not see Pt #1.

B. Based on a review of the CAH Medical Staff Bylaws, a review of the Medical Staff Rules and Regulations, medical record review, and staff interview, it was determined in 2 of 4 (Pts #6, #7) medical records reviewed, in which the patient presented to the OB department for a MSE, the CAH failed to ensure the MSE was conducted by a qualified practitioner in accordance with its Medical Staff Bylaws, Rules and Regulations.
Findings include:

1. The Medical Staff Bylaws (approved November 28, 2012) were reviewed on 4/17/13. It indicated "Definitions: 7.The term "practitioner" means all individuals licensed as medical physician, osteopathic physician, dentist, podiatrist, optometrist, PA (Physician Assistant), CNM (Certified Nurse Midwife), NP (Nurse Practitioner), CRNA (Certified Registered Nurse Anesthetist)."

2. The Medical Staff Rules and Regulations (approved May 25, 2011) were reviewed on 4/17/13. It indicated "E. Emergency Services: 2. The hospital will provide a proper credentialed practitioner who will provide every person who comes to the hospital seeking acute medical care with an appropriate medical screening examination to determine whether the patient has an emergency medical condition or is in active labor."

3. The medical record of Pt #6 was reviewed on 4/18/13. Pt #6 presented to the OB unit on 3/23/13 at 9:00PM with chief complaint of Intermittent Aching and Threat of Premature Labor. Nursing documentation indicated the MSE was conducted by an OB RN in lieu of practitioner approved by the Medical Staff Bylaws, Rules and Regulations. Pt #6 was discharged home at 10:58PM.

4. The medical record of Pt #7 was reviewed on 4/18/13. Pt #7 presented to the OB unit on 3/22/13 at 2:25PM with chief complaint of Abdominal Pain and Painful Urination. Nursing documentation indicated the MSE was conducted by an OB RN in lieu of practitioner approved by the Medical Staff Bylaws, Rules and Regulations. A physician's telephone order for Pt #7 was received at 5:32PM to "Send home."

5. During a staff interview conducted with the OB Director on 4/17/13 at 2:00 PM, the following was verbalized. The Director stated the MSEs are usually done by the RN. If the OB doctor happens to be here, the doctor will do the MSE. The OB Director was asked if this practice had been approved by the Governing Body and the OB Director replied that "it had been discussed in the OB unit committee meeting in September 2012, but it had not been taken to the Governing Body as of yet."