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Based on documentation review and staff interview, the Department of Emergency Medicine did not ensure that the mid-level practitioners (MLP's) practiced within the delineation of clinical privileges as approved by the Hospital's Credential Committee for two of two mid-level practitioners practicing in the main emergency department.

The findings are as follow:

MLP/NP REVIEW:

Review of the Credential File and Scope of Practice and Clinical Privileges for a Nurse Practitioner working in the Emergency Department indicated the duties for the MLP included performing the assessment and treatment of patients triaged to the fast track by the ED triage nurse, in accordance with established triage guidelines, with another MLP working in the main ED seeing any patient initially except a Level I triage patient. The MLP will have complete access to the on-duty emergency physician(s) for advice and consultation as needed. The emergency physician(s) on duty will evaluate, upon request of the MLP, any patient present in the ED currently under the care of the MLP. The Scope of Practice for Diagnostic Tests specific to the Fast Track MLP/Nurse Practitioner indicated Radiologic tests such as chest and extremity x-rays, excluding any invasive or contrast imaging studies., CT scans and ultrasound examinations may be ordered after discussion with the ED Physician. The MLP/NP working in the main ED had clinical privileges to order tests if indicated, diagnose, write prescriptions and discharge patients with the exception of Level I patients.

Review of the Triage ED Record dated 03/29/10 for the Patient indicated the Patient was designated as a Level 3 Emergency Service Index (ESI) and triaged the Patient to the main ED.

Review of one of one applicable ED record for a Patient evaluated on 03/29/10 indicated the Nurse Practitioner evaluated the Patient in the main ED and ordered a head computerized tomography (CT) scan The Patient presented to the ED with a complaint of a headache for three days.

The MLP/NP conducted a thorough medical screening and transferred the care of the Patient for discharge to the ED Attending Physician.

The NP was interviewed in person on 04/29/10 at 10 AM. The NP said the Patient reported being evaluated by the Primary Care Physician (PCP ). The NP said the Patient was instructed to come to the ED for a head CT. The NP said there was no reason to doubt the Patient; so the head CT was ordered. The NP did not discuss the Patient with the ED Attending Physician (which was acceptable for patients being evaluated in the main ED by the MLP assigned and credentialed to work the main ED). The NP said before leaving for the day, the Patient was discussed with the ED Attending Physician, who discharged the Patient, with follow-up instruction to return to the ED, if necessary. The Patient's head CT was negative for any hemorrhage or focal brain abnormality.

Review of the NP's Credential File dated 02/12/10 indicated the NP's privileges were neither requested nor recommended for Part A: Cognitive Privileges and Part A-2 Procedural Privileges which included ordering diagnostic procedures, as described in the Scope of Practice. The NP's Privilege Card was signed by the supervising physician who documented privileges were not granted.

MLP/PA REVIEW:

Review of the Credential File and Scope of Practice and Clinical Practice for a Physician's Assistant (PA)qualified by academic and clinical training to care for patient in the Fast Tract section of the ED indicated the MLP/PA will perform the assessment and treatment of patients triaged to the Fast Tract by the ED triage nurse in accordance with established triage guidelines. The MLP/PA will have complete access to the on-duty emergency physician(s) for advice and consultation as needed. The emergency physician(s) will evaluated, upon the request of the MLP, any patient present in the Fast Track currently under the care of the MLP. The MLP's medical records did not require a countersignature by a physician. If the MLP and nurse feel that a patient has been incorrectly triaged to the Fast Track, or the patient deteriorated in the Fast Track, they have the option of sending the patient back to the main ED. The Scope of Practice for Diagnostic Tests specific to the Fast Track MLP/PA indicated Radiologic tests such as chest and extremity x-rays, excluding any invasive or contrast imaging studies., CT scans and ultrasound examinations may be ordered after discussion with the ED Physician.

Review of the Triage ED Record dated 04/02/10 for the Patient indicated the Patient was designated as a Level 3 Emergency Service Index (ESI) and triaged the Patient to the main ED.

Review of one of one applicable ED record for a Patient evaluated in the ED on 04/02/10 indicated the Patient was evaluated in the main ED by the PA with a complaint of hoarseness, neck pain and difficulty swallowing. The PA ordered a CT of the soft tissue neck with contrast in consultation with the ED Attending Physician. The PA documented the review of the previous medical screening and history for a previous ED visit date of 03/29/10. The PA documented the CT of the soft tissue with contrast was negative as reported by the radiologist.

The MLP/PA discharged the Patient with instructions to return to the ED, if necessary and to follow-up with a ear, nose and throat physician and the Patient's own PCP. The PA failed to inform the ED Attending Physician that the Patient was being discharged without a diagnosis.

The PA was interviewed in person on 04/28/10 at 11 AM. The PA said the Patient had been evaluated four days earlier on (03/29/10). The PA said the Patient complained of having trouble swallowing and evaluated by a dentist. The PA said the Patient denied having a headache. The PA said the Patient was neurologically stable and there was a concern for a retropharyngeal abscess. The PA said the best study was a CT of the soft tissue neck with contrast which equaled a CT Angiogram.

Continued review of the Patient's ED record lacked documentation by the ED Attending Physician who according to interview, approved the order for the Patient's CT scan of the soft tissue neck with contrast.

The PA did not document the advice and/or consultation with the ED Attending Physician for the CT of the soft tissue neck done on 04/02/10.

There was no physician documentation in the Patient's ED record for the visit date of 04/02/10.

The ED Attending Physician was identified by the Director of the ED as scheduled during the two days of survey for the Patient's visit date of 04/02/10.

The ED Attending Physician was interviewed on 04/29/10 at 12:30 PM. The ED Attending Physician said the PA discussed the need for the CT scan of soft tissue neck with contrast on 04/02/10. However, the ED Attending Physician said the Patient's provider was the PA. The ED Attending Physician denied being the ED Attending and/or Supervising Physician for the PA on 04/02/10.

The MLP/PA Clinical Procedures included initial assessment and treatment of patients triaged to the Fast Track in accordance with triage policies, medical staff policies, privileges for specific clinical procedures and individual requests reviewed by the medical director and recommended for approval, based on the MLP's prior experience and expertise.

Review of the MLP/PA Scope of Practice and Clinical Privileges dated 02/12/10 did not designate privileges to work in the main ED.

Radiologist #2 was interviewed in person on 04/29/10 at 1:30 PM. Radiologist #2 said the Patient's PCP reported on 04/04/10, the Patient had been diagnosed with a carotid artery dissection and treated in another hospital. Radiologist #2 said the Patient's carotid artery dissection was not diagnosed.. Radiologist #2 said a CT Angiogram would have detected the carotid artery dissection with 100% accuracy.

The Department of Emergency Medicine did not ensure that the mid-level practitioners (MLP's) practiced within the delineation of clinical privileges as approved by the Hospital's Credential Committee for two of two MLP's practicing in the main ED.

Based on documentation review and staff interview, the Chief of the ED did not ensure that the mid-level practitioners practiced within the delineation of clinical privileges as approved by the Hospital's Credential Committee for two of two mid-level practitioners practicing in the main Emergency Department.

The findings are as follow:

MLP/NP REVIEW:

Review of the Credential File and Scope of Practice and Clinical Privileges for a Nurse Practitioner working in the Emergency Department indicated the duties for the MLP included performing the assessment and treatment of patients triaged to the fast track by the ED triage nurse, in accordance with established triage guidelines, with another MLP working in the main ED seeing any patient initially except a Level I triage patient. The MLP will have complete access to the on-duty emergency physician(s) for advice and consultation as needed. The emergency physician(s) on duty will evaluate, upon request of the MLP, any patient present in the ED currently under the care of the MLP. The Scope of Practice for Diagnostic Tests specific to the Fast Track MLP/Nurse Practitioner indicated Radiologic tests such as chest and extremity x-rays, excluding any invasive or contrast imaging studies., CT scans and ultrasound examinations may be ordered after discussion with the ED Physician. The MLP/NP working in the main ED had clinical privileges to order tests if indicated, diagnose, write prescriptions and discharge patients with the exception of Level I patients.

Review of the Triage ED Record dated 03/29/10 for the Patient indicated the Patient was designated as a Level 3 Emergency Service Index (ESI) and triaged the Patient to the main ED.

Review of one of one applicable ED record for a Patient evaluated on 03/29/10 indicated the Nurse Practitioner evaluated the Patient in the main ED and ordered a head computerized tomography (CT) scan. The Patient presented to the ED with a complaint of a headache for three days.

The MLP/NP conducted a thorough medical screening and transferred the care of the Patient for discharge to the ED Attending Physician.

The NP was interviewed in person on 04/29/10 at 10 AM. The NP said the Patient reported being evaluated by the Primary Care Physician (PCP ). The NP said the Patient was instructed to come to the ED for a head CT. The NP said there was no reason to doubt the Patient; so the head CT was ordered. The NP did not discuss the Patient with the ED Attending Physician (which was acceptable for patients being evaluated in the main ED by the MLP assigned and credentialed to work the main ED). The NP said before leaving for the day, the Patient was discussed with the ED Attending Physician, who discharged the Patient, with follow-up instruction to return to the ED, if necessary. The Patient's head CT was negative for any hemorrhage or focal brain abnormality.

Review of the NP's Credential File dated 02/12/10 indicated the NP's privileges were neither requested nor recommended for Part A: Cognitive Privileges and Part A-2 Procedural Privileges which included ordering diagnostic procedures, as described in the Scope of Practice. The NP's Privilege Card was signed by the supervising physician who documented privileges were not granted.

MLP/PA REVIEW:

Review of the Credential File and Scope of Practice and Clinical Practice for a Physician's Assistant (PA)qualified by academic and clinical training to care for patient in the Fast Tract section of the ED indicated the MLP/PA will perform the assessment and treatment of patients triaged to the Fast Tract by the ED triage nurse in accordance with established triage guidelines. The MLP/PA will have complete access to the on-duty emergency physician(s) for advice and consultation as needed. The emergency physician(s) will evaluated, upon the request of the MLP, any patient present in the Fast Track currently under the care of the MLP. The MLP's medical records did not require a countersignature by a physician. If the MLP and nurse feel that a patient has been incorrectly triaged to the Fast Track, or the patient deteriorated in the Fast Track, they have the option of sending the patient back to the main ED. The Scope of Practice for Diagnostic Tests specific to the Fast Track MLP/PA indicated Radiologic tests such as chest and extremity x-rays, excluding any invasive or contrast imaging studies., CT scans and ultrasound examinations may be ordered after discussion with the ED Physician.

Review of the Triage ED Record dated 04/02/10 for the Patient indicated the Patient was designated as a Level 3 Emergency Service Index (ESI) and triaged the Patient to the main ED..

Review of one of one applicable ED record for a Patient evaluated in the ED on 04/02/10 indicated the Patient was evaluated in the main ED by the PA with a complaint of hoarseness, neck pain and difficulty swallowing. The PA ordered a CT of the soft tissue neck with contrast in consultation with the ED Attending Physician. The PA documented the review of the previous medical screening and history for a previous ED visit date of 03/29/10. The PA documented the CT of the soft tissue with contrast was negative as reported by the radiologist.

The MLP/PA discharged the Patient with instructions to return to the ED, if necessary and to follow-up with a ear, nose and throat physician and the Patient's own PCP. There was no diagnosis or differential diagnosis made at the time of discharge nor evidence the PA discussed the findings with a ED Attending Physician.

The PA was interviewed in person on 04/28/10 at 11 AM. The PA said the Patient had been evaluated four days earlier on (03/29/10). The PA said the Patient complained of having trouble swallowing and evaluated by a dentist. The PA said the Patient denied having a headache. The PA said the Patient was neurologically stable and there was a concern for a retropharyngeal (oral) abscess. The PA said the best study was a CT of the soft tissue neck with contrast which equaled a CT Angiogram.

Continued review of the Patient's ED record lacked documentation by the ED Attending Physician who according to interview, approved the order for the Patient's CT scan of the soft tissue neck with contrast.

The PA did not document the advice and/or consultation with the ED Attending Physician for the CT of the soft tissue neck done on 04/02/10.

There was no physician documentation in the Patient's ED record for the visit date of 04/02/10.

The ED Attending Physician was identified by the Director of the ED as scheduled during the two days of survey for the Patient's visit date of 04/02/10.

The ED Attending Physician was interviewed on 04/29/10 at 12:30 PM. The ED Attending Physician said the PA discussed the need for the CT scan of soft tissue neck with contrast on 04/02/10. However, the ED Attending Physician said the Patient's provider was the PA. The ED Attending Physician denied being the ED Attending and/or Supervising Physician for the PA on 04/02/10.

The MLP/PA Clinical Procedures included initial assessment and treatment of patients triaged to the Fast Track in accordance with triage policies, medical staff policies, privileges for specific clinical procedures and individual requests reviewed by the medical director and recommended for approval, based on the MLP's prior experience and expertise.

Review of the MLP/PA Scope of Practice and Clinical Privileges dated 02/12/10 did not designate privileges to work in the main ED.

The Chief of the ED was interviewed in person on 04/28/10 at 9:29 AM. The Chief of the ED said a CT Angiogram was 100% specific for the diagnosis of a carotid artery dissection according to the literature. The Chief of the ED said the Patient had a CT with contrast of the soft tissue in the neck which was the same diagnostic study. The Chief of the ED said the ED care was appropriate and the correct tests were ordered. The Chief of the ED said the Patient did not meet the criteria for a neurological consultation as there were no focal deficits found. The Chief of the ED said a carotid artery dissection may take up to seven days to diagnosis. The Chief of the ED said the focus of the medical screening on 04/02/10 was to rule out an infectious process.

Radiologist #2 was interviewed in person on 04/29/10 at 1:30 PM. Radiologist #2 said the Patient's PCP reported on 04/04/10, the Patient had been diagnosed with a carotid artery dissection and treated in another hospital. Radiologist #2 said the Patient's carotid artery dissection was not diagnosed. Radiologist #2 said a CT Angiogram would have detected the carotid artery dissection with 100% accuracy.

The Department of Emergency Medicine did not ensure that the mid-level practitioners (MLP's) practiced within the delineation of clinical privileges as approved by the Hospital's Credential Committee for two of two MLP's practicing in the main ED.

The MLP/PA did not have physician oversight for a Patient discharged on 04/02/10 without a diagnosis.