HospitalInspections.org

Based on review of the Emergency Department on-call physician lists for services provided, it was determined the facility failed to ensure lists do not include individual physician names.

Findings include:

1. The Gastroenterology on-call list from January-June 2022, indicated; "1st call *see note - 2nd call (name of practitioner)."

a. On the bottom of the page, the note indicated, "Cooper Transfer Center 1-855-284-9337 ... *Switchboard to check who patient is assigned to (physician names) Once that is confirmed a call should be put out to the assigned provider. IF the call is declines by assigned provider, the 2nd call goes to Dr. [name] (unless it is his patient and he has declines to take the call) The final call then goes to COOPER TRANSFER CENTER."

b. During an interview with Staff #11 (an ED physician), on 6/20/22 at 11:29 AM, he/she stated, "Physicians will call the operator to get consult (specialist) information or if the patient needs to be transferred to Cooper." When questioned by this surveyor, if there was ever an issue concerning contacting consults, Staff #11 stated, "there was an occasion when there was no GI consult."

2. On the Neurology on-call list from January-June 2022, for multiple days between January and June, "Cooper," "n/a," or "Cooper Transfer," was indicated. On the bottom of the on-call page is a statement, "If no one is listed call goes to Cooper Transfer Center."
During an interview with Staff #3, he/she stated "Cooper" means the Cooper neurology service for tele-health and the facility will obtain an on-call person within the Cooper tele-health service.

3. On the Orthopedics service on-call list from January-June 2022, the list indicated "Cooper," from 1/3/22 through 1/9/22. Upon interview, Staff #3 confirmed "Cooper" is pertaining to Cooper Hospital Transfer Center.

4. On the Urology service on-call list for March, May, and June 2022, the list entry for multiple dates indicated "n/a" or "Cooper Transfer."

The above findings were confirmed with Staff #1, Staff #2, and Staff #3.

Based on review of the ED Log, review of five (5) of thirty-four (34) medical records (#2, #11, #20, #21, #22), staff interview, and review of facility documents, it was determined the facility failed to ensure all entries in the log are complete and accurate.

Findings include:

Reference: Facility policy titled, "EMTALA" states, "... c. Recordkeeping: ... 3. An EMTALA Central Log shall be maintained in the DED or other area, where an individual may present for emergency services or have an MSE. a. The Central Log shall include the patient's name and outcome and indicate whether the individual: i. Refused treatment (whether left without being seen-LWBS, or against medical advice - AMA) ii. refused treatment iii. was transferred iv. was admitted and treated v. was stabilized and transferred or vi. was discharged."

1. Review of the ED Log for Medical Record #2 indicated the patient's disposition was "Eloped: LWBS." Medical Record #2 revealed the patient was seen by a provider at 5:40 PM, however the patient eloped before treatment was completed.

Upon interview, Staff #4 stated the disposition should be "left without treatment," since the patient left before treatment could be completed. Upon request, Staff #2 was unable to provide a policy that defines the disposition "left without being seen (LWBS)," versus "left without treatment (LWOT)."

2. Review of the ED Log revealed four (4) incomplete entries among the medical record sample selection, related to EMTALA requirements:

a. Medical Record #11 (no diagnosis documented). Review of Medical Record #11 revealed the patient was seen by a provider at 9:51 AM.

b. Medical Record #20 (no diagnosis, departure time, condition, and disposition documented). Review of Medical Record #20 revealed the patient was seen by a provider at 9:51 PM and was admitted.

c. Medical Record #21 (no diagnosis, departure time, condition, and disposition documented). Review of Medical Record #21 revealed the patient was seen by a provider at 10:15 PM. The patient eloped at 12:48 AM.

d. Medical Record #22 (no diagnosis, departure time, condition, and disposition documented). Review of Medical Record #22 revealed the patient was seen by a provider at 12:15 AM. The patient left AMA at 5:46 AM.

These findings were confirmed with Staff #1, Staff #2, and Staff #3.

Based on the review of two (2) of six (6) Medical Records (#19 and #30), staff and patient interviews, and review of facility documents, it was determined that the facility failed to ensure that patients who are not provided a complete medical screening are provided an appropriate transfer to another facility to rule out an emergency medical condition (EMC) .

Findings include:

1. Medical Record #19:

On 6/10/22 at 20:36 [8:36 pm], the patient arrived in the ED with complaints of abdominal cramping, nausea, vomiting, pounding headache, pain to forehead. Pain was rated 10 out of 10. The patient was pregnant (unknown gestation). ED Physician documentation indicated the patient had not had prenatal care for the pregnancy.

ED Physician documentation at 20:58 [8:58 PM] stated, "Differential diagnosis: ... Concern for a subarachnoid hemorrhage based on history. No CT available at this time. She is attempting to find a ride as a transfer make [may] take some time. Will reassess." At 21:00 [9:00 PM] the ED physician documented, "Pt found a ride. Will d/c".

The patient was discharged at 21:05 [9:05 PM]. ED Nurse Documentation indicated, "Discharged to Advised to go to nearest hospital with CT capability."

On 6/22/22 at 1:41 PM, during interview with Staff #5, an ED Physician, he/she stated there was a concern for subarachnoid hemorrhage and ectopic pregnancy due to the patient presenting with the worst headache (pain 10/10) and abdominal cramping. According to Staff #5, "there was no lab or CT services available on 6/10/22. The patient was offered an ambulance which might take a significant delay, or the patient can find a ride to go to another facility with CT capability."

During the interview with Staff #5, he/she stated that the patient's vital signs were stable, there were no neurological deficits, and the patient was not bleeding vaginally, thus he/she deemed it safe for the patient to be discharged to go to another facility.

Review of ED Divert Log indictaed that on 6/10/22, the facility was on Total Care Divert from 1900-2300 [7:00 PM - 11:00 PM] due to, "No Lab, No Blood Bank, No CT Scan".

On 6/23/22 at 3:13 PM, during an interview with Patient #19, the patient stated that she did not go to another facility with CT capability because she had no transportation to get to another facility. Patient #19 further stated that she did not feel coerced to leave the ED.

2. Medical Record #30:

On 6/13/22 at 21:35 [9:35 PM], the patient arrived in the ED with complaints of chest pain from an injury. Review of the ED Physician Documentation indicated the patient fell 3 days prior and developed worsening pain and shortness of breath. According to the ED Physician documentation, "D/W [discussed with] PT [patient] and family going to Elmer as we do not have CT at all and that's what I think [he/she] needs regardless of X-Ray."

The patient was ordered for discharge on 6/13/22 at 21:47 [9:47 PM] and left the ED at 22:03 [10:03 PM]. Review of the Nurse's Documentation stated, "... Discharge instructions given to patient. Instructed on need for CT at closest facility. EDP [ED Physician] called (facility name) Elmer to let them know pt would be arriving shortly." The patient left the ED at 10:03 PM.

Review of the CT Staff Schedule, with Staff #6, for 6/10/22, revealed there was no staff coverage for the 7:00 PM-7:00 AM shift.

Review of ED Divert Log indicated that on 6/10/22, the ED was on Total Care Divert from 19:00 - 23:00, due to "No Lab, No Blood Bank, No CT Scan."

3. On 6/23/22 at approximately 3:15 PM, during an interview with Staff #3, it was stated that the arrangement with [facility name - Hospital B] was made a long time ago. Staff #3 further stated that a request was made to place an ambulance rig at the facility [Salem Medical Center - SMC] property however, this was not agreed upon. Staff #3 then stated that the final agreement was for a rig to be placed on stand-by between the facility [SMC] and the facility in Elmer [Hospital B]. Upon request, Staff #3 was unable to provide a written contract or documentation of the agreement that was established between the facility and Hospital B.

The above findings were confirmed with Staff #1, Staff #2, and Staff #3.