HospitalInspections.org

Based on review of facility documents, and staff interviews (EMP), it was determined the facility failed to ensure that policies and procedures were in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control.

Findings include:

Review of Nason Hospital's policy entitled "Plan For Delivery Of Emergency Services", dated 2010, revealed "... C. An on-call listing is posted in the ED suite which provides specialty coverage for medicine, Internal Medicine, Pediatrics, Obstetrics and Gynecology, Surgery, Oral Maxillo-facial Surgery and Orthopedics. These individuals will be available within a medically-appropriate time to provide care ... 3. On-call Physicians A. The Hospital will maintain a list of physicians who are on-call for duty after the initial exam to provide treatment necessary to stabilize and individual with an emergency medical condition. The purpose of the on-call list is to ensure that the ED staff knows which physicians/specialists are available to provide treatment to stabilize patients with emergency conditions. This list will be retained by medical staff coordinator for 7 years ... ."

Review of the "Medical Staff Bylaws, Rules & Regulations", dated July 23, 2008, revealed "... Medical Staff Organization & Functions and Rules and Regulations, Approvals: Review in process ... Article 3: Patient Care Functions: ... 3.3-3 On Service Schedules: An On-Service Schedule will be developed by the Medical Staff President or his designee, with input from Department Chairpersons. (a) This schedule will be updated as needed to accommodate changes in services, staff membership, or participants' schedules, but at least annually. (b) A physician "on service" for a department or medical specialty; (1) Will be assigned new admissions or consulted if a patient has no physician or preference for physicians within the needed specialty; (2) May not refuse such patients based on type or lack of health care insurance coverage; and (3) Must arrange for appropriate physician coverage of any absences during his/her designated on service time and notify of same. (c) Active and Courtesy staff members will be required to participate in the On Service Schedule ... ." (kat, lh, ms)

1) Interview with EMP1 on May 28, 2010, at 12:45 PM, [related to on call policies], confirmed that the current policies do not address situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control.

Based on facility documents and ambulance records, and staff interviews (EMP), it was determined the facility failed to maintain a central log for one of one patients presenting to the Emergency Department. (PT1)

Findings include:

Review of the ED policy entitled "Emergency Department Medical Record", dated 2010, revealed "I. Standard: A. An ED Record will be completed on all patients who present to the ED for emergency services (medical screening exam and treatment). B. All records will contain complete, legible, and accurate documentation ... VII. General Information: A. A record will be completed for all patients who present for examination and treatment ... C. ED cases should be logged in the ED log book ... ."

Review of the policy entitled "Emergency Department Log Book", dated 2010, revealed "I. Standard: The Emergency Department will maintain a registry of all patients seen and treated in the ED ... ."

Review of Nason Hospital's policy entitled "Plan for Delivery of Emergency Services", dated 2010, revealed "... O. Documentation 1. LOG A. The Hospital will maintain a log of each individual who comes to the ED seeking assistance and whether that patient refused treatment, was refused treatment or whether the patient was transferred, admitted and treated, stabilized and transferred or discharged. The log will be maintained a minimum of five years ... ."

1) Review of the Ambulance Trip Sheet for the patient (PT1), dated May 22, 2010, stated "... We proceeded to Nason ED. Took pat. [patient] in ED and attending told us to proceed to [other hospital] ... ."

2) Review of the Emergency Department Registration Log revealed on May 22, 2010, that PT1 was not registered into the log.

3) Interview with EMP1 on May 27, 2010, confirmed that PT1 was not listed on the ED log.

4) Interview with EMP4 on May 28, 2010, at 9:35 AM, revealed "This should have been ... entered in a log."

Based on review of facility documents, and ambulance records, and staff interviews (EMP), it was determined the facility failed to provide a medical screening examination for one of one patients presenting to the Emergency Department. (PT1)

Findings include:

Review of Nason Hospital's policy entitled " Plan For Delivery Of Emergency Services", dated 2010, revealed " A. Scope Of Care 1. The Emergency Department is a level II facility which is organized to meet the emergency medical needs of the community, 24 hours a day. All patients who present on Nason Hospital property and request care will have a screening exam done by an ED physician. ... B. Goals And Objectives 1. To provide an appropriate medical screening exam and initial treatment to all patients who present seeking treatment within reasonable amount of time relative to their injuries or illness consistent with the capacity of the hospital ... C. Staffing 1. Medical Staff A. Timely emergency care will be continuously available 24 hours a day, seven days a week by a physician who has been credentialed and is present in-hospital to provide Emergency Services. This physician will provide the Medical Screening Exam (MSE) for all patients who present requesting emergency services. ... G. Access 1. The Emergency Medical treatment and Active Labor Act (EMTALA), which sets forth Federally-mandated responsibilities to Medicare-participating hospitals, requires hospitals to provide medical assessment and stabilizing care to any patient presenting on the hospital property (e.g. Emergency Department, entrance areas, physician offices) who request care to determine whether they have an emergency condition. a. No patient will be refused care on the basis of age, race, religion, socioeconomic status or ability to pay. b. Hospital staff will use their best judgement in meeting the needs of these patients outside of the Hospital with consideration being given not to jeopardize the needs of existing patients inside the hospital to their own safety. ... I. Medical Screening Exam: The hospital must provide a medical screening exam to any person who comes seeking emergency services to determine if an emergency medical condition exists or if the patient is in active labor. 1. The medical screening exam will be done by the ED physician and will include the use of appropriate ancillary studies and procedures and/or diagnostic testing, to the extent of the Hospital's facilities to determine whether the patient has an emergency medical condition or is in active labor ... ."

1) Review of the Ambulance Trip Sheet for the patient (PT1), dated May 22, 2010, stated "... We proceeded to Nason ED. Took pat. [patient] in ED and attending told us to proceed to [other hospital] ... ."


2) Interview with EMP3 on May 28, 2010, at 9:15 AM, revealed " I eyeballed [the patient] and it appeared [the patient's] leg was swollen ... I did a cursory medical exam, but I didn't document ... ."

Based on review of facility documents, ambulance records, and staff interviews (EMP), it was determined that the facility failed to provide a proper transfer to another facility for one of one patients presenting to the Emergency Department. (PT1)

Findings include:

Review of Nason Hospital's Policy entitled "Plan For Delivery Of Emergency Services", dated 2010, revealed " A. Scope Of Care 1. The Emergency Department is a level II facility which is organized to meet the emergency medical needs of the community, 24 hours a day. All patients who present on Nason Hospital property and request care will have a screening exam done by an ED physician. If the individual has such a condition, the hospital will provide, within the capabilities of its staff and facilities, treatment to stabilize the condition, regardless of the individual's insurance status or ability to pay for treatment. Unstable patients will only be transferred if the treating physician certifies that the benefit of treatment elsewhere outweighs the risks and benefits of transfer and/or transfer is requested by the patient ... 2. In the event that transfer is needed, care will be given to stabilize the patient's condition, appropriate informed consent will be obtained, and the transfer will be carried out ... L. Stabilizing treatment 1. Each patient will receive a screening exam by a physician to determine if the patient has an emergency condition or is in active labor. If an EMC exists, the hospital is required to stabilize the medical condition of the individual within the staff and facilities available to the hospital prior to discharge or transfer. Only after a patient is stabilized can transfer to another facility be considered. 2. Stabilizing treatment for EMC will include: A. Stabilizing treatment for EMC will include: A. Stabilization for Transfer: When the treating physician has provided such medical treatment of the condition necessary to assure within reasonable medical probability that the patient is expected to leave the hospital and be received at the second facility and that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the hospital. ... 3. Hospitals are required to stabilize patients with an emergency condition EXCEPT in the following circumstances: A) the patient refuses to consent to examination or treatment B) the patient refuses to consent to an appropriate transfer C) the patient requests transfer to another facility D) the physician certifies that "based upon the reasonable risks and benefits to the patient, and based upon the information at the time, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual's medical condition from making the transfer." M. Transfer (See appropriate Hospital policy) ... ."

Review of the ED policy entitled "Transfers from the Emergency Department", dated 2010, revealed " Policy: 1. Unless extenuating circumstances are documented in the Medical Record, no patient should be arbitrarily transferred to another hospital if the hospital where he is initially seen has the means for providing adequate care ... 2. The Emergency Department physician will inform the individual (or person acting on the individual's behalf) of the risks and benefits to the individual on transfer and secure written informed consent from the patient either consenting or refusing transfer. The transferring physician will complete certificate of transfer and will include a summary of the risks and benefits upon which the certification is based. 3. If it is determined that a patient should be transferred to another medical facility, the Emergency physician will contact the physician to whom the patient will be referred in order to make specific transfer arrangements. No patient will be transferred from the Emergency Department before necessary arrangements are made by the transferring physician and the physician to whom the patient is being referred ... 5. While arranging for the transfer, the Hospital will provide medical treatment within its capacity which minimizes the risks to the individual's health and, in the case of the woman in labor, the health of the unborn child. 6. Transfer should not be initiated until the receiving hospital has consented to accept the patient, the patient's condition has been stabilized, and the risk of transfer has been minimized ... 7. The referring hospital should prepare the patient for transfer, notify the receiving facility about the pending transfer, ensure that the facility is equipped to render the needed care and ensure that the facility agrees to accept the patient ... 9. A copy of all pertinent data ... related to the emergency condition shall be sent at the time of transfer of the individual ... ."


1) Review of the Ambulance Trip Sheet for the patient (PT1), dated May 22, 2010, stated "... We proceeded to Nason ED. Took pat. [patient] in ED and attending told us to proceed to [other hospital] ... ."

2) Interview with EMP3 on May 28, 2010, at 9:15 AM, revealed "... I thought he needed a higher level of care. I attempted to call [the other hospital] twice. I got busy with another patient. I received a call from [the other hospital]. [The other hospital's Emergency Department physician] said 'this is a potential violation'. I said yes, I know and apologized ... It was not my intent to dump this patient. I should have kept [the patient] here until I reached [the other hospital] ... My only intent was that the patient needed a higher level of care. It's never happened before and it will never happen again. "

3) Interview with EMP1 on May 28, 2010, at 9:50 AM, confirmed that the patient wasn't transferred according to facility policy.