HospitalInspections.org

.
Based on interviews, review of medical records and review of documents, it was determined that the hospital failed to comply with all requirements of 489.24.

Refer to citations and examples at:
A 2404 - On Call Physicians
A 2405 - Emergency Room Log
A 2406 - Medical Screening Exam
A 2409 - Appropriate Transfer

.

.
Based on interview, it was determined that the hospital failed to have written policies and procedures in place to respond to situations in which a particular specialty was not available or the on-call physician could not respond, and failed to have written policies and procedures in place to assure that emergency services were available for patients with emergency medical conditions if it elected to permit on-call physicians to schedule elective surgery when they were on-call or to have simultaneous on-call duties.

Failure to develop such policies and procedures places patients with emergency medical conditions at risk for unmet medical needs.

Findings included:

1. On 06/12/19 at 10:15 AM, Investigator #1 presented to hospital staff a written list of requested documents. The list included a request for medical staff policies and procedures for:

a. time limits for response of on-call physicians

b. whether or not elective surgery may be scheduled while on-call

c. availability of on-call physicians when covering more than one hospital

d. non-availability of an on-call physician

e. provisions for on-call availability during vacations or when a specific specialty is not available.

2. On 06/12/19 at 4:00 PM, Investigator #1 interviewed the Chief Quality and Transformation Officer (Staff #1). Staff #1 stated that the hospital did not have any of the requested policies, nor was the requested information contained in the medical staff bylaws.

.

.
Based on interview and review of documents, it was determined that the hospital failed to maintain a complete central log on each individual who went to the Emergency Department (ED) seeking assistance, specifically the log did not identify patients who had been transferred to another hospital.

Failure to maintain a complete central log on each individual who was transferred from the ED to another hospital resulted in an inability to identify potentially inappropriate transfers.

Findings included:

1. On 06/12/19 at 10:15 AM, Investigator #1 presented to hospital staff a written list of requested documentation. The list included a request for a list of patients seen in the ED during specific time periods, to include identification of which patients had been transferred.

2. Record review of the patient list showed that there was no way to identify transferred patients.

3. On 06/12/19 at 2:25 PM, Investigator #1 interviewed the Chief Quality and Transformation Officer (Staff #1) about the ED log. Staff #1 stated that the transferred patients could not be identified on the ED log and a separate report had to be generated.

4. The separate report was generated and reviewed by Investigator #1. The record review showed that the list did not identify the hospital to which the patient had been transferred, only "PHU" which Staff #1 stated meant psychiatric hospital, or ""STH" which Staff #1 stated meant acute care hospital.

.

.
Based on interview and document review, the hospital failed to determine which individuals were qualified to provide medical screening examinations (MSEs).

Failure to determine which individuals are qualified to provide medical screening examinations places patients at risk for MSEs provided by unqualified personnel.

Findings included:

1. Record review of the hospital's Medical Staff Bylaws, approved by the medical staff on 05/07/19 and 06/14/19, showed that the individuals who had been determined by the medical staff to be qualified to perform MSEs were qualified physicians with appropriate privileges, other qualified advanced clinical practitioners (ACPs) with appropriate competencies and privileges and/or non-physicians/non-ACP qualified individuals who were qualified to conduct examination through appropriate and demonstrated competencies, were functioning within the scope of his or her license,were performing the MSEs based on medically approved guidelines, protocols or algorithms and were approved by the Board.

2. Record review of the hospital's policy titled, "COBRA/EMTALA Patient Transfers," no number, last reviewed 04/03/19, showed that stated that MSEs must be performed by a doctor of medicine or osteopathy, a physician's assistant, advanced practice providers including nurse practitioners with hospital privileges and paramedics under authority of EMS Medical Control. Registered Nurses from the Obstetrics (OB) Unit were not mentioned.

3. On 06/12/19 at 4:00 PM, Investigator #1 interviewed the Chief Quality and Transformation Officer (Staff #1) and Chief Nursing Officer (CNO), (Staff #2), about the facility definition of qualified physicians or appropriate privileges. Staff #2 stated that there was no documented definition of what was meant by qualified physicians or appropriate privileges. Both also stated that there were no ACPs in the Emergency Department, but the language had been added to the medical staff bylaws in anticipation of ACPs being hired in the future.

4. On 06/12/19 at 10:50 AM, Investigator #1 interviewed a Registered Nurse (RN) (Staff #4) on the OB Unit about her role and training relative to performing MSEs. Staff #4 stated that she had not taken any specific classes or training regarding MSEs and did not know if she could perform a MSE on any patient. When asked by Investigator #1 if she thought she would be qualified to conduct a MSE on a 45-year-old male patient with chest pain in the Emergency Department, she said yes. The interview was witnessed and confirmed by the Chief Nursing Officer (Staff #2).

5. On 06/12/19 at 4:00 PM, Investigator #1 interviewed the Chief Nursing Officer (Staff #2) about EMTALA training materials and MSE training materials for OB nurses. Staff #2 stated that she could not find directives regarding how how the OB nurses were to assess for labor or that the nurses were to notify the physicians or midwives of their assessment findings. She confirmed that the OB nurse job description did not include the performance of MSEs.

.

.
Based on interviews, review of medical records and review of documents, the hospital failed to identify the appropriate transfer forms that were to be completed by staff and sent with each transferred patient for 6 of 9 patients (Patients #6, #7, #16, #19, #21 and #23) transferred.

Failure to identify required transfer forms for transferred patients places patients at risk for unmet care needs and results in incomplete documentation.

Findings included:

1. Record review of the hospital's policy and procedure titled, "EMTALA/Patient Transfers," last reviewed date 03/08/18, did not show guidance regarding which forms were required to be completed when patients were transferred.

2. Record review of the hospital's policy and procedure titled, "COBRA/EMTALA," reviewed 04/03/19, did not show guidance regarding which forms were required.

3. Record review of the medical records of patients who were transferred to other facilities showed:

a. Patient #6's medical record contained 3 different transfer forms.

b. Patient #7's medical record contained contained 1 transfer form.

c. Patient #16's medical record contained 3 transfer forms, much of which was illegible and/or incomplete.

d. Patient #19's medical record contained 1 transfer form.

e. Patient # 21's medical record did not contain documentation that the patient had received a triage. The record did contain 3 transfer forms, but 1 was for an ambulance company and did not belong to the hospital.

f. Patient #23's medical record contained 1 transfer form.

4. On 12/12/19 at 10:36 AM, Investigator #1 interviewed the Manager of the Obstetrical (OB) Unit (Staff #3) about the forms used when transferring patients to other facilities. Staff #3 provided copies of the forms used when patients were transferred from the OB unit. The Chief Nursing Officer (CNO) (Staff #2) was present during the interview and stated that the Emergency Department (ED) did not use the same forms.

5. On 12/13/19 at 11:50 AM, Investigator #1 interviewed the ED Hospital Unit Coordinator (HUC) (Staff #8) about ED transfer forms. Staff #8 stated that the ED used three forms when patients were transferred to other facilities. Staff #8 found two forms but needed assistance to find the third form.

6. On 12/12/19 at 2:25 PM, Investigator #1 interviewed the CNO (Staff #2) about missing transfer documentation in the medical records. The CNO confirmed the findings regarding missing documentation in the medical records of transferred patients.

.