HospitalInspections.org

Based on observations, review of facility documents and staff interviews (EMP), it was determined that Lewistown Hospital failed to post signs (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital participates in the Medicaid program under a State plan approved under Title XIX., conspicuously in the Emergency Department or in places likely to be noticed by all individuals entering the Emergency Department, as well as those individuals waiting for examinations and treatment in areas other than the traditional emergency departments.

Findings include:

A review of the Administrative and of the Emergency Department Policy manuals failed to reveal any documented evidence of a policy related to EMTALA requirements.


1) During a tour of the Emergency Department on August 22, 2011 at approximately 10:00 AM, a sign located in the waiting room was observed which revealed, "Notice: This facility is legally obligated to serve the Community ... ." Further observation revealed that the sign did not include verbiage specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and the sign was not likely be noticed by all individuals entering the Emergency Department. No additional signs were observed when entering into the Emergency Department, the Receptionist area, Triage and Treatment areas.

Interview with EMP2 on August 22, 2011 confirmed the above findings and revealed "We don't have the signs where they should be."

2) The Labor/Delivery Log that the facility utilizes for patient tracking, was reviewed for the months of June, July and August 2011. The Log revealed that approximately 33% of patients presented to the Obstetric Department were unscheduled, for the treatment of an emergency medical condition (EMC). A random sample of 24 medical records were selected from the Obstetrics Log and reviewed. It was determined that eight (8) of 24 patients presented unscheduled, with an EMC, requiring emergency medical screening.

It was noted that the facility failed to designate their Obstetrical Department as a Dedicated Emergency Department (DED).

Interview on August 22, 2011 at approximately 2:00 PM, with EMP3 revealed, "I do not think we are a dedicated emergency department. If anyone comes in with shortness of breath, they go to the emergency department.

3) During a tour of the Labor/Delivery Department on August 23, 2011, at approximately 10:00 AM, no EMTALA signage was observed.

An interview on August 23, 2011 at approximately 10:45 AM, was conducted with EMP3. "We use a labor room or (room) 6130 for our scheduled and unscheduled patients. We don't have any signage on our unit, or in (room) 6130."

An interview on August 23, 2011 at approximately 10:55 AM, was conducted with EMP1, "There is no signage on the Labor and Delivery Unit, there never was."

Based on review of facility documents and interviews with staff (EMP), it was determined that Lewistown Hospital failed to maintain a Central Log, by failing to make an entry on each individual who presents to the Emergency Department, as defined in &489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged.

Findings include:

Review of "ED Nursing Policy No. 10.1 ... "Emergency Department Log" reviewed January 20, 2011, revealed " ... A. All patients seen in the Emergency Department will be recorded per computer into an Emergency Daily Log. ... ".

1) Review of the Emergency Room Central Log dated January to July 31, 2011, revealed that the Log failed to indicate whether the patient was transferred, admitted and treated, stabilized and transferred, refused treatment or discharged.

An interview was conducted with EMP2 on August 21, 2011 at approximately 12:00 PM. "We need to add to our Log. We are able to pull out the data from different sources, but it is not part of the Log."

2) The Labor/Delivery Log that the facility utilizes for patient tracking, was reviewed for the months of June, July and August 2011. The Log revealed that approximately 33% of patients presented to the Obstetric Department were unscheduled, for the treatment of an emergency medical condition (EMC). A random sample of 24 medical records were selected from the Obstetrics Log and reviewed. It was determined that eight (8) of 24 patients presented unscheduled, with an EMC, requiring emergency medical screening. All entries on the Log failed to indicate whether the patient was scheduled or unscheduled, admitted or disharged and transferred.

An interview was conducted with EMP3 on August 22, 2011 at approximately 11:30 AM. "This is my complete Log of everyone in and out of the Labor/Delivery Department. We can't tell if the person is scheduled or unscheduled when arriving to the Department, or whether they are admitted or discharged. We have a documentation issue."

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined that Lewistown Hospital failed to specify in their Bylaws, and or their Rules and Regulations, who is qualified and meets the requirements to provide a medical screening examination.

A review of "Lewistown Hospital By-laws of Medical-Dental Staff and Rules and Regulations", approved February 28, 2011, revealed no documented evidence specifying who can provide a medical screening examination.

Review of "Lewistown Hospital Credentialing Policy", approved January 31, 2011, revealed " ... 14. Practitioner means, unless otherwise expressly limited, any Physician, Dentist, Independent Limited Health Professional, or Specified Professional Personnel, including those who are licensed to practice medicine, osteopathic medicine, dentistry, oral surgery, podiatry, and optometry, and are applying for or exercising clinical privileges in the Hospital.... "

1) An interview was conducted on August 23, 2011 at 10:50 AM with EMP6. "There is nothing in the By-laws that our Obstetric nurses or Nurse mid-wives can rule out labor. It is not defined by our Rules or Regulations either. A qualified medical person is not defined."

2) An interview with EMP3 was conducted on August 23, 2011 at 10:45 AM. "I have an orientation policy that educates my staff how to identify true and false labor. Their job description does not state it, we just use a generic registered nurse job description."

Based on review of facility documents and interviews with staff (EMP), it was determined that Lewistown Hospital failed to appropriately transfer two patients. (MR1, MR37)

Findings include:

Review of " Lewistown Hospital By-laws of Medical-Dental Staff" approved February 28, 2011 , revealed "... Article III. Categories of the Medical Staff ... 3.2.1 Responsibilities of Active Medical Staff ... (b) If a Member of the Active Staff is not participating in his or her Department emergency on-call schedule or specialty on-call schedule by name, that member shall participate on the unassigned emergency call schedule in his or her specialty for at least ten (10) days per month. The ten (ten) days shall include equal distribution of weekend coverage.

A review of " Medical -Dental Staff, Rules and Regulations of Lewistown Hospital" approved February 28, 2011 revealed "... H. Emergency Services. General: ... 3.(a) Introduction: The Lewistown Hospital Emergency Department is a Level II emergency department/service which offers 24 hour a day emergency care, with at least one physician experienced in emergency care on duty in the emergency care aea, and with specialty consultation available in person within approximately 30 minutes by members of the medical staff. Initial consultation through two-way voice communication is acceptable. (b) Private Attending Physicians ... Private attending physicians shall be placed on the list of specialists on call for emergency physicians in their area of specialty ... (d) Specialist On Call (Backup) Schedule (Panel) This schedule is to insure the orderly referral of emergency patients and coverage for inpatient emergencies also when the attending physician is not immediately available or requests for support. Administration and each department chairman will formulate and provide at weekly intervals a specialist on-call schedule. The function of this panel is to accept emergency consultations from the Department of Emergency Medicine and to provide a mechanism for follow-up care of the patient. The specialist on the backup panel is responsible for consultations on emergency patients within his specialty. Procedure: 1) Determine if a patient has a private physician and, if so, that physician is the consultant needed. 2) In life-threatening or urgent cases, consultation should be obtained as soon as possible, beginning with that patient's private physician. If the patient has no private physician, use the appropriate specialist from the on-call schedule. 3) Whenever possible, patients are given a choice of an appropriate specialist for consultation, if that physician is available. 4) If the patient has no preference, consultation is made only to the specialist on call ... ."


1) A review of the "Emergency Department On Call Schedule for January 24-30, 2011, revealed that Dr. ... was on call for OB/GYN on January 28. [EMP2] confirmed the on-call schedule on August 22, 2011 at approximately 12:25 PM.

It is noted that Dr. ..., who was assigned to be on call for OB/GYN services, was not notified that the patient was in the ED. The patient was sent via taxi to another physician's office.


A review of " Medical -Dental Staff Rules and Regulations of Lewistown Hospital", approved February 28, 2011, revealed "... Transfer of Patients to Another Facility. ... 12. When the Hospital does not provide the services required by a patient or for any reason the Hospital cannot admit a particular patient who requires inpatient care, the Hospital and/or the attending physician will assist the patient in making arrangements for care at another facility so as not to jeopardize the health or safety of the patient. The transfer shall not occur until the patient's condition has been sufficiently evaluated and it has been determined by the attending physician that the patient's medical condition is stable enough for transport or that the benefits available at the receiving medical facility outweigh any risk associated with transport. ... ."

A review of "Lewistown Hospital, Administrative Policies and Procedures. AD 8.2.1 Title: Patient Transport / transfer policy. Effective Date: October 2002. Areas Affected: All Departments I. State Of Policy: To outline procedure and define a standard of care for the transfer of patients from Lewistown Hospital to other facilities and locations. II. Scope: Department of Nursing, Advanced Life Support, Case Management, Cardiopulmonary Services, Medical/Dental staff, Pre-Hospital Ambulance/Transport/EMS Services, and any other Lewistown Hospital Department or Lewistown Healthcare Foundation entity. III. Definition(s) Advanced Life Support (ALS) - Ambulance transport requiring IV therapy, cardiac monitoring, and advanced airway control to oxygen administration. Basic Life Support (BLS) - basic ambulance transport requiring oxygen administration and patient monitoring by a basic level Emergency Medical Technician only. Para - transit (wheelchair Van) - Transport services via wheelchair or litter requiring no patient monitor / treatment. Specialized taxi service. Mixed Provider Transport - Transport requiring nurse, respiratory therapist and/or healthcare providers to meet patient needs exceeding the scope of practice of pre-hospital personnel. IV. Procedure Action (Responsibility). ... 2. Case Management Department Roles & Responsibilities (Case Management Staff) a. provide the ambulance staff with a copy of the patient information listed below for the receiving facility. This information should be placed in an envelope with the patient's name, destination, ambulance / van service name and departure time (using pre-printed labels). Required patient information: Electronic Chart - Master Chart Format (includes MAR) Demographic Sheet, Medication profile, Paper chart Found on Nursing Unit ... ."

2) A review of MR1 dated January 28, 2011 revealed " ... ED Triage ... 06:36 EST ... Chief Complaint: Description. Pt awoke this AM to "severe" vag bleed. Pt denies being pregnant but period is 9 weeks late. Pt has 5 children with the youngest 8 months. Pt has had problems with all pregs. ... History of Present Illness: The patient presents with vaginal bleeding. Amish lady with 5 children at home. Last menstrual periods 8 or 9 weeks ago. Patient started bleeding 4 days ago and the bleeding became heavy today. This is unusual for patient menses which are usually 2 or 3 days call. Patient felt lightheaded at home, no longer lightheaded. ... Differential Diagnosis: Vaginal bleeding, ectopic pregnancy, dysfunctional uterine bleeding, threatened abortion ... ultrasound ... present but no signs of life. ... Notes discussed in detail with [EMP10] states they think this patient has had a large fibroid in the past and [EMP10] wants to see the patient in their office now. I think patient is stable enough to leave the ER.
Impression and Plan: missed abortion. Uterine mass. ... Progress Notes ... 0909 pt discharged with piv in place, called taxi to pick patient up and take to [EMP10] office ... D/C (discharge) to [EMP10] keep lock in... "
Review of " ... Emergency Department Discharge Instructions ... " dated January 28, 2011, at 0905 revealed " ... Go to [EMP10] office now ... ."



MR1 also contained "Pennsylvania EMS Report" dated January 28, 2011 at 10:50 AM revealed "... Narrative: At 1048 hrs ...EMS was dispatched to ... [EMP10]'s office for a 32 year old with vaginal bleeding possible miscarriage. ... Arrived on scene to find a 32 yr old ... lying supine on the floor of a patient room. Patient had already obtained a 20G IV at R (right) hand with NSS (normal saline solution) running wide. Patient obtained about 150 ml of NSS. Pt was CAO (conscious, alert, oriented) x 4, clammy, and diphoretic. Patient seemed to be distress. ... [EMP10] explained that patient was in today to be checked about the vaginal bleeding. While being examined patient began to bleed more heavily, patient was then advised that they were to go to the OR for a D and C procedure. While attempting to walk out of the room, patient became very lightheaded and dizzy. Patient sat down on a chair and then passed out. [EMP10] then layed patient on the floor, ... obtained vitals finding that patient was hypotensive, and then established an IV20 G R Hand with NSS running wide. They then called 911 for assistance. Patient was then to be transported directly to the OR for ... procedure. ... . "

3) A telephone interview was conducted on August 25, 2011 at approximately 1:45 PM with EMP15. "I asked the patient [MR1] if they had a physician and they responded that EMP10 was their physician, that they had seen that doctor in the past. I do not believe the patient was bleeding heavily at the time of discharge. Patient was discharged and advised to go to the doctor's office. Because the Amish don't have vehicles, we send them in a taxi."

4) A telephone interview was conducted with EMP10 on August 23, 2011, at approximately 01:30 PM, "I had seen this patient in my office back in 2000. They had one or two babies then. I did a D&C back in 2000. The ED doctor thought the patient was stable enough to be brought to my office. By the time the patient arrived they were absolutely hemorrhaging. My office is approximately 2 miles from the hospital. The patient was having a miscarriage. It was an acute emergency. I sent the patient back to the hospital by ambulance, they went directly to the operating room, and ended up having a hysterectomy."

5) A review of the Complaint /Grievance Log revealed that a complaint was filed at the facility by the parent which stated " ... my child was seen in the ED on August 7 for a wrist injury, and was found to have a fracture. The ED physician recommended transfer to Geisinger because no Orthopedic service was available that day. My child had an IV and was receiving IV pain meds, so the ED physician recommended ambulance transport. I requested that the IV be pulled or capped so I could drive my child to Geisinger. Several days later, when we were at the Orthopedic office for followup, the doctor asked me why the ED did not call them as they were on call the day of the accident and would have gladly seen my child and would have avoided a transfer to Geisinger."

6) A review of MR37 dated August 7, 2010 revealed, "...ED Documentation ...patient fell at 1030 this AM and injured their right wrist. Deformity noted. ... Medical Decision Making ... Notes: no local Orthopedics available in Lewistown today. ... transfer to Geisinger Medical Center via POV. ... Medically indicated transfer ... Patient's condition For Transfer: Stable ... IV Secured with tape ... via private vehicle ... ".