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Based on medical record review, ED physician contract review, plan of correction review, staff interview, and employee personnel file review, it was determined the facility failed to credential and approve privileges for 2 of 24 Providers (Staff A and B) working in the ED. This had the potential to affect all patients in the ED due to non credentialed and non privileged Providers working in the ED. Findings include:

The facility was cited at A 1100 during a recertification survey conducted on 12/02/22 for failure of the provider to see all ED patients face to face. In response, the facility responded to the citation with a plan of correction which stated, "A contract was signed with an ED Provider Group (EPIC) which encompasses 12 ED providers and all providers have been credentialed for MVH ED and will provide 24/7 coverage." This plan of correction was not fully implemented. Examples include:

A document titled, "Emergency Room Physician Care Services Agreement," effective 12/20/22 was reviewed. The contract stated, "Continuously throughout the term of this agreement, Provider ... shall: Qualify for and maintain valid medical staff appointments and clinical privileges at MVH to perform Emergency Care Services." This was not followed. Examples include:

1. Patient #4 was seen in MVH ED on 1/12/23 for a fall. Patient #4's record stated she was seen by Provider A.

Credentialing and approved privileges for the MVH ED for Provider A were requested. The facility provided Provider A's credentialing and privileges, which were approved on 1/25/23, two days after survey entrance and 13 days after Provider A saw Patient #4 in the ED.

2. Patient #2 was seen in MVH ED on 1/6/23 for abdominal and chest pain. Patient #2's record stated she was seen by Provider B.

Credentialing and approved privileges for the ED for Provider B were requested. The facility provided Provider B's credentialing and privileges, which were approved on 1/25/23, two days after survey entrance and 19 days after Provider B saw Patient #2 in the ED.

The Credentialing Specialist was interviewed on 1/25/23 beginning at 5:00 PM. The Credentialing Specialist was asked when Provider A and Provider B were approved for ED privileges. The Credentialing Specialist stated, "they went through committee today." The Credentialing Specialist confirmed that Provider A and B should have been privileged prior to working in the ED.

The Quality Manager was interviewed on 1/25/23 beginning at 5:00 PM. The Quality Manager confirmed that Provider A and B worked in the ED without being credentialed or having approved privileges for the ED.

The facility failed to ensure Providers were credentialed and had approved privileges to provide care to patients in the ED.



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Based on record review, plan of correction review, policy review, and staff interview, it was determined the facility failed to ensure emergency services were integrated with other departments of the hospital for 2 of 9 patients (Patients #4 and #8) whose records were reviewed. This resulted in emergency patients who were transferred without having diagnostic services performed. Findings include:

A facility policy titled, "MVH Emergency Services: EMTALA Guidelines," updated 10/2022 was reviewed. It stated, "All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient." This policy was not followed.

A plan of correction was submitted from the facility for deficiencies cited during a recertification survey completed on 12/02/22. A citation was issued at A 110 for lack of diagnostic treatment and testing of patients seen in the ED. The plan of correction for the citation stated, "All MVH ED patients will have documented assessments, stabilizing treatment, and diagnostic testing as applicable prior to transfer." This plan of correction was not followed.

1. Patient #4 was an 82 year old female who presented to the MVH ED on 1/12/23 at 2:11 AM with an admitting diagnosis of back pain. Patient #4 was transferred to the adjoining hospital at 3:48 AM. Her record included a note from the NP which stated, "CT is not available and therefore transfer was initiated." It stated Patient #4 was unable to move to get an x-ray.

The NP who cared for Patient #4 was interviewed on 1/25/23 beginning at 11:05 AM and Patient #4's record was reviewed in his presence. He confirmed he cared for Patient #4. He confirmed Patient #4 did not receive a CT scan during her ED visit at MVH. He stated he was told CT was not available the day Patient #4 presented to the ED. He stated if CT was available he would have done a CT scan for Patient #4.

The RN who cared for Patient #4 was interviewed on 1/25/23 beginning at 6:05 PM and Patient #4's record was reviewed in her presence. She confirmed CT was not available the night Patient #4 presented to the ED. She stated it was due to a technical issue and the computer systems needed to process the CT scans were not able to share data.

2. Patient #8 was a 72 year old female who presented to the ED on 1/24/23 at 11:28 AM with a diagnosis of epigastric pain. Patient #8's record also stated she had vomiting. Patient #8's record showed the PA ordered a urinalysis. Her ED record did not include documentation of other diagnostic procedures that were done that could determine what was causing Patient #8's epigastric pain and nausea. Patient #8's record stated she was transferred to the adjoining hospital at 12:02 PM.

The PA who cared for Patient #8 was interviewed on 1/24/23 at 4:32 PM. She stated Patient #8 was transferred due to comorbidities including weakness, nausea and vomiting, epigastric pain, and history of a hiatal hernia. When asked what diagnostic treatment was done at MVH, the PA stated her assessment and a urinalysis. When asked if they could have performed a CT scan at MVH, the PA stated, "we probably could have done a CT." She stated she thought Patient #8 would probably end up getting admitted as an inpatient and therefore did not do the CT scan at MVH.

The facility failed to ensure emergency services were integrated with other departments of the hospital.

Based on plan of correction review, as worked schedule review, personnel file and orientation review, and staff interview, it was determined the facility failed to ensure all staff were trained to the ED for 1 of 13 CNAs (Staff C) who worked in the facility's ED. This resulted in a CNA working in the ED without documented evidence she was trained and oriented to the ED. Findings include:

A plan of correction was submitted from the facility for deficiencies cited during a recertification survey completed on 12/02/22. A citation was issued for ED staff having no specific ED training at A 1100. The plan of correction for citation A 1100 stated, "ED nursing competencies for RNs and CNAs were revised to ensure staff training is specific to the emergency department which includes EMTALA and all emergency documentation that needs to be completed." It stated the correction would be completed 12/28/22. This plan of correction was not followed. An example includes:

Staff C's personnel file was provided and reviewed. Staff C's personnel file did not include specific training, competencies, or orientation to the ED.

The ED as-worked schedule was provided and reviewed. It stated Staff C worked the evening shift in the ED on 1/06/23. It was unclear how she worked in the ED if she did not have specific ED training.

The ED Manager was interviewed on 1/24/23 beginning at 10:01 AM and Staff C's personnel file was reviewed in his presence. He confirmed there was no training, competencies, or orientation to the ED in Staff C's personnel file. He stated it should have been there and he would look for it. No proof of specific training, competencies, or orientation to the ED for Staff C was provided prior to survey exit.

The facility failed to ensure all ED staff were specifically trained and oriented to the ED.