HospitalInspections.org

Based on record review, document review, staff interview, physician interview and policy review, the hospital failed to comply with special responsibilities of Medicare hospitals in emergency cases. The hospital failed to:
1. Perform a medical screening and failed to provide necessary stabilizing treatment to an individual with an Emergency Medical Condition (EMC) in one (1) of one (1) known cases, Patient #1, and on five (5) of five (5) days documented that the hospital Emergency Room (ER) was closed and on diversion; and
2. Have policies and procedures regarding EMTALA violations and whistleblowers.
Findings include:
Hospital #2 ' s Risk Manager reported to the State Agency, that on 04-08-13, eight (8) month old Patient #1 was found unresponsive by his parents and taken by private vehicle to Hospital #1. It is alleged the family of this patient was told at Hospital #1 that the emergency room (ER) was closed and they were flagged on to Hospital #2. In route their car broke down and they called 911. When the patient was brought into Hospital #2 via ambulance, he was pronounced dead on arrival. Hospital #2 ' s Risk Manager was reporting this to the State Agency as an EMTALA.
On 04-12-2013 at 10:30 a.m., an interview with the mother of Patient #1, revealed that when they pulled up to Hospital #1, her husband ran up to the doors and started beating on the doors yelling, " My baby needs help! " " I stayed in the car doing CPR (Cardio Pulmonary Resuscitation) on my baby and a man came to the door and told us the Emergency Room was closed and we needed to go to one of the nearby hospitals. "
On 04-15-2013 at 6:03 p.m., a phone call was placed to Hospital #1. A Registered Nurse (RN) answered the phone stating, " Emergency Room. " When asked if the ER was open the RN stated, " Yes. " At 10:17 p.m., another call was placed to the same phone number at Hospital #1. A Licensed Practical Nurse (LPN) answered and stated, " Emergency Room. " She identified herself as an LPN and stated that the ER was open.
On 04-16-2013 at 9:01 a.m., an unannounced visit was made to Hospital #1. When the hospital Administrator and/or the Director of Nursing (DON) were asked for, the receptionist stated that the hospital was without an administrator and the DON was an interim and she was not there. The receptionist called the Administrative Assistant (Employee #5) and told her a State Surveyor was there. A short entrance conference was held with Employee #5, who stated that she knew of the incident that had occurred on 04-08-2013 when they did not have a doctor. When asked, " How does the hospital with a dedicated emergency room close? " she stated, " We divert. " The policy for diversion was requested.
On 04-16-13 at 9:15 a.m., a tour of the ER revealed signage for EMTALA was posted in the waiting room and the triage room. The ER was staffed by a RN (Employee #1), who was covering the entire hospital that day, and the ER Physician for the 7:00 a.m. to 7:00 p.m. shift (Employee #2/Assistant Chief of Staff).
In an interview at 9:30 a.m. on 04-16-13, Employee #1 stated that he arrived for his 7:00 a.m. to 7:00 p.m. shift on Monday, 04-08-13, and was told that a baby had been brought to the ER in the early hours of 04-08 and the family was told the hospital had no ER physician. He stated that the county coroner had come to the hospital at 6:00 a.m. and told them the baby was dead on arrival to another hospital. He further stated, " I had already heard about it because I work at (Hospital #2) too and they had called to give me a heads up. When I arrived for my 7:00 a.m. to 7:00 p.m. shift here , there was no physician. A ward clerk was the only one in the ER that night and there was an RN on the floor. " When asked, " What does your ER do when there is no physician? " Employee #1 stated, " We divert. We fill out a form every 12 hours and there is a list of people we also notify. " When asked, " How does the public know? " he stated, " A sign is posted on the outside of the door. " During this interview the hospital ' s Diversion Book was reviewed. This review revealed that the diversion dates documented in the book were: 03-10-2013, 03-11-2013, 03-12-2013, 04-07-13 and 04-08-13. There was only one (1) diversion sheet filled out. The diversion sheet stated that two (2) ambulance services must be called and a diversion sheet must be done every 12 hours that the hospital is on diversion. Employee #1 stated, " There was a policy in the front of the book, but it is gone. " A copy of the Diversion Policy was requested from Employee #5 at that time. Employee #1 stated, " There has been only one RN per shift for some time and at night there is not always an RN. " Review of the hospital ' s staffing schedule confirmed his statement. (This hospital has a med-surg unit, a geri-psych unit and an ER.) Employee #1 also stated, " The emergency room used to have telemedicine but the last administrator got rid of it. We are getting it back. And we are getting a new administrator. "
On 04-16-13 at 10:30 a.m., an interview with Employee #2 revealed, " The ER is hard to staff because it is so rural and the pay is low because of low census. The board is in discussion right now regarding salaries. " When asked about diversion, Employee #2 stated, " The Interim Director of Nursing told us that if there is no physician, then put the sign on the outside of the emergency room door stating the emergency room is closed and lock the doors. Then the hospital goes on diversion... Neither the Chief of Staff or the Assistant Chief of Staff are notified when there is no ER physician...The Chief of Staff only lives two (2) blocks away.
There is no on-call policy for the days or nights there is not a physician in house... Telecommunication is supposed to be returned to the emergency room... The diversion policy and other problems were reviewed at the last trustees meeting about three (3) weeks ago. " Employee #2 was asked for the policy for diversion and a policy for what the emergency room does if there is no physician. Review of the hospital ' s Emergency Policies submitted by Employee #2 revealed that they had been last updated in 2008. There was no documented evidence of EMTALA policies, a whistleblower policy, or of a diversion policy.
In an interview on 04-16-13, Employee #5 was notified that the minutes from the last trustees meeting were needed. They were submitted for review at 1:15 p.m. on 04-16-13. When updated policies were requested for the Emergency Room, Employee #5 stated she would go into the Administrator and the DON ' s offices and see if they could be located. On 04-17-13 Employee #5 stated that she could not find any EMTALA policies and no updated ER policies.
On 04-17-13 at 10:50 a.m., an interview with the Ward Clerk (Employee #3), revealed, " I was working the night of April 08, 2013. I was restocking the ER and I looked outside as a white SUV flies up in the parking lot, a man jumps out and runs up the walk way. I walked outside and asked could I help him. He said, ' My child is having trouble breathing. ' I said, ' We are on diversion. We do not have a doctor. ' Before I could tell him the nearest hospital he could go to, he jumped back in his car and drove away. I then reported it to my charge nurse. The coroner came by about 6:00 a.m. and told us what had happened to the baby and that it was pronounced dead on arrival at (Hospital #2). " When asked how long the ER had been having problems with staffing of physicians the Ward Clerk stated, " Since early March. " The Ward Clerk ' s statement was read back to him and he signed it.
04-18-13 at 10:00 a.m., a meeting was held with the complainant, the Risk Manager at Hospital #2. She stated, " As soon as I heard about this, I began to investigate the situation. When I realized it was a possible EMTALA violation, I notified you (State Agency). I also called the other hospital (Hospital #1), so they would know I was reporting it. "
Review of the ER record submitted for Patient #1 by Hospital #2 revealed that the baby was 8 months old and weighed 9 pounds. He was born two (2) months early and had one (1) kidney, spinal bifida, mitral valve replacement, and an open cleft palette. The baby was brought into the ER by ambulance, because the parent ' s car broke down on the way, and was pronounced dead on arrival.
On 04-19-13 at 9:00 a.m., both ambulance agencies used by Hospital #1, Ambulance Service #1 and Ambulance Service #2, were contacted by phone. Both agencies took down the dates that the hospital diverted and stated they would investigate whether they were notified by the hospital of their diversion on those dates and would call back. Neither ambulance agency called back.
On 04-19-13 at 10:15 a.m., an exit conference was held with Hospital #1 officials. Officials stated that in a meeting held that morning, the trustees had named an Interim Director of Nursing. There were still no policies for the emergency room, but they were working on that and that telecommunications was going to be put back in, but no date was given. No further information was provided.
On 04-23-13 at 1:45 p.m., Ambulance Service #1 was called via phone and an employee was told of the information needed. She stated that she would call back in fifteen minutes. No call back was received. An attempt to call Ambulance Service #1 again went unanswered.
On 04-23-13 at 2:00 p.m., Ambulance Service #2 was called via phone and a supervisor was requested. After speaking with a supervisor and explaining the information needed, she stated, " I do not know if historically we keep that information. " She stated that she would need an hour and she would call back, but that it might be their compliance officer returning the call. No call back was received.

Based on record review, document review, staff interview, physician interview and policy review, the hospital failed to have an on call list of physicians to provide necessary stabilizing treatment for emergency medical conditions within the hospitals capabilities and capacity for five (5) of five (5) days reviewed.
Findings include:
Cross Refer to A2400 for the facility ' s failure to have an Emergency Room (ER) physician and for the closing of the ER for five dates.

Based on record review, document review, staff interview, physician interview and policy review, Hospital #1 failed to have a complete control log documenting the patients they refused treatment in the five (5) of five (5) days they diverted and failed to ensure the Emergency Room was open 24/7.

Findings include:

Cross Refer to A2400 for the facility ' s failure to have a central/diversion log with patients listed even if the hospital refused to see them and refused treatment; failure to ensure there were policies and procedures regarding the central log; and failure to ensure there was a physician on-call.

Based on record review, document review, staff interview, physician interview and policy review, Hospital #1 failed to provide medical screenings in the Emergency Room (ER) for five (5) of five (5) days it was on diversion.

Findings include:

Cross Refer to A2400 for the hospital ' s failure to provide an appropriate medical screening within the capability of the hospital, for Patient #1, as listed in the complaint, as well as all other patients who presented to their ER on 03-10, 03-11, 03-12, 04-07 and 04-08-2013 when the ER was closed or diverted.