HospitalInspections.org

Based on interview and record review, the hospital provider failed to comply with the special responsibilities of Medicare participating hospitals in emergency cases for 1 of 20 sampled pediatric patients. (Patient #20).

The findings include:

1. Based on staff interviews, medical record reviews, Policies and Procedures, on-call schedule review, and medical staff by-laws reviews, it was determined the facility failed to maintain a list of on-call physicians in a manner that best met the needs with sources available at the hospital to include availability of on-call physicians a specialty physician, (pediatrician), responded to a consultation request from the emergency department Physician for 1 of 20 sampled pediatric patients. (Patient #20). Refer to findings in Tag A -2404.

2. Based on medical record reviews, policy and procedure reviews, Licensed Bed Capacity review, Physician on-call schedules, and interviews, the facility failed to ensure that an appropriate medical screening examination was conducted that was within the capability of the hospital's emergency department, including ancillary services (on-call pediatrician) routinely available to the emergency department, to determine whether an emergency medical condition existed for 1 (#20) out of 20 Sampled pediatric patients. Refer to findings in Tag A- 2406.

3. Based on medical record reviews, Policy and Procedure review, staff interview and record review, it was determined that the hospital failed to ensure the hospital provided within its capabilities of staff and facilities available at the hospital stabilizing treatment as required for 1 (#20) of 20 sampled pediatrics patients who required further examination and treatment of the on-call pediatrician with specialized capabilities. Refer to findings in Tag A-2407.

Based on staff interviews, medical record reviews, Policies and Procedures, on-call schedule review, medical staff by-laws reviews it was determined the facility failed to maintain a list of on-call physicians in a manner that best meet the needs with sources available at the hospital to include availability of on-call physicians a specialty physician, (pediatrician), responded to a consultation request from the emergency department Physician for 1 of 20 sampled pediatric patients. (Patient #20).

The findings include:

The facility's policy titled, "Emergency Dept. Policy EMTALA Guidelines", Effective 06/00 was reviewed. The policy stated in part, "POLICY ...6. Jackson Hospital will provide an on-call physician list which will includes all specialty privileged at this facility ...The specialist must respond to the hospital to render an evaluation and care.

The Jackson Hospital Call Schedule dated January 2021 ...Includes 12/18/2020-12/31/2020 ...Date Published: December 18, 2022." was reviewed. The on-call schedule revealed that Pediatrician #C was on call on 12/30/2020 when the APRN requested that Pediatrician #C come to the ED to provide further evaluation and treatment of Patient #1's identified emergency medical condition.

Jackson Hospital emergency department (ED) clinical record for patient #20 was reviewed and revealed a 17-year-old male was brought to the ED on 12/30/20 at 1719 (5:19 PM) by his parents for worsening respiratory distress and a history of asthma. The patient received a triage at 1724 (5:24 PM) and determined to be an acuity level 3 (urgent). The patient's initial vital signs were heart rate (HR) 160 beats per minute (BPM), BP (blood pressure) 137/63, Temperature 103 degrees Fahrenheit (F) orally. The patient was complaining of body aches, fever, headache, and cough for approximately 1 week. The patient was assessed by an Advanced Practice Registered Nurse (APRN #A) and provided intravenous fluids, fever reducing medications, antibiotics, and intramuscular steroids. A series of laboratory studies were obtained including a Coronavirus Disease 2019 (COVID-19) screen which was pending at the time of discharge, an EKG (electrocardiogram, which records the electrical signal from the heart) which revealed tachycardia (rapid heart rate), and chest X-Ray which revealed right upper lobe consolidating pneumonia. APRN #A described the patient as "ill appearing and in moderate distress," with a clinical impression of "pneumonia, unspecified organism." The RN Chart document dated 12/20/2020 at 5:19 was reviewed. Review of the section titled "Sepsis Screening" revealed in part, "Pediatric Sepsis Screening: The patient does not have risk factors for infection which include heart rate > (greater than )110, temp > 103 or < (less than) 96.8. The patient's initial vital signs on 12/20/2020 at 5:19 PM were Heart Rate 160 and Temperature 103. The patient's Sepsis screen was positive on 12/30/2020.

At 1912, (7:12 PM), APRN #A contacted the on-call Pediatrician #C and reviewed the case with him. The APRN recommended the patient be admitted as an inpatient and relayed to the pediatrician that the patient's temperature remained high at 103 degrees F orally and he was tachycardic with a heart rate of 140 BPM. The pediatrician refused to admit the patient, declined to come to the ED to evaluate the patient further, and indicated the patient could be discharged. Documentation under the consultation section of the clinical record revealed, "pediatrician refused admission of the patient since oxygen saturation was fine, he could go home. States that his heart can beat fast for a long, long period of time before there's any issues."

On 4/4/22 at approximately 2:20 PM, an interview was conducted with APRN #A at Jackson Hospital. She recalled the patient and reviewed components of the clinical record. She indicated the patient appeared to be ill, and she contacted the on-call pediatrician due to her belief the patient would benefit from the inpatient admission for continued monitoring. She indicated she was "irritated" the patient was not being admitted. The APRN indicated she later learned the patient had been admitted to another hospital and she only discharged him from Jackson Hospital based on the pediatrician's order and recommendation. The APRN also confirmed she did not have admitting privileges and would require an attending physician to admit patients.

On 4/5/22 at approximately 10:20 AM, an interview was conducted with Jackson Hospital Pediatrician #C on-call 12/30/20. He indicated he recalled the patient and being called by the APRN regarding a possible inpatient admission due to elevated pulse rate 148-160 BPM and fever 102 degrees F orally. He indicated he recommended giving him Rocephin (an antibiotic), intravenous fluids, and send home. He stated, "I believe the heart rate was around 120 at discharge and febrile would not be considered outside normal limits if otherwise stable." He indicated that in his opinion "no APRN should alone admit a patient to the hospital and one of the MDs in the ED should have evaluated and called me if they felt the kid needed admission."

On 4/5/22 at approximately 10:00 AM and again at 12:10 PM, an interview was conducted with Jackson Hospital's Risk Manager (RM) and Chief Nursing Officer (CNO). They indicated the physicians and APRNs in the ED do not have admission privileges and would have to contact an admitting physician. They indicated patient #20's case was taken through the hospital's PEER review process and the APRN received a letter of instruction on 5/14/21 notifying her that she failed to require the on-call physician to respond in person to evaluate the patient and in the event there is a discrepancy between the ER provider and the on-call physician regarding admission, she was to require the on-call physician to personally evaluate or discharge the patient, contact the ED physician on duty to personally evaluate the patient or follow her chain of command and contact the Chief of Staff and House Supervisor when the on-call physician or ED physician refuses to respond in person.

A review of the medical staff by-laws last revised 10/27/21 confirmed ED physicians and midlevel practitioners do not have admitting privileges and must obtain an admitting physician.

A review of the hospital's on-call physician services calendar for 2021 revealed the hospital has pediatric services capabilities for ED.

A review of the hospital's on-call physician services calendar for 2021, (which included physician on call schedules for 12/18/2020 through 12/31/2020) revealed the hospital had the availability of an on-call pediatrician and pediatric services capabilities for ED on 12/30/2020. The facility failed to ensure that on 12/30/2020, the on-call pediatric physician responded to the hospital to render an evaluation
and care for patient #20 as stated in their policy and procedure.

A review of the hospital's licensed bed capacity revealed the hospital was licensed for 100 beds. The hospital's census on 12/30/2020 was approximately 61 inpatients. The hospital had the bed capacity to admit patient #20.

Based on medical record reviews, policy and procedure reviews, Licensed Bed Capacity review, Physician on-call schedules, and interviews, the facility failed to ensure that an appropriate medical screening examination was conducted that was within the capability of the hospital's emergency department, including ancillary services (on-call pediatrician) routinely available to the emergency department, to determine whether an emergency medical condition existed for 1 (#20) out of 20 Sampled pediatric patients.

The findings include:

The facility's policy titled, "Emergency Dept. Policy EMTALA Guidelines", Effective 06/00 was reviewed. The policy stated in part, "POLICY ...2. All patients shall receive a Medical Screening Exam that included 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."

Jackson Hospital emergency department (ED) clinical record for patient #20 was reviewed and revealed a 17-year-old male was brought to the ED on 12/30/20 at 1719 (5:19 PM) by his parents for worsening respiratory distress and a history of asthma. The patient received a triage at 1724 (5:24 PM) and determined to be an acuity level 3 (urgent). The patient's initial vital signs were heart rate (HR) 160 beats per minute (BPM), BP (blood pressure) 137/63, Temperature 103 degrees Fahrenheit (F) orally. The patient was complaining of body aches, fever, headache, and cough for approximately 1 week. The patient was assessed by Advanced Practice Registered Nurse #A (APRN #A) and provided intravenous fluids, fever reducing medications, antibiotics, and intramuscular steroids. A series of laboratory studies were obtained including a Coronavirus Disease 2019 (COVID-19) screen which was pending at the time of discharge, an EKG (electrocardiogram, which records the electrical signal from the heart) which revealed tachycardia (rapid heart rate), and chest X-Ray which revealed right upper lobe consolidating pneumonia. The APRN described the patient as "ill appearing and in moderate distress," with a clinical impression of "pneumonia, unspecified organism." The RN Chart document dated 12/30/2020 at 5:19 was reviewed. Review of the section titled "Sepsis Screening" revealed in part, "Pediatric Sepsis Screening: The patient does not have risk factors for infection which include heart rate > (greater than )110, temp > 103 or < (less than) 96.8. The patient's initial vital signs on 12/20/2020 at 5:19 PM were Heart Rate 160 and Temperature 103. The patient's Sepsis screen was positive on 12/30/2020.

At 1912, (7:12 PM), the APRN contacted the on-call pediatrician and reviewed the case with him. The APRN recommended the patient be admitted as an inpatient and relayed to the pediatrician that the patient's temperature remained high at 103 degrees F orally and he was tachycardic with a heart rate of 140 BPM. The pediatrician refused to admit the patient, declined to come to the ED to evaluate the patient further, and indicated the patient could be discharged. Documentation under the consultation section of the clinical record revealed, "pediatrician refused admission of the patient since oxygen saturation was fine, he could go home. States that his heart can beat fast for a long, long period of time before there's any issues."

At 2009 (8:09 PM) the patient was discharged home with his parents and instructions. The last noted documentation of the patient's vital signs revealed his temperature remained 103 degrees F orally and a heart rate of 129 BPM.

On 12/31/20 at 1026 (10:26 AM), the patient was brought by his parents to a hospital located in Panama City for continued symptoms including heart rate of 133 BPM and elevated temperature of 100.4 degrees F orally. An additional chest X-Ray was obtained and revealed atelectatic changes. The patient was placed on bronchodilator, steroids, intravenous fluids and admitted to the pediatric floor. The patient's COVID-19 test was now available and noted to be COVID-19 positive. The ED physician documented "patient seen yesterday at Jackson Hospital with diagnosis of pneumonia, but pediatrician refused to admit him." Shortly after admission to the pediatric floor, the patient's condition worsened, and he was moved to the progressive care unit (PCU) for a higher level of care. He ultimately was transferred to pediatric intensive care unit for increased breathing demands and need for a higher level of non-invasive respiratory support.

On 1/1/21 the pediatrician at the Panama City hospital documented the patient clinically appeared getting worse and likely was developing ARDS (acute respiratory distress syndrome) in addition to the right middle lobe pneumonia. The patient was transferred to a hospital in Pensacola, Florida on 1/1/21 at 1254 (12:54 PM) for pediatric pulmonary intensive care management.

A review of the hospital's licensed bed capacity revealed the hospital was licensed for 100 beds. The hospital's census on 12/30/2020 was approximately 61 inpatients. The hospital had the bed capacity to admit and treat patient #20 on 12/30/2020.

A review of the hospital's on-call physician services calendar for 2021 revealed the hospital had pediatric services capabilities for ED services for Patient #20 presented to the ED on 12/30/2020.

The facility failed to ensure that their own policy and procedures were followed as evidenced by failing to ensure that on 12/30/2020 Patient #20 received an appropriate medical screening examination that included providing on-call services (pediatrician-who was on call and available), within the capability of the hospital to reach a diagnosis as stated in the facility's Policy and procedure.

On 4/4/22 at approximately 2:20 PM, an interview was conducted with APRN #A at Jackson Hospital. She recalled the patient and reviewed components of the clinical record. She indicated the patient appeared to be ill, and she contacted the on-call pediatrician due to her belief the patient would benefit from the inpatient admission for continued monitoring. She indicated she was "irritated" the patient was not being admitted. The APRN indicated she later learned the patient had been admitted to another hospital and she only discharged him from Jackson Hospital based on the pediatrician's order and recommendation. The APRN also confirmed she did not have admitting privileges and would require an attending physician to admit patients.

On 4/5/22 at approximately 10:20 AM, an interview was conducted with Jackson Hospital Pediatrician #C on-call 12/30/20. He indicated he recalled the patient and being called by the APRN regarding a possible inpatient admission due to elevated pulse rate 148-160 BPM and fever 102 degrees F orally. He indicated he recommended giving him Rocephin (an antibiotic), intravenous fluids, and send home. He stated, "I believe the heart rate was around 120 at discharge and febrile would not be considered outside normal limits if otherwise stable." He indicated that in his opinion "no APRN should alone admit a patient to the hospital and one of the MDs in the ED should have evaluated and called me if they felt the kid needed admission."

On 4/5/22 at approximately 10:00 AM and again at 12:10 PM, an interview was conducted with Jackson Hospital's Risk Manager (RM) and Chief Nursing Officer (CNO). They indicated the physicians and APRNs in the ED do not have admission privileges and would have to contact an admitting physician. They indicated patient #20's case was taken through the hospital's PEER review process and the APRN received a letter of instruction on 5/14/21 notifying her that she failed to require the on-call physician to respond in person to evaluate the patient and in the event there is a discrepancy between the ER provider and the on-call physician regarding admission, she was to require the on-call physician to personally evaluate or discharge the patient, contact the ED physician on duty to personally evaluate the patient or follow her chain of command and contact the Chief of Staff and House Supervisor when the on-call physician or ED physician refuses to respond in person.

Based on medical record reviews, Policy and Procedure review, staff interview and record review, it was determined that the hospital failed to ensure the hospital provided within its capabilities of staff and facilities available at the hospital stabilizing treatment as required for 1 (#20) of 20 sampled pediatrics patients who required further examination and treatment of the on-call pediatrician with specialized capabilities.

The findings include:

The facility's policy titled, "Emergency Dept. Policy EMTALA Guidelines", Effective 06/00 was reviewed. The policy revealed in part, "4. Jackson Hospital may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said discharge. If a patient is a reasonable risk to deteriorate due to the natural process of their medical condition they are considered legally unstable."

Jackson Hospital emergency department (ED) clinical record for patient #20 was reviewed and revealed a 17-year-old male was brought to the ED on 12/30/20 at 1719 (5:19 PM) by his parents for worsening respiratory distress and a history of asthma. The patient received a triage at 1724 (5:24 PM) and determined to be an acuity level 3 (urgent). The patient's initial vital signs were heart rate (HR) 160 beats per minute (BPM), BP (blood pressure) 137/63, Temperature 103 degrees Fahrenheit (F) orally. The patient was complaining of body aches, fever, headache, and cough for approximately 1 week. The patient was assessed by Advanced Practice Registered Nurse #A (APRN #A) and provided intravenous fluids, fever reducing medications, antibiotics, and intramuscular steroids. A series of laboratory studies were obtained including a Coronavirus Disease 2019 (COVID-19) screen which was pending at the time of discharge, an EKG (electrocardiogram, which records the electrical signal from the heart) which revealed tachycardia (rapid heart rate), and chest X-Ray which revealed right upper lobe consolidating pneumonia. The APRN described the patient as "ill appearing and in moderate distress," with a clinical impression of "pneumonia, unspecified organism." The RN Chart document dated 12/20/2020 at 5:19 was reviewed. Review of the section titled "Sepsis Screening" revealed in part, "Pediatric Sepsis Screening: The patient does not have risk factors for infection which include heart rate > (greater than )110, temp > 103 or < (less than) 96.8. The patient's initial vital signs on 12/20/2020 at 5:19 PM were Heart Rate 160 and Temperature 103. The patient's Sepsis screen was positive on 12/30/2020.

At 1912, (7:12 PM), the APRN contacted the on-call pediatrician and reviewed the case with him. The APRN recommended the patient be admitted as an inpatient and relayed to the pediatrician that the patient's temperature remained high at 103 degrees F orally and he was tachycardic with a heart rate of 140 BPM. The pediatrician refused to admit the patient, declined to come to the ED to evaluate the patient further, and indicated the patient could be discharged. Documentation under the consultation section of the clinical record revealed, "pediatrician refused admission of the patient since oxygen saturation was fine, he could go home. States that his heart can beat fast for a long, long period of time before there's any issues."

At 2009 (8:09 PM) the patient was discharged home with his parents and instructions. The last noted documentation of the patient's vital signs revealed his temperature remained 103 degrees F orally and a heart rate of 129 BPM.

On 4/4/22 at approximately 2:20 PM, an interview was conducted with APRN #A at Jackson Hospital. She recalled the patient and reviewed components of the clinical record. She indicated the patient appeared to be ill, and she contacted the on-call pediatrician due to her belief the patient would benefit from the inpatient admission for continued monitoring. She indicated she was "irritated" the patient was not being admitted. The APRN indicated she later learned the patient had been admitted to another hospital and she only discharged him from Jackson Hospital based on the pediatrician's order and recommendation. The APRN also confirmed she did not have admitting privileges and would require an attending physician to admit patients.

On 4/5/22 at approximately 10:20 AM an interview was conducted with Jackson Hospital Pediatrician #C on-call 12/30/20. He indicated he recalled the patient and being called by the APRN regarding a possible inpatient admission due to elevated pulse rate 148-160 BPM and fever 102 degrees F orally. He indicated he recommended giving him Rocephin (an antibiotic), intravenous fluids, and send home. He stated, "I believe the heart rate was around 120 at discharge and febrile would not be considered outside normal limits if otherwise stable." He indicated that in his opinion "no APRN should alone admit a patient to the hospital and one of the MDs in the ED should have evaluated and called me if they felt kid needed admission."

On 4/5/22 at approximately 10:00 AM and again at 12:10 PM, an interview was conducted with Jackson Hospital's Risk Manager (RM) and Chief Nursing Officer (CNO). They indicated the physicians and APRNs in the ED do not have admission privileges and would have to contact an admitting physician. They indicated patient #20's case was taken through the hospital's PEER review process and the APRN received a letter of instruction on 5/14/21 notifying her that she failed to require the on-call physician to respond in person to evaluate the patient and in the event there is a discrepancy between the ER provider and the on-call physician regarding admission, she was to require the on-call physician to personally evaluate or discharge the patient, contact the ED physician on duty to personally evaluate the patient or follow her chain of command and contact the Chief of Staff and House Supervisor when the on-call physician or ED physician refuses to respond in person.

The facility failed to ensure that the facility's policy and procedure was followed as evidenced by discharging Patient #20 on 12/30/2020 who was at risk to deteriorate with discharge with abnormal vital signs, (elevated heart rate 129 BPM and temperature 103 degrees Fahrenheit). Patient #20 was not stable prior to discharge, the on -call pediatrician did not come to evaluate the patient when contacted by the APRN.