HospitalInspections.org

The Condition of Participation of Governing Body was not met.

Findings included:

Based on records reviewed and interviews the Hospital failed to ensure that Emergency Services provided at the Hospital complied with the requirements of §482.55 (Emergency Services Condition of Participation) to meet the emergency needs of patients.

Refer to TAG: A-0092.

Based on records reviewed and interviews the Hospital failed to ensure that Emergency Services provided at the Hospital complied with the requirements of §482.55 (Emergency Services Condition of Participation) to must meet the emergency needs of patients.

Findings included:

1.) The Hospital failed to ensure Emergency Services were thoroughly integrated into the Hospital.

The Surveyor interviewed the Chief Nursing Officer at 10:00 A.M. on 7/26/19. The Chief Nursing Officer said that the Hospital Emergency Departments used Cautionary Status (the process of diverting patients to other hospitals when the use of the Hospital's Computed Tomography Scanner (CT scan) was unavailable to create and or share radiology images for life-saving treatment of emergency department patients).

The Board of Directors Goals, dated Fiscal Year 2019, indicated no documentation of a goal regarding Cautionary Status.

Board of Directors (Governing Body) Meeting Minutes, dated 8/2018 through 6/2019, indicated no documentation of problems with providing Emergency Department patients at either of the two Hospital Emergency Departments with diagnostic imaging by Computerized Tomograph (CT) scan.

The Surveyor interviewed the Chief Executive Officer at 10:00 A.M. on 7/25/19. The Chief Executive Officer said that it was not often that the Hospital went on Cautionary Status.

Review of the Hospital's Cautionary Status Logs for Emergency Department #1 and Emergency Department #2 indicated that both Emergency Departments went on Cautionary Status a total of 90 times since 1/2/19.

2.) The Surveyor interviewed the Chief Medical Officer at 11:15 A.M. on 7/25/19. The Chief Medical Officer said the Medical Executive Meeting Minutes did not reflect the Hospital's Emergency Department's activation of Cautionary Status because no one raised it as a problem until after the Hospital's Emergency Medical Treatment and Labor (EMTALA) concern regarding Patient #1.

Record review indicated that, on 5/29/19, Patient #1 was brought into Emergency Department #2 by an Emergency Medical Service with complaints of numbness and a question of a stroke. At the time, the Hospital's computer software/server was not working properly so any images taken could not be viewed virtually by the telestroke neurology team.

3.) The Hospital failed to ensure that Emergency services were thoroughly integrated into the Hospital's Quality Assessment and Performance Program activities.

The Surveyor interviewed the Chief of the Emergency Department at 10:45 A.M. on 7/26/19. The Chief of the Emergency Department said that the Hospital did not track (formally through the Hospital event reporting computer system) the occurrences of Cautionary Status.

4.) The Hospital failed to ensure Emergency Services had policies and procedures for Cautionary Status.

The Surveyor interviewed the Director of Quality, Risk and Patient Safety at 10:30 A.M. on 7/26/19. The Director of Quality, Risk and Patient Safety said that the Hospital did not have a policy on Cautionary Status.

The Condition of Participation of Quality Assessment and Performance Improvement was not met.

Findings include:


1.) The Hospital failed to monitor the effectiveness and safety of services and quality of care when they failed to accurately identify that the Emergency Departments in two of two locations (Emergency Department #1 and Emergency Department #2) utilized a process called Cautionary Status to divert patients to other hospitals when the use of the Hospital's Computed Tomography Scanner (CT scan) was unavailable to create and or share radiology images for life-saving treatment of emergency department patients.

Refer to TAG: A-0273.

2.) The Hospital failed to identify an opportunity for improvement for two of two Emergency Department locations (Emergency Department #1 and Emergency Department #2) when Emergency Department #1 and Emergency Department #2 utilized a process called Cautionary Status to divert patients to other hospitals when the use of the Hospital's Computed Tomography Scanner (CT scan) was unavailable to create and or share radiology images for life-saving treatment of emergency department patients.

Refer to TAG: A-0283.

Based on records reviewed and interviews, the Hospital failed to monitor the effectiveness and safety of services and quality of care when they failed to accurately identify that the Emergency Departments in two of two locations (Emergency Department #1 and Emergency Department #2) utilized a process called Cautionary Status to divert patients to other hospitals when the use of the Hospital's Computed Tomography Scanner (CT scan) was unavailable to create and or share radiology images for life-saving treatment of emergency department patients.

Findings include:

Review of the Hospital's license and the Hospital's web site indicated that both Emergency Department #1 and Emergency Department #2 were designated Primary Stroke Service Centers, providing telestroke services designed to provide 24 hours a day and seven days a week on-demand emergency neurology consultation to subscriber hospitals in order to improve the care of stroke patients in the community.

Review of the Cautionary Status Log for Emergency Department #1 indicated that from 1/2/19 to 7/23/19 the Hospital utilized Cautionary Status 62 times. The rationale listed for Cautionary Status was:

a. 34 times the CT scan was being utilized for a scheduled interventional radiology procedure.

b. 19 times the CT scan was not available due to computer server/software issues.

c. Three times the CT scan was not available because it needed maintenance.

d. One time the CT scan was not available due to being "broken".

e. Two times the CT scan was not available for unspecified reasons.

Review of the Cautionary Status Log for Emergency Department #2 indicated that from 1/10/19 through 7/18/19 the Hospital utilized Cautionary Status 28 times. The rationale listed for Cautionary Status was:

a. 23 times the CT scan was not available due to computer server/software issues.

b. One time the CT scan was not available due to lab issues.

c. Four times the CT scan was not available for unspecified reasons.

The Surveyor interviewed Nurse #1 and Nurse #2 at 10:45 A.M. on 7/24/19. Nurse #1 and Nurse #2 said that Emergency Department #1 went on Cautionary Status often. Nurse #1 and Nurse #2 said that because Emergency Department #1 had only one CT scanner and the CT scanner is shared with Interventional Radiology, the Hospital's Emergency Department #1 had to go on Cautionary Status during planned Interventional Radiology procedures. Nurse #1 and Nurse #2 said that the Interventional Radiology Department would notify Emergency Department #1 15 minutes prior to a planned Interventional Radiology procedure so that Emergency Department #1 can make the telephone call to Central Medical Emergency Direction (CMED) to activate Cautionary Status and alert Emergency Medical Services not to bring patients who may require a CT scan to this Emergency Department. Nurse #1 and Nurse #2 said that Emergency Department #1 also went on Cautionary Status when the CT scan was unavailable or when the computer system used to view images was not working properly.

The Surveyor interviewed Nurse #3 at 7:20 A.M. on 7/26/19. Nurse #3 said that Emergency Department #2 went on Cautionary Status for reasons including: computer software or server issues, the CT scan wasn't working or the CT scan needed maintenance. Nurse #3 said that Hospital #2 did not perform Interventional Radiology procedures so that would not be a reason to utilize Cautionary Status at Emergency Department #2.

The Surveyor interviewed the Chief Nursing Officer at 10:00 A.M. on 7/26/19. The Chief Nursing Officer said that there were only two reasons why Emergency Department #1 and Emergency Department #2 would utilize Cautionary Status. The first reason was due to computer server/system issues and the second reason was if the CT scan was down. He did confirm that if there was a planned Interventional Radiology procedure the Radiology Department would notify the Emergency Department so that Emergency Department #1 would know the CT scan would be unavailable for a certain amount of time. The Chief Nursing Officer did not identify Interventional Radiology procedures to be a reason for Cautionary Status being utilized.

The Surveyor interviewed The Director of Quality, Patient Safety and Risk Management at 11:30 A.M. on 7/26/19. The Director of Quality, Patient Safety and Risk Management said that she was not aware that the Hospital utilized Cautionary Status for Interventional Radiology procedures. The Director of Quality, Patient Safety and Risk Management said that the Hospital utilized a computer software to track events, but that Cautionary Status was not tracked.

The Hospital provided no Quality Assessment and Performance Improvement activities to track, analyze and recommend improvement interventions regarding Cautionary Status.

Based on records reviewed and interviews, the Hospital's Quality Assessment & Performance Improvement (QAPI) activities failed to identify an opportunity for improvement for two of two Emergency Department locations (Emergency Department #1 and Emergency Department #2) when Emergency Department #1 and Emergency Department #2 utilized a process called Cautionary Status to divert patients to other hospitals when the use of the Hospital's Computed Tomography Scanner (CT scan) was unavailable to create and or share radiology images for life-saving treatment of Emergency Department patients.

Review of the Hospital's license and the Hospital's web site indicated that Emergency Department #1 and Emergency Department #2 were both designated Primary Stroke Service Centers with telesroke monitoring that are designed to provide 24 hour per day and seven days per week on-demand emergency neurology consultation to subscriber hospitals in order to improve the care of stroke patients in the community.

Review of the Hospital's Cautionary Status Logs for Emergency Department #1 and Emergency Department #2 indicated that both Emergency Departments went on Cautionary Status a total of 90 times since 1/2/19. Cautionary Status was initiated when the Hospital was unable to use the CT scan for emergency medical treatment in patients. The Hospital would contact Central Medical Emergency Direction (CMED-a communication system used to notify ambulance companies when a hospital is unable to provide care to incoming emergency patients) and informed them that all patient's being transported through Emergency Medical Services that may require the utilization of a CT Scan for emergency medical treatment should be taken to another hospital. The Cautionary Status Log indicated that the rationales for the Cautionary Status were:

a. Interventional Radiology procedures

b. Computer system/server technical issues

c. CT scan maintenance

d. Lab issues

e. Unspecified reasons.

The Surveyor interviewed The Director of Quality, Patient Safety and Risk Management at 11:30 A.M. on 7/26/19. The Director of Quality, Patient Safety and Risk Management said that she was not aware that the Hospital utilized Cautionary Status for Interventional Radiology procedures. The Director of Quality, Patient Safety and Risk Management said that the Hospital utilized a computer software to track events, but that Cautionary Status was not tracked.

The Condition of Participation of Emergency Services was not met.

Findings included:

The Hospital failed to ensure that it's Emergency Services were integrated with other departments being able to immediately make available the full extent of it's patient care resources to provide appropriate care for an emergency patient.

Refer to TAG A-1103.

Based on record reviews and interviews, the Hospital failed to ensure that it's Emergency Services were able to immediately make available the full extent of it's patient care resources to provide appropriate care for an emergency patient in two of two Emergency Departments. (Emergency Department #1 and Emergency Department #2).

Findings include:

Review of the Hospital's license and the Hospital's web site indicated that both Emergency Department #1 and Emergency Department #2 were designated Primary Stroke Service Centers providing telestroke services designed to provide 24 hour per day and seven days a week on-demand emergency neurology consultation to subscriber hospitals in order to improve the care of stroke patients in the community.

Record review indicated that, on 5/29/19, Patient #1 was brought into Emergency Department #2 by an Emergency Medical Service with complaints of numbness and a question of a stroke. At the time, the Hospital's computer software/server was not working properly so any images taken could not be viewed virtually by the telestroke neurology team. The nurses working informed the Central Medical Emergency Direction (CMED-a communication system used to notify ambulance companies when a hospital is unable to provide care to incoming emergency patients) that Emergency Department #2 had utilized cautionary status and couldn't appropriately care for a patient with signs and symptoms of a stroke because Emergency Department #2's CT scan images couldn't be read virtually by the telestroke Neurologists. The Central Medical Emergency Direction alert was not communicated effectively and the Emergency Medical System Ambulance brought the patient to Emergency Department #2 for treatment. The patient was not treated at Emergency Department #2 and was emergently transferred to a tertiary facility for treatment of stroke symptoms because Emergency Department #2 was unable to utilize their CT scan to effectively treat Patient #1.

Review of the Cautionary Status Logs for Emergency Department #1 and Emergency Department #2 from 1/2/19 through 7/23/19 indicated that there were 90 instances in which the Hospital was unable to provide Computed Tomography scans (CT Scans) to emergency patients. The rationale for the inability to provide the emergency care was that the CT scan was unavailable due to:

a. Interventional Radiology procedures

b. Computer server and software technical issues,

c. CT Scan failure

d. Other unspecified reasons for the CT scan being unavailable to emergency patients.

The Surveyor interviewed Nurse #1 and Nurse #2 at 10:45 A.M. on 7/24/19. Nurse #1 and Nurse #2 said that Emergency Department #1 went on Cautionary Status often. Nurse #1 and Nurse #2 said that Emergency Department #1 had only one CT scan and the CT scan is shared with Interventional Radiology. Nurse #1 and Nurse #2 said the Hospital's Emergency Department #1 had to go on Cautionary Status during planned Interventional Radiology procedures. Nurse #1 and Nurse #2 said that the Interventional Radiology Department would notify Emergency Department #1 15 minutes prior to a planned Interventional Radiology procedure so that Emergency Department #1 can make the telephone call to Central Medical Emergency Direction (CMED) to activate Cautionary Status and alert Emergency Medical Services not to bring patients who may require a CT scan to this Emergency Department. Nurse #1 and Nurse #2 said that Emergency Department #1 also went on Cautionary Status when the CT scan was unavailable or when the computer system used to view images was not working properly.

The Surveyor interviewed Nurse #3 at 7:20 A.M. on 7/26/19. Nurse #3 said that Emergency Department #2 went on Cautionary Status for reasons including: computer software or server issues, the CT scan wasn't working or the CT scan needed maintenance. Nurse #3 said that Emergency Department #2 did not perform Interventional Radiology procedures so that would not be a reason to utilize Cautionary Status at Emergency Department #2.

The Surveyor interviewed the Chief Nursing Officer at 10:00 A.M. on 7/26/19. The Chief Nursing Officer said that there were only two reasons why Emergency Department #1 and Emergency Department #2 would utilize Cautionary Status. The first reason was due to computer server/system issues and the second reason was if the CT scan was down. He did confirm that if there was a planned Interventional Radiology procedure the Radiology Department would notify the Emergency Department so that Emergency Department #1 would know the CT scan would be unavailable for a certain amount of time. The Chief Nursing Officer did not identify Interventional Radiology procedures to be a reason for Cautionary Status being utilized.

The Surveyor interviewed the Vice President of Nursing and Ancillary Services at 10:00 A.M. on 7/24/19. The Vice President of Nursing and Ancillary Services said that the Hospital is working on upgrades to the computer software and server, but the test environment has shown problems and the upgrade has been pushed out to August.

The Hospital was unable to provide immediate services to emergency patients due to continued CT Scan issues in relation to Interventional Radiology procedures, server/system technical issues, CT scan maintenance and other unspecified reasons.

The Hospital provided no clear documentation that the Hospital was able to meet the emergency needs of patients when the Hospital utilized Cautionary Status in Emergency Department #1 and Emergency Department #2.