HospitalInspections.org

Based on observations, staff interviews, clinical record and document reviews, and review of the Hospital's policies and procedures, Critical Access Hospital A's (CAH A) noncompliance with the requirements under EMTALA occurred when:

1. CAH A did not have on call list of physicians who are on the hospital's medical staff or who had privileges at the hospital to provide continued stabilizing treatment and /or treatment after the initial evaluation of individuals with emergency medical conditions (Refer to 2404)

2. CAH A's ED physician failed to provide Patient 122 with a Medical Screening Examination (The process required to reach within reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists or a woman is in labor) after Patient 122 arrived via ambulance to the hospital on 8/9/16. (Refer to 2406)

Based on observation, interview, and document review, Critical Access Hospital (CAH) A's Emergency Department (ED) failed to:


A. Have an on call list of physicians who are on the hospital medical staff or who had privileges at the hospital to provide continued stabilizing treatment and /or treatment after the initial evaluation of individuals with emergency medical conditions.

B. Have written policies and procedures that address circumstances when CAH A's ED physician is not available or cannot respond because of unforeseen circumstances.

Findings:

A. During a tour of the ED with concurrent interview, on 8/10/16 at 8 a.m., ED Licensed Staff M (LS M) explained the nurse's role in obtaining the list of physicians who would be available after the initial medical screening examination to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC. LS M explained the process was to call CAH BB and Hospital C at the beginning of the 7 a.m. shift for a list of specialists that were 'on call' at CAH BB and Hospital C. The white board (markerboard, dry-erase board, dry-wipe board) located on the wall visible at the ED's nurse's station would be updated accordingly. On 8/10/16 the whiteboard displayed the following information:

CAH BB [Critical Care Hospital BB]:

Ortho (-) [Orthopedic]

Hospital C [Acute Care Hospital]:

Ortho (+)
Neuro (-) [Neurology]
Neurosurg (-) [Neurosurgery]
Plastic (-) [Plastic Surgeon]
Urology (+) [Urinary Tract]
GI (+) [Digestive System]
ENT (-) [Ears, Nose and Throat]
SV [Psychiatric Hospital]


During an interview and concurrent document review, on 8/10/16 at 8:50 a.m., LS M described how ED staff used the white board to learn the location of the hospital with the physicians that would be available to either continue the MSE and/or provide stabilizing treatment for EMS. The plus sign meant a physician was available and the negative sign indicated there was no physician available.


LS M was asked if there was a current list of physician's names, contact numbers, and times the provider would be available in the event the ED physician determined the individual required further examination or treatment. She retrieved the binder titled, 'Specialty Physicians Available for Consult." The binder had an indexed list of specialists that included CAH BB and Hospital C's 'Allied Health Professional and Medical Staff Rosters'. The list was dated 6/10/16 (two months old) and contained no documentation of schedules of physician on call availability. LS M concurred that this was the most recent list of physicians received from CAH BB and Hospital C. CAH A had no call list of physicians who were on the hospital's medical staff or who had privileges at the hospital to provide continued stabilizing treatment and /or treatment after the initial evaluation of individuals with emergency medical conditions.


During an interview, on 8/10/16 at 5:15 p.m., the Hospital's Chief Nursing Officer (CNO) stated CAH A used CAH BB's and Hospital C's Transfer Call Center. The Transfer Call Center arranged for patient transfers from CAH A to the other hospitals depending on the availability of specialists that were on call. The CNO stated CAH BB and Hospital C declined to provide CAH A with their hospitals' On-call List. She also stated she attempted to obtain the list from the Transfer Call Center without success.


During review of the Hospital's policy and procedure titled, "Roster of Specialty Physicians Available for Consult" with an effective date of 6/30/16, indicated the purpose of this Policy was to "...keep this list [roster] current in order to facilitate rapid and appropriate transfers of patients..." Under Procedure: "Our Medical Staff Coordinator will get a monthly list of subspecialty physicians that are on call, as well as any changes/updates made thru out [sic] the month, from the Medical Staff Coordinator at [CAH BB] and [Hospital C]." During the Re-Visit survey on 8/10/16, the list in the "Specialty Physicians Available for Consult" binder was dated 6/10/16 and the effective date of the policy was 6/30/16. The policy and procedures did not include information related to CAH A's physicians available to CAH A's ED staff.


CAH A's policy and procedure titled, "Compliance with Emergency Medical Treatment and Active Labor Act (EMTALA), dated 4/28/16, documented "On-Call List means the list of physicians who are "on-call" after the initial medical screening examination to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC. The "list of physicians" did not specify that they are physicians with staff privileges at CAH A.


B. During a document review, on 8/10/16 CAH A presented signed policies related to the on-call physician "Community Call Plan" and the "Roster of Specialty Physicians Available for Consult."

The Policy and Procedure titled "Community Call Plan" effective date of 8/25/16, under 'Procedure' indicated, "Due to our hospital not having specialty on-call coverage the identified specialty on-call coverage for our community is through the nearest accepting facilities with the available specialties ..." "...Communications for consults and transfers go through [Hospital A's] Transfer Center ..."

In addition, in the policy titled, Compliance with Emergency Medical Treatment and Active Labor Act (EMTALA), dated 4/28/16, under General Policies, documented, 'On-Call Coverage' indicated, "The Hospital will maintain a list of physicians who are on-call to come to the Hospital to consult or provide treatment necessary to stabilize an individual with an EMC. The on-call list will be maintained in a manner that best meets the needs of the individuals who are receiving emergency services in accordance with the resources available to the Hospital, including the availability of on-call physicians ..."

The Policy and Procedure titled, "Roster of Specialty Physicians Available for Consult" effective date of 8/30/16 indicated it was the policy of CAH A to keep an up to date list of subspecialty physicians that work on call shifts at other facilities in the community, specifically Hospital A and CAH BB.

Based on interview, record review, and review of the Hospital's policy and procedure review, Critical Access Hospital A (CAH A)'s Emergency Department's (ED) Physician L failed to provide a prompt Medical Screening Exam (MSE) in order to rule out an emergency medical condition (EMC) for one of six sampled Patients (Patient 122). This failure had the potential for delayed treatment and worsening of the patient's symptoms.

Findings:

CAH A is a Stand-by ED (a specific type of ED that is equipped and maintained at all times to receive patients with urgent medical problems and capable of providing physician services within a reasonable time by using on-call physicians.) CAH A's ED physicians are provided a home (lodging) across the street from the Hospital 24 hours a day seven days a week during their one week work rotation.

Review of Patient 122's medical record on 8/10/16 at 10 a.m., indicated Patient 122 presented to CAH A's ED by ambulance on 8/9/16 at 2:30 a.m. The following information was documented in the "ED Visit Record":

8/9/16 at 2:30 a.m. - Patient 122, a 33 year old male presented to the ED via ambulance. The Emergency Medical Services (EMS - ambulance) reported Patient 122 was "found passed out on the toilet at a local bar." The patient presented to the ED with the Chief Complaint- "Found passed out at bar."

8/9/16 at 2:38 a.m. - The first set of vitals were taken and were within normal limits.

8/9/16 at 2:41 a.m. - Patient 122 was given a Triage Level 4, "Semi-Urgent".

LS N nurse's notes indicated that on arrival the patient had a saline lock (an intravenous [IV] catheter that is inserted into a vein, flushed with saline and then capped off for later use to deliver medication or fluids through the vein), the patient was able to give name, no other identification.

Under "Existing Conditions" Patient 122 was noted to have "altered mental status, unspecified" (AMS is a disruption in how the brain works that causes a change in behavior. This change can happen suddenly or over days. AMS ranges from slight confusion to total disorientation and increased sleepiness to coma.)

8/9/16 at 2:46 a.m. - The assessment noted the date and time under the section "Glascow Coma Scale" (a score based neurological evaluation used to to provide an objective way of recording the conscious state of a person for initial as well as subsequent assessment). There was no documentation of the Glascow Coma scale assessment or how Patient 122 scored under this section.

8/9/16 at 3:00 a.m. - LS N documented Physician L was notified by phone of the patient's arrival. No orders were given at that time.

8/9/16 at 4:00 a.m. - Patient remained stable. Opened eyes to his name, was non-compliant with answering questions or verbalizing. Had been non-communicative and slept when not disturbed.

8/9/16 at 6:30 a.m. - Continues easy to arouse to name, otherwise keeps his head covered with blankets.

8/9/16 at 7:25 a.m. - LS M (day shift) documented Patient 122 removed [his] own IV.

8/9/16 at 7:30 a.m. - LS M documented Patient 122 awoke when aroused. The patient was A & O (Alert and Oriented) x 4 not remembering the events of last night claiming he was just tired. Cooperative and appropriate behavior. "LWBS (Left Without Being Seen) signed appropriate papers ... "

8/9/16 7:35 a.m. - LS M documented the patient left without being seen, signed appropriate papers, and gave current information on demographics.

During an interview, on 8/10/16 at 10:40 a.m., ED Licensed Staff M (LS M) stated she took care of Patient 122 when he, "Left Without Being Seen" (LWBS- a term often used by ED staff to designate a patient encounter that ended with the patient leaving the ED before the patient could be seen by a physician.) She stated the patient had told her he was from out of state, came up here and he was left in the bar by his friends. LS M stated she believed the patient was sleep deprived and had passed out.

During a phone interview, on 8/10/16 at 4 p.m., LS N stated she notified Physician L of Patient 122's arrival in the ED [on 8/9/16] at 2:30 a.m. LS N stated when she spoke by phone with Physician L he had stated, "He would be in, in the morning." LS N added that she did not receive any orders from the ED Physician L during the time Patient 122 was present in the ED. LS N further stated, "Patient 122's breath did not have a smell of alcohol, he probably was sleep deprived." LS N was asked if Patient 122 refused to be evaluated by the ED Physician L, she stated, "No, he did not." LS N stated ED Physician L made the comment, "People come drunk to the ED and just being there to sleep it off." [sic] LS N stated on 8/9/16 she completed her shift and left the ED at 7:45 a.m., at which time she had not seen ED Physician L in the department.

LS N was asked about EMTALA (Emergency Medical Treatment and Labor Act) and hospital policy regarding patient admission to the ED. She stated she was familiar with EMTALA regulations and hospital policy was to notify the ED Physician of patient's arrival for the MSE and subsequently discharging the patient.

During an interview, on 8/10/16 at 1 p.m., ED Physician L was asked if he saw Patient 122 and if so, did he perform a Medical Screening Exam. ED Physician L stated he did not see the patient and that Patient 122 had refused to be seen by a Physician. ED Physician L was asked if the patient's refusal was documented. He stated the licensed nurse caring for the patient should have documented patient's refusal to be seen.

Review of ED Physician L's dictation report on 8/10/16, titled "Emergency Department Report-Transcription-Preliminary" dated 8/10/16 at 2:14 p.m., indicated Chief Complaint: Altered mental status. History of present illness: "This is a 33-year old male, who was found "passed out" in the bathroom of a local bar. The patient denies that to nursing and was alert and awake when he arrived in the ED. At that time, he kept the blankets over his head, did not wish to be seen by a provider, and was minimal to uncooperative with nursing. The patient remained undisturbed and actually left prior to my evaluation..."

Review of Hospital's policy titled, "Patient Triage" on 8/10/16, dated 6/28/07 with a review date of 2015 indicated, "A three level triage system follows. This triage system should be used consistently as guidelines for the evaluation of patients presented for emergency care." The three level system includes, 'Emergent, Urgent and Non-urgent'. Patient 122 was a "Triage Level 4, Semi-Urgent." The description for semi-urgent was not included in this policy.

Review of Hospital's policy titled, "Emergency Medical Screening and Treatment" on 8/10/16, dated 7/20/16 (Superseded; 6/28/07) indicated, "It is the policy of the Hospital to ensure that all individuals presenting to the hospital or outpatient clinic for emergency services or care will receive a prompt Medical Screening Examination (MSE) sufficient to determine whether an individual has an Emergency Medical Condition (EMC). The MSE will be conducted by a physician." Under 'Procedure' A. "Upon entering into the ED, a patient requesting medical attention, will receive an Initial MSE to rule out the existence or potential existence of an EMC." Under B. "The MSE will be conducted by a physician."

Under section F, "Should a patient refuse to consent to examination or stabilizing treatment the following steps shall be taken. 1. The provider will offer the patient further medical examination or stabilizing treatment 2. The provider informs the patients of the risks and benefits to the patient of the examination and treatment; and 3. The provider shall take all reasonable steps to secure the written informed refusal of the individual."


Review of the Hospital's policy titled, "Assessment and Evaluation of all Patients Presenting to the Emergency Room" on 8/10/16, with an effective date of 6/28/07 indicated, "... The patient will be admitted to the ER and receive further assessment to include a medical screening exam (MSE) by an ER physician...The patient will receive quality care with a minimal waiting time without regard to race, creed, color, religion, gender or ability to pay."


Patient 122 was in the ED for five hours (2:30 a.m. to 7:30 a.m.) Physician L was made aware of the patient's admission in the ED at 3 a.m. Physician L did not exam the Patient 122 nor did he give any orders during the patient's time in the ED. Physician L wrote In the ED Report- Chief Complaint: Altered mental status.