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Based on staff interview and administrative document review, the hospital's governing body failed to be responsible for the conduct of the hospital as an institution when the governing body failed to ensure the administrative structure of the hospital promoted communication among the nursing staff, medical staff, the chief medical officer and the Medical Executive Committee. The governing body failed to ensure the administrative structure of the hospital elevated detailed information regarding a disruptive physician (Medical Doctor [MD] 3) to the chief medical officer (CMO 6) and the Medical Executive Committee in accordance with hospital policy and procedure.

Findings:

A signed copy of the KERN MEDICAL CENTER BYLAWS FOR GOVERNANCE dated June 13, 2000 was reviewed on 1/27/14 at 4 PM. It states on page 3 "ARTICLE IV BOARD OF SUPERVISORS SECTION 1. GOVERNING BODY The Board of Supervisors of Kern County shall be the governing body of the Kern Medical Center and shall at all times be vested with the ultimate authority and responsibility for direction, control and operation of the Kern Medical Center. The duties, responsibilities and privileges of all other boards,committees or persons provided for herein shall be only as designated by the Board of Supervisors. SECTION 5. POWERS AND DUTIES With respect to the Kern Medical Center, the powers and duties of the Board of Supervisors include but are not limited to:(a) Establishment of general goals, objectives and policies of the Kern Medical Center, including long-range plans for the future. (b) Ultimate responsibility for ensuring the execution of policies and the attainment of objectives. (c) Appointment of the Chief Executive Officer of Kern Medical Center. (d) Appointment of physicians and certain allied professionals to the Medical Staff. ARTICLE V ADMINISTRATION SECTION 1. CHIEF EXECUTIVE OFFICER The Chief Executive Officer of Kern Medical Center shall be appointed by the Board of Supervisors. The Chief Executive Officer shall be qualified by education, experience and personal qualities, in accordance with specifications for the position adopted by the Board of Supervisors, and published and promulgated by the Kern County Personnel Department SECTION 2. DUTIES AND RESPONSIBILITIES Subject to the provisions of Kern County Ordinances, the Rules and Regulations of the Civil Service Commission, Kern County Administrative Procedures Manual and various policies adopted by the Board of Supervisors, the Chief Executive Officer shall be delegated authority for the direction, supervision and management of Kern Medical Center. The Chief Executive Officer shall act as the duly authorized representative of the Board of Supervisors in all matters pertaining to the operation of the Medical Center not formally delegated to some other person or agency. The Chief Executive Officer shall have the authority to: (a) Appoint, discipline and terminate employees; (b) Establish and implement rules, regulations, policies and procedures necessary to carry out the objectives and goals of the Kern Medical Center; (c) Approve and implement the policies and procedures of all basic and supplemental services provided at Kern Medical Center; (d) Coordinate activities of Medical Staff and Kern Medical Center personnel; (n) Recommend to the Board of Supervisors the appointment of persons to the Medical Staff.

A signed copy of the BYLAWS OF THE MEDICAL STAFF KERN MEDICAL CENTER dated 1/31/12 was reviewed on 1/27/14 at 4 PM. It states on Page 11"ARTICLE III RESPONSIBILITIES OF THE MEDICAL STAFF ORGANIZATION 3.1 RESPONSIBILITIES 3.1-2 The responsibilities of the medical staff organization to be fulfilled through the actions of its officers, departments and committees include: H. Initiating and pursuing corrective action with respect to practitioners when warranted. I. Initiating, developing, adopting, administering, and seeking compliance with these bylaws, the rules and regulations of the medical staff and other pertinent care related medical center policies. L. Exercising the authority granted by these bylaws as necessary to adequately fulfill the foregoing responsibilities." It states on Page 17 "ARTICLE IV MEMBERSHIP 4.5 BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP Except for the honorary and retired staff, the ongoing responsibilities of each member of the medical staff include: B. Abiding by medical staff bylaws, rules and regulations, and all other standards and policies of the medical staff:" It states on Page 78 "ARTICLE XII PEER REVIEW AND CORRECTIVE ACTION 12.2 FORMAL CORRECTIVE ACTION 12.2-2 CRITERIA FOR INITIATION Any person may provide information to the medical staff about the conduct, performance, or competence of its members. When reliable information indicates a member may have exhibited acts, demeanor, or conduct reasonably likely to be (3) contrary to the medical staff bylaws, rules, regulations, policies or other applicable medical center policies, procedures or documents; (5) disruptive of medical staff or medical center operations a request for an investigation or action against such member may be initiated by the president of staff, any other medical staff officer, a department chair, the medical executive committee, the medical director or the chief executive officer. 12.2-3 INITIATION A request for an investigation shall be submitted to the medical executive committee in writing, and supported by reference to specific activities or conduct alleged. If the medical executive committee initiates the request, it shall make an appropriate recordation of reasons.

An unsigned copy of the KERN MEDICAL CENTER MEDICAL STAFF Behavior or Behaviors That Undermine a Culture of safety Medical Staff Member or Practitioner Policy and Procedure dated 8/13/12 was reviewed on 1/27/14 at 4 PM. It states on page 1"I. PURPOSE: BEHAVIOR OR BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY, DISCRIMINATION, AND HARASSMENT PROHIBITED II. POLICY: All members of the medical staff are expected to conduct themselves at all times while on hospital premises in a courteous, professional, respectful, collegial, and cooperative manner. This applies to interactions and communications with or relating to medical staff colleagues, allied health professional (AHF) staff, nursing and technical personnel, other care-givers, other hospital personnel, patients, patients' family members and friends, visitors, and others. Such conduct is necessary to promote high quality patient care and to maintain a safe work environment. Disruptive, discriminatory, or harassing behavior, as defined below, will not be tolerated. III. DEFINITIONS a) "Behaviors That Undermine a Culture of safety" is aberrant behavior manifested through personal interaction with physicians, hospital personnel, healthcare professionals, patients, family members, or others, which interferes with patient care or could reasonably be expected to interfere with the process of delivering quality care. IV. EXAMPLES OF PROHIBITED CONDUCT: (4) Yelling, screaming, or using unduly loud voice directed at patients, hospital employees, other practitioners, patients or others; (7) Criticism of hospital personnel (including other practitioners), policies or equipment, or other negative comments that undermine patient trust in the hospital, in the presence or hearing of patients, patients' family members or visitors. V. ENFORCEMENT a) Allegations All allegations of behavior or behaviors that undermine a culture of safety, discrimination, harassment, or sexual harassment, as defined above, by a member of the medical or allied practitioner staff (individually, "Practitioner") involving a patient or involving another member of the medical or allied practitioner staff, shall be forwarded to the President of Staff or other appropriate medical staff officer. In the event the allegations involve the President of Staff, the allegation will be forwarded to another medical staff officer as deemed appropriate by the Chief Medical Officer. b) Investigation 1. The President of Staff, or designee, and two (2) voting members of the Medical Executive Committee ("MEC") shall undertake a prompt initial investigation to determine whether the complaint appears to be supported by reliable evidence. If the complaining party is a non-physician hospital employee, the Director of Human Resources, or his or her designee, shall take written statements from the complaining party and from witnesses. The complaining party shall be informed of the process to investigate and respond to such allegations and shall be informed that retaliation for making such allegations will not be tolerated. Written statements and other documents produced during the initial administrative investigation may not be protected from discovery. 2. If the complaint appears to be supported by reliable evidence, the President of Staff, or designee, shall promptly meet with the Practitioner who is the subject of the complaint. The Practitioner shall be advised of his or her obligations under this policy, that a complaint has been made, and that no retaliation against any complaining person, witness or investigator will be tolerated. The President of Staff shall provide the Practitioner with sufficient information to understand and respond to the allegations made by the complaining party. The Practitioner shall be permitted to respond orally or in writing to the allegations. Any written statement provided by the Practitioner and all documentation of the investigation created by the President of Staff shall be maintained as confidential medical staff documents. d) Medical Executive Committee Action - Formal 1. If the parties are not able or willing to agree to an informal resolution, the President of Staff shall ask the MC to initiate a formal corrective investigation of the complaint in accordance with Article XI, section 11.2 of the Bylaws. 2. If immediate action must be taken in order to prevent or reduce an imminent risk of injury to any person, the CEO or the President of Staff or both, may act to of injury to any person, the CEO or the President of Staff, or both, may act to summarily suspend the Practitioner's staff privileges in accordance with Article XI, section 11.3, of the Bylaws. 3. If the MEC (medical executive committee) initiates a corrective action investigation of the complaint, it shall, where feasible, assure that the investigation, although not constituting a hearing, shall include the following elements: A. The Practitioner shall be entitled to review, but not retain copies of, statements made by complaining parties and witnesses. The Practitioner shall also be entitled to receive a summary of other adverse information considered relevant to the investigation. B. The Practitioner shall be entitled to respond to the adverse statements and information and to submit oral or written information in response, subject to such conditions and limitations as the investigating body may determine; and C. The investigating body may include one or more hospital employees, appointed by the MEC, who are not members of the medical or allied practitioner staff. 4. If the MEC determines there is substantial evidence that a violation of this policy has occurred, it may do any one or more of the following: A. Issue a written or oral reprimand. If a written or oral reprimand is issued, the Practitioner shall be entitled to reply orally or in writing to the MEC. A copy of any written reprimand and any written reply shall be maintained in the Practitioner's credentials file. B. Recommend that the Practitioner undertake analysis, therapy, counseling or sensitivity training; C. Refer the Practitioner to the Wellness Committee with such conditions and stipulations as the MEC may make; or D. Recommend other corrective action. 5. The MEC may recommend corrective action constituting a restriction, termination or other material impairment of a Practitioner's clinical privileges or practice rights at the hospital, only if the MEC finds that a Practitioner's behavior has or, if continued, is likely to: (i) violate the legal rights of a hospital employee or other person; (ii) adversely affect patient care; or (iii) adversely affect the ability of one or more hospital employees or others from performing their assigned duties. 6. If the MEC recommends action, which would entitle the Practitioner to request a medical staff hearing, notice to the Practitioner shall be given in accordance with Article XII, section 12.3, subsection 12.3-1 of the Bylaws.

An unsigned copy of the KERN MEDICAL CENTER MEDICAL policy entitled "Transfers - FROM Another Facility (Non- Psychiatric Patients) dated 10/2014 was reviewed on 1/27/14 at 4 PM (Policy No. ADM-PC-311). It states"I. PURPOSE:To outline the process for transfer of non-psychiatric patients to Kern Medical Center. II. DEFINITIONS:
Transfer Officer - The Utilization Review case manager assigned to that duty from 08:00 am to 04:00 PM Monday through Friday. The Hospital Shift Supervisor is assigned to this duty on a evening, night, weekend and holiday schedule. All transfer requests must be made directly to the Kern Medical Center Transfer Officer on duty who is the only person authorized to accept the patient. Available resources - The number and availability of qualified nurses physicians and beds and Kern Medical Center hospital capacity to accommodate additional patients in excess of its usual occupancy limits. Decisions will be decided by the Kern Medical Center Transfer Officer on a case by case basis. c. Availability of care - Treatment, which is not available at the original treating facility, but may be within the capability and resources available at Kern Medical Center. Availability of care pertains only to medical care and excludes all financial considerations for emergency outpatient transfers. D. Transfer request - A real time multi-step process initiated by a physician at an outside facility who wishes to transfer a patient to Kern Medical Center. (See Procedures) E. Request for Patient Transfer - A single sheet form that the physician requesting the transfer completes. The information contains to patient data and medical status information and is sent by fax to the Kern Medical Center Transfer Officer. Completion of this form is the basis for decision for transfer acceptance based upon COBRA guidelines. (See Addendum A). F. Accepting physician - The attending faculty physician who provides the specialty care appropriate to the problem(s) of the patient to be transferred. The accepting physician is generally not an emergency physician except in the case of the patient with multiple problems, which are not related to trauma and cannot be clearly defined beyond the fact that the patient is unstable. The role of the Kern Medical Center emergency department staff physician is to refer all non-trauma transfer requests to the Transfer Officer in order to facilitate communication between the outside referring physician and the Kern Medical Center accepting physician. Stabilization - The assessment, treatment and care that is provided to the patient prior to transfer to include an assessment of the patient's ability to travel without jeopardizing life or unduly aggravating existing problems. Multiple patients with greater than 4 cm dilatation or primip patients with greater than 6 cm dilatation are considered unstable for transport. Transfer Log - A computerized or manual permanent record maintained by the Transfer Officer and initiated by any request for transfer. Ill. POLICY STATEMENT: A. It is the policy of Kern Medical Center to accept transfer patients contingent on the availability of resources at KMC at the time of the transfer request. All transfers will comply with applicable regulations. IV. PROCEDURES: A. Non-Trauma Transfers - Patients Transferring to Kern Medical Center (Excluding Trauma Transfers) 1. Anyone receiving a request for transfer will refer the caller to the Transfer Officer's pager number. 2. The Transfer Officer will respond to pages immediately. 3. The Transfer Officer sends a Request for Patient Transfer form (see Addendum A) to the requesting physician by fax if needed. 4. The requesting physician/facility completes the Request for Patient Transfer form and returns it by fax. 5. The requesting facility will fax appropriate clinical information from the medical records which will include the history and physical, last 2 days of progress notes, labs, diagnostic studies, and any other pertinent information such as infections requiring monitoring, treatment, and/or isolation if appropriate. a) If a patient is transferred from another facility to Kern Medical Center and it is later discovered that information supplied by the transferring facility was inaccurate or insufficient that may have impacted patient care the Case Manager will be notified. When the inaccurate or insufficient information includes any omission in infectious process the Case Manager will notify the Infection Control Coordinator by phone or the House Supervisor during off hours. The Infection Control Coordinator will be provided with the patient information and contact information for the transferring facility. The Infection Control Coordinator will then notify the Infection Preventionist for the transferring facility and inform the Kern County Department of Public Health for any reportable infectious diseases. 6. The Transfer Officer determines whether the transfer can be accepted by the hospital based on the following:Outpatients from Emergency Facilities: 1) Appropriateness of patient care within the scope of services provided by Kern Medical Center; 2) Availability of appropriate nursing personnel; 3) Availability of appropriate bed; (to include discussion with emergency room) 4) All acceptance will be without regard to the financial ability or method of payment of the patient, or the race, creed, color, national origin, sex, sexual preference, condition of disability of the patient to the extent that such disability is not a decisive medical factor in the ability of this hospital to care for the patient. b) Inpatients 1) In addition to 1-4 above, Transfer Officer will determine insurance coverage, if any; 2) Agreement of insurance provider to transfer; 3) As appropriate, Transfer Officer will obtain written agreement of transferring facility for: (a) Return of patient once KMC's treatment plan is complete; (b) Payment of return transport costs. 7. After confirmation of available hospital resources, the Transfer Officer will identify an accepting KMC physician from the on-call list for the appropriate service and facilitate direct communication between the requesting and accepting physicians. In the circumstance of inpatient transfers, when a KMC specialty physician has been contacted by a referring physician, the Transfer Officer will identify that specialty physician as the accepting physician. After the discussion, the accepting physician advises the Transfer Officer whether or not he will accept the medical care for the patient. 8. Upon acceptance of the transfer by hospital and physician, the Transfer Officer will notify the receiving unit of the anticipated transfer, identity of accepting physician, and estimated time of arrival. The Transfer Officer will ask that a verbal report be given by the nurse caring for the patient to the nurse who will assume care of the patient once transferred. 9. Patient will be registered through Admitting Department. 1O. If the transfer is accepted by the Transfer Officer, the transferring facility will be requested to provide a copy of all pertinent information such as progress notes, x-ray, laboratory data, operative reports, pathology reports, records of blood and blood products transfusion and nursing records. 11. The Transfer Officer will enter the request in the Transfer Log regardless of the outcome. B. Trauma Transfers 1. The Trauma Center will immediately accept all patients who meet the "trauma triage criteria" from all receiving hospitals in Kern County unless emergency department is on closure, or hospital disaster closure is in effect. Upon reopening of the Trauma Center or opening with the status of "trauma activation only", the Trauma Center will once again receive all trauma patient transfers who meet "trauma triage criteria." Receiving hospital will use the following process to initiate the transfer: a. The transferring facility will call the Trauma Center's direct number (661 ) 326-2994 and describe to the Mobile Intensive Care Nurse (MICN) the reason for patient transfer and patient's qualifications for transfer as a trauma. b. The MICN will transfer telephone call to Emergency Department (ED) physician for physician to physician verbal report prior to transfer. c. As soon as possible, transferring facility will complete the Kern Medical Center Request for Patient Transfer form (Addendum A) and fax to Kern Medical Center at the number indicated along with all pertinent information such as progress notes, x-ray, laboratory data, operative reports, pathology reports, records of blood and blood products transfusions and nursing records at the number indicated. The transferring facility will also complete the Receiving Hospital Trauma Care System Data Form (Adult - Addendum B; Child - Addendum C) and fax to EMS as indicated. d. Kern Medical Center ED physician or designee will notify KMC Transfer Officer of any accepted or declined trauma transfer requests. The Transfer Officer will enter the information in the Transfer Log. C. Other Considerations 1. It remains the responsibility of the transferring facility to provide appropriate stabilization of the patient and timely and appropriate transportation of the patient to Kern Medical Center, informing the Kern Medical Center Transfer Officer of estimated times of departure and arrival. 2. Unless expressly assumed by the accepting physician, all responsibility for medically appropriate transfer of the patient shall be that of the transferring physician. Any responsibility assumed by the accepting physician, including on-line medical control during transport, shall be duly noted upon the patient record. 3. In the event of a physician denial of a transfer, in which Kern Medical Center has available the necessary resources, the Department Chair will be notified. 4. In the event of the emergency department arrival of a transfer patient without advance acceptance by a Kern Medical Center Transfer Officer, the emergency department physician on duty or other qualified evaluator shall perform a medical screening examination and provide emergency services as if the patient were not a transfer patient. Upon completion of the necessary care a report shall be made to the Transfer Officer consistent with the patient care services policy (PCS-PC-146) Titled Improper Transfers to this Facility. The Transfer Officer will submit this report to the Manager, Case Management, who will perform an investigation and report any negative findings to the Chief Executive Officer.

On 12/11/12 during the late morning and early afternoon hours MD 3 attempted to have Patient 1 admitted to the hospital thru the Emergency Room (ER) without adhering to the process delineated in policy no. ADM-PC-311 (the hospital's transfer policy and procedure). The nursing shift manager (Registered Nurse [RN] 17) and the Chief Nursing Officer (CNO 5) both attempted to appropriately intervene and interact with MD 3 while attempting to explain to him that he would not be allowed to admit Patient 1 without adhering to the process delineated in the hospital's transfer policy and procedure. MD 3 became uncooperative, disruptive and abusive toward both RN 17 and CNO 5. He began using an unduly loud voice in addressing both RN 17 and CNO 5 and began using profanity in an unduly loud voice in addressing both RN 17 and CNO 5.

MD 3 was interviewed by telephone on 1/27/14 at 11 AM. He refused to discuss his disruptive behavior at the hospital on 12/11/12 during the late morning and early afternoon hours.

CNO 5 was interviewed in a group format on 1/28/14 at 8:30 AM along with RN 10, RN 11, RN 12 and RN 13. She stated she was the CNO for the hospital. She stated she had been involved in an incident which had occurred in the ER setting, on 12/11/12 during the late morning and early afternoon hours, in which MD 3 had been disruptive. She stated as the CNO she had been asked by RN 17 (nursing shift manager (NSM) ) to intervene in an interaction between RN 17 and MD 3 during which MD 3 had been uncooperative, angry and disruptive. She stated she tried to intervene and offer MD 3 an explanation supporting RN 17's position as the NSM simply maintaining adherence to the hospital's transfer policy and procedure as required. She stated MD 3 had engaged in inappropriate, unprofessional disruptive behavior including using profanity while addressing her and RN 17.

RN 14 and RN 15 were interviewed together on 1/28/14 at 9:30 AM. They both stated MD 3 was a disruptive influence in the ER setting at the hospital on those days when he was assigned to work at the hospital. They stated the ER nursing staff routinely had difficulties working with MD 3. They stated he was uncooperative in managing the flow of patients thru the intermediate care center of the ER. They stated he would sit in his office while the resident physicians assigned to the ER took care of the patients in the intermediate care center without his help.

RN 17 was interviewed 1/28/14 at 10:50 AM. He stated he was the nursing shift manager (NSM) in the ER at the hospital. He stated one of his responsibilities as the NSM of the ER was ensuring physicians attempting to make appropriate transfers were maintaining adherence to the hospital's transfer policy and procedure. He stated on 12/11/12 during the late morning and early afternoon hours MD 3 had attempted to transfer Patient 1 into the hospital thru the ER without adhering to the process delineated in hospital's transfer policy and procedure. He stated he tried to explain to MD 3 there was a specific transfer process which could not be violated. He stated MD 3 then became angry and disruptive. He stated while he attempted to explain the process MD 3 continued to engage in inappropriate, unprofessional disruptive behavior including speaking in an unduly loud voice and using profanity while addressing him. He stated he asked CNO 5 to intervene in the interaction with MD 3. He stated CNO 5 tried to intervene and offer MD 3 an explanation supporting his position as the NSM maintaining adherence to the hospital's transfer policy and procedure. He stated MD 3 had engaged in inappropriate, unprofessional disruptive behavior including using profanity while addressing him and CNO 5.

CMO 6, Chairman of the Emergency Department (MD 4), Chief Executive Officer (CEO 18) and CNO 5 were interviewed in a group on 1/28/14 at 1:50 PM. MD 4 stated he was the Chairman of The Emergency Department. He stated he had been made aware of MD 3's disruptive behavior during the early afternoon hours of 12/11/12. He stated he had verbally counseled MD 3. He stated he had never forwarded a written complaint to CMO 6 in accordance with the KERN MEDICAL CENTER MEDICAL STAFF Behavior or Behaviors That Undermine a Culture of safety Medical Staff Member or Practitioner Policy and Procedure and the BYLAWS OF THE MEDICAL STAFF KERN MEDICAL CENTER. CNO 5 stated she had verbally complained about MD 3's behavior to MD 4 and CMO 6, however, she had never forwarded a written complaint to CMO 6 in accordance with the KERN MEDICAL CENTER MEDICAL STAFF Behavior or Behaviors That Undermine a Culture of safety Medical Staff Member or Practitioner Policy and Procedure and the BYLAWS OF THE MEDICAL STAFF KERN MEDICAL CENTER. CMO 6 stated he had never received a written complaint from either CNO 5 or MD 4 which he could have elevated to the level of the Medical Executive Committee in accordance with the KERN MEDICAL CENTER MEDICAL STAFF Behavior or Behaviors That Undermine a Culture of safety Medical Staff Member or Practitioner Policy and Procedure and the BYLAWS OF THE MEDICAL STAFF KERN MEDICAL CENTER. He stated he had informally been made aware of MD 3's disruptive behavior. CMO 6 stated he had never elevated his concerns regarding MD 3's disruptive behavior to the Medical Executive Committee in a written form which would have allowed for a formal investigation by the appropriate individuals within the medical staff leadership and the governance structure. He stated due to the lack of written complaints detailing MD 3's violations/concerns regarding MD 3 were never elevated appropriately and were never investigated by the MEC or the Joint Conference Committee in accordance with the Medical Staff bylaws, Quality Management Improvement Plan and hospital policies.

Chief Executive Officer 18 (CEO 18) stated he had been CEO for a month and was not previously aware of MD 3's violations. He stated MD 3's behavior and violations were unacceptable. He stated the failure to elevate and address MD 3's violations of the Bylaws, Rules, Regulations and policies which had been in place was unacceptable.

Based on interview and record review, the hospital's Quality Assessment Performance Improvement (QAPI) program failed to ensure persons presenting to the Emergency Department (ED) received a medical screen examination (MSE) which resulted in a delay in medical care for one patient (1).

Findings:

During an interview with the Chief Nursing Officer (CNO) on 1/28/14 at 11 AM, she stated some patients are discharged from other hospital EDs and told to follow up with KMC (Kern Medical Center). She stated the patients show up in the ED with paperwork from the other hospitals and wanting to be seen. So depending on the situation, the patient might be directed to a clinic for care and not receive a medical screening examination when they present to the ED.

During an interview with Patient 1 on 1/28/14 at 9:25 AM, he stated, "I came to the hospital (Hospital B) for back pain with my wife. I was told I had kidney stones. They (Hospital B) did not have a kidney specialist so they gave me papers and told me to go the the other hospital (KMC). When I got there, the nurse wanted to see my transfer papers. Since I did not have them, the nurse told me to go to the clinic and make an appointment. I did not make an appointment, I returned to (Hospital B) when the pain came back." Patient 1 stated he did not sign in or see a doctor at Hospital A.

The transfer log and ED patient log for 12/2012 was reviewed. Per this log on 12/11/12, Hospital B requested transfer of Patient 1 for urology to KMC. The log indicated KMC refused the transfer because there were not beds available.

The ED patient log for 12/2012 did not show Patient 1 came to the ED to be seen and no records were found for any day in that month.

During an interview with Registered Nurse 20 (ED Quick Look nurse) on 1/28/14 at 11:28 AM, she stated, "We don't have a record on everyone that comes to the ED; it depends on what needs to be done."

During an interview with the ED Chairman (Medical Doctor 4) on 1/28/14 at 1:45 PM, he stated, "The process has always been for any patient to be referred to a clinic, they must be seen in the ED to determine what type of services they need."

The hospital policy and procedure titled "Medical Screening Examination" dated 1/2014, read "It is the policy of Kern Medical Center that all persons presenting to the emergency department for evaluation shall receive a medical screening examination within the capabilities of the emergency department and the ancillary services routinely available to the hospital, including examination, testing, treatment, and the services of appropriate on-cal physicians where indicated."

The hospital policy and procedure titled "Quality Management and Performance Improvement Plan" dated 1/2012 was reviewed. It read "It is the policy of Kern Medical Center to develop and implement a Quality Management program that will promote continuous and measurable improvement of processes, customer service, and service quality...."

Based on staff interview and administrative document review, the hospital's governing body failed to ensure the institution had a quality assessment performance improvement (QAPI) program which mirrored the complexity of the hospital's organizational services. The governing body failed to ensure the QAPI program adhered to the hospital's quality management and performance improvement policy when the quality reporting structure failed to capture violations of hospital policy and procedure as well as Medical Staff bylaw violations. The QAPI program failed to adhere to the hospital's quality management and performance improvement policy when violations of hospital policy and procedure as well as Medical Staff bylaw violations were not elevated to the Joint Conference Committee or the Quality Council as called for in the hospital's quality management and performance improvement policy.

Findings:

A signed copy of the BYLAWS OF THE MEDICAL STAFF KERN MEDICAL CENTER dated 1/31/12 was reviewed on 1/27/14 at 4 PM. It states on Page 11"ARTICLE III RESPONSIBILITIES OF THE MEDICAL STAFF ORGANIZATION 3.1 RESPONSIBILITIES 3.1-2 The responsibilities of the medical staff organization to be fulfilled through the actions of its officers, departments and committees include: H. Initiating and pursuing corrective action with respect to practitioners when warranted. I. Initiating, developing, adopting, administering, and seeking compliance with these bylaws, the rules and regulations of the medical staff and other pertinent care related medical center policies. L. Exercising the authority granted by these bylaws as necessary to adequately fulfill the foregoing responsibilities." It states on Page 17 "ARTICLE IV MEMBERSHIP 4.5 BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP Except for the honorary and retired staff, the ongoing responsibilities of each member of the medical staff include: B. Abiding by medical staff bylaws, rules and regulations, and all other standards and policies of the medical staff:" It states on Page 78 "ARTICLE XII PEER REVIEW AND CORRECTIVE ACTION 12.2 FORMAL CORRECTIVE ACTION 12.2-2 CRITERIA FOR INITIATION Any person may provide information to the medical staff about the conduct, performance, or competence of its members. When reliable information indicates a member may have exhibited acts, demeanor, or conduct reasonably likely to be (3) contrary to the medical staff bylaws, rules, regulations, policies or other applicable medical center policies, procedures or documents; (5) disruptive of medical staff or medical center operations a request for an investigation or action against such member may be initiated by the president of staff, any other medical staff officer, a department chair, the medical executive committee, the medical director or the chief executive officer. 12.2-3 INITIATION A request for an investigation shall be submitted to the medical executive committee in writing, and supported by reference to specific activities or conduct alleged. If the medical executive committee initiates the request, it shall make an appropriate recordation of reasons.

An unsigned copy of the KERN MEDICAL CENTER MEDICAL STAFF Behavior or Behaviors That Undermine a Culture of safety Medical Staff Member or Practitioner Policy and Procedure dated 8/13/12 was reviewed on 1/27/14 at 4 PM. It states on page 1"I. PURPOSE: BEHAVIOR OR BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY, DISCRIMINATION, AND HARASSMENT PROHIBITED II. POLICY: All members of the medical staff are expected to conduct themselves at all times while on hospital premises in a courteous, professional, respectful, collegial, and cooperative manner. This applies to interactions and communications with or relating to medical staff colleagues, allied health professional (AHP) staff, nursing and technical personnel, other care-givers, other hospital personnel, patients, patients' family members and friends, visitors, and others. Such conduct is necessary to promote high quality patient care and to maintain a safe work environment. Disruptive, discriminatory, or harassing behavior, as defined below, will not be tolerated. III. DEFINITIONS a) "Behaviors That Undermine a Culture of safety" is aberrant behavior manifested through personal interaction with physicians, hospital personnel, healthcare professionals, patients, family members, or others, which interferes with patient care or could reasonably be expected to interfere with the process of delivering quality care. IV. EXAMPLES OF PROHIBITED CONDUCT: (4) Yelling, screaming, or using unduly loud voice directed at patients, hospital employees, other practitioners, patients or others; (7) Criticism of hospital personnel (including other practitioners), policies or equipment, or other negative comments that undermine patient trust in the hospital, in the presence or hearing of patients, patients' family members or visitors V. ENFORCEMENT a) Allegations All allegations of behavior or behaviors that undermine a culture of safety, discrimination, harassment, or sexual harassment, as defined above, by a member of the medical or allied practitioner staff (individually, "Practitioner") involving a patient or involving another member of the medical or allied practitioner staff, shall be forwarded to the President of Staff or other appropriate medical staff officer. In the event the allegations involve the President of Staff, the allegation will be forwarded to another medical staff officer as deemed appropriate by the Chief Medical Officer. b) Investigation 1. The President of Staff, or designee, and two (2) voting members of the Medical Executive Committee ("MEC") shall undertake a prompt initial investigation to determine whether the complaint appears to be supported by reliable evidence. If the complaining party is a non-physician hospital employee, the Director of Human Resources, or his or her designee, shall take written statements from the complaining party and from witnesses. The complaining party shall be informed of the process to investigate and respond to such allegations and shall be informed that retaliation for making such allegations will not be tolerated. Written statements and other documents produced during the initial administrative investigation may not be protected from discovery. 2. If the complaint appears to be supported by reliable evidence, the President of Staff, or designee, shall promptly meet with the Practitioner who is the subject of the complaint. The Practitioner shall be advised of his or her obligations under this policy, that a complaint has been made, and that no retaliation against any complaining person, witness or investigator will be tolerated. The President of Staff shall provide the Practitioner with sufficient information to understand and respond to the allegations made by the complaining party. The Practitioner shall be permitted to respond orally or in writing to the allegations. Any written statement provided by the Practitioner and all documentation of the investigation created by the President of Staff shall be maintained as confidential medical staff documents. d) Medical Executive Committee Action - Formal 1. If the parties are not able or willing to agree to an informal resolution, the President of Staff shall ask the MC to initiate a formal corrective investigation of the complaint in accordance with Article XI, section 11.2 of the Bylaws. 2. If immediate action must be taken in order to prevent or reduce an imminent risk of injury to any person, the CEO or the President of Staff or both, may act to of injury to any person, the CEO or the President of Staff, or both, may act to summarily suspend the Practitioner's staff privileges in accordance with Article XI, section 11.3, of the Bylaws. 3. If the MEC initiates a corrective action investigation of the complaint, it shall, where feasible, assure that the investigation, although not constituting a hearing, shall include the following elements: A. The Practitioner shall be entitled to review, but not retain copies of, statements made by complaining parties and witnesses. The Practitioner shall also be entitled to receive a summary of other adverse information considered relevant to the investigation. B. The Practitioner shall be entitled to respond to the adverse statements and information and to submit oral or written information in response, subject to such conditions and limitations as the investigating body may determine; and C. The investigating body may include one or more hospital employees, appointed by the MEC, who are not members of the medical or allied practitioner staff. 4. If the MEC determines there is substantial evidence that a violation of this policy has occurred, it may do any one or more of the following: A. Issue a written or oral reprimand. If a written or oral reprimand is issued, the Practitioner shall be entitled to reply orally or in writing to the MEC. A copy of any written reprimand and any written reply shall be maintained in the Practitioner's credentials file. B. Recommend that the Practitioner undertake analysis, therapy, counseling or sensitivity training; C. Refer the Practitioner to the Wellness Committee with such conditions and stipulations as the MEC may make; or D. Recommend other corrective action. 5. The MEC may recommend corrective action constituting a restriction, termination or other material impairment of a Practitioner's clinical privileges or practice rights at the hospital, only if the MEC finds that a Practitioner's behavior has or, if continued, is likely to: (i) violate the legal rights of a hospital employee or other person; (ii) adversely affect patient care; or (iii) adversely affect the ability of one or more hospital employees or others from performing their assigned duties. 6. If the MEC recommends action, which would entitle the Practitioner to request a medical staff hearing, notice to the Practitioner shall be given in accordance with Article XII, section 12.3, subsection 12.3-1 of the Bylaws.

An unsigned copy of the KERN MEDICAL CENTER MEDICAL policy entitled "Transfers - FROM Another Facility (Non- Psychiatric Patients) dated 10/2014 was reviewed on 1/27/14 at 4 PM. It states"I. PURPOSE:To outline the process for transfer of non-psychiatric patients to Kern Medical Center. II. DEFINITIONS:
Transfer Officer - The Utilization Review case manager assigned to that duty from 08:00 am to 04:00 PM Monday through Friday. The Hospital Shift Supervisor Is assigned to this duty on a evening, night, weekend and holiday schedule. All transfer requests must be made directly to the Kern Medical Center Transfer Officer on duty who is the only person authorized to accept the patient. Available resources - The number and availability of qualified nurses physicians and beds and Kern Medical Center hospital capacity to accommodate additional patients In excess of its usual occupancy limits. Decisions will be decided by the Kern Medical Center Transfer Officer on a case by case basis. c. Availability of care - Treatment, which is not available at the original treating facility, but may be within the capability and resources available at Kern Medical Center. Availability of care pertains only to medical care and excludes all financial considerations for emergency outpatient transfers. D. Transfer request - A real time multi-step process initiated by a physician at an outside facility who wishes to transfer a patient to Kern Medical Center. (See Procedures) E. Request for Patient Transfer - A single sheet form that the physician requesting the transfer completes. The information contains to patient data and medical status information and is sent by fax to the Kern Medical Center Transfer Officer. Completion of this form is the basis for decision for transfer acceptance based upon COBRA guidelines. (See Addendum A). F. Accepting physician - The attending faculty physician who provides the specialty care appropriate to the problem(s) of the patient to be transferred. The accepting physician is generally not an emergency physician except in the case of the patient with multiple problems, which are not related to trauma and cannot be clearly defined beyond the fact that the patient is unstable. The role of the Kern Medical Center emergency department staff physician is to refer all non-trauma transfer requests to the Transfer Officer in order to facilitate communication between the outside referring physician and the Kern Medical Center accepting physician. Stabilization - The assessment, treatment and care that is provided to the patient prior to transfer to include an assessment of the patient's ability to travel without jeopardizing life or unduly aggravating existing problems. Multiple patients with greater than 4 cm dilatation or primip patients with greater than 6 cm dilatation are considered unstable for transport. Transfer Log - A computerized or manual permanent record maintained by the Transfer Officer and initiated by any request for transfer. Ill. POLICY STATEMENT: A. It is the policy of Kern Medical Center to accept transfer patients contingent on the availability of resources at KMC at the time of the transfer request. All transfers will comply with applicable regulations. IV. PROCEDURES: A. Non-Trauma Transfers - Patients Transferring to Kern Medical Center (Excluding Trauma Transfers) 1. Anyone receiving a request for transfer will refer the caller to the Transfer Officer's pager number. 2. The Transfer Officer will respond to pages immediately. 3. The Transfer Officer sends a Request for Patient Transfer form (see Addendum A) to the requesting physician by fax if needed. 4. The requesting physician/facility completes the Request for Patient Transfer form and returns it by fax. 5. The requesting facility will fax appropriate clinical information from the medical records which will include the history and physical, last 2 days of progress notes, labs, diagnostic studies, and any other pertinent information such as infections requiring monitoring, treatment, and/or isolation if appropriate. a) If a patient is transferred from another facility to Kern Medical Center and it is later discovered that information supplied by the transferring facility was inaccurate or insufficient that may have impacted patient care the Case Manager will be notified. When the inaccurate or insufficient information includes any omission in infectious process the Case Manager will notify the Infection Control Coordinator by telephone or the House Supervisor during off hours. The Infection Control Coordinator will be provided with the patient information and contact information for the transferring facility. The Infection Control Coordinator will then notify the Infection Preventionist for the transferring facility and inform the Kern County Department of Public Health for any reportable infectious diseases. 6. The Transfer Officer determines whether the transfer can be accepted by the hospital based on the following:Outpatients from Emergency Facilities: 1) Appropriateness of patient care within the scope of services provided by Kern Medical Center; 2) Availability of appropriate nursing personnel; 3) Availability of appropriate bed; (to include discussion with emergency room) 4) All acceptance will be without regard to the financial ability or method of payment of the patient, or the race, creed, color, national origin, sex, sexual preference, condition of disability of the patient to the extent that such disability is not a decisive medical factor in the ability of this hospital to care for the patient. b) Inpatients 1) In addition to 1-4 above, Transfer Officer will determine insurance coverage, if any; 2) Agreement of insurance provider to transfer; 3) As appropriate, Transfer Officer will obtain written agreement of transferring facility for: (a) Return of patient once KMC's treatment plan is complete; (b) Payment of return transport costs. 7. After confirmation of available hospital resources, the Transfer Officer will identify an accepting KMC physician from the on-call list for the appropriate service and facilitate direct communication between the requesting and accepting physicians. In the circumstance of inpatient transfers, when a KMC specialty physician has been contacted by a referring physician, the Transfer Officer will identify that specialty physician as the accepting physician. After the discussion, the accepting physician advises the Transfer Officer whether or not he will accept the medical care for the patient. 8. Upon acceptance of the transfer by hospital and physician, the Transfer Officer will notify the receiving unit of the anticipated transfer, identity of accepting physician, and estimated time of arrival. The Transfer Officer will ask that a verbal report be given by the nurse caring for the patient to the nurse who will assume care of the patient once transferred. 9. Patient will be registered through Admitting Department. 1O. If the transfer is accepted by the Transfer Officer, the transferring facility will be requested to provide a copy of all pertinent information such as progress notes, x-ray, laboratory data, operative reports, pathology reports, records of blood and blood products transfusion and nursing records. 11. The Transfer Officer will enter the request in the Transfer Log regardless of the outcome. B. Trauma Transfers 1. The Trauma Center will immediately accept all patients who meet the "trauma triage criteria" from all receiving hospitals in Kern County unless emergency department is on closure, or hospital disaster closure is in effect. Upon reopening of the Trauma Center or opening with the status of "trauma activation only", the Trauma Center will once again receive all trauma patient transfers who meet "trauma triage criteria." Receiving hospital will use the following process to initiate the transfer: a. The transferring facility will call the Trauma Center's direct number (661 ) 326-2994 and describe to the Mobile Intensive Care Nurse (MICN) the reason for patient transfer and patient's qualifications for transfer as a trauma. b. The MICN will transfer telephone call to Emergency Department (ED) physician for physician to physician verbal report prior to transfer. c. As soon as possible, transferring facility will complete the Kern Medical Center Request for Patient Transfer form (Addendum A) and fax to Kern Medical Center at the number indicated along with all pertinent information such as progress notes, x-ray, laboratory data, operative reports, pathology reports, records of blood and blood products transfusions and nursing records at the number indicated. The transferring facility will also complete the Receiving Hospital Trauma Care System Data Form (Adult - Addendum B; Child - Addendum C) and fax to EMS as indicated. d. Kern Medical Center ED physician or designee will notify KMC Transfer Officer of any accepted or declined trauma transfer requests. The Transfer Officer will enter the information in the Transfer Log. C. Other Considerations 1. It remains the responsibility of the transferring facility to provide appropriate stabilization of the patient and timely and appropriate transportation of the patient to Kern Medical Center, informing the Kern Medical Center Transfer Officer of estimated times of departure and arrival. 2. Unless expressly assumed by the accepting physician, all responsibility for medically appropriate transfer of the patient shall be that of the transferring physician. Any responsibility assumed by the accepting physician, including on-line medical control during transport, shall be duly noted upon the patient record. 3. In the event of a physician denial of a transfer, in which Kern Medical Center has available the necessary resources, the Department Chair will be notified. 4. In the event of the emergency department arrival of a transfer patient without advance acceptance by a Kern Medical Center Transfer Officer, the emergency department physician on duty or other qualified evaluator shall perform a medical screening examination and provide emergency services as if the patient were not a transfer patient. Upon completion of the necessary care a report shall be made to the Transfer Officer consistent with the patient care services policy (PCS-PC-146) Titled Improper Transfers to this Facility. The Transfer Officer will submit this report to the Manager, Case Management, who will perform an investigation and report any negative findings to the Chief Executive Officer.

An unsigned copy of the KERN MEDICAL CENTER Quality Management and Performance Improvement Plan (Policy No. ADM-PI-504) It states on page 1" PURPOSE: Purpose of Program: Under the guidance of the County Board of Supervisors, the direction of the Chief Executive Officer and Medical Director, and the Medical Executive Committee, Kern Medical Center (KMC) performance improvement strategy will be a coordinated, comprehensive, and ongoing effort to assess the effectiveness of care and services provided. KMC realizes that true quality is a complex, dynamic relationship between the customer, employees, and the process. Its goal and purpose will be to: a. Strive to achieve optimal outcomes within available resources. b. Seek continuous improvements that are consistently evidence based and representative of a high standard of practice in the community. c. Provide safe, cost-effective care, minimizing risks to the patient and facility. DEFINITION: A. Quality: Kern Medical Center defines quality as doing the right things right, and consistently to ensure: 1. The best possible clinical outcomes for patients. 2. Satisfaction for all of our many customers, including staff. 3. Recruitment and retention of qualified staff. 4. Sound financial performance D. Intense Analysis: A process for identifying the basic or causal factor(s) that underlies variation in performance, including the occurrence or possible occurrence of a sentinel and/or significant event. Ill. POLICY: A. It is the policy of Kern Medical Center (KMC) to develop and implement a Quality Management program that will promote continuous and measurable improvement of processes, customer service, and service quality based on the following Mission, Vision and Values of the organization: 3. Values: e. Respect - Demonstrate the highest esteem for our patients, one another and ourselves; we celebrate our diversity. f. Teamwork - Embrace teamwork "The ability to work together toward a common vision. The ability to direct individual accomplishments toward organizational objectives. It is the fuel that allows common people to attain uncommon results." - Andrew Carnegie 4. The Pillars a. Academics b. Innovation c. People d. Quality e. Stewardship V. PROCEDURE a. Quality Framework 1. Administrative Structure (See Addendum "A") a. The Board of Supervisors of the County of Kern, as an elected body, serves as the governing body of KMC with the ultimate authority and responsibility for all improvement activities in the organization. The Board operates through the Joint Conference committee, which is composed of members of the Board, Medical Staff, and Administration of KMC. The structure through which the performance improvement (Pl) efforts are accomplished is the Quality Council and Medical Executive Committee. The leadership and the Board of Supervisors shall facilitate Performance Improvement as follows: 3) Establish an organizational culture that supports commitment to quality and performance improvement. 4) Provide adequate resources, both material and staff, to accomplish the performance improvement function. 5) Identify opportunities for continuous performance improvement. 8) Evaluate the effectiveness of the organization's quality management and performance improvement activities. b. The Joint Conference Committee is a chartered committee of the Medical Staff as outlined in the Medical Staff bylaws. 1) Composition: a) Two (2) members of the Board b)Three (3) officers of the Active Staff (1) President of the Medical staff (2) President -Elect of the Medical Staff (3) Immediate Past President of the Medical Staff c) Chief Executive Officer or his/her representative/designee d) Chief Nursing Officer e) Chief Medical Officer, without vote f) County Administrative Officer, without vote g) Chief Financial Officer, without vote 4) The responsibilities and duties of the committee are: a) To promote communication among the Board, Medical Executive Committee, Medical Staff, and the Chief Executive Officer. d) To provide a medium in which matters of interest to all groups may be discussed in the interest of mutual understanding. f) To review the pertinent findings of quality management activities throughout the Medical Center, as compiled by the committees assigned responsibility for oversight of quality. c. Quality Council is a standing committee of the Joint Conference Committee as outlined in the Medical Staff bylaws. The Quality Council membership consists following voting members: a) Representative from the County Board of Supervisors b) Chief Medical Officer, who will be the Chairperson c) Chief Executive Officer (CEO), who will act as the Vice-Chairperson d) Chief Nurse Officer Executive e) Chief Operation Officer f) President of the Medical Staff g) President-Elect of the Medical Staff h) Immediate Past President of the Medical Staff i) Chairperson of the Quality Management Committee j) Manager of Quality Resource Center 2) The Quality Council is delegated by the Board of Supervisors to prioritize and coordinate all organization wide performance improvement activities. Specific responsibilities are as follows: i) Receive, review, and approve action plans related to quarterly performance improvement reports on the following topics: (6) Employee Satisfaction j) Forward quarterly reports related to the above topics with the improvement projects/action plans to the Joint Conference Committee. d. Medical Executive Committee: A chartered committee of the Medical Staff as outlined in the Medical Staff bylaws 1) The Medical Executive Committee shall be composed of the following voting members, of which the majority must be physician members of the medical staff: a) The officers of the medical staff b) The chairs of the clinical departments c) Two (2) members of the active staff elected at large d) The following are non-voting members of the medical executive committee: (1) Chief Executive Officer (2) Chief Medical Officer (3) Chief Nursing Officer (4) Associate Director of Medical Education f) The president shall serve as chair of the Medical Executive Committee. g) The president-elect of staff shall serve as the vice chair. Duties of the Medical Executive Committee shall include without limitation: b) Coordinating and implementing the professional and organizational activities of the medical staff c) Receiving and acting upon reports and recommendations from each medical staff department, division, committee, and assigned activity group. d) Recommending actions to the board on matters of a medical-administrative nature. h) Reviewing the qualifications, credentials, performance and professional competence, and character of applicants and staff members and making regular recommendations to the Board regarding staff appointments and reappointments, assignments to departments, clinical privileges, and corrective action. i) Taking reasonable steps to promote ethical conduct and competent clinical performance on the part of all members including the initiation of and participation in medical staff corrective or review measures when warranted.

On 12/11/12 during the late morning and early afternoon hours Medical Doctor (MD) 3 attempted to have Patient 1 admitted to the hospital thru the Emergency Room (ER) without adhering to the process delineated in policy no. ADM-PC-311 (the hospital's transfer policy and procedure). The nursing shift manager (RN 17) and the Chief Nursing Officer (CNO 5) both attempted to appropriately intervene and interact with MD 3 while attempting to explain to him that he would not be allowed to admit Patient 1 without adhering to the process delineated in the hospital's transfer policy and procedure. MD 3 became uncooperative, disruptive and abusive toward both RN 17 and CNO 5. He began using an unduly loud voice in addressing both RN 17 and CNO 5 and began using profanity in an unduly loud voice in addressing both RN 17 and CNO 5.

MD 3 was interviewed by telephone on 1/27/14 at 11 AM. He refused to discuss his disruptive behavior at the hospital on 12/11/12 during the late morning and early afternoon hours.

CNO 5 was interviewed in a group format on 1/28/14 at 8:30 AM along with RN 10, RN 11, RN 12 and RN 13. She stated she was the CNO for the hospital. She stated had been involved in an incident which had occurred in the ER setting, on 12/11/12 during the late morning and early afternoon hours, in which MD 3 had been disruptive. S he stated as the CNO she had been asked by RN 17 (nursing shift manager (NSM) ) to intervene in an interaction between RN 17 and MD 3 during which MD 3 had been uncooperative, angry and disruptive. She stated she tried to intervene and offer MD 3 an explanation supporting RN 17's position as the NSM simply maintaining adherence to the hospital's transfer policy and procedure as required. She stated MD 3 had engaged in inappropriate, unprofessional disruptive behavior including using profanity while addressing her and RN 17.

RN 14 and RN 15 were interviewed together on 1/28/14 at 9:30 AM. They both stated MD 3 was a disruptive influence in the ER setting at the hospital on those days when he was assigned to work at the hospital. They stated the ER nursing staff routinely had difficulties working with MD 3. They stated he was uncooperative in managing the flow of patients thru the intermediate care center of the ER. They stated he would sit in his office while the resident physicians assigned to the ER took care of the patients in the intermediate care center without his help.

RN 17 was interviewed 1/28/14 at 10:50 AM. He stated he was the nursing shift manager (NSM) in the ER at the hospital. He stated one of his responsibilities as the NSM of the ER was ensuring physicians attempting to make appropriate transfers were maintaining adherence to the hospital's transfer policy and procedure. He stated on 12/11/12 during the late morning and early afternoon hours MD 3 had attempted to transfer Patient 1 into the hospital thru the ER without adhering to the process delineated in hospital's transfer policy and procedure. He stated he tried to explain to MD 3 there was a specific transfer process which could not be violated. He stated MD 3 then became angry and disruptive. He stated while he attempted to explain the process MD 3 continued to engage in inappropriate, unprofessional disruptive behavior including speaking in an unduly loud voice and using profanity while addressing him. He stated he asked CNO 5 to intervene in the interaction with MD 3. He stated CNO 5 tried to intervene and offer MD 3 an explanation supporting his position as the NSM maintaining adherence to the hospital's transfer policy and procedure. He stated MD 3 had engaged in inappropriate, unprofessional disruptive behavior including using profanity while addressing him and CNO 5.

The Chief Medical Officer (CMO) 6, Chairman of the Emergency Department (MD 4), Chief Executive Officer (CEO) 18 and CNO 5 were interviewed in a group on 1/28/14 at 1:50 PM. MD 4 stated he was the Chairman of The Emergency Department. He stated he had been made aware of MD 3's disruptive behavior during the early afternoon hours of 12/11/12. He stated he had verbally counseled MD 3. He stated he had never forwarded a written complaint to CMO 6 in accordance with the KERN MEDICAL CENTER MEDICAL STAFF Behavior or Behaviors That Undermine a Culture of safety Medical Staff Member or Practitioner Policy and Procedure and the BYLAWS OF THE MEDICAL STAFF KERN MEDICAL CENTER. CNO 5 stated she had verbally complained about MD 3's behavior to MD 4 and CMO 6, however, she had never forwarded a written complaint to CMO 6 in accordance with the KERN MEDICAL CENTER MEDICAL STAFF Behavior or Behaviors That Undermine a Culture of safety Medical Staff Member or Practitioner Policy and Procedure and the BYLAWS OF THE MEDICAL STAFF KERN MEDICAL CENTER. CMO 6 stated he had never received a written complaint from either CNO 5 or MD 4 which he could have elevated to the level of the Medical Executive Committee in accord

Based on staff interview and administrative document review, the hospital's Medical Staff failed to operate under and enforce the bylaws approved by the governing body when members of the Medical Staff leadership failed to ensure a physician acted in accordance with hospital policy and procedure. The Medical Staff failed to operate under and enforce the bylaws approved by the governing body when a physician (Medical Doctor [MD] 3) failed to act in accordance with an approved hospital policy and procedure and members of Medical Staff leadership failed to exercise the authority granted by the bylaws to pursue corrective action with respect to the physician's violation. Members of the Medical Staff leadership (MD 4, Chief Medical Officer [CMO] 6) failed to exercise the authority granted by the bylaws when they failed to initiate and pursue corrective action of a MD 3's policy and procedure violation.

Findings:

A signed copy of the BYLAWS OF THE MEDICAL STAFF KERN MEDICAL CENTER dated 1/31/12 was reviewed on 1/27/14 at 4 PM. It states on Page 11"ARTICLE III RESPONSIBILITIES OF THE MEDICAL STAFF ORGANIZATION 3.1 RESPONSIBILITIES 3.1-2 The responsibilities of the medical staff organization to be fulfilled through the actions of its officers, departments and committees include: H. Initiating and pursuing corrective action with respect to practitioners when warranted. I. Initiating, developing, adopting, administering, and seeking compliance with these bylaws, the rules and regulations of the medical staff and other pertinent care related medical center policies. L. Exercising the authority granted by these bylaws as necessary to adequately fulfill the foregoing responsibilities." It states on Page 17 "ARTICLE IV MEMBERSHIP 4.5 BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP Except for the honorary and retired staff, the ongoing responsibilities of each member of the medical staff include: B. Abiding by medical staff bylaws, rules and regulations, and all other standards and policies of the medical staff:" It states on Page 78 "ARTICLE XII PEER REVIEW AND CORRECTIVE ACTION 12.2 FORMAL CORRECTIVE ACTION 12.2-2 CRITERIA FOR INITIATION Any person may provide information to the medical staff about the conduct, performance, or competence of its members. When reliable information indicates a member may have exhibited acts, demeanor, or conduct reasonably likely to be (3) contrary to the medical staff bylaws, rules, regulations, policies or other applicable medical center policies, procedures or documents; (5) disruptive of medical staff or medical center operations a request for an investigation or action against such member may be initiated by the president of staff, any other medical staff officer, a department chair, the medical executive committee, the medical director or the chief executive officer. 12.2-3 INITIATION A request for an investigation shall be submitted to the medical executive committee in writing, and supported by reference to specific activities or conduct alleged. If the medical executive committee initiates the request, it shall make an appropriate recordation of reasons.

An unsigned copy of the KERN MEDICAL CENTER MEDICAL STAFF Behavior or Behaviors That Undermine a Culture of safety Medical Staff Member or Practitioner Policy and Procedure dated 8/13/12 was reviewed on 1/27/14 at 4 PM. It states on page 1"I. PURPOSE: BEHAVIOR OR BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY, DISCRIMINATION, AND HARASSMENT PROHIBITED II. POLICY: All members of the medical staff are expected to conduct themselves at all times while on hospital premises in a courteous, professional, respectful, collegial, and cooperative manner. This applies to interactions and communications with or relating to medical staff colleagues, allied health professional (AHP) staff, nursing and technical personnel, other care-givers, other hospital personnel, patients, patients' family members and friends, visitors, and others. Such conduct is necessary to promote high quality patient care and to maintain a safe work environment. Disruptive, discriminatory, or harassing behavior, as defined below, will not be tolerated. III. DEFINITIONS a) "Behaviors That Undermine a Culture of safety" is aberrant behavior manifested through personal interaction with physicians, hospital personnel, healthcare professionals, patients, family members, or others, which interferes with patient care or could reasonably be expected to interfere with the process of delivering quality care. IV. EXAMPLES OF PROHIBITED CONDUCT: (4) Yelling, screaming, or using unduly loud voice directed at patients, hospital employees, other practitioners, patients or others; (7) Criticism of hospital personnel (including other practitioners), policies or equipment, or other negative comments that undermine patient trust in the hospital, in the presence or hearing of patients, patients' family members or visitors V. ENFORCEMENT a) Allegations All allegations of behavior or behaviors that undermine a culture of safety, discrimination, harassment, or sexual harassment, as defined above, by a member of the medical or allied practitioner staff (individually, "Practitioner") involving a patient or involving another member of the medical or allied practitioner staff, shall be forwarded to the President of Staff or other appropriate medical staff officer. In the event the allegations involve the President of Staff, the allegation will be forwarded to another medical staff officer as deemed appropriate by the Chief Medical Officer. b) Investigation 1. The President of Staff, or designee, and two (2) voting members of the Medical Executive Committee ("MEC") shall undertake a prompt initial investigation to determine whether the complaint appears to be supported by reliable evidence. If the complaining party is a non-physician hospital employee, the Director of Human Resources, or his or her designee, shall take written statements from the complaining party and from witnesses. The complaining party shall be informed of the process to investigate and respond to such allegations and shall be informed that retaliation for making such allegations will not be tolerated. Written statements and other documents produced during the initial administrative investigation may not be protected from discovery. 2. If the complaint appears to be supported by reliable evidence, the President of Staff, or designee, shall promptly meet with the Practitioner who is the subject of the complaint. The Practitioner shall be advised of his or her obligations under this policy, that a complaint has been made, and that no retaliation against any complaining person, witness or investigator will be tolerated. The President of Staff shall provide the Practitioner with sufficient information to understand and respond to the allegations made by the complaining party. The Practitioner shall be permitted to respond orally or in writing to the allegations. Any written statement provided by the Practitioner and all documentation of the investigation created by the President of Staff shall be maintained as confidential medical staff documents. d) Medical Executive Committee Action - Formal 1. If the parties are not able or willing to agree to an informal resolution, the President of Staff shall ask the MEC to initiate a formal corrective investigation of the complaint in accordance with Article XI, section 11.2 of the Bylaws. 2. If immediate action must be taken in order to prevent or reduce an imminent risk of injury to any person, the CEO (chief executive officer) or the President of Staff or both, may act to of injury to any person, the CEO or the President of Staff, or both, may act to summarily suspend the Practitioner's staff privileges in accordance with Article XI, section 11.3, of the Bylaws. 3. If the MEC initiates a corrective action investigation of the complaint, it shall, where feasible, assure that the investigation, although not constituting a hearing, shall include the following elements: A. The Practitioner shall be entitled to review, but not retain copies of, statements made by complaining parties and witnesses. The Practitioner shall also be entitled to receive a summary of other adverse information considered relevant to the investigation. B. The Practitioner shall be entitled to respond to the adverse statements and information and to submit oral or written information in response, subject to such conditions and limitations as the investigating body may determine; and C. The investigating body may include one or more hospital employees, appointed by the MEC, who are not members of the medical or allied practitioner staff. 4. If the MEC determines there is substantial evidence that a violation of this policy has occurred, it may do any one or more of the following: A. Issue a written or oral reprimand. If a written or oral reprimand is issued, the Practitioner shall be entitled to reply orally or in writing to the MEC. A copy of any written reprimand and any written reply shall be maintained in the Practitioner's credentials file. B. Recommend that the Practitioner undertake analysis, therapy, counseling or sensitivity training; C. Refer the Practitioner to the Wellness Committee with such conditions and stipulations as the MEC may make; or D. Recommend other corrective action. 5. The MEC may recommend corrective action constituting a restriction, termination or other material impairment of a Practitioner's clinical privileges or practice rights at the hospital, only if the MEC finds that a Practitioner's behavior has or, if continued, is likely to: (i) violate the legal rights of a hospital employee or other person; (ii) adversely affect patient care; or (iii) adversely affect the ability of one or more hospital employees or others from performing their assigned duties. 6. If the MEC recommends action, which would entitle the Practitioner to request a medical staff hearing, notice to the Practitioner shall be given in accordance with Article XII, section 12.3, subsection 12.3-1 of the Bylaws.

An unsigned copy of the KERN MEDICAL CENTER MEDICAL policy entitled "Transfers - FROM Another Facility (Non- Psychiatric Patients) dated 10/2014 was reviewed on 1/27/14 at 4 PM. It states"I. PURPOSE: To outline the process for transfer of non-psychiatric patients to Kern Medical Center. II. DEFINITIONS: Transfer Officer - The Utilization Review case manager assigned to that duty from 08:00 am to 04:00 PM Monday through Friday. The Hospital Shift Supervisor Is assigned to this duty on a evening, night, weekend and holiday schedule. All transfer requests must be made directly to the Kern Medical Center Transfer Officer on duty who is the only person authorized to accept the patient. Available resources - The number and availability of qualified nurses physicians and beds and Kern Medical Center hospital capacity to accommodate additional patients In excess of its usual occupancy limits. Decisions will be decided by the Kern Medical Center Transfer Officer on a case by case basis. c. Availability of care - Treatment, which is not available at the original treating facility, but may be within the capability and resources available at Kern Medical Center. Availability of care pertains only to medical care and excludes all financial considerations for emergency outpatient transfers. D. Transfer request - A real time multi-step process initiated by a physician at an outside facility who wishes to transfer a patient to Kern Medical Center. (See Procedures) E. Request for Patient Transfer - A single sheet form that the physician requesting the transfer completes. The information contains to patient data and medical status information and is sent by fax to the Kern Medical Center Transfer Officer. Completion of this form is the basis for decision for transfer acceptance based upon COBRA guidelines. (See Addendum A). F. Accepting physician - The attending faculty physician who provides the specialty care appropriate to the problem(s) of the patient to be transferred. The accepting physician is generally not an emergency physician except in the case of the patient with multiple problems, which are not related to trauma and cannot be clearly defined beyond the fact that the patient is unstable. The role of the Kern Medical Center emergency department staff physician is to refer all non-trauma transfer requests to the Transfer Officer in order to facilitate communication between the outside referring physician and the Kern Medical Center accepting physician. Stabilization - The assessment, treatment and care that is provided to the patient prior to transfer to include an assessment of the patient's ability to travel without jeopardizing life or unduly aggravating existing problems. Multiple patients with greater than 4 cm dilatation or primip patients with greater than 6 cm dilatation are considered unstable for transport. Transfer Log - A computerized or manual permanent record maintained by the Transfer Officer and initiated by any request for transfer. Ill. POLICY STATEMENT: A. It is the policy of Kern Medical Center to accept transfer patients contingent on the availability of resources at KMC at the time of the transfer request. All transfers will comply with applicable regulations. IV. PROCEDURES: A. Non-Trauma Transfers - Patients Transferring to Kern Medical Center (Excluding Trauma Transfers) 1. Anyone receiving a request for transfer will refer the caller to the Transfer Officer's pager number. 2. The Transfer Officer will respond to pages immediately. 3. The Transfer Officer sends a Request for Patient Transfer form (see Addendum A) to the requesting physician by fax if needed. 4. The requesting physician/facility completes the Request for Patient Transfer form and returns it by fax. 5. The requesting facility will fax appropriate clinical information from the medical records which will include the history and physical, last 2 days of progress notes, labs, diagnostic studies, and any other pertinent information such as infections requiring monitoring, treatment, and/or isolation if appropriate. a) If a patient is transferred from another facility to Kern Medical Center and it is later discovered that information supplied by the transferring facility was inaccurate or insufficient that may have impacted patient care the Case Manager will be notified. When the inaccurate or insufficient information includes any omission in infectious process the Case Manager will notify the Infection Control Coordinator by phone or the House Supervisor during off hours. The Infection Control Coordinator will be provided with the patient information and contact information for the transferring facility. The Infection Control Coordinator will then notify the Infection Preventionist for the transferring facility and inform the Kern County Department of Public Health for any reportable infectious diseases. 6. The Transfer Officer determines whether the transfer can be accepted by the hospital based on the following:Outpatients from Emergency Facilities: 1) Appropriateness of patient care within the scope of services provided by Kern Medical Center; 2) Availability of appropriate nursing personnel; 3) Availability of appropriate bed; (to include discussion with emergency room) 4) All acceptance will be without regard to the financial ability or method of payment of the patient, or the race, creed, color, national origin, sex, sexual preference, condition of disability of the patient to the extent that such disability is not a decisive medical factor in the ability of this hospital to care for the patient. b) Inpatients 1) In addition to 1-4 above, Transfer Officer will determine insurance coverage, if any; 2) Agreement of insurance provider to transfer; 3) As appropriate, Transfer Officer will obtain written agreement of transferring facility for: (a) Return of patient once KMC's treatment plan is complete; (b) Payment of return transport costs. 7. After confirmation of available hospital resources, the Transfer Officer will identify an accepting KMC physician from the on-call list for the appropriate service and facilitate direct communication between the requesting and accepting physicians. In the circumstance of inpatient transfers, when a KMC specialty physician has been contacted by a referring physician, the Transfer Officer will identify that specialty physician as the accepting physician. After the discussion, the accepting physician advises the Transfer Officer whether or not he will accept the medical care for the patient. 8. Upon acceptance of the transfer by hospital and physician, the Transfer Officer will notify the receiving unit of the anticipated transfer, identity of accepting physician, and estimated time of arrival. The Transfer Officer will ask that a verbal report be given by the nurse caring for the patient to the nurse who will assume care of the patient once transferred. 9. Patient will be registered through Admitting Department. 1O. If the transfer is accepted by the Transfer Officer, the transferring facility will be requested to provide a copy of all pertinent information such as progress notes, x-ray, laboratory data, operative reports, pathology reports, records of blood and blood products transfusion and nursing records. 11. The Transfer Officer will enter the request in the Transfer Log regardless of the outcome. B. Trauma Transfers 1. The Trauma Center will immediately accept all patients who meet the "trauma triage criteria" from all receiving hospitals in Kern County unless emergency department is on closure, or hospital disaster closure is in effect. Upon reopening of the Trauma Center or opening with the status of "trauma activation only", the Trauma Center will once again receive all trauma patient transfers who meet "trauma triage criteria." Receiving hospital will use the following process to initiate the transfer: a. The transferring facility will call the Trauma Center's direct number (661 ) 326-2994 and describe to the Mobile Intensive Care Nurse (MICN) the reason for patient transfer and patient's qualifications for transfer as a trauma. b. The MICN will transfer telephone call to Emergency Department (ED) physician for physician to physician verbal report prior to transfer. c. As soon as possible, transferring facility will complete the Kern Medical Center Request for Patient Transfer form (Addendum A) and fax to Kern Medical Center at the number indicated along with all pertinent information such as progress notes, x-ray, laboratory data, operative reports, pathology reports, records of blood and blood products transfusions and nursing records at the number indicated. The transferring facility will also complete the Receiving Hospital Trauma Care System Data Form (Adult - Addendum B; Child - Addendum C) and fax to EMS as indicated. d. Kern Medical Center ED physician or designee will notify KMC Transfer Officer of any accepted or declined trauma transfer requests. The Transfer Officer will enter the information in the Transfer Log. C. Other Considerations 1. It remains the responsibility of the transferring facility to provide appropriate stabilization of the patient and timely and appropriate transportation of the patient to Kern Medical Center, informing the Kern Medical Center Transfer Officer of estimated times of departure and arrival. 2. Unless expressly assumed by the accepting physician, all responsibility for medically appropriate transfer of the patient shall be that of the transferring physician. Any responsibility assumed by the accepting physician, including on-line medical control during transport, shall be duly noted upon the patient record. 3. In the event of a physician denial of a transfer, in which Kern Medical Center has available the necessary resources, the Department Chair will be notified. 4. In the event of the emergency department arrival of a transfer patient without advance acceptance by a Kern Medical Center Transfer Officer, the emergency department physician on duty or other qualified evaluator shall perform a medical screening examination and provide emergency services as if the patient were not a transfer patient. Upon completion of the necessary care a report shall be made to the Transfer Officer consistent with the patient care services policy (PCS-PC-146) Titled Improper Transfers to this Facility. The Transfer Officer will submit this report to the Manager, Case Management, who will perform an investigation and report any negative findings to the Chief Executive Officer.

On 12/11/12 during the late morning and early afternoon hours MD 3 attempted to have Patient 1 admitted to the hospital thru the Emergency Room (ER) without adhering to the process delineated in policy no. ADM-PC-311 (the hospital's transfer policy and procedure). The nursing shift manager (Registered Nurse [RN] 17) and the Chief Nursing Officer (CNO) 5 both attempted to appropriately intervene and interact with MD 3 while attempting to explain to him that he would not be allowed to admit Patient 1 without adhering to the process delineated in the hospital's transfer policy and procedure. MD 3 became uncooperative, disruptive and abusive toward both RN 17 and CNO 5. He began using an unduly loud voice in addressing both RN 17 and CNO 5 and began using profanity in an unduly loud voice in addressing both RN 17 and CNO 5.

MD 3 was interviewed by telephone on 1/27/14 at 11 AM. He refused to discuss his disruptive behavior at the hospital on 12/11/12 during the late morning and early afternoon hours.

CNO 5 was interviewed in a group format on 1/28/14 at 8:30 AM along with RN 10, RN 11, RN 12 and RN 13. She stated she was the CNO for the hospital. She stated had been involved in an incident which had occurred in the ER setting, on 12/11/12 during the late morning and early afternoon hours, in which MD 3 had been disruptive. She stated as the CNO she had been asked by RN 17 (nursing shift manager (NSM) ) to intervene in an interaction between RN 17 and MD 3 during which MD 3 had been uncooperative, angry and disruptive. She stated she tried to intervene and offer MD 3 an explanation supporting RN 17's position as the NSM simply maintaining adherence to the hospital's transfer policy and procedure as required. She stated MD 3 had engaged in inappropriate, unprofessional disruptive behavior including using profanity while addressing her and RN 17.

RN 14 and RN 15 were interviewed together on 1/28/14 at 9:30 AM. They both stated MD 3 was a disruptive influence in the ER setting at the hospital on those days when he was assigned to work at the hospital. They stated the ER nursing staff routinely had difficulties working with MD 3. They stated he was uncooperative in managing the flow of patients thru the intermediate care center of the ER. They stated he would sit in his office while the resident physicians assigned to the ER took care of the patients in the intermediate care center without his help.

RN 17 was interviewed 1/28/14 at 10:50 AM. He stated he was the nursing shift manager (NSM) in the ER at the hospital. He stated one of his responsibilities as the NSM of the ER was ensuring physicians attempting to make appropriate transfers were maintaining adherence to the hospital's transfer policy and procedure. He stated on 12/11/12 during the late morning and early afternoon hours MD 3 had attempted to transfer Patient 1 into the hospital thru the ER without adhering to the process delineated in hospital's transfer policy and procedure. He stated he tried to explain to MD 3 there was a specific transfer process which could not be violated. He stated MD 3 then became angry and disruptive. He stated while he attempted to explain the process MD 3 continued to engage in inappropriate, unprofessional disruptive behavior including speaking in an unduly loud voice and using profanity while addressing him. He stated he asked CNO 5 to intervene in the interaction with MD 3. He stated CNO 5 tried to intervene and offer MD 3 an explanation supporting his position as the NSM maintaining adherence to the hospital's transfer policy and procedure. He stated MD 3 had engaged in inappropriate, unprofessional disruptive behavior including using profanity while addressing him and CNO 5.

CMO 6, Chairman of the Emergency Department (MD 4), Chief Executive Officer (CEO) 18 and CNO 5 were interviewed in a group on 1/28/14 at 1:50 PM. MD 4 stated he was the Chairman of The Emergency Department. He stated he had been made aware of MD 3's disruptive behavior during the early afternoon hours of 12/11/12. He stated he had verbally counseled MD 3. He stated he had never forwarded a written complaint to CMO 6 in accordance with the KERN MEDICAL CENTER MEDICAL STAFF Behavior or Behaviors That Undermine a Culture of safety Medical Staff Member or Practitioner Policy and Procedure and the BYLAWS OF THE MEDICAL STAFF KERN MEDICAL CENTER. CNO 5 stated she had verbally complained about MD 3's behavior to MD 4 and CMO 6, however, she had never forwarded a written complaint to CMO 6 in accordance with the KERN MEDICAL CENTER MEDICAL STAFF Behavior or Behaviors That Undermine a Culture of safety Medical Staff Member or Practitioner Policy and Procedure and the BYLAWS OF THE MEDICAL STAFF KERN MEDICAL CENTER. CMO 6 stated he had never received a written complaint from either CNO 5 or MD 4 which he could have elevated to the level of the Medical Executive Committee in accordance with the KERN MEDICAL CENTER MEDICAL STAFF Behavior or Behaviors That Undermine a Culture of safety Medical Staff Member or Practitioner Policy and Procedure and the BYLAWS OF THE MEDICAL STAFF KERN MEDICAL CENTER. He stated he had informally been made aware of MD 3's disruptive behavior. CMO 6 stated he had never elevated his concerns regarding MD 3's disruptive behavior to the Medical Executive Committee in a written form which would have allowed for a formal investigation by the appropriate individuals within the medical staff leadership and the governance structure. He stated due the lack of a written complaints detailing MD 3's violations concerns regarding MD 3 were never elevated appropriately and were never investigated by the MEC or the Joint Conference Committee in accordance with the Medical Staff bylaws, Quality Management Improvement Plan and hospital policies.

CEO 18 stated he had been CEO for a month and was not previously aware of MD 3's violations. He stated MD 3's behavior and violations were unacceptable. He stated the failure to elevate and address MD 3's violations of the Bylaws, Rules, Regulations and policies which had been in place was unacceptable.

Based on observation, interview, and record review, the hospital failed to ensure:

1. Every person presenting to the Emergency Department (ED) received a Medical Screening Examination.

2. The "Quick Look" nurse was available when persons present to the ED in the lobby. (The Quick Look nurse determines which area in the ED the patient needs to go depending on the patients presenting medical issue.

3. The ED patient logs were correct and complete.

4. Transfer logs for patient transfer requests to and from the hospital were complete and accurate.

These failures had a potential for medical adverse patient outcomes.

Findings:

1. During an interview with the Chief Nursing Officer (CNO) on 1/28/14 at 11 AM, she stated some patients are discharged from other hospital EDs and told to follow up with KMC (Kern Medical Center). She stated the patients show up in the ED with paperwork from the other hospitals and wanting to be seen. So depending on the situation, the patient might be directed to a clinic for care and not receive a medical screening examination when they present to the ED.

During an interview with Patient 1 on 1/28/14 at 9:25 AM, he stated, "I came to the hospital (Hospital B) for back pain with my wife. I was told I had kidney stones. They (Hospital B) did not have a kidney specialist so they gave me papers and told me to go the the other hospital (Kern Medical Center). When I got there, the nurse wanted to see my transfer papers. Since I did not have them, the nurse told me to go to the clinic and make an appointment. I did not make an appointment, I returned to (Hospital B) when the pain came back." Patient 1 stated he did not sign in or see a doctor at Hospital A.

The transfer log and ED patient log for 12/2012 was reviewed. Per this log on 12/11/12, Hospital B requested transfer of Patient 1 for urology to Kern Medical Center. The log indicated Kern Medical Center refused the transfer because there were not beds available.

The ED patient log for 12/2012 did not show Patient 1 came to the ED to be seen and no records were found for any day in that month.

During an interview with Registered Nurse (RN) 20 (ED Quick Look nurse) on 1/28/14 at 11:28 AM, she stated, "We don't have a record on everyone that comes to the ED; it depends on what needs to be done."

During an interview with the ED Chairman (Medical Doctor [MD] 4) on 1/28/14 at 1:45 PM, he stated, "The process has always been for any patient to be referred to a clinic, they must be seen in the ED to determine what type of services they need."

The hospital policy and procedure titled "Medical Screening Examination" dated 1/2014, read "It is the policy of Kern Medical Center that all persons presenting to the emergency department for evaluation shall receive a medical screening examination within the capabilities of the emergency department and the ancillary services routinely available to the hospital, including examination, testing, treatment, and the services of appropriate on-cal physicians where indicated."

2. During an observation of the "Quick Look Desk" area in the ED waiting room with the ED clinical supervisor (RN 15) on 1/27/14 at 1:45 PM, there was not a staff member present to assess the patients' needs as they came through the doors to be seen. At this time, a person came through the doors and stood at the desk. RN 15 stated RN 18 was the nurse assigned to the desk and should be there when a patient presents to the ED. After a few minutes, the ED clinical supervisor (RN 15) went up to the desk and asked the person to fill out a paper that included patient name and chief complaint.

During an interview with RN 18 after he returned to the desk on 1/27/14 at 1:55 PM, he stated sometimes he had to leave the area to take a patient back to the main ED area when everyone was busy. He stated he always tried to hurry to get back but he had to let the ED charge nurse know why the patient was coming to that area.

The hospital job duty statement titled "Quick Look RN Job Duties" undated, read "Greet all patients who enter the lobby. Gather information to fill out the quick look ID form, make decision of whether the patient continues through the intake process or goes to the main ED...."

3. The ED logs were reviewed and compared with the sampled patients electronic and scanned ED clinical record. The following incorrect information was listed on the ED logs:

3a. The ED clinical record for Patient 10 was reviewed. The document titled "Quick ID Form" dated 9/7/13, indicated Patient 10 arrived at the ED at 4:33 AM. The document titled "ED NSG (nursing) Rapid Triage" indicated Patient 10's arrival time was 4:38 AM. The ED log dated 9/7/13, indicated Patient 10 arrived at the ED at 4:55 AM. A 22 minute difference between the earliest and the later. The ED log indicated MD 5 was in charge of Patient 10's care but according to the ED History and Physical, Resident MD 6 and MD 7 were the treating doctors.

3b. The ED clinical record for Patient 11 was reviewed. The document titled " Quick ID Form" dated 9/19/13, indicated Patient 11 arrived at the ED at 7:47 AM. The ED log indicated Patient 11's arrived at 7:52 AM. A 5 minute difference between the above times. The ED log indicated MD 3 was in charge of Patient 11's care but the clinical record indicated Resident MD 8 and MD 9 were the treating doctors.

3c. The ED clinical record for Patient 13 was reviewed. The document titled "Quick ID Form" dated 10/8/13, indicated Patient 13 arrived at the ED at 10:58 AM. The document titled "ED NSG Rapid Triage" indicated Patient 13 arrived at the ED at 10:55 AM. The ED log dated 10/8/13 indicated Patient 13 arrived at the ED at 11:02 AM. A seven minute difference between the above times.

3d. The ED clinical record for Patient 14 was reviewed. The document titled "Quick ID Form" had a dated stamp that was unreadable but was part of the ED record for Patient 14's 11/8/13 ED visit. The document titled "ED NSG Rapid Triage" indicated Patient 14 arrived to the ED at 1:15 PM. The ED log dated 11/8/13 indicated Patient 14 arrived at the ED at 2:16 PM. An one hour and one minute difference between the above times.

3e. The ED clinical record for Patient 16 was reviewed. The document titled "Quick ID Form" indicated Patient 16 arrived to the ED on 11/30/13 but the time was unreadable. The document titled "ED NSG Rapid Triage" indicated Patient 16 arrived at the ED on 11/30/13 at 12:35 PM. The ED log indicated Patient 16 arrived at the ED on 12/1/13 at 3:26 AM but the electronic record indicated this was the time the patient was admitted to the hospital not the time she arrived at the ED.

During a concurrent interview with the ED supervisor (RN 15) and review of the above ED clinical records on 1/30/14, at 8:35 AM, RN 15 verified the findings. She stated she did not know the reasons for the discrepancies in the ED log. She stated the ED logs should contain the correct information about the patients' visits to the ED.

4. The hospital's Case Management Log was reviewed. The log did not indicate if Patients 23 and 24 had been transferred to the hospital after the transfer requests were accepted.

During a concurrent interview with the Case Manager (CM) and review of the transfer log concerning Patient 23 and 24 in complete on 1/30/14 at 8:45 AM, she stated, "I don't know what happened to the patients...there are not records of them being seen at the hospital...I guess they did not come for some reason." The CM stated, "The transfer logs should be reviewed and completed within the same month...the transfer logs have not been monitored...they should be completed and accurate."

The hospital policy and procedure titled "Transfers from Another Facility" dated 10/2011, read "A record of all transfers, accepted or not, shall be available in the...Case Management Transfer Logs...The transfer log will contain the following information: If the transfer request is denied or placed on hold because of the status of Kern Medical Center resources or refusal of the transfer by the accepting physician, a statement of current Kern Medical Center resources, and the reason for denying the transfer will be entered in the log.