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Based on a tour of the Emergency Department (ED) and staff interviews, conducted on February 18, 2015, it was determined that the facility failed to conspicuously post signage specifying the rights of individuals under section 1866 of the Act with respect to examination and treatment of emergency medical conditions and women in labor or information indicating whether or not the hospital participates in the Medicaid program.

Findings include:

1. The following observations were made in the ED:

a. There was no signage posted in the ED triage/phlebotomy room.

b. There was no signage posted in the ED triage/medical screening exam room.

c. The above findings were confirmed by Staff #1 and Staff #2.

2. The following observations were made in the Labor and Delivery (L&D) Unit:

a. The signage posted in the entrance/waiting area was obstructed by a podium.

b. The signage posted at the L&D nursing station was inconspicuously posted next to a pile of papers.

3. The above findings were confirmed by Staff #1 and Staff #2.

Based on review of the facility's physician on call logs, and review of facility policy and procedure, it was determined that the facility failed to maintain an on call list with individualized physician names, as opposed to group names, for all disciplines.

Findings include:

Reference: Facility Policy: # T-2.1, titled 'Transfer of the Patient (E.M.T.A L.A.)' states "... PROCEDURE: ... 7. On Call Physicians. --[facility's initials]-- shall maintain a list of on call physicians available after the initial examination to provide stabilizing treatment to individuals with an emergency medical condition. Physician group names are not acceptable; individual physician names are to be identified on the list."

1. On 2/18/15 the on call lists for the previous seven months was reviewed. The physician on call list for 'Foot and Ankle' and 'Orthopedic' identified a group name on the following dates:

a. Foot and Ankle:

i. July 2, 4-7, 9-10, 16, 18-20, 23, 28, and 31 of 2014

ii. August 1-3, 5, 7, 11, 13, 15-17, 25, and 29-31 of 2014

iii. September 2, 4, 12-14, 16, 18, 22, 24, and 26-29 of 2014

iv. October 2, 6-8, 10-12, 14, 17, 24-26, and 28 of 2014

v. November 3-5, 7-10, 13, 18, 20-22, and 24-25 of 2014

vi. December 2-3, 5-8, 16, 19-22, 25, and 30 of 2014

vii. January 2-4, 6, 8, 16-19, 21-22, 30-31

b. Orthopedic:

i. July 2, 4-5, 7-10, 16-20, 22-24, 28, and 31 of 2014

ii. September 2-5, 8, 10, 12-14, 16-18, 22, 24, 27-30

iii. October 2, 6-8, 10-15, 17, 20, 22, 25-26, and 28-29 of 2014

iv. November 3-10, 13, 17-18, 20-22, and 24-26 of 2014

v. December 1-3, 5-9, 11, 15-16, 19-21, 24-26, and 30 of 2014

vi. January 2-6, 8, 15-19, 21-22, 26, and 30-31 of 2015

vii. February 4, 9-16, and 18 of 2015

c. The same orthopedic group served as the on call physician(s) for the foot and ankle, and orthopedic service dates above.

2. The facility did not implement their policy and procedure above for identifying individual physician names on the on-call list.

Based on review of facility policy and procedure, staff interview, and review of the facility's Emergency Department (ED) and Labor and Delivery (L&D) logs, it was determined that the facility failed to maintain ED and L&D specific logs that identify whether a patient was transferred, admitted and treated, or discharged from the ED or L&D.

Findings include:

Reference: Facility Policy: # T-2.1, titled 'Transfer of the Patient (E.M.T.A L.A.)' states "... DEFINITIONS: ... DOCUMENTATION: ... 3. Central Log. A central log will be maintained which reflects- the arrival time and disposition of all patients, including whether these individuals refused treatment; were denied treatment; were treated, admitted, stabilized, and/or transferred or were discharged. The disposition of all transferred patients will include, the date and time transferred as well as the facility the patient was transferred to. ..."

1. On 2/18/15 the ED and L&D logs were reviewed. The logs do not specify the disposition of the patient from the ED or L&D. Rather, it is a running log from the time each patient arrived to the facility, until the time the patient was discharged from the facility. Without an ED and L&D specific log, the disposition of a patient, following their medical screening exam, could not be determined. Examples include, but are not limited to, the following:

a. Per review of the ED log, Patient #16 arrived to the facility on 1/12/15 at 9:05 PM for complaints of "post op bleed." The log indicates the patient was transferred to a hospital for inpatient care, but does not specify the name of the hospital the patient was transferred to.

b. Per review of the L&D log, Patient #37 arrived to the facility on 1/16/15 to "rule out labor." The log indicates the patient was discharged. Per further review, it was determined that the patient was not discharged from L&D, but was admitted thru 1/18/15 and then discharged.

c. Per review of the ED log, Patient #38 arrived to the facility on 8/1/14 for complaints of a "DVT" [deep vein thrombosis] in his/her left leg. The log indicates the patient was discharged. Per further review, it was determined that the patient was admitted to the facility and discharged on 8/3/14.

2. On 2/19/15 at 9:45 AM, Staff #1, Staff #16, and Staff #17 printed out a second log for the month of January 2015 for review. This log also did not accurately reflect the patients dispositions.

a. Patient #39 arrived to the facility on 1/1/15 and his/her disposition was "transfer to hospital for inpatient" care.

b. Staff #16 confirmed in interview that Patient #39 did arrive to the facility thru the ED on 1/1/15, but he/she was admitted to the facility, stayed thru 1/6/15, and then was transferred to a hospital within the facility's healthcare system for cardiac care.

3. The facility failed to implement their policy for the central log as referenced above.

A. Based on review of facility policy and procedure, review of the medical staff bylaws, rules and regulations, and staff interview, it was determined that the facility failed to define all qualified medical persons (QMP) in it's policy, medical staff bylaws, or rules and regulations.

Findings include:

Reference #1: Facility Policy: # T-2.1, titled 'Transfer of the Patient (E.M.T.A L.A.)' states "... Qualifications: 1. For the purpose of who may perform a "medical screening examination" a "qualified medical person" is a credentialed physician on staff at --[initials of facility]-- operating within their scope of practice or a nurse practitioner in the Emergency Department of the hospital. In the case of maternal patients, a credentialed Certified Nurse Midwife utilizing the EMTALA Algorithm will also be considered a qualified medical person."

Reference #2: Facility's 'General Rules and Regulations of the Medical Staff of --[facility name ]--' states "... ARTICLE III. ADMISSION OF PATIENTS ... 12. ... (e) For the purpose of a "medical screening examination" a "qualified medical person" is a credentialed physician on staff at --[facility name]-- or nurse practitioner in the Emergency Department of the Hospital, in each case operating within his/her scope of practice or the patient's physician providing such examination within the scope of such physician's specialty. In the case of maternal patients, a credentialed Certified Nurse Midwife utilizing the EMTALA Algorithm will also be considered a qualified medical person."

1. On 2/19/15 the facility's above policy, medical staff bylaws rules and regulations were reviewed. There was no evidence that the facility included physician assistants (PA) in its definition of a QMP within its policy, or medical staff bylaws rules and regulations.

2. Staff #1 confirmed in interview that the facility has PAs on staff in the ED and L&D.

B. Based on medical record review, staff interview, and review of facility policy and procedure, it was determined that the facility failed to stabilize a patient prior to transferring the patient to another acute care hospital, in one of five pediatric transfers reviewed (Medical Record #16).

Findings include:

Reference: Facility Policy: # T-2.1, titled 'Transfer of the Patient (E.M.T.A.L.A.)' states "... DEFINITIONS: ... Medical Screening Examination: ... Stabilized. "Stabilized" means, with respect to an Emergency Medical Condition (EMC), that the treating practitioner has determined (i) within reasonable medical probability, no material deterioration of the condition is likely to result from or occur during transfer; ... . A patient is considered stabilized when the treating practitioner has determined, with reasonable clinical confidence, that the patient's Emergency Medical Condition has been resolved. ... Practitioners should use great care when determining if the medical condition is in fact stable since the patient may experience an exacerbation of the EMC. ... PROCEDURE: ... 2. Ongoing Process. A medical screening examination is an ongoing process, not an isolated event. The patient's record shall reflect continued monitoring in accordance with the patient's needs and must continue until the patient is stabilized or appropriately transferred or discharged. There should be evidence of this evaluation in the medical record prior to discharge or transfer. ... 6. Stabilization. Each patient with an emergency medical condition shall be treated and stabilized within the capabilities of --[facility's initials]--, including the use of on-call specialists as necessary. 7. On Call Physicians. --[facility's initials]-- shall maintain a list of on call physicians available after the initial examination to provide stabilizing treatment to individuals with an emergency medical condition. ... On-call physicians shall respond , in person or by telephone, within 20 minutes of a call being placed, or being beeped. ... With regard to patients age 18 or under, the in-person response time, when requested by the ED physician, shall not be longer that 60 minutes after the initial call to the on-call physician. ... 8. Appropriate Transfer. The physician or other qualified medical person determines if the patient needs treatment at anther medical facility and whether the medical benefits of this treatment outweigh the medical risks of the transfer. The hospital shall provide, prior to transfer, medical treatment for an emergency medical condition within its capacity to minimize risks to the individual ... ."

1. On 2/19/15 a review of Medical Record #16 was completed. The following was indicated in Medical Record #16:

a. Per the triage nursing notes, a four year old patient was brought to the ED on 1/12/15 at 9:05 PM with a complaint of "... spitting up bright red blood post tonsillectomy." He/she was triaged at 9:20 PM at an ESI (Emergency Severity Index) level of 3-Urgent.

b. A medical screening exam was completed at 9:30 PM and indicated "the patient presents with vomiting blood and s/p tonsillectomy. The onset was 20 minutes ago. The course/duration of symptoms is constant and Child felt sick in stomach., vomited once but continues to spits (sic) fresh blood. Vomiting: bright res. The relieving factors is none. Risk factors consist of T&A, ear tubes this morning at --[name of another acute care facility]--, discharged about 3 PM. therapy today: antibiotic ear drops. Associated symptoms: vomiting, denies abdominal pain, denies fever, and denies diarrhea. ... Physical Examination ... Ears, nose, mouth and throat: Oral mucosa moist, minimal blood in right ear canal. Throat: fresh blood cover the throat, unable to visualized [sic] bleeding area."

c. Per the physician notes, "Calls-Consults - 01/12/15 21:30:00, --[Dr.'s name]--, phone call, recommends ... to transfer to --[name of another acute care facility]--."

d. A nursing free text note [T2] on 1/12/15 at 22:00 states "pt. vomited x2 [times two] with blood clots noted. Pt. is pale. Skin warm and dry. Cap. refill 3 secs"

e. The physician's reexamination note states the following:

i. "10 PM: no vomiting, no spitting up blood"

ii. "Child had vomited blood again, O2 nasal cannula applied"

iii. "Spoke to Dr. --[Name]-- associates: to transfer to --[name of another acute care facility]--."

iv. "Spoke to transport team: 1:30 am is the earlist (sic)"

v. "Flying is not possible due to the weather."

vi. "Spoke to Dr. (ENT on call at this facility): to transfer to --[name of another acute care facility]--."

vii. "Child will transfer to -- [name of another acute care facility]--/OR directly under Dr. (Name of receiving MD)."

viii. "Child had 2 episodes of vomiting-clots, pale, HR 130, BP 96/61 will transfuse 10 cc/kg"

ix. "Spoke with Dr. (ENT on call at this facility): he will call OR here at CMC/ awaiting call back."

x. "11:55 pm transport team from --[name of another acute care facility]-- is here. Dr. (ENT on call at this facility) arrived while start [SIC] transporting child."

2. The patient's hemoglobin was 10.4 and a blood transfusion was ordered. The blood transfusion was started at 11:50 PM and the transport ambulance arrived at 12:00 AM and left at 12:15 AM with the patient. The risks on the consent to transfer form states, "Shock, Aspiration."

3. This facility does have pediatric services. The on-call surgeon was contacted and on his/her way to the facility when the patient was transported.

4. Staff #1 stated the following, upon interview on 2/19/15 at 11:00 AM:

a. The facility was made aware of this unstable transfer when the Chief Medical Officer received notice from the receiving facility's Department of Surgery Chair.

b. The receiving facility was lead to believe that this facility's ENT physician that was on call, refused to see the patient.

c. This facility's ENT did not refuse to see the patient, but arrived on site just as the ambulance left to transfer the patient.

d. Upon review of the case by this facility, it was determined that the patient was transferred in unstable condition, and this facility reported the event to the NJ Department of Health.