HospitalInspections.org

Based on observation, interviews and record reviews, the hospital failed to:

1) Ensure all patients presenting to the Emergency Department (ED) from 01/01/11 to 10/06/11 received an appropriate medical screening examination to determine whether or not an emergency medical condition existed, stabilizing treatment was provided and appropriate transfers were initiated if needed. The Registered Nurse's (RN's) who performed the medical screening examinations (MSE's) in Labor and Delivery (L&D) were not appointed through the hospital's credentialing process as Qualified Medical Providers (QMP) to determine if an Emergency Medical Condition (EMC) exists. The RN's performing MSE's were not recommended by the Medical Staff, nor appointed by the Governing Board to provide MSE as QMP.
Cross Reference Tag A2406

2) The hospital refused a transfer request for treatment and stabilization of a patient after a MSE was performed at another facility and an EMC was determined to exist. The hospital routinely provides acute dialysis treatment and had the capacity to treat the individual requesting transfer to the facility.
Cross Reference Tag A2411

Based on observation, interviews and record reviews, the hospital failed to:

1)Ensure all patients presenting to the Emergency Department (ED) receive an appropriate medical screening examination by a QMP to determine whether or not an EMC existed. Citing 2 of 4 patients (Patients #24 and #25) for a 10 month period (01/01/11 to 10/06/11) who presented to the hospital ED and/or L&D (Labor and Delivery) for a potential EMC.

The RN's who performed the MSE's in L&D were not appointed through the hospital's credentialing process as QMP's to determine if an EMC exists. The RN's performing MSE's were not recommended by the Medical Staff, nor appointed by the Governing Board to provide MSE as QMP.

2) Enforce the hospital policy's and procedures to ensure EMTALA requirements are met in order to provide for all patients presenting to the ED and L&D for emergency care an appropriate MSE by a QMP to determine whether or not an EMC exists, provide stabilizing treatment and appropriate transfers.

Findings Included:

Medical Records and ED Logs:

1) Review of the ED Log reflected Patient #25 who was 28 weeks pregnant presented to the ED on 06/13/11 at 8:21 P.M. for complaints of a fall trying to get into a truck. The log reflected Patient #25 was rated as an acuity level (ESI, Emergency Severity Index) ESI 4 and disposition listed as LWBS (left without being seen).
Review of Patient #25's ED Medical Record (MR) reflected "Nurses Notes...8:22 P.M...Presenting complaint: Patient states: fall from standing position getting into truck c/o left leg pain, right abdominal pain...Acuity: ESI 4...Trauma Patient? Yes...8:24 Patient pregnant...8:26 P.M. Patient moved to OB Holding...No charge for patient in the ED. Patient transported to OB observation...12:49 A.M. Patient left without being seen...Patient left the ED...OB Triage: Arrival 8:29 P.M....Attending (Physician) MD #42...RN #39...Comments: L&D Observation per Dr's orders..."

Review of Patient #25's L&D MR from 06/13/11 reflected:
8:29 P.M. "Physician Order - Labor & Delivery Outpatient...Diagnosis: Abdominal Pain/Threatened Labor...Observe x 4 hours...Discharge to home: with reactive NST and no contractions...VO (verbal order) Dr.: #42/RN #43..."
9:00 P.M. "LD Flowsheet...Phone report to MD #44, orders received to observe patient x 4 hours...RN #35"
9:48 P.M. "LD Flowsheet...Patient is G 6, P 0 (six pregnancies, no live births, G - gravida, number of pregnancies, P - para, number of viable births). At 28.6 weeks c/o (complains of) fall at 8:00 P.M., patient states she was getting into her truck when she tripped on the curb, patient fell on hands and knees, denies hitting abdomen...RN#35"
9:53 P.M. "LD Flowsheet...Patient has ABD (abdominal) Cerclage (also known as a cervical stitch, is used for the treatment of cervical incompetence (or insufficiency), a condition where the cervix has become slightly open and there is a risk of miscarriage because it may not remain closed throughout pregnancy. Usually this treatment would be done for a woman who had suffered one or more miscarriages in the past, in the second trimester of pregnancy. Abdominal cerclage involves stitching at the very top of the cervix, inside the abdomen, usually only done if the cervix is too short to attempt a standard cerclage, or if a vaginal cerclage has failed or is not possible) place by MD #45 for multiple miscarriages...RN#35"
12:21 A.M. "LD Flowsheet...Patient Discharged Home...RN #35."
The medical records for Patient #25 did not reflect an appropriate MSE was provided by a QMP or an attending physician to determine if an EMC existed in the ED or L&D.

2) Review of the ED Log reflected Patient #24 presented to the ED on 05/27/11 at 8:30 P.M. for complaints of pregnancy problem, greater than 16 weeks pregnant. The log reflected Patient #24 was rated as an acuity level ESI 4 and disposition listed as LWBS (left without being seen).
Review of Patient #24's ED Medical Record (MR) reflected "Nurses Notes...8:32 P.M...Chief Complaint: Preg. (pregnancy) problem, > 16 weeks...Presenting Complaint: Patient states: Abd (abdominal) cramping and back spasms patient is 24 weeks preg...Vital Signs (VS) B/P 136/91 (blood pressure, elevated, normal range 120/80), Pulse: 106 (elevated, normal range 60-100)...Acuity: ESI 4...8:24 Patient moved to waiting...8:33 Patient moved to OB Holding...10:15 P.M. Patient sent to labor and delivery was evaluated and discharged at 10:15 P.M..."

Review of Patient #24's L&D MR from 05/27/11 reflected:
8:52 P.M. "LD Flowsheet...Here for c/o back spasms and cramping. States she had UTI (urinary tract infection) diagnosed 5/2/11 and did not finish antibiotic course. Urine sample today dark and concentrated...RN #47."
9:00 P.M. "Physician Order - Labor & Delivery Outpatient...Diagnosis: Abdominal Pain/Threatened Labor, External Fetal Monitor...Labs: UA (urinalysis) and Urine Culture...Please call Bactrim DS (antibiotic)...into pharmacy of choice...10:08 P.M. May discharge to home...VO (verbal order) Dr.: #46/RN #47"
10:00 P.M. "LD Flowsheet...MD #46 notified of patient arrival, G/P, gestation, c/o back pain and cramping, reactive FHT's (fetal heart tones) for gestational age, UA results and hx (history) of intercourse today around 3:00 P.M.. New orders received and noted...RN #47."
10:15 P.M. "LD Flowsheet...Prescription called into pharmacy for patient. Verbal and written discharge instructions given. Discharged ambulatory...RN #47"

The medical records for Patient #24 did not reflect an appropriate MSE was provided by a QMP or an attending physician to determine if an EMC existed in the ED or L&D"

Record Reviews:
Review of the ED or OB/GYN Nursing Staff files did not contain letters of recommendation from the Medical Staff or letters of appointment from the Governing Board determining any nurses as QMP's to perform MSE's to determine if an EMC exists for patient's that present to the hospital for emergencies. The ED or OB/GYN Nursing Staff files did not contain specific QMP privileges, competencies or evaluations to perform MSE's for EMC's.

The Job Description for "Registered Nurse, Labor & Delivery" dated "June 2008" does not include the RN's responsibility of providing care as a QMP to perform MSE's to determine if an EMC exists and to provide stabilizing treatment and appropriate transfers in the event of an EMC.

The hospital policy "EMTALA Policy" dated 04/09 requires "To set forth policies and procedures for hospital's use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA...Emergency Medical Condition means...A medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably be expected to result in either: Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy...Labor means the process of childbirth beginning with the latent or early phase and continuing through the delivery of the placenta. A woman is in true labor unless a physician or other qualified medical person certifies, after a reasonable period of observation that she is in false labor. Certification of false labor by a non-physician (i.e., physician assistant, nurse practitioner, or qualified registered nurse) requires physician certification...Medical Screening Examination means the screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist...Qualified Medical Personnel means an individual or individuals determined qualified by Hospital bylaws or rules and regulations (and consistent with state licensure) to perform a Medical Screening Examination. In the hospital, QMP are limited to physicians, physician assistants, nurse practitioners, and registered nurses who have been deemed qualified to certify false labor in conjunction with physician certification...Triage is not a MSE, as it does not determine the presence or absence of an EMC...Medical Screening Examination. The hospital shall provide a MSE to any individual who comes to the emergency department...is the examination of the patient by the QMP...MSE and ongoing patient assessment must be documented in the medical record..."

Medical Staff Bylaws and Rules and Regulations: Dated 05/24/11 requires "Bylaws...The Medical Staff is responsible for the quality of medical care in the hospital and must accept and assume this responsibility, subject to the ultimate authority of the hospital's governing board...Membership on the medical staff of this hospital and/or clinical privileges is a privilege that shall only be granted and maintained by those professionally qualified and currently competent practitioners who continuously meet the qualifications, standards, and requirements set forth in these bylaws, rules and regulations...Medical Executive Committee Review and Recommendation...will review and analyze all relevant information regarding each requesting practitioner's current licensure status, training, experience, current competence, ability to perform the requested privilege...shall submit its written recommendation to the governing board...the governing board has the final authority for granting, renewing or denying privileges...Allied Health Professionals (AHP's) are health care providers who may work independently or dependently to provide health care services to patients...must be under the supervision of a member of the medical staff...are not members of the medical staff but may hold designated clinical practice prerogatives...each AHP must apply and qualify for practice prerogatives...and agree to be bound by the applicable medical staff bylaws, rules and regulations and medical staff and hospital policies...Clinical Privileges...Every practitioner providing direct clinical services...be entitled to exercise only those privileges specifically granted to him by the governing board. The privileges must be within the scope of the license authorizing the practitioner to practice in this state...Rules and Regulations...A physician member of the medical staff shall be responsible for the medical care and treatment of each patient in the hospital. All patients shall have a complete history and physician performed and recorded in the medical record by a physician who is either a member of the medical staff or has been approved by the medical staff to do so...Medical screening exams will be completed by a licensed nurse on all patients presenting to the L&D unit. Medical screening exams will be completed by a licensed MD/DO (Doctor of Osteopathy), nurse practitioner or physician assistant presenting to the Emergency Department..."

The Governing Body Rules and Regulations: not dated, requires, "The purpose of the Governing Board is to recommend and implement hospital policy, promote patient safety...provide quality patient care...has the ultimate responsibility and legal authority for safety and quality of care, treatment and services rendered in the hospital...The Governing Board shall have authority and responsibility for all appointments and reappointments of medical staff members, granting of clinical privileges...is to be exercised in accordance with Medical Staff Bylaws, Rules and Regulations......"

At 10:00 A.M. on 10/07/11 the surveyor interviewed Personnel #35, the ED Director. She was asked if the nurses perform MSE's in the ED. She stated, "No. The nurses perform triage and the physician's do the medical screening." She was asked if the nurses make the determination when the patient's are taken back to the ED to see a physician. She stated, "Yes. We use the 5 level triage system. We make the determination based on the triage system who is seen first by the physician." She was asked if it is the ED policy to send patient's to L&D without medical screening. She stated, "We send all of our patient's that are greater than 18 weeks pregnant to L&D for screening unless they are trauma patients. If they are trauma patients, they are seen and cleared first by the ED physician." She was asked if patient's are taken to L&D prior to medical screening by the ED physician. She stated, "Yes. The L&D nurses medically screen the patient's in L&D. If they are less than 18 weeks pregnant the ED physician see's them in the ED."

At 10:00 A.M. on 10/10/11 the surveyor interviewed Personnel #37, the Women's Services Director. She was asked if the nurses perform MSE's in the L&D. She stated, "Yes. All of our RN's are qualified to perform medical screening exams." She was asked if each individual RN that is performing MSE's as a QMP has been approved by the Medical Staff and referred to the Governing Body and approved and granted privileges as a QMP to determine if an EMC exists. She stated, "No. None of the RN's have been granted privileges as a QMP."

At 11:00 A.M. on 10/10/11 the surveyor interviewed the CNO (Personnel #14). She was asked if the hospital Governing Body has approved and appointed the ED and L&D RN's as QMP's to perform MSE's. She stated, "No." She verified the hospital is not following the required policies and procedures for providing appropriate MSE's with QMP's in the ED and L&D.

At 11:05 A.M. on 10/10/11 the surveyor interviewed the CEO (Personnel #15). He was asked if the hospital Governing Body has approved and appointed the ED and L&D RN's as QMP's to perform MSE's. He stated, "No." He verified the hospital is not following the required policies and procedures for providing appropriate MSE's with QMP's in the ED and L&D.

Based on interviews and record reviews, the hospital refused a transfer request for treatment and stabilization for 1 of 1 patient (Patient #1) needing acute dialysis after a MSE was performed at another facility and an EMC was determined to exist. The hospital routinely provides acute dialysis treatment and had the capacity to treat the individual requesting transfer to the facility.

Findings Included:

Review of Patient #1's Medical Record reflected an 86 year-old female was admitted to Hospital A's Emergency Department (ED) on 09/20/11at 2:45 P.M. via EMS (Emergency Medical Services) from Nursing Home B for the chief complaint of high potassium, rash to entire body, weeping wounds to legs, open healing sores on arms.

Her past medical history includes hypertension (HTN, high blood pressure), Congestive Heart Failure (CHF), Post Menopausal, Dementia, Diabetes and DVT (Deep Vein Thrombosis, blood clot). Past Surgical History includes a greenfield filter for DVT.

Current medications include Catapres (used for treatment of high blood pressure), Exelon (used to treat dementia), Humulin N (used to treat diabetes), Keflex (antibiotic), Lantus (used to treat diabetes), Norvasc (used for treatment of high blood pressure and chest pain), Protonix (used to treat gastroesophageal reflux disease), Spironolactone (diuretic, used to treat CHF). There were no known allergies to medication.

The "Physician Clinical Report" timed at 3:04 P.M. reflected, "Chief Complaint: Abnormal Potassium (High). This started today and is still present. It was abrupt in onset and has been constant...Similar symptoms previously: None...Extremities: Bilateral 3+ pitting edema of the lower extremities involving both feet, both ankles and both lower legs...Alert, no acute distress..."

Laboratory Results reflected within normal limits except for:
BNP (B-Type Natriuretic Peptide): 334.0 elevated (reference range 0.0 - 100.0, used as an aid in the diagnosis and assessment of severity of CHF).
Urinalysis: pH 5.0 (reference range 5.5 - 7.5, low is acidosis), Moderate yeast (none is normal).
CMP (Comprehensive Metabolic Panel):
Potassium 7.4 (critical high, reference range 3.5 - 5.0.)
Chloride 113 (high, reference range 98-107)
CO2 13.7 (critical low, reference range 21.0 -32.0)
Glucose 201 (high, reference range 74-106)
BUN 56 (high, reference range 7-18, Blood urea nitrogen, measures kidney function, suggestive of impaired kidney function)
Creatinine 2.3 (high, 0.60-1.30, measures kidney function, suggestive of impaired kidney function)
CBC (Complete Blood Count):
RBC (red blood cells) 3.30 (low, reference range 3.8-5.5)
Hemoglobin 9.7 (low, reference range 12.0-17.0)
Hematocrit 28.9 (low, reference range35.9- 44.6)

Treatment Provided reflected IV Saline Lock (intravenous), Vancomycin IV (antibiotic), Sodium Bicarb IV (treatment for acidosis), Insulin IV (treatment for high blood sugar), D-50 IV (treatment for low blood sugar), Albuterol Nebulizer (breathing treatment), Kayexalate (treatment for high potassium), Lasix (diuretic), Labs including CBC, Urinalysis, CMP, Portable Chest X-ray, EKG (electrocardiogram), Pulse oximeter (measures oxygen saturation), Cardiac monitor, Urine culture, Blood culture, and Foley catheter.

The "Clinical Report - Nurses" reflected at 5:08 P.M. "Stat bed contacted for transfer "At 5:23 P.M. "MD #10 accepted...Administration Approval - Patient going to ER..." At 5:48 P.M. "Lake Pointe contacted for Transfer - spoke to Personnel #13 - 5:45 P.M. called back and declined patient - no known reason..." At 7:07 P.M. "Transferred to Hospital C."

The "Physician Clinical Report" reflected "Progress and Procedures. Course of Care: Patient is stable, awake and alert...Patient accepted for transfer at Hospital C for management of Hyperkalemia and renal insufficiency as we are unable to perform dialysis at this facility...Discussed case with hospitalist, (MD #9 4:14 P.M., she agrees for patient transfer). Reviewed test results. Agreed upon treatment plan. Discussed case with on-call health care provider...Reviewed test results. Agreed upon treatment plan...Disposition: Transferred. Condition: Stable. Clinical Impression: Renal insufficiency. Cellulitis of the right leg, right ankle, right foot, left leg, left ankle and left foot. Hyperkalemia..."

Policies and Procedures:

The hospital policy "Transfers" dated 08/11 requires "To establish guidelines in accordance with the Texas Department of State Health Services regarding the evaluation, treatment, and transfer of patients between hospitals licensed...and shall govern transfers not covered by a transfer agreement...The hospital staff who has authority to represent the hospital and physician with regard to the transfer from or receipt of patients into the hospital include Administrative personnel, members of the management staff, and the house supervisors...The hospital shall recognize the right an individual to request transfer into the care of a physician and a hospital of his own choosing...A public hospital or a hospital district shall accept the transfer of its eligible residents if the public hospital or hospital district has appropriate facilities, services, and staff available for providing care to the patient...the transfer of patients may occur routinely or as part of a regionalized plan for obtaining optimal care for patients at a more appropriate or specialized facility..."

The hospital policy "EMTALA Policy" dated 4/09 requires "To set forth policies and procedures for hospital's use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA)...It is the policy of this hospital...to accept from a referring hospital within the boundaries of the United States the appropriate transfer of individuals who require the Hospital ' s specialized capabilities or facilities if the Hospital has the capacity to treat the individual...Obligation to Accept Transfers...To the extent that the hospital has specialized capabilities...or facilities...that are not available at the transferring facility, the hospital shall accept appropriate transfers of an individual needing such specialized capabilities or facilities if the hospital has the capacity to treat the individual...Personnel who accept or reject another facility's request for transfer should record the request, the response to the request, and the basis for any denial of such request, in a patient transfer request log which should be maintained in the ED in order to document the appropriateness of any transfers that were refused..."

INTERVIEWS:

During an interview at approximately 3:30 P.M. on 10/06/11 interviewed Personnel #14. She verified Patient #1's transfer request from Hospital A was denied. She was asked if the hospital had staffing and bed availability on 09/20/11 to accommodate an emergent dialysis patient. She stated, "Yes." She was asked if they had a Renal Consult and/or Nephrologists on call. She stated, "Yes." She was asked if the hospital had dialysis available that day and the capabilities to provide the patient with acute dialysis services. She stated, "Yes."