HospitalInspections.org

Based on review of the hospital's Medical Staff Bylaws, medical staff policies and procedures and staff interviews, the hospital failed to ensure written policies and procedures were in place that ensured: a medical record was established for each patient presenting to the emergency department seeking treatment; physicians, physician assistants, and nurse practitioners were credentialed in accordance with hospital bylaws; and hospital bylaws clarified who can perform medical screening exams.

Based on record review and interview the hospital failed to ensure a medical record was created for each patient presenting to the emergency department seeking treatment. The hospital failed to ensure a medical record accompanied a patient that was transferred from the emergency department to a clinic that was not hospital owned or operated. Findings:
Review of the emergency room log revealed a patient's name entered on 11/22/10 at 3:55 pm. The entry had a line drawn through it and under the section "Nature of Injury/Illness" was written "Pt went to clinic".
On 12/13/10 Medical record staff was asked if there was an Emergency Department record for this patient on 11/22/10. Medical record staff confirmed there was no patient record. Interview on 12/14/10 at 3:30 pm with RN #3 revealed that on 11/22/10 a mother brought a child in with a foot laceration. RN #3 described the mother as having a "panicked" look. RN #3 said the mother requested the child be examined. RN #3 stated she did a brief assessment and determined the foot laceration would need suturing. RN #3 called the physician on-call, who was working next door in the Ilanka Clinic at the time. She spoke with an administrative assistant at the clinic who told her the physician's schedule was full and that he could see the patient in the clinic, but not the emergency room. The administrative assistant came over to the hospital side and confirmed with the acting hospital administrator that the physician was on-call for the emergency room. RN #3 stated "I was frustrated". She said that she told the director of nursing that the doctor was on-call but didn't want to come. After approximately 20 minutes the patient was transferred to the Ilanka Clinic for treatment.
During an interview with the hospital's acting administrator on 12/15/10 at 9:55 am, she confirmed the Ilanka Clinic, which is located next to the hospital, was a Community Health Center that was tribally owned and managed. She also confirmed the Ilanka Clinic was not a department of the hospital and that it billed under a different Medicare number.

Based on review of emergency room patient records, Medical Staff Bylaws, Bylaws of the Health Services Board, hospital policies and procedures and interviews, the hospital failed to ensure: 1) medical staff bylaws and emergency department policies and procedures included EMTALA requirements and 2) medical screening examinations were conducted by qualified individuals. Findings:

EMTALA Requirements

Review on 12/13-15/10 of Medical Staff Bylaws, Bylaws of The Community Health Services Board (hospital's governing body), and Medical Staff policies and procedures revealed EMTALA requirements were not included.


Medical Screening Exams by Qualified Individuals - Physicians, Physician Assistants, Nurse Practitioners

Review on 12/14/10 of the Medical Staff Bylaws revealed the bylaws included, "...Membership on the staff of Cordova Community Medical Center is a privilege which shall be extended only to those practitioners who strictly meet and continue to meet the standards and requirements set forth in these bylaws...Terms of Appointment: Appointments shall be made by the Health Services board after recommendations of the active staff and shall be for a period of two (2) years or until the end of the Medical Staff two (2) year period, which ends in the even year. Before the end of the Medical Staff two (2) year period, the Chief of Staff shall submit to the health Services Board, through the administrator, the recommendation for reappointment of a member to the medical Staff for an additional two-year period, together with recommendations concerning the privileges to be accorded such member."

Review on 12/14/10 of the Bylaws of The Community Health Services Board (hospital's governing body) revealed, "...Medical Staff C. Membership. Membership of the medical staff shall be restricted to physicians, dentists, podiatrists, and mid-level health professionals competent in their respective fields, in good standing...Appointment to the medical staff shall be made by the board after recommendation of the medical staff as outlined in the by-laws of the medical staff...G. Action of the Board; Corrective Action; Summary Suspension. In accordance with the rules set forth in the medical staff by-laws, the board shall take action or make a decision: 1. Approve or deny an application for membership to the medical staff; 2. Revoke membership of the medical staff; 3. Approve or deny a request by a member of the medical staff for additional privileges; 4. Impose additional limitations with respect to the practice of medicine, dentistry, or podiatry; 5. The Administrator may grant temporary privileges to any other providers for up to 2 weeks."

Review on 12/14-15/10 of the physician credentialing files revealed no documented evidence the credentialing process, including the granting of temporary privileges, had been started or completed for the following physicians, physician assistants and nurse practitioners who covered the hospital's emergency department:

Nurse practitioner #1 - between 7/10/10 - 12/14/10 the nurse practitioner treated 191 patients; transferred 16 patients. There was no documented evidence of the governing body's appointment/approval.

Physician assistant #1 - between 12/18/09 - 4/15/10 the physician assistant treated 105 patients; transferred 5 patients. There was no documented evidence of the governing body's appointment/approval.

Nurse practitioner #2 - between 6/7/10 - 7/2/10 the nurse practitioner treated 47 patients; transferred 1 patient. There was no documented evidence that the credentialing process had been started.

Physician #1 - between 7/3/10 - 7/7/10 the physician treated 22 patients and transferred 1 patient. There was no documented evidence that the credentialing process had been started.

Physician #2 - between 8/28/10 - 9/22/10 the physician treated 21 patients. There was no documented evidence that the credentialing process had been started.

Physician assistant #2 - between 8/25/10 - 11/15/10 the physician assistant treated 19 patients; transferred 1 patient. There was no documented evidence that the credentialing process had been started.

Physician #3 - between 6/5/10 - 6/26/10 the physician treated 18 patients. There was no documented evidence of the governing body's appointment/approval.

Physician #4 - between 10/7/10 - 10/14/10 the physician treated 6 patients. There was no documented evidence of the governing body's appointment/approval.

Physician #5 - review of the November's emergency room on-call schedule revealed physician #5 was on-call 11/9; 13; 16; 20; and 24/2010. There was no documented evidence of the governing body's appointment/approval.

During an interview on 12/14/10 at 9:55 am with the acting hospital administrator, she was asked to review the physician/provider credentialing files for documented evidence of the completed credentialing process. The acting administrator did not find any additional documentation. No documentation was presented prior to exit.



Medical Screening Exams by Qualified Individuals - Registered Nurses

During an interview with the hospital's acting administrator on 12/15/10 at 9:55 am she stated that only physicians, physician assistants, and nurse practitioners could perform medical screening exams. She stated, "No nurse should be doing that; I always direct them to call the doctor."

Review on 12/14/10 of the "Nursing-Emergency Room EMTALA/COBRA Compliance", a nursing policy and procedure with an effective date of 3/19/08, included: "Policy: Cordova Community Medical Center (CCMC) will comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) and the Consolidate Omnibus Budget Reconciliation Act (COBRA) regulations...Procedures: 2. medical screening examinations, beyond initial triaging, must be offered to any individual presenting for examination or treatment of a medical condition...4. Personnel Qualified To Perform medical Examinations: a. Persons qualified to perform emergency medical examinations, and the Certification of False Labor are defined in the Medical Staff Rules and Regulations. The following are designated as qualified medical personnel to perform emergency medical examinations:...3. Emergency Room Registered Nurses and Sexual Assault Nurses who meet job description criteria, and have completed orientation, which includes successful completion of a medical screening examination competency test, may perform the medical screening in accordance with Emergency Department Policy and Procedures." (Interview on 12/15/10 with the director of nursing at 3 pm and the hospital administrator on 12/15/10 at 9:55 am confirmed the Medical Staff Rules and Regulations referred in this policy were also known as the Medical Staff Bylaws).

Review on 12/14/10 of the Medical Staff Bylaws and the Bylaws of The Community Health Services Board (hospital's governing body) revealed the bylaws did not define personnel qualified to perform emergency medical screening examinations.

Review of the "Non-Medical Provider Medical Screening Examinations", a nursing policy and procedure, last reviewed on 5/18/10, revealed "...Qualifications: 1. In order to qualify for the privileges as a designated screening professional, the applicant must meet the following criteria: a. Be a Registered Nurse (RN) or a Sexual Assault Nurse Examiner who: Has completed orientation to CCMC, The Emergency Room (ER), and EMTALA regulations. Has passed a qualifying exam established by CCMC, confirming his/her understanding of EMTALA regulations and requirements of a medical screening exam. 2. In addition the applicant must: b. Have been approved by the Medical Chief of Staff.

Based on review of emergency room patient records, findings were as follows:

Patient # 1 was a 16 year old male who arrived via car to the Emergency Department at 2340 on 7/5/2001 following a motor vehicle accident (MVA). Patient was a passenger in the accident, who stated to RN he " rolled out of car " and had chief compliant of neck pain. Following initial triage and assessment by the Emergency Department (ED) RN, the ED physician was notified via telephone at 2355 on 7/5/2010. RN obtained a telephone order to "Assess for point tenderness on neck. " Patient was discharge to home with Discharge Instructions that included "Handout for closed head injury. " Discharge at 0010 on 7/5/2010.

Patient who sustained a MVA was discharged to home and was not given a medical screening evaluation (MSE) by a qualified medical health professional.

Patient #2 was a 52 year old female who arrived via Emergency Medical Service (EMS) at 2210 on 8/10/2011 with a chief compliant of cough, sore throat and nausea. Following initial triage and assessment by the Emergency Department (ED) RN, the ED RN telephoned the Nurse Practitioner who was the mid-level health professional covering the Emergency Department. Telephone orders were obtained for blood glucose test and medications. Patient was discharged to home and given Discharge Instructions that included: antiemetic, antibiotics, cough syrup, and instructions to increase fluids and rest.

Patient was discharged to home at 2325 on 8/10/2010 without given a medical screening evaluation (MSE) by a qualified medical health professional.

Interviews on 12/14/10 at 8:20 am with RN #1; 8:50 am with RN #2; 3:30 pm with RN #3; and on 12/15/10 at 12:50 pm with RN #4 confirmed they all performed medical screening exams in the emergency department. In addition, they all confirmed there was no formal training in EMTALA; they were to refer to an EMTALA notebook. The registered nurses also confirmed they had not taken a medical screening examination competency test.

During an interview with the director of nursing on 12/15/10 at 1:55 pm she confirmed the registered nurses, who performed medical screening exams, had not completed competencies or passed a qualifying exam. There was no documented evidence of approval by the Medical Chief of Staff.