HospitalInspections.org

Based on interviews and documentation review, it was determined the Hospital failed to fully implement its POC related to Deficiencies associated with its 7/15-7/16/10 EMTALA Survey.

Findings included:

1.) The SOD associated with the Hospital's 7/15-7/16/10 EMTALA Survey indicated the Hospital failed to provide an appropriate Medical Screening Examination (MSE) to Patient #16 (Tag A2406).

The Hospital's POC related to Tag A2406 indicated: a random sample of 30 Emergency Department (ED) records would be reviewed/audited each month for 3 months beginning in September 2010 to determine if adequate MSEs were performed; the results of the September audits would be reviewed at the 9/28/10 Patient Care Assessment Committee (PCAC) Meeting; subsequent audits would be reviewed at the 11/16/10 PCAC Meeting and; the Hospital's President & CEO (who is also the Chairperson of the PCAC) was responsible for assuring that the POC related to Tag A2406 was implemented.

Documentation indicated the records of 30 patients presenting to the ED between 8/31 and 9/19/10 were reviewed and: 29 records were found to have documentation of an adequate MSE and; 1 patient left without being seen. The Audit was reported to the PCAC on 9/28/10 and the related minutes read: "The Nurse Manager of the ER and the DEM provided a summary of chart audits conducted on ER visits from September 2010. The preliminary results show that all patients had adequate medical screening examinations" . . . "A final report will be prepared and submitted to PCAC. The results will also be reported to the Board of Trustees."

The Vice President (VP) of Quality Systems and Managed Care was interviewed in person throughout the Follow-Up Survey. She said the "Final Report" was not (yet) completed.

The 10/12/10 Board of Trustees Meeting Minutes indicated the VP of Quality Systems and Managed Care updated the Board on the Hospital's activities following the recent EMTALA Survey and there were "ongoing audits of ER visits and transfer forms."

The VP of Quality Systems and Managed Care said there was discussion regarding the MSE audits at the 10/12/10 Board of Trustees Meeting, but she could not recall the specifics of the discussion. There were no associated handouts/reports/slides etc.

A review of MSE audits conducted since 9/19/10 revealed 20 audits had been completed.

The VP of Quality Systems and Managed Care said the 11/16/10 PCAC Meeting was postponed until 11/23/10.

A review of 15 randomly selected records of patients transferred from the ED between 10/30 and 11/17/10 determined 14 patients had an appropriate MSE (See Tag A1104).

2.) The SOD associated with the Hospital's 7/15-7/16/10 EMTALA Survey indicated the only patient in a sample of 17 patients transferred from the Hospital's ED during the time period of 1/1-7/7/10 with an unstabilized emergency medical condition (Patient #3), was transferred without physician certification containing a summary of the risks and benefits upon which the transfer decision was based (Tag A2409).

The Hospital's POC related to Tag A2409 indicated that: beginning on 9/1/10, the transfer forms of all unstable patients transferred from the Emergency and/or Obstetric Departments would be reviewed/audited to determine if the risks and benefits of transfer were documented; the audits would continue until 100% compliance was achieved for 3 consecutive months; the ED Nurse Manager would conduct the audits on a monthly basis and; the results of the audits would be discussed at the 9/28 and 11/16/10 PCAC Meetings.

The ED Nurse Manager was interviewed in person throughout the Follow-Up Survey. She said she identified unstable transfers by reviewing Transfer Forms, and there was only 1 unstable transfer from the Hospital's ED in September 2010 (Patient A).

A review of the Transfer Form related to Patient A revealed the physician checked boxes indicating: "Patient has been stabilized so, within reasonable medical probability, no material deterioration of the patient's condition is likely to result from transfer" and "Patient is unstable, but expected medical benefits of transfer outweigh potential risks associated with transfer".

The Nurse Manager did not report a review of Patient A's medical record in order to determine if the patient was stable or unstable at the time of transfer, but said the Director of Emergency Medicine discussed proper completion of the Transfer Form with the physician who completed it, because the risks and benefits of transfer were not documented.

Documentation indicated the September Transfer Form Audit was reported to the PCAC on 9/28/10 and the related minutes read: ("The Nurse Manager of the ER and the DEM provided a summary of chart audits conducted on ER visits from September 2010.") "There were some transfer documents that were not thoroughly completed." ("A final report will be prepared and submitted to PCAC. The results will also be reported to the Board of Trustees.")

The VP of Quality Systems and Managed Care said the "Final Report" was not (yet) completed.

The 10/12/10 Board of Trustees Meeting Minutes indicated the VP of Quality Systems and Managed Care updated the Board on the Hospital's activities following the recent EMTALA Survey and there were "ongoing audits of ER visits and transfer forms."

The VP of Quality Systems and Managed Care said there was discussion regarding the Transfer Form Audits at the 10/12/10 Board of Trustees Meeting, but she could not recall the specifics of the discussion. There were no associated handouts/reports/slides etc.

A review of Transfer Form audits conducted since September 2010 revealed 10 Transfer Forms on which the box indicating "The patient may be at risk for deterioration from or during transport" (see below) had been collected and blanks on the Forms had been highlighted. The Forms had not (yet) been analyzed.

Note: The Hospital revised its Transfer Form sometime in September 2010. The revised Form eliminated the Patient condition options of:
"Patient has been stabilized so, within reasonable medical probability, no material deterioration of the patient's condition is likely to result from transfer" and "Patient is unstable, but expected medical benefits of transfer outweigh potential risks associated with transfer"
and replaced them with:
"There is no reasonable likelihood of deterioration from or during transport", "The patient may be at risk for deterioration from or during transport" and "Patient is pregnant with contractions" followed by: "Based upon my examination of the patient and the information available to me at the time of transfer, I certify that the risks of are outweighed by the benefits reasonably anticipated from proper care at the receiving facility."

The VP of Quality Systems and Managed Care said the 11/16/10 PCAC Meeting was postponed until 11/23/10.

A review of 15 randomly selected records of patients transferred from the ED between 10/30 and 11/17/10 determined the Transfer Forms associated with 6 stable patients (Patients #2, #4, #8, #9, #10 and #12) had the box indicating "The patient may be at risk for deterioration from or during transport" checked and the Transfer Form associated with 1 unstable patient (Patient #7) had the box indicating "There is no reasonable likelihood of deterioration from or during transport" checked.

The review of the randomly selected records of patients transferred from the ED between 10/30 and 11/17/10 also determined that documentation related to the provision of medical record information to receiving facilities was not present for 3 of 3 unstable ED transfer patients (Patients #1, #7 and #13).

Based on medical record review, it was determined the Hospital's ED failed to obtain an electrocardiogram (EKG; a record of the electrical activity of the heart) on a patient with possible/probable cardiac symptoms (Patient #1) within the American Heart Association's time guideline.

Findings included:

The American Heart Association's time guideline for obtainment of EKGs on patients with possible/probable cardiac symptoms is 10 minutes.

Medical record documentation indicated Patient #1; a 45+ year old male, presented to the ED at 1:56 PM with complaint of 9/10 mid-sternal chest pain/pressure and left arm numbness and an EKG was not obtained until 2:34 PM.

The ED Nurse Manager said she the ED did not have a policy/procedure regarding the obtainment of EKGs on patients presenting with possible/probable cardiac symptoms, but the EKGs were usually obtained within minutes of such patients arrival.

Patient #1 was evaluated, diagnosed with an inferior myocardial infarction (heart attack), provided with medical treatment within the Hospital's capacity, and transferred to a tertiary care hospital by helicopter; in unstable condition.