HospitalInspections.org

Based on observation, record review and interview for six patients (Patient #10, #11, #12, #13, #14, and #15) of sixteen patients sampled, the facility failed to establish policies and procedures governing the medical care provided in their emergency services department and failed to practice under established policies and standards of care.

Findings include:

The surveyor interviewed the Chief Medical Officer (CMO), on 4/10/18 at 7:50 A.M. The CMO said that Hallmark Health's Emergency Services encompassed 4 sites, Hallmark Melrose Wakefield, Hallmark Lawrence Memorial, Hallmark Urgent Care at Lawrence Memorial, and Hallmark Urgent Care in Reading. The CMO said that along with the Emergency Room physicians the facility employed Physician Assistants (PAs) as well. The CMO said that the Hallmark Urgent Care in Reading was staffed by a PA and a nurse with telephone access to a supervising physician. The CMO said that the hospital had a waiver to allow the PA to work remotely without having a physician on site. The CMO said that all PA charts are reviewed by the MD the same day.

Review of a document sent from the Executive Office of Health and Human Services, Department of Public Health, Division of Health Professions Licensure, Board of Registration of Physician's Assistants, dated February 22, 2013. reads "A Physician Assistant may be used in an urgent care setting as the sole clinician on site in accordance with the following" and included: The PA/supervising physician scope of practice agreement must state the parameters within which the PA is to consult with the physician (i.e., procedures) as well as measures to maintain quality care.

The Surveyor requested the scope of practice agreement for the PA and supervising physician and the following document was submitted : "Hallmark Health, Role of Physician Assistant in the Emergency Department (ED)". Review of the section Duties and Responsibilities of the Emergency Medicine Physician Assistant, section 1. (l.), indicated that all PA charts are reviewed and co-signed by the on-duty ED physician on the day of the patient interaction. PAs are expected to consult with the on duty ED physician for any questions or concerns on any case at which time the ED physician will review the case in detail with the PA, and, if necessary, directly evaluate the patient and write a brief additional note.

The Surveyor interviewed PA #1 at the Hallmark Urgent Care in Reading, on 4/10/18 at 12:55 P.M. PA #1 said that he was the only PA on service. PA #1 said that he rarely consults the physician for advice. When asked if he would care for a one day old newborn, PA #1 said yes. PA #1 said there were no patient age limitations for PAs. PA #1 said "I see all age patients" or words to that effect. PA #1 said that he would only refer patients that needed a more thorough workup, requiring lab work or radiology.

The Surveyor interviewed the CMO, on 4/11/18 at 10:55 A.M. The CMO said that the expectation of the Hospital is that PAs see patients that are 90 days old or older and with an Emergency Severity Index (ESI) score of 3 or higher (The Emergency Severity Index (ESI) is a five-level emergency department triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs). The CMO again said that the MD reviews the chart the same day. The CMO said that the MD signs the chart after reviewing the chart.

The Surveyor interviewed the Chief PA at the Hallmark Urgent Care in Reading on 4/12/18 at 07:45 A.M. The Chief PA said that there was no age limitation to the patients he was permitted to examine. The Chief PA said that they do not assign an ESI score in the Urgent Care.

The Surveyor reviewed Patient #10's chart. Patient #10 is a seven month old that was seen on 1/25/18 by the PA at the Hallmark Urgent Care in Reading for an earache. The Discharge Instructions read: alternate Tylenol and Motrin as needed for fever. The Discharge Instructions did not indicate dose amount or administration frequency. The physician reviewer did not electronically sign this chart for over 24 hours.

The Surveyor reviewed Patient #11's chart. Patient #11 is a three year old that was seen on 2/14/18 by the PA at the Hallmark Urgent Care in Reading for headache for two days. Patient #11's Hallmark Health Urgent Care -Departure Note indicated under Discharge Instructions, "Go to E.R. for further management". Patient #13 was not weighed. The record was electronically signed by the MD four days after Patient #13 was seen.

The Surveyor reviewed Patient #12's chart. Patient #12 is an 11 month old that was seen on 1/28/18 by the PA at the Hallmark Urgent Care in Reading for bilateral eye drainage. Patient #12 was not weighed and the nursing note indicated that vital signs were obtained by the Radiology Technician.

The Surveyor reviewed Patient #13's chart. Patient #13 is a five year old that was seen on 2/27/18 by the PA at the Hallmark Urgent Care in Reading for left ear pain. Patient #13 was not weighed. Patient #15's Discharge Instructions and Treatment section of the Urgent Care Center Report indicated Patient #13 was prescribed Cefdinir (an antibiotic), Tylenol and Ibuprofen. The Discharge Instructions did not indicate the dose amount. No doses were included in the Discharge Instructions.

The Surveyor reviewed Patient #14's chart. Patient #14 is an eight year old that was seen in 1/3/18, by the PA at the Hallmark Urgent Care in Reading for a lip laceration. Patient #14's Hallmark Health Urgent Care -Departure Note indicated that the patient was instructed to take Tylenol as needed for pain and have stitches removed in 5 days. No doses were included in the Discharge Instructions and the Urgent Care Center Report did not indicate how many sutures were placed or how many were to be removed.

The Surveyor reviewed Patient # 15's chart. Patient #15 is a seven year old that was seen on 4/10/18 by the PA at the Hallmark Urgent Care in Reading for a left earache and fever. Patient #15's Discharge Instructions and Treatment section of the Urgent Care Center Report indicated that Patient #15 was prescribed Amoxicillin, Tylenol, and Ibuprofen. No doses were included in the Discharge Instructions.

The Chief Nursing Officer (CNO) was interviewed on 4/12/18 at 1:17 P.M. The Surveyor reviewed Patient #10, #11, #12, #13, #14, and #15's charts with the CNO. After review, the CNO said that the standard of care and the Facility's expectation is that all pediatric patients are weighed regardless of why they are being seen. The CNO said that her expectation is that the emergency trained RN's obtain all pediatric vital signs in the Urgent Care setting. The CNO said that a Radiology Technician obtaining vital signs on a pediatric patient is unacceptable.

The CMO was interviewed on 4/12/18 at 1:35 P.M. The Surveyor reviewed Patient #10, #11, #12, #13, #14, and #15's charts with the CMO. After review, the CMO said that he and the Facility expects that all pediatric patients are weighed during assessment or triage. The CMO said that the Hospital expects that all medications reviewed during discharge must include a dose. The CMO said that all patients who are examined by a PA must have evidence of an MD review documented in the chart or the chart must be signed on the same day of the patient examination.