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Based on review of hospital emergency services policies and procedures, Medical Staff Bylaws/Rules and Regulations, on-call physicians rosters, medical records and interviews with hospital staff, the hospital failed to do the following: (a) post EMTALA signs conspiculously for individuals entering the emergency department - Refer to Tag 2402; (b) provide physician-specific general surgery on-call rosters - Refer to Tag 2404; and (c) provide a medical screening examination to 1 of 26 emergency department patients who arrived by ambulance - Refer to Tag 2406.

Based on observation and interviews, the hospital failed to post EMTALA signs conspicuously in places that individuals entering the emergency department could see easily.

Findings:

1. During the Emergency Department (ED)
tour on 04/15/2010 at 11:00 AM only 1 sign
was observed posted throughout the ED areas.
The 1 sign was located in the ED waiting
area located over the west corner of ED
entrance. This location made it difficult
for individuals to see or read the EMTALA
sign. This sign could only be viewed by
individuals who were present in the ED
Registration areas.

2. On 04/15/2010 at 11:00 AM, during an
interview with the Relief Charge Nursing
in the main ED, reported that no signs
were posted in the main ED or actual
patient exam rooms. Observation of
exam room #10 determined that no signs
were posted explaining the patient rights
regarding the EMTALA Laws.

3. The Risk Manager and ED Medical Director
confirmed that only one sign was posted in the
ED areas. The hospital failed to conspicuously
post signs specifying the rights of individuals
under the EMTALA Law.

I. Based on review of Medical Staff Bylaws,
Rules and Regulations, interviews with ED
staff and medical staff coordinator, the
hospital failed to develop physician-specific
on-call lists/rosters.

Failure to complete on-call physician
lists/rosters with individual physician names and
contact information, fails to ensure that ED
personnel can contact the correct specialist to
provide prompt treatment/stabilization to the
ED patients.

Findings:

1. On 04/21/2010 at 3:00 PM, this investigator
reviewed the Medical Staff Bylaws. The Medical
Staff Bylaws were revised on 02/2009 by the
Medical Staff. Page 7 in section C of the
Medical Staff Bylaws documented that physicians
are to participate in covering the emergency
room and other specialty programs on campus.
The physicians would provide on call coverage to
patients in the ED. The on call physician names
were placed on the monthly on call rosters.
The physicians could be exempted from the
on call duty by presenting reasons to the Medical
Staff Committee.

2. During the interview on 04/21/2010 at 10:00 AM the Medical Staff Coordinator explained that ED physicians used on-call physician rosters/lists to serve patients in the ED that required special medical services. The investigator reviewed 6 months of on call physician rosters/lists (Nov 2009 - May 2010) for General Surgery, OB/Gynecology, Orthopedics, and Neurology specialists.

On-Call Physician General Surgery
Roster Review:

3. The investigator reviewed the General Surgery on-call physician rosters on 4/22/2010 at 2:00 PM. The review of the General Surgery 6 month on-call rosters revealed that a group named "Fast Surgeon" were identified on the monthly rosters with a contact number.

4. During the interview on 04/21/2010 with the Medical Staff Coordinator. S/he explained this group was made up of four surgeons. S/he reported when ED staff needed surgery services, the staff contacted the "Fast Surgeons" group contact number. ED staff
would receive a message identifying what surgeon was on-call for that day.

5. General surgery on-call rosters had the group surgeon names but failed to document
individual physician names and individual physician contact phone numbers on all 6 month on-call rosters.

Based on medical record reviews, administration
interviews and policy reviews, the hospital failed
to provide a medical screening exam for 1 of 26
patients (Pt #26) in the ED.


Findings:
1. On 04/15/2010 at 10:30 AM, the investigator reviewed the ED policy titled, "EMTALA How to Comply with the Law." The policy was revised by administration on 09/2006 and was referenced with # 345.00. The review noted an entry in section E1, onpage 3 of 10, that individuals who come to a dedicated ED must receive a medical
screening exam (MSE) to determine if an emergency medical condition exists (EMC).

2. On 04/15/2010 at 10:45 AM, the investigator
interviewed the ED Medical Director of SCH.
The ED Medical Director reported Pt #26
came by ambulance with chest pain on
March 2, 2010 at 12:00 noon. The Pt #26
remained in the ambulance. A paramedic
came into the ED and gave the patient's
(EKG) electrocardiogram strip to a nurse.
The paramedic thought the patient's EKG
was showing Sinus Tachycardia (ST)
ventricular rhythm. The nurse gave the strip
to ED Physician #1 to evaluate the EKG strip.
ED Physician #1 agreed with paramedics EKG
interpretation. ED Physician #! informed the
paramedics this hospital did not have a
cardiac cath lab and the patient would be
better served in another hospital that had the
capabilities. ED Medical Director reported
the Pt #26 did not receive a MSE. The ED
Medical Director reported s/he was not aware
of the incident until March 5, 2010.

3. On 04/21/2010 at 1:30 PM, the investigator
interviewed ED Physician #1. The ED Physician #1 stated
that ED staff come to him/her asking
questions regarding patients medical problems.
ED Physician #1 reported s/he is aware of EMTALA
Laws and has worked in EDs for several years.
ED Physician #1 recalled that a nurse brought him/her
an EKG strip to review. ED Physician #1 explained
s/he was not aware the patient was in the
ambulance. ED Physician #1 told the paramedics
that the patient would be better served in a hospital
that had cath capabilities and asked the
question, "What do you usually do in this case?"
The paramedic returned to the ambulance
and left the hospital's ED.

4. On 04/21/2010 at 2:10 PM, the investigator
interviewed Emergency Services Director RN.
The investigator asked how paramedic calls
are received in the ED. The director explained
the Ambulance Alert procedure works as follows:
a. ED charge nurse or ED physician can take
the paramedic call.
b. ED staff documents the paramedic's report
on the ED Ambulance Tracking Log to include
information i.e. patient vital signs, patient's
complaints, what treatment was provided
and when the ambulance will arrive to ED.
c. The charge nurse assigns an exam room to
the patient and alerts the ED physician about
the new patient arriving to ED.
d. When paramedics arrive to the ED, the charge
nurse directs paramedics to the assigned room
and patient is moved from the stretcher to the
ED gurney. During the ED tour this procedure
was observed on 04/15/2010 at 11:00 AM.

5. The investigator asked the director for a copy
of the Ambulance Tracking Log dated 03/02/2010
for review. The Ambulance Tracking Log was
provided and review determined the following:
a. On 03/02/2010 at 12:00 PM, the ED charge
nurse took a call from the Lakewood Fire
Department # 20. The parametrics reported
arrival time was within 10-15 minutes.
b. ED charge nurse documented on the
Ambulance tracking Log that Pt #26 was
a 53 year old male who experienced a syncope
event (ie, faint, a spontaneous loss of consciousness caused by insufficient blood to the brain), with an elevated orthostatic blood pressure
and vital signs were documented.
c. The charge nurse pre-assigned Pt #26 to exam room #19 where the patient would be
medically evaluated.
d. Charge nurse documented on the Ambulance
Tracking Log at 2:31 PM that Pt #26 had been sent
"directly" to a hospital that had cardiac cath capabilities.

6. In the case of Pt #26, the ED staff did not ask the paramedics to move Pt #26 from the ambulance and to place in the assigned ED exam room for a medical screening exam. The ED staff failed to follow the usual ED admitting procedures for ambulance patients. No MSE was conducted by the ED physician to determine if the patient had an EMC.