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Tag No.: A2400
Based on review of facility documents and medical records (MR) and staff interviews (EMP) interviews, it was determined the facility failed to comply with 489.24 related to On Call Physicians, Medical Screening Examination and Stabilizing Treatment.
Findings include:
The review of facility documentation and medical records and staff interview revealed the facility failed to maintain an on call physician list, failed to ensure an appropriate medical screening examination (MSE) was completed in two of two MRs reviewed (MR1 and MR7) and failed to ensure transfer of a patient with an emergency medical condition for further medical examination and treatment required to stabilize the condition when the facility lacked those capabilities in two of two applicable MRs reviewed (MR1 and MR2).
Cross reference
489.20(r)(2) and 489.24(j)(1-2) - On Call Physicians
489.24(a) and 489.24(c) - Medical Screening Exam
489.24(d)(1-3) - Stabilizing Treatment
Tag No.: A2404
Based on review of facility documents, observations made, and staff interview (EMP) it was determined the facility failed to develop and utilize on-call physician schedules in the Emergency Department.
Findings:
Review on January 5, 2023, of the facility document, "UPMC Lock Haven Medical Staff Rules and Regulations," last approved May 12, 2021, revealed "UPMC Lock Haven Medical Staff Rules and Regulations The Medical Staff Rules and Regulations represent a set of standards established by the Medical Staff for the day to day function and delivery of care by Medical Staff members. ... Article VI Emergency Medical Screening, Treatment, Transfer and On-Call Roster Policy... 6.2 Consultations, Referrals and Emergency Department Call 6.2(a) An appropriate attempt to contact the physician after verifying that the physician is on call, will be considered to have been made when the Emergency Department Physician or Emergency Department designee has: (1) Attempted to reach the physician in the hospital; (2) Called the physician at his/her office; and (3) Called once on the physician's pager (4) Called the physician at home; Twenty minutes will be considered a reasonable time to carry out this procedure. 6.2(b) The rotation call list, containing the names and phone numbers of the on-call physicians shall be posted in the Emergency Department. In the event that the patient does not have a private physician, or the physician cannot be contacted within twenty (20) minutes of the initial request, the rotation call list shall be used to select a private physician to provide the necessary consultation or treatment for the patient. A physician who has been called from the rotation list may not refuse to respond. The Emergency Department physician's determination shall control whether the on-call physician is required to come in to personally assess the patient. Any such refusal shall be reported to the CEO and Chief of Staff for further action and may constitute ground for revocation of the physician's Medical Staff appointment and clinical privileges. 6.2(c) The physician called from the rotation schedule shall be held responsible for the care of a patient until the problem prompting the patient's assignment to that physician is satisfactorily resolved or stabilized to permit disposition of the patient. This responsibility may include follow-up care of the referred patient in the physician's office. If, after examining the patient, the physician who is consulted or is called from the rotation schedule feels that a consultation with another specialist is indicated, it will be that physician's responsibility to make the second referral. The first physician consulted retains responsibility for the patient until the second consultant accepts the patient. 6.2(d) Members of the Active Staff shall participate in the on-call backup to the Emergency Department if required by State and Federal Law if required by the Board, upon recommendation of the MEC. The MEC and the Board shall retain ultimate authority for making determinations regarding call requirements based upon the needs of the Hospital and its patients, and upon the Hospital's obligation to ensure that the services regularly available to its Hospital patients are available to the Emergency Department. In the event any physician or specialty represented on the Active Staff is excused from call, the MEC and the Board shall document the reasons, and shall ensure that such decision does not negatively impact upon the Hospital's ability to fulfill its obligations as outlined above. At the age of 60, this requirement shall become voluntary, so long as this provision does not impair the ability of the Hospital to meet its obligations under EMTALA. Physicians must notify the Medical Executive Committee in writing, at least 90 days prior, requesting a change to the emergency call schedule. Physicians called are required to respond to Emergency Department call by telephone within ten (10) minutes. If requested to come in, they are required to do so within thirty (30) minutes after responding by telephone. Anesthesiologists and CRNA's are required to arrive within twenty (20) minutes of initial contact. 6.2(e) The system for providing on-call coverage, including specification of which specialties shall cover call and the minimum obligations, therefore, shall be approved by the Board of Trustees and documented in writing. As a condition of Medical Staff appointment, all emergency department physicians and any physician who is or may be required to take unassigned call for Emergency Department patients pursuant to the provisions of the Bylaws, Rules and Regulations shall be required to receive hospital-sponsored or hospital-approved EMTALA training prior to initial appointment and prior to each subsequent reappointment to the medical staff. ..."
Review on January 5, 2023, of the facility policy, "Emergency Medical Treatment and Active Labor Act (EMTALA)," last reviewed February 14, 2022, revealed "... I. Policy UPMC seeks to comply with all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C.1395dd. II. Purpose This policy sets forth the system hospitals' requirements under EMTALA, including guidelines for providing the appropriate setting (department) for conducting medical screening. ...V. Procedure... 12. Each UPMC hospital Emergency Department shall maintain a list of physicians who are on call 24/7 to provide further evaluation and/or treatment necessary to stabilize an individual with an Emergency Medical Condition. Physicians on-call are required to personally attend to the patient when requested to do so by the treating physician or QMP. The on-call physician records are maintained similar to the medical record. ... 14. Each UPMC hospital shall maintain policies and procedures to (a) respond to situations in which a particular specialty physician is not available or if the on-call physician is not able to respond due to circumstances beyond his or her control; and (b) provide that emergency services are available if the hospital elects to permit its on-call physicians to schedule elective surgery during the time that they are on call or permit physicians to participate in simultaneous on-call service. ..."
An observation tour of the Emergency Department was completed on January 5, 2023, at approximately 1000. There were no on-call physician schedules posted in the Emergency Department or accessible to Emergency Department staff.
Interview on January 5, 2023, with EMP2, at approximately 1015 confirmed there were no physician on-call schedules posted. EMP2 revealed the facility does not utilize physician on-call schedules.
A request was made for the facility policy related to on-call physician procedure. None was provided.
Interview on January 5, 2023, with EMP2, at approximately 1230, confirmed there was no policy or procedure related to the process for on-call physicians at the facility. EMP2 stated the facility would call the transfer center rather than use on-call schedules. EMP2 confirmed there was no procedure in writing for this process.
Tag No.: A2406
Based on review of facility policy and medical records (MR) and staff (EMP) interviews, it was determined the facility failed to ensure an appropriate medical screening examination was performed for a patient with an emergency psychiatric condition in two of two MRs reviewed (MR1 and MR7).
Findings include:
Review on January 5, 2023, of the facility document, "UPMC Lock Haven Medical Staff Rules and Regulations," last approved May 12, 2021, revealed "...Article VI Emergency Medical Screening, Treatment, Transfer & On-Call Roster Policy 6.1 Screening, Treatment & Transfer 6.1(a) Screening (1) Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition. Generally, an "emergency medical condition" is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual or unborn child. ...(3) All patients shall be examined by qualified medical personnel, which shall be defined as a physician, or in the case of a woman in labor, a registered nurse trained in obstetric nursing where permitted under State law and Hospital policy. ..."
Review on January 5, 2023, of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)," dated February 14, 2022, revealed "I. Policy UPMC seeks to comply with all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C.1395dd. ... IV. Definitions...2. Emergency Medical Condition is "a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse)..." 3. Medical Screening Exam (MSE) is an exam within the capability of the hospital to determine whether an emergency medical condition exists. ...V. Procedure...14. Each UPMC hospital shall maintain policies and procedures to (a) respond to situations in which a particular specialty physician is not available..."
Request was made to EMP3 on January 5, 2023, for a policy outlining the essential elements of a medical screening exam. No policy or documentation of the essential elements of a medical screening exam was provided.
Review on January 5, 2023, of MR1 revealed s/he was brought to the emergency department (ED) by law enforcement on October 7, 2022, at 0935 due to paranoia, family reports of suicidal ideation (SI) and threats to harm his/her family. A 302 (involuntary commitment) was petitioned with documentation by CF6 MR1 was a threat to self and others and was suffering from acute paranoia. The 302 was upheld by the county administrator at 1045 on October 7, 2022. Review of MR1 revealed during the initial examination by CF6 on October 7, 2022, at 1016 the assessment was incomplete and did not include a provisional diagnosis or plan for treatment. Further review of MR1 revealed, during the ED stay from October 7 through October 12, 2022, MR1 was not evaluated by a psychiatrist to determine the presence of a psychiatric disturbance and/or the necessity of treatment for his/her psychiatric emergency.
Review on MR1 on January 5, 2023, revealed a 303 (extended involuntary commitment) hearing was held on October 11, 2022, at 1300 via a conference call team meeting. Documentation by CF5 on the 303 petition revealed on October 11, 2022, MR1 denied SI and making threats to others and MR1 was calm and cooperative. CF5 documented a history, provided by staff caring for MR1 for the past four days, of threats to his/her father and and a plan to commit suicide on October 17, 2022. CF5 documented MR1 did not deny these thoughts but did not want to respond to staff allegations. CF5 recommended a psychiatric hold or admission for medications, group therapy, individual therapy, and family therapy. The mental health review officer (MHRO) documented the findings from the 303 hearing which included MR1 was originally admitted for treatment of SI and depression but had no history of mental illness, was able to care for his/her own needs and was not exhibiting any current symptoms of mental illness. The MHRO documented CF5 testified s/he did not believe MR1 was a danger to self or others and therefore the 303 petition was denied and MR1 was discharged.
Interview with EMP8 on January 5, 2023, at 1045 confirmed documentation of the information presented to the MHRO during the 303 hearing from the ED provider. EMP8 further confirmed there was no information presented at the 303 hearing from a psychiatrist.
Interview with EMP3 on January 5, 2023, at approximately 1340 revealed the facility does not have psychiatric services available, either in person or via telemedicine. EMP3 further revealed the facility does not have written policies or procedures to direct staff when a physician specialty is unavailable. EMP3 confirmed the initial examination of MR1 by CF6 was incomplete and did not include a provisional diagnosis or plan for treatment. EMP3 further confirmed MR1 was discharged on October 12, 2022, from the ED without a psychiatric evaluation.
Review on January 5, 2023, of MR7 revealed the patient was brought to the ED via EMS on December 30, 2022, for evaluation of mental health. There was physician documentation MR7 had a history of mental retardation and threatened to harm self and family members. There was ED physician documentation MR7 denied suicidal ideation and homicidal ideations. There was documentation a 302 was petitioned, upheld, and the patient was medically cleared for bed search.
Continued review of MR7 revealed the patient remained in the ED from December 30, 2022 until January 4, 2023. There was no documentation MR7 was evaluated by psychiatry throughout the stay.
Continued review of MR7 revealed the patient's family member called the ED on January 4, 2023, and requested the facility discharge the patient once stable. There was documentation the patient was agreeable to this plan. The patient was discharged on January 4, 2023, at approximately 1610.
Interview on January 5, 2023, with EMP9, at approximately 1110 confirmed MR7 was brought to the facility ED for mental health evaluation on December 30, 2022. EMP9 confirmed a 302 was obtained for MR7. EMP9 confirmed MR7 did not receive a psychiatry evaluation throughout her ED stay from December 30, 2022, to January 4, 2023. EMP9 confirmed the patient was discharged home with a family member on January 4, 2023, in stable condition.
Tag No.: A2407
Based on review of facility documents and medical records (MR) and staff (EMP) interviews, it was determined the facility failed to ensure transfer of a patient with an emergency medical condition for further medical examination and treatment required to stabilize the condition when the facility lacked those capabilities in two of two applicable MRs reviewed (MR1 and MR2).
Findings include:
Review on January 5, 2023, of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)," dated February 14, 2022, revealed "I. Policy UPMC seeks to comply with all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C.1395dd. ... IV. Definitions...2. Emergency Medical Condition is "a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) ..."
Review on January 5, 2023, of facility policy " Transfer and Transportation of Patient,"last approved February 2020, revealed "...Policy: It is the policy of UPMC Susquehanna to transfer patients within or outside UPMC Susquehanna as required in order to accommodate the following: ... The patient's need for specialized inpatient care, diagnostic testing and/or therapeutic services. ..."
Review on January 6, 2023, of facility policy "Care of the Behavioral Health Patient," approved May 2021, revealed, "...Procedure: ...4. If a 302 involuntary commitment is initiated a staff member will collaborate with a crisis worker at Lycoming-Clinton County MH/ID office. The crisis worker facilitates the admission of the patient to the most appropriate mental health facility with the least delay. ..."
Review on January 5, 2023, of the "UPMC Lock Haven Medical Staff Rules and Regulations," final approval May 12, 2021, revealed "...Article I Admission and Discharge of Patients...1.4 Suicidal Patients...1.4(b) The hospital case worker should be consulted for assistance ... "
Review on January 5, 2023, of MR1 revealed s/he was brought to the emergency department (ED) by law enforcement on October 7, 2022, at 0935 due to paranoia, family reports of suicidal ideation (SI) and threats to harm his/her family. A 302 (involuntary commitment) was petitioned and upheld at 1045 on October 7, 2022. The local mental health (MH) crisis center was contacted and MR1 was evaluated by a MH crisis worker at 1045 on October 7, 2022. MR1 remained in the ED while the MH crisis center searched for inpatient bed placement.
Further review on January 5, 2023, of MR1 revealed orders on October 7, 2022, at 1006 to notify Social Services of a suicide/homicide risk and for a Social Work consult for suicide risk. There was no documentation in MR1 of the notification of Social Services or documentation of a consult performed by a Social Services. The bed search was unsuccessful and MR1 was discharged prior to a psychiatric examination and transfer.
Interview with EMP3 on January 5, 2023, at approximately 1340 revealed the facility does not have psychiatric services available, either in person or via telemedicine. If a patient with a psychiatric emergency presents to the ED, the MH crisis center is contacted to make arrangements for transfer to an inpatient facility. EMP3 confirmed MR1 did not receive a Social Services consult to assist in placement and, other than contacting the MH crisis center, there were no efforts on the part of the facility to facilitate a transfer for psychiatric evaluation. EMP3 further confirmed MR1 was discharged prior to a psychiatric examination and transfer.
Review on January 5, 2023, of MR2 revealed an admission to the ED on Tuesday, November 29, 2022, at 0706 for complaints of weakness, nausea, vomiting and diarrhea with a history of end stage renal disease (ESRD) in need of dialysis. Provider documentation noted MR2 receives dialysis on Tuesday, Thursday, and Saturday and was scheduled for today (November 29th) and because MR2 was non ambulatory s/he could not be sent to the local dialysis center and since the facility does not offer dialysis, MR2 would need to be transferred to a facility within their health care system for dialysis. Documentation indicated the sister facility denied transfer due to no availability and a large hold volume for inpatient beds. A call was placed to a facility outside the health system and MR2 was accepted for transfer pending bed placement. MR2 continued to remain in the ED awaiting transfer. Over the next 36 hours laboratory results included a level of potassium of 5.2 and creatinine of 5.68 at 1830 on November 29, 2022. Results on November 30, 2022, at 0710 included a potassium of 5.2 and creatinine of 6.91 and potassium of 6.1 and creatinine of 7.41 at 1815. At 1908 on November 30, 2022, CF2 documented following receipt of the critical potassium result of 6.1, an electrocardiogram and medications were ordered for potassium reversal, and a call was placed to the accepting facility. While awaiting a return call from the accepting facility, MR2 experienced a change in mental status and respiratory failure with PEA (pulseless electrical activity). Resuscitation efforts began and were ceased at 2002 on November 30, 2022, due to futility. MR2's cause of death was listed as cardiac arrest/missed dialysis, fluid overload, and hyperkalemia (increased potassium).
A request on January 6, 2023, to EMP3 for an interview with CF3 revealed s/he had no ability to contact the provider by phone and s/he was not scheduled at the facility until the evening of January 10, 2023.
Interview with EMP3 on January 6, 2023, at 1045 confirmed the facility did not contact the accepting facility to inquire about bed availability after the initial acceptance of MR2 on November 29, 2022, at 1141 until November 30, 2022, after 1900, when MR2's condition began to further deteriorate. EMP3 further confirmed once MR2 had been accepted at the facility outside of the health system pending bed placement, no further attempts were made to find a facility that could accept MR2 sooner. EMP3 confirmed the facility did not attempt an ED-to-ED transfer to a facility within their health care system with dialysis capability.