HospitalInspections.org

Based on review of facility documents, staff interview (EMP), review of personnel files (PF), and review of credential files (CF), it was determined the facility failed to ensure registered nurses in the Emergency Department (ED) and any physician who may be required to take unassigned call at the facility for ED patients completed EMTALA training for three (3) of twenty two (22) personnel records reviewed (PF9, PF21, PF22) and four (4) of five (5) credential files reviewed (CF2, CF3, CF4, CF5).
Findings include:
Review on February 23, 2022, of facility policy "Emergency Department Scope," revised May 2020, revealed "...General Requirements for Staff All Emergency Department staff members will complete ...Legal obligations to the provision of emergency care, including EMTALA, annually ..."
Review on February 23, 2022, of the facility document, "Medical Staff Bylaws Of Wilkes-Barre General Hospital," last reviewed by the board April 22, 2021 revealed "...Article XIV General Provisions 14.1 Staff Rules & Regulations Subject to approval by the Board, the Medical Staff shall adopt rule and regulations necessary to implement more specifically the general principles found within these bylaws. These shall relate to the proper conduct of Medical Staff organizational activities as well as embody the level of practice that is required of each staff member or affiliate in the hospital. ...Wilkes Barre General Hospital Medical Staff Rules & Regulations ... Article VI Emergency Medical Screening, Treatment. Transfer & On-Call Roster Policy ... 6.2(g) 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 & Regulations shall be required to received Hospital-sponsored or Hospital-approved EMTALA training prior to initial appointment and prior to each subsequent reappointment to the medical staff. ..."

Review on February 23, 2022, of PF9, revealed this employee was a registered nurse in the ED and there was no documentation of annual EMTALA training.
Interview on February 23, 2022, with EMP4 confirmed PF9 was a registered nurse in the ED and there was no documentation of annual EMTALA training.
Review on February 23, 2022, of PF21, revealed this employee was a registered nurse in the ED and there was no documentation of annual EMTALA training.
Interview on February 23, 2022, with EMP4 confirmed PF21 was a registered nurse in the ED and there was no documentation of annual EMTALA training.
Review on February 23, 2022, of PF22, revealed this employee was a registered nurse in the ED and there was no documentation of annual EMTALA training.
Interview on February 23, 2022, with EMP4 confirmed PF22 was a registered nurse in the ED and there was no documentation of annual EMTALA training.
Review on February 23, 2022, of CF2 revealed a privilege date of February 17, 2022 until February 16, 2024. No documentation EMTALA training was completed.
Interview on February 23, 2022, with EMP5 confirmed CF2 had a privilege date of February 17, 2022 until February 16, 2024.
Review on February 23, 2022, of the Physician On-Call Schedule from January 1, 2022 through January 31, 2022, revealed CF2 was on-call January 5, 10, 17, 26, and 31, 2022.
Interview on February 23, 2022, with EMP2, at approximately 1100, confirmed CF2 was on-call January 5, 10, 17, 26, and 31, 2022.
Review on February 23, 2022, of CF3 revealed a privilege date of December 3, 2020 until December 2, 2022. No documentation EMTALA training was completed.
Interview on February 23, 2022, with EMP5 confirmed CF3 had a February 17, 2022 until February 16, 2024.
Review on February 23, 2022, of the Physician On-Call Schedule from January 1, 2022 through January 31, 2022, revealed CF3 was on-call January 12, 18, and 24, 2022.
Interview on February 23, 2022, with EMP2, at approximately 1115, confirmed CF3 was on-call January 12, 18, and 24, 2022.
Review on February 23, 2022, of CF4 revealed a privilege date of September 23, 2021 until September 22, 2023. No documentation EMTALA training was completed.
Interview on February 23, 2022, with EMP5 confirmed CF4 had a privilege date of September 23, 2021 until September 22, 2023.
Review on February 23, 2022, of the Physician On-Call Schedule from January 1, 2022 through January 31, 2022, revealed CF4 was on-call January 4, 6, 12, 13, 19, 25 and 27, 2022.
Interview on February 23, 2022, with EMP2, at approximately 1130, confirmed CF4 was on-call January 4, 6, 12, 13, 19, 25 and 27, 2022.
Review on February 23, 2022, of CF5 revealed a privilege date of October 21, 2021 until October 20, 2023. No documentation EMTALA training was completed.
Interview on February 23, 2022, with EMP5 confirmed CF5 had a privilege date of October 21, 2021 until October 20, 2023.
Review on February 23, 2022, of the Physician On-Call Schedule from January 1, 2022 through January 31, 2022, revealed CF5 was on-call January 3, 11, 14, 18, 20, 24, 26, and 31, 2022.
Interview on February 23, 2022, with EMP2, at approximately 1145, confirmed CF5 was on-call January 3, 11, 14, 18, 20, 24, 26, and 31, 2022.
Interview on February 23, 2022, with EMP1 confirmed CF2, CF3, CF4, CF5 did not complete EMTALA training.
Cross reference:
489.20(r)(2) and 489.24(j)(1-2) On Call Physicians

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to provide adequate on-call lists and physician coverage for 82 of 82 on-call lists reviewed.

Findings:

Review on February 23, 2022, of the facility document, "Medical Staff Bylaws Of Wilkes-Barre General Hospital," last reviewed by the board April 22, 2021 revealed "...Article XIV General Provisions 14.1 Staff Rules & Regulations Subject to approval by the Board, the Medical Staff shall adopt rules and regulations necessary to implement more specifically the general principles found within these bylaws. These shall relate to the proper conduct of Medical Staff organizational activities as well as embody the level of practice that is required of each staff member or affiliate in the hospital. ...Wilkes Barre General Hospital Medical Staff Rules & Regulations ... Article VI Emergency Medical Screening, Treatment. Transfer & On-Call Roster Policy ... 6.2 Consultations. Referrals & Emergency Department Call 6.2(a) When the Emergency Department Physician determines that a consultation or specialized treatment beyond the capability of the Emergency Department Physician is needed, the patient shall be permitted to request the services of a specific private physician. This request will be documented in the patient's medical record. The Emergency Department Physician will utilize the rotation call list as set forth in this Section 6.2 if the patient does not have a private Physician who is available and qualified to provide the necessary services. ... 6.2(d) 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, the private physician refuses the patient's request to come to the Emergency Department, 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 Administration and/or Medical Executive Committee for further action and may constitute grounds for revocation of the physician's Medical Staff appointment and clinical privileges. 6.2(e) 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 feels that a consultation with another specialist is indicated, it will be the responsibility of the Emergency Room provider to arrange for the additional consultations. 6.2(f) All members of the Active Staff shall participate in the on-call backup to the Emergency Department as required by the Board, upon recommendation of the MEC. Staff Members are not required to provide on-call coverage any more frequently than every third night. Each Active Staff member must establish current competence in and maintain a sufficient breadth of clinical privileges in his/her specialty to meaningfully participate in emergency department unassigned call as required in the Rules & Regulations of the Medical Staff. 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. 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 twenty (20) minutes after responding by telephone. Anesthesiologists and CRNAs are required to arrive within twenty (20) minutes of initial contact. (Revised 12/12) 6.2(g) 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 & Regulations shall be required to received Hospital-sponsored or Hospital-approved EMTALA training prior to initial appointment and prior to each subsequent reappointment to the medical staff. ..."

Review on February 22, 2022, of the facility policy, "EMTALA," last reviewed January 2020 revealed "Purpose: The Purpose of this policy is to ensure that the emergency medical treatment and patient transfer policy is based on federal law relating to the emergency medical treatment and medically appropriate transfer of individuals between hospitals. ... Definitions: ... Capability refers to the Hospital's physical space, equipment, supplies and services (e.g. trauma care, surgery, intensive care, pediatrics, obstetrics, burn unit, neonatal unit or psychiatry), including ancillary services that the Hospital provides. The capabilities of the Hospital's staff mean the level of care that the Hospital's personnel can provide within the training and scope of their professional licenses. ... On-Call List refers to the list that the Hospital maintains that identifies those physicians who are "on-call" for duty after the initial Medical Screening Examination to provide further evaluation and/or treatment necessary to stabilize an individual with an Emergency Medical Condition. The purpose of the On-Call List is to ensure that the Dedicated Emergency Department is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide treatment necessary to stabilize individuals with Emergency Medical Conditions. ... II Transfer Of Individuals A. Evaluation of Individual Prior to Immediate Transfer 1. Initial Evaluation. In the event of a potential need to transfer the individual, the individual shall be (1) evaluated by the physician who is on duty in the Emergency Department at the time the patient presents or is presented, or (2) evaluated by a physician on call who is physically able to reach the patient within a reasonable amount of time after being informed that an individual who requires immediate medical attention is present at the Hospital. 2 Immediate Transfer. The transferring physician will personally examine and evaluate the individual before an attempt to transfer is made; however, if after receiving a report on the individuals condition by telephone, the physician on call determines that an immediate transfer of the individual is medically appropriate, and that the time required to conduct a personal examination and evaluation of the individual will unnecessarily delay the transfer to the detriment of the individual, the physician on call may order the transfer by telephone. 3. Physician Certification. If the physician on call issues orders for the transfer of an individual by telephone, those orders shall be reduced to writing in the individuals medical record, signed by the Hospital staff member receiving the order, and countersigned by the physician authorizing transfer. The certification form must be sign by the Hospital personnel affecting the transfer and the transferring physician. ... C. Transfer of Individuals after Stabilization Transfer to another medical facility by appropriate means may occur after stabilization, under the following circumstances: 1. Specialized Treatment. The individual requires specialized treatment not available at the Hospital and a hospital with specialized facilities has space and personnel available in the specialized facility. ... III. On-Call 1. The Hospital maintains a list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition or a woman in labor. 2. This list is available in the Emergency Department. The list is retained for a period of five years. 3. All physicians or specialties are not required to be present on the Hospital's on-call list at all times. 4. On-call physicians, after being contacted by the Emergency Department, must respond within a reasonable timeframe. 5. If the attending Emergency Department physician determines that the patient's medical condition requires the services of a specialist and the on-call specialist is not available or there is no physician on call for the particular specialty, the Emergency Department physician will arrange for appropriate transfer of the patient in accordance with this Policy and the requirements of EMTALA. ..."

Review on February 22, 2022, of the facility policy, "Emergency Department On-Call," last reviewed May 2020 revealed "Purpose: To assure that ER physician on-call schedules are maintained in an orderly manner Policy: ER physician on-call schedules will be maintained for no less than five years Procedure: A. Staff on-call schedules will be maintained in a binder at the Secretary's desk in the ER B. All on-call changes made during the active month will be written on the specific involved schedule, dated and initialed by the ED staff making the change C. The retired schedules will be delivered to the ER director for filing and archiving D. The medical Staff Office will archive call schedules by year and maintain those schedules for not less than five (5) years. ..."

Review on February 22, 2022, of the facility Physician On-Call Schedules dated December 31, 2021, January 20, 2022, January 23, 2022, January 30, 2022, February 6, 2022, and February 12, 2022, revealed there was no on-call General Surgery coverage.

Interview on February 22, 2022, with EMP2, at approximately 1255, confirmed there was no on-call General Surgery coverage on December 31, 2021, January 20, 2022, January 23, 2022, January 30, 2022, February 6, 2022, and February 12, 2022.

Review on February 22, 2022, of MR16 revealed MR16 presented to the facility on February 6, 2022, with abdominal and back pain that had become more severe over the past two days. There was documentation MR16 was evaluated, and ultrasound revealed distended gallbladder with gallstones and gallbladder sludge without significant gallbladder wall thickening. There was provider documentation for concern for acute cholecystitis. There was documentation there was no on-call general surgeon coverage at the facility on February 6, 2022. There was documentation a call was placed to another facility, the surgeon accepted the patient, and MR16 was transferred to another facility on February 7, 2022, at 0154.

Interview on February 22, 2022, with EMP3, at approximately 1400, confirmed MR16 contained documentation MR16 presented to the facility on February 6, 2022, with acute cholecystitis. EMP3 confirmed there was no General Surgery on-call coverage on February 6, 2022. EMP3 confirmed there was documentation a call was placed to another facility, the surgeon accepted the patient, and MR16 was transferred to another facility on February 7, 2022, at 0154. EMP3 confirmed the accepting facility was approximately 100 miles from the transferring facility.

Interview on February 23, 2022, with EMP1, at approximately 1000, revealed Department Chairs were responsible for scheduling on-call coverage.

Review on February 22, 2022, of MR18 revealed MR18 presented to the ED on February 6, 2022, for evaluation of abdominal pain and dark tarry stools. There was documentation MR18's CT of abdomen revealed gallbladder hydrops with recommendation to be evaluated by general surgery. There was documentation there was no general surgeon on-call and MR18 was transferred to an accepting facility on February 6, 2022, at 1845.

Interview on February 22, 2022, with EMP3, at approximately 1430, confirmed MR18 presented to the ED on February 6, 2022, for gallbladder disease symptoms and was recommended to be evaluated by general surgery. EMP3 confirmed there was documentation there was no general surgeon on-call and MR18 was transferred to an accepting facility on February 6, 2022, at 1845.

Review on February 23, 2022, of the facility policy, "Scope of Service-Imaging," last reviewed June 5, 2019, revealed "Scope Of Service Imaging Services is a full-service department staffed to provide a full complement of diagnostic and therapeutic procedures. Services provided include Diagnostic Radiology and Fluoroscopy, Mammography, Ultrasound, CT Scan, Interventional Radiology, Nuclear Medicine, PET/CT, MRI, and Dexascan. In-patient and emergency services are provided 24 hours/day 7 days/week. Scheduled services are provided according to individual section policy. ..."

Review on February 22, 2022, of the facility Physician On-Call Schedules from December 1, 2021, through February 21, 2022, revealed no Interventional Radiology on-call coverage from December 1, 2021, through February 21, 2022.

Interview on February 22, 2022, with EMP2, at approximately 1300, confirmed there was no on-call Interventional Radiology coverage scheduled from December 1, 2021, through February 21, 2022.

A request was made for the Interventional Radiology Department Scope of Service on February 22, 2022. None was provided.

Interview on February 23, 2022, with EMP1, at approximately 1030 revealed there was no specific Scope of Service for Interventional Radiology, the facility had six interventional radiologists five of which were locum tenens.

Cross reference:
489.20(l) Compliance with 482.24