HospitalInspections.org

Based on record review, policy review, and interview, the facility failed to comply with the conditions of participation outlined in §489.24:

The facility failed to have posted and have available a list of on-call physicians for each shift at the hospital. The facility failed to consult an on-call physician for 14 patients (#3, #4, #5, #6, #22, #23, #26, #27, #28, #29, #30, #31, #32, and #33) who were determined to be emergent in their medical condition. The on-call physician responsible for evaluating the risks and benefits of such transfers was not contacted. The facility failed to maintain a central log on each individual who comes to the emergency department. The facility failed to provide a medical screening exam and treatment for one patient (#21). These failures could cause unintended adverse medical consequences for all emergency department patients, including those being transferred to other facilities.

Findings include:

1. In a review of the physician on-call list from May 2022 through October 2022, mid-level providers were scheduled each month. Physicians were listed throughout the months, but not on the days that mid-level providers were scheduled. In an interview on 10/17/2022 at 4:30 p.m., staff member B said the facility did not have an on-call physician list and the facility utilized the provider schedule. Refer to C-2404.

2. Review of the facility's ED log for 08/24/2022 showed the log lacked information that a patient (patient #21) presented at the ED and requested a medical examination. In an interview on 10/19/2022 at 12:15 p.m., staff member H stated she recalled family member #1 bring patient #21 to the ED on 08/24/2022, and family member #1 requested that patient #21 receive a medical examination. Refer to C-2405.

3. Based on interviews and record review, the facility failed to provide a medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for patient #21. In an interview on 10/19/2022 at 12:15 p.m., staff member H stated patient #21 presented at the ED with family member #1. She stated family member #1 requested patient #21 be evaluated for an alleged sexual assault that had occurred earlier. Staff member H stated she scheduled a forensic examination for patient #21 for 08/31/22 and instructed family member #1 to return with the patient on the scheduled date and time. Staff member H stated patient #21 did not receive a medical examination. Refer to C-2406.

4. Review of the medical records for 14 patients showed the facility lacked evidence that an on-call physician for the facility was consulted regarding the patient's condition prior to transfer to another facility. The Physician did not assess the risks and benefits of transfers prior to the implementation of the transfers. The facility did not ensure a physician counter-signed the Transfer of a Patient certificate for 14 patients. The facility did not ensure all Transfer of Patient certificates were completed in their entirety with all necessary information, including the reason for transfer and the receiving physician name and facility for 10 patients. The facility failed to ensure a Transfer of a Patient certificate was completed for 2 sampled patients Refer to C-2409.

5. Review of facility documents showed the facility failed to have posted and have available a list of on-call physicians for each shift at the hospital. Review of the Provider Schedule for the months of May 2022 through October 2022, provided by the facility as their on-call physician list, showed mid-level providers were scheduled as the on-call physicians for 16 of the 22 weeks reviewed. Refer to C-2404 and C-2409.

Based on record review and interview, the facility failed to have posted and have available a list of on-call physicians for each shift at the hospital. This failure could cause the patients to have a decreased availability of an on-call physicians to assist with needed assessment and care. This failure could affect all patients receiving services through the emergency department (ED), with a monthly average census of 10. Findings include:

Review of the Provider Schedule for the months of May 2022 through October 2022, provided by the facility as their on-call physician list, showed mid-level providers were scheduled as the on-call physician for 16 of the 22 weeks reviewed.

During an interview on 10/17/2022 at 4:30 p.m., staff member B stated the facility's Provider Schedule was the same as the facility's Physician On-Call list.

Review of the facility's Medical Staff By-laws showed, "Physicians who are assuming the responsibility of "back-up" to an allied health care provider" or acting as a Supervising Physician to a Physician's Assistant are required to be available by telephone."

Based on interview and record review, the facility failed to maintain a central log on each individual who came to the emergency department seeking assistance for 1 (#21) of 34 sampled patients. This failure had the potential to cause harm to patient #21, who was a minor that presented to the ED as a victim of alleged sexual assault by an adult male.

Findings include:

During an interview on 10/18/22 at 9:55 a.m., NF6 stated family member #1 brought patient #21 to the clinic and requested the patient be examined for an alleged sexual assault that had just occurred. NF6 told family member #1 to take patient #21 to the ED next door. NF6 stated she observed family member #1 and patient #21 walk next door to the ED.

During a phone interview on 10/18/2022 at 10:42 a.m., family member #1 stated she took patient #21 to the ED on 08/24/22. She stated she wanted patient #21 to be examined for an alleged sexual assault. Family member #1 stated she was turned away by the ED staff and was told to return with patient #21 on 08/31/22.

During a phone interview on 10/19/2022 at 12:15 p.m., staff member H stated she worked in the ED on 08/24/22. Staff member H stated family member #1 brought patient #21 to the ED and asked that he be examined for suspected sexual assault. She stated she set up an appointment with staff member I to have a SANE examination on 08/31/22. Staff member H stated she informed family member #1 to bring patient #21 back to the ED at the scheduled time. Staff member H stated patient #21 did not receive a medical screening examination by an ED provider. Staff member H stated she did not log patient #21 into the facility ED log.

Record review of the facility ED log, dated 08/24/22 showed, there was no entry made for patient #21 when he was brought to the ED.

Review of facility policy, "Emergency Medical Services: Access to Care" showed, "An appropriate log of persons assessing emergency medical services shall be kept ... It is the policy of this hospital to attend the emergency medical needs of all patients presenting to the Emergency Room."

Based on interviews and record review, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists for 1 (#21) of 34 sampled patients. This failure had the potential to cause harm to patient #21, who was a minor that presented to the ED as a victim of alleged sexual assault by an adult male.

On 12/6/2022, the facility administration was notified by CMS that an immediate jeopardy existed for failure to provide appropriate medical screening examinations.

Findings include:

1. During an interview on 10/18/2022 at 9:55 a.m., NF6 stated family member #1 brought patient #21 to the clinic on 08/24/2022 at approximately 4:30 p.m. and requested that he be evaluated. Family member #1 stated she had just found patient #21 coming out of her next-door neighbor's home, and when he exited the door, she observed patient #21 pulling up his pants. She stated family member #1 told her she suspected that patient #21 had been sexually abused. Family member #1 reported her neighbor was an adult male, and he creeped her out; he would often try to lure patient #21 to his home with candy and treats. NF6 stated she instructed family member #1 to take patient #21 to the ED so that he could receive a medical evaluation. NF6 stated she observed family member #1 walk patient #21 to the ED.

During a phone interview on 10/18/2022 at 10:42 a.m., family member #1 stated she took patient #21 to the ED on 08/24/22. She stated she was approached by a nurse in the lobby and she explained that she brought patient #21 to the facility because she was concerned that the patient had just been sexually abused by an adult male neighbor. Family member #1 stated patient #21 was her grandson, and she had been his primary caregiver since he was born. Family member #1 stated she requested that patient #21 be examined. She stated the nurse at the ED told her to return to the ED on 08/31/22. Family member #1 stated patient #21 did not receive a medical examination.

During a phone interview on 10/19/2022 at 12:15 p.m., staff member H stated she worked in the ED on 08/24/22. She stated she recalled speaking to family member #1 when she presented at the ED with patient #21. Staff member H stated family member #1 requested patient #21 be examined for suspected sexual assault. She stated she went to the clinic to ask staff member I when she had availability to conduct a SANE examination, and she set up an appointment for patient #21 to have the examination with staff member I on 08/31/22. Staff member H stated she informed family member #1 to bring patient #21 back to the ED at the scheduled time. Staff member H stated patient #21 did not receive a medical screening examination by an ED provider.

During a phone interview on 10/19/2022 at 1:06 p.m., staff member I stated she was a Nurse Practitioner for the facility and was certified to conduct SANE examinations. She stated she worked in the clinic on 08/24/22. Staff member I stated she was approached by staff member H and was asked if she had upcoming availability to conduct a SANE examination on a minor child. She stated the examination was scheduled for 08/31/22. Staff member I stated she was unaware that patient #21 presented at the ED. She stated, "This information was not shared with me. If the concern of sexual assault was immediate and obvious, I should have been called. The patient should have received a medical screening."

Record review of patient #21's IHS "Nurse Note" dated 08/24/2022 at 4:10 p.m., electronically signed by NF6 showed, "An elderly woman came to the registration window and wanted to talk with someone about [patient #21] she is raising. Took [family member #1] and patient to triage room. [Family member #1] stated she wanted patient to be checked. Stated that neighbor has been offering [patient #21] candy to come over. Noticed first time a week ago then a couple days ago. She observed [patient #1] coming out of the house pulling pants up. Was scared to check wanted to check and make sure nothing happened to him ...Spoke to charge nurse and was advised to send patient to ER ...[Family member #1] walked patient over to ER next door."

Record review of patient #21's EHR showed there was no documentation on file for a medical screening exam on 08/24/22.

Record review of patient #21's "Hospital Progress Notes", dated 08/31/22, electronically signed by staff member I showed, patient #21 was brought to the hospital for a forensic examination. Staff member I documented, "Exam was not complete today. Rapport needs to be built up with this patient gradually to allow a good exam without fear or struggle."

Review of video surveillance footage for 08/24/2022 was requested, but the facility was not able to produce the requested information, as the video footage re-records itself after a period of two weeks time.

Record review of the facility's nursing schedule for 08/24/22 showed, staff member H was scheduled in the ED from 7:00 a.m. to 7:00 p.m.

Record review of staff member I's timecard, dated 08/24/22 showed, staff member I clocked in at 8:02 a.m., and clocked out at 8:02 p.m.

Record review of facility policy, "EMTALA Guidelines", approved June 2022 showed, "It is the policy of [facility name] that all individuals requesting an examination or treatment for a medical condition from the hospital's emergency department (ED) will be screened to determine whether an emergency medical condition exists."

Record review of facility policy, "Sexual Assault/Abuse Evaluation Orders", reviewed on 10/19/22 showed, "Assess and refer to Emergency Department Provider for any emergent health care needs. Including: ...Identified injuries or other concerns ...Desire by the patient to be evaluated by the ED physician ...Perform forensic medical examination ...Collect forensic evidence using Sexual Assault Kit in cases of sexual assault occurring in 120 hours or less ...Provide follow-up plan or care with referrals as indicated ...Offer contact information for victim's advocate ...Recommend counseling/evaluation by counselor, set up if at risk."

Record review of the facility's EMTALA training for dedicated ED staff showed none of the ED providers have received EMTALA training during their employment with the facility. There was no documentation to show that staff member H had received EMTALA training. There was also no documentation of the ED's Administrator receiving EMTALA training at any time during her employment.

Based on record review and interview, the facility failed to:

a) consult the facility on-call physician prior to the transfer of patients in an emergency status, including review of the risk and benefits of transfer for 14 (#3, #4, #5, #6, #22, #23, #26, #27, #28, #29, #30, #31, #32, and #33) of 34 sampled patients;

b) ensure a physician counter-signed the Transfer of a Patient certificate for 14 (#3, #4, #5, #6, #22, #23, #26, #27, #28, #29, #30, #31, #32, and #33) of 34 sampled patients;

c) ensure all Transfer of Patient certificates were completed in their entirety with all necessary information, including the reason for transfer and the receiving physician name and facility for 10 (#1, #3, #4, #23, #24, #26, #27, #28, #29, and #30) of 34 sampled patients; and

d) ensure a Transfer of a Patient certificate was completed for 2 (#25, and #34) of 34 sampled patients.

These failures placed the patients at a higher possible risk for deterioration during transfer and contributed to incomplete documentation of the transfers.

Findings include:

1. Record review of patient #3, #4, #5, #6, #22, #23, #26, #27, #28, #29, #30, #31, #32, and #33's EHR showed patients #3, #4, #5, #6, #22, #23, #26, #27, #28, #29, #30, #31, #32, and #33 were provided care in the facility ED by mid-level providers. The patients were transferred to alternate facilities for a higher level of care. Prior to the transfer of the patients, mid-level providers did not consult the facility's on-call physician.

During an interview on 10/19/2022 at 11:31 a.m., staff member F stated he is a Nurse Practitioner and works in the facility ED. Staff member F stated he transfers patients to alternate facilities for higher levels of care that cannot be provided in the facility's ED. He stated, "I do not consult with a facility physician prior to transferring a patient to another facility, and certificates of transfer are not counter signed by physicians, I didn't know that was a requirement."

Review of the Provider Schedule for the months of May 2022 through October 2022, provided by the facility as their on-call physician list, showed mid-level providers were scheduled as the on-call physician for 16 of the 22 weeks reviewed.

During an interview on 10/17/2022 at 4:30 p.m., staff member B stated the facility's Provider Schedule was the same as the facility's Physician On-Call list.

During an interview on 10/19/2022 at 2:40 p.m., staff member A stated the facility does not require mid-level providers to consult with an on-call physician prior to the transfer of a patient.

Review of the facility's Medical Staff By-laws showed, "Physicians who are assuming the responsibility of "back-up" to an allied health care provider" or acting as a Supervising Physician to a Physician's Assistant are required to be available by telephone.

2. Review of patient #1's EHR, provided in hard copy by the facility, showed patient #1 was seen in the ED on 10/08/22 at 1930, by staff member K. Patient #1 was transferred to another facility. Review of the transfer sheet showed the transfer sheet lacked information regarding the condition of the patient, the patient's reason for transfer, lacked information regarding the risks associated with the transfer, lacked information about the receiving physician/facility, and lacked information pertaining to how the patient would be transferred.

3. Review of patient #3's EHR, provided in hard copy by the facility, showed patient #3 was seen in the ED on 9/16/22 at 1745, by staff member L. Patient #3 was transferred to another facility. Review of the transfer sheet showed the transfer sheet lacked information regarding the condition of the patient, the patient's reason for transfer, lacked information regarding the risks associated with the transfer, and lacked information pertaining to how the patient would be transferred. Review of the certificate showed the accepting physician was listed as [staff member L], who is not a physician, and is licensed as a certified nurse midwife, and the certificate was not countersigned by a physician, nor dated by staff member L.

4. Review of patient #4's EHR, provided in hard copy by the facility, showed patient #4 was seen in the ED on 10/15/22 at 1952, by staff member F. Patient #4 was transferred to another facility. Review of the transfer sheet showed the transfer sheet lacked a signature from the patient or his representative, consenting to the transfer, and the certificate was not counter-signed by a physician.

5. Review of patient #5's EHR, provided in hard copy by the facility, showed patient #5 was seen in the ED on 07/16/22 at 2317, by staff member M. Patient #5 was transferred to another facility. Review of the transfer sheet showed the accepting physician was listed as [staff member L], who is not a physician, and is licensed as a certified nurse midwife. The certificate was not countersigned by a physician, and it was signed by staff member L.

6. Review of patient #6's EHR, provided in hard copy by the facility, showed patient #6 was seen in the ED on 09/18/22 at 2124, by staff member F. Patient #6 was transferred to another facility. Review of the transfer sheet showed the certificate was not countersigned by a physician. Staff member F signed the certificate, but failed to indicate a date or time on the form.

7. Review of patient #22's EHR, provided in hard copy by the facility, showed patient #22 was seen in the ED on 09/02/22 at 1248, by staff member F. Patient #22 was transferred to another facility. Review of the transfer sheet showed the certificate was not countersigned by a physician.

8. Review of patient #23's EHR, provided in hard copy by the facility, showed patient #23 was seen in the ED on 07/07/22 at 1134, by staff member F. Patient #22 was transferred to another facility. Review of the transfer sheet showed the transfer sheet lacked information regarding the condition of the patient, the patient's reason for transfer, lacked information regarding the risks associated with the transfer, lacked information about the receiving physician/facility, and lacked information pertaining to how the patient would be transferred. The certificate was not countersigned by a physician.

9. Review of patient #24's EHR, provided in hard copy by the facility, showed patient #24 was seen in the ED on 09/23/22 at 0620, by staff member N. Patient #24 was transferred to another facility. Review of the transfer sheet showed the transfer sheet lacked information regarding the receiving physician/facility. The certificate was signed by staff member N but it was not dated.

10. Review of patient #25's EHR, provided in hard copy by the facility, showed patient #25 was seen in the ED on 08/20/22 at 2218, by staff member O. Patient #25 was transferred to another facility. Review of patient #25's EHR showed there was no copy of the facility's Transfer of a Patient certificate on file for patient #25.

11. Review of patient #26's EHR, provided in hard copy by the facility, showed patient #26 was seen in the ED on 09/15/22 at 2337, by staff member F. Patient #26 was transferred to another facility. Review of the transfer sheet showed the transfer sheet was not counter signed by a physician. The certificate was signed by staff member F, but it was not dated.

12. Review of patient #27's EHR, provided in hard copy by the facility, showed patient #27 was seen in the ED on 10/03/22 at 0307, by staff member F. Patient #27 was transferred to another facility. Review of the transfer sheet showed the transfer sheet lacked information regarding how the patient was transferred. The certificate was not counter signed by a physician. Additionally, the certificate was signed by staff member F, but it was not dated.

13. Review of patient #28's EHR, provided in hard copy by the facility, showed patient #28 was seen in the ED on 09/26/22 at 2132, by staff member F. Patient #28 was transferred to another facility. Review of the transfer sheet showed the transfer sheet was not counter signed by a physician. The certificate was signed by staff member F, but it was not dated.

14. Review of patient #29's EHR, provided in hard copy by the facility, showed patient #29 was seen in the ED on 09/16/22 at 1424, by staff member F. Patient #29 was transferred to another facility. Review of the transfer sheet showed the transfer sheet lacked information regarding the condition of the patient, the reason for transfer, and how the patient was transferred. The certificate was not counter-signed by a physician.

15. Review of patient #30's EHR, provided in hard copy by the facility, showed patient #30 was seen in the ED on 09/07/22 at 1516, by staff member F. Patient #30 was transferred to another facility. Review of the transfer sheet showed the transfer sheet was not counter-signed by a physician. The certificate was signed by staff member F, but it was not dated.

16. Review of patient #31's EHR, provided in hard copy by the facility, showed patient #31 was seen in the ED on 09/06/22 at 1559, by staff member F. Patient #31 was transferred to another facility. Review of the transfer sheet showed the transfer sheet was not counter-signed by a physician.

17. Review of patient #32's EHR, provided in hard copy by the facility, showed patient #32 was seen in the ED on 09/05/22 at 1101, by staff member F. Patient #32 was transferred to another facility. Review of the transfer sheet showed the transfer sheet was not counter-signed by a physician.

18. Review of patient #33's EHR, provided in hard copy by the facility, showed patient #33 was seen in the ED on 09/03/22 at 1806, by staff member F. Patient #33 was transferred to another facility. Review of the transfer sheet showed the transfer sheet was not counter-signed by a physician.

19. Review of patient #34's EHR, provided in hard copy by the facility, showed patient #34 was seen in the ED on 09/04/22 at 1653, by staff member F. Patient #34 was transferred to another facility. Review of patient #34's EHR showed there was no copy of the facility's Transfer of a Patient certificate on file for patient #34.

Review of facility policy, "Transfer of a Patient with Emergency Medical Condition", revised 12/11/06 showed, "POLICY: The following must be performed to transfer a patient with an emergency medical condition: 1. Obtain a provider's order for transfer ... 2. Complete a certification for transfer that is signed, timed, and dated by the provider, and documents the medical reason for transfer and the medical risks and benefits of the transfer."

During an interview on 10/19/2022 at 2:45 p.m., staff member A stated the facility does not require physicians to counter sign Transfer of Patient certificates.