HospitalInspections.org

The Critical Assess Hospital reported 476 patients received emergency medical care from the hospital's emergency department (ED) and transferred 63 patients to other health facilities for follow up emergency care. The survey included a sample of 20 ED patient records for review. Based on document and policy review, patient record review and staff interview the hospital failed to develop ED policies and procedures with specific guidelines for the scope of practice that may be performed by the hospital's Advanced Practice Registered Nurse (APRN). The hospital failed to develop and implement policies and procedures to meet all medical conditions that present to the ED.

Findings include:

- After multiple requests by the surveyor on 9/24/13 to 9/26/13 the hospital failed to provide policies and procedures that described the scope of medical acts that may be completed by their Advanced Practice Registered Nurse (APRN).

- Review of Medical Staff By-laws dated 4/14/03 lacked guidelines for the medical management of health problems that included a description of the scope of medical acts that may be preformed by their Advanced Practice Registered Nurse (APRN). The Medical Staff By-laws lacked evidence of EMTALA considerations within the document.

- Hospital emergency department policies were requested on 9/24/13 at 2:00pm. Administrative staff A and Corporate staff J on 9/24/13 at 4:45pm reported the hospital had hospital polices and corporate policies available to staff for use. Staff J reported the hospital staff should be using the management company's policies to limit the amount of confusion as to what policies were to be provided. Corporate vice president of clinical services indicated the hospital should be using the policies that the management company provided.

- Review of Governing Body By-laws dated 6/1/08 lacked evidence of who can cover the medical needs of patients who present to the Emergency Department and lacked evidence of EMTALA considerations within the document.

- The hospital lacked policies for review to direct care for probable conditions that present to the Emergency Department such as: a precipitous delivery of a newborn, resuscitation of a child, how to care for a mentally unstable patient, emergency care for a snakebite victim, how to care for a prisoner.

- Hospital Medical Staff by-law and rules and regulations, dated 4/14/2003, reviewed on 9/25/13 revealed the hospital required all active medical staff members to live within 30 minutes of the hospital to ensure the emergency department had continuous and timely care ....and participate in emergency department coverage.

Administrative staff A on 9/23/13 at 10:20am during entrance conference stated the hospital used locums (hired providers) to help cover the ED and that the hospital also used an Advanced Practice Registered Nurse (APRN) staff F to cover the ED one day a week.

- The undated Hospital/ Corporate policy for Emergency Medical Treatment and Labor Act (EMTALA)-Medical Screening Exam and Stabilization policy stated the purpose of the policy is to establish guidelines for providing appropriate medical screening examinations and, if the individual is determined to have an emergency medical condition (EMC), any necessary, stabilization treatment or an appropriate transfer for the individual as required by EMTALA.

The EMTALA policy stated "An appropriate Medical Screening Exam (MSE), within the capabilities of the hospital (including ancillary services) shall be performed by a physician in order to determine whether an EMC exists ....If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment within the capacity and capability of the hospital, or an appropriate transfer as required by EMTALA.

The EMTALA policy stated the Extent of the Medical Screening Examination:
1. Determination if an EMC exists. The hospital is obligated to perform the MSE in order to determine if an EMC exists. It is not appropriate to merely "log in" or triage an individual with a medical condition and not provide an MSE.
2. Judgment by Physician. The extent of the necessary examination to determine the presence or absence of an EMC is within the discretion of the examining physician. However, the elements of an appropriate MSE should include:
a. Log entry with disposition.
b. Triage record
c. Ongoing recording of vital signs
d. Oral history
e. Physical exam
f. Use of all available/necessary testing resources
g. Discharge and transfer vital signs and
h. Adequate documentation of the above.

Who may perform a MSE:
1. Only a physician may perform an MSE at the hospital ...
2. The Emergency Department (ED) physician on duty is responsible for the general care of all individuals presenting to the ED.
3. The responsibility remains with the ED physician until the individual is admitted, transferred or discharged.

On 11/20/13 the hospital provided a copy of a Board approved resolution dated 1/21/11 that revealed approval of physician assistants, advanced practice nurses and registered nurses as QMPs.

The Critical Assess Hospital reported 476 patients received emergency medical care from the hospital's emergency department (ED) and transferred 63 patients to other health facilities for follow up emergency care. The survey included a sample of 20 emergency department patient records for review. Based on document and policy review, patient record review and staff interview the hospital failed to ensure a physician was on call to the ED to provide for consultation and further assessment and treatment if needed. This deficient practice occurred for 50 days over the past year and affected 1 of 20 selected emergency department patients (patient #17).

Findings include:

- Hospital Medical Staff by-law and rules and regulations dated 4/14/2003, reviewed on 9/25/13 revealed the hospital required all active medical staff members to live within 30 minutes of the hospital to ensure the emergency department had continuous and timely care ... and participate in emergency department coverage.

Administrative staff A on 9/23/13 at 10:20am during entrance conference stated the hospital used locums to help cover the ED and that the hospital also used an Advanced Practice Registered Nurse (APRN) F to cover the ED one day a week.

- Hospital emergency department policies were requested on 9/24/13 at 2:00pm. Administrative staff A and Corporate staff J on 9/24/13 at 4:45pm reported the hospital had hospital polices and corporate policies available to staff for use. Staff J reported the hospital staff should be using the management company's policies to limit the amount of confusion as to what policies were to be provided. Corporate vice president of clinical services indicated the hospital should be using the policies that the management company provided.

- The undated Hospital/ Corporate policy for Emergency Medical Treatment and Labor Act (EMTALA)- Medical Screening Exam and Stabilization policy stated the purpose of the policy is to establish guidelines for providing appropriate medical screening examinations and, if the individual is determined to have an emergency medical condition (EMC), any necessary, stabilization treatment or an appropriate transfer for the individual as required by EMTALA.

The EMTALA policy stated "An appropriate Medical Screening Exam (MSE), within the capabilities of the hospital (including ancillary services) shall be performed by a physician in order to determine whether an EMC exists .... If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment within the capacity and capability of the hospital, or an appropriate transfer as required by EMTALA.

Who may perform a MSE:
1. Only a physician may perform an MSE at the hospital ....
2. The Emergency Department (ED) physician on duty is responsible for the general care of all individuals presenting to the ED.
3. The responsibility remains with the ED physician until the individual is admitted, transferred or discharged.

On 11/20/13 the hospital provided a copy of a Board approved resolution dated 1/21/11 that revealed approval of physician assistants, advanced practice nurses and registered nurses as QMPs.

- Patient #17's (an 11 year-old child) medical record reviewed on 9/25/13 revealed they presented to the emergency department with a church camp staff member on 7/25/13 at 10:03am with a chief complaint of a laceration to their upper left lip. Registered Nurse E documented the patient refused a nursing assessment until their parents arrived. Patient #17 reported their pain was at a "2" (on a scale of 1-10) at 10:03am.

Registered Nurse E called APRN staff F at 10:05am (the assigned on-call ED provider) and documented the APRN arrived at 10:10am.

Patient #17's medical record revealed the APRN staff F notified physician Z's office in a near by town of the patient's need for sutures on the left upper lip. Administrative staff B on 9/25/13 at 4:00pm reported physician Z was not credentialed at the hospital and stated physician G was APRN staff F's sponsoring physician.

Patient #17's medical record lacked evidence of ongoing recording of vital signs and lacked evidence the APRN consulted with their sponsoring physician or a staff physician prior to transferring the patient to a doctors office for repair of their laceration.

Administrative staff A on 11/26/13 at 9:00am reported APRN staff F provided emergency room coverage for 50 days during the last year and cared for 102 emergency department patients.

- Review of the Provider Call Schedule for the past year revealed APRN staff F was the sole scheduled on-call provider for the ED on part or all of 58 days in the past year.