HospitalInspections.org

The Critical Assess Hospital (CAH) reported the Emergency Department (ED) treated 427 emergency cases for the last six months from October 2013 to March 2014. Based on document review and staff interview the CAH failed to follow EMTALA requirements in the hospital Bylaws and follow the protocols, policies and procedures for the ED that direct the practitioner [qualified medical personnel(QMP's)] to contact the designated physician in the absence of the responsible physician and the QMP's to consult the physician prior to admission for 2 of 2 patients sampled. (Patient #'s 3 and 7)
The CAH's failure to include in the Bylaws the EMTALA requirements for the QMP to contact the designated physician during a time of the responsible physician's absence and failure to follow their protocols, policies and procedures to ensure the QMP consulted the physician prior to admission had the potential to affect all patients treated in the ED by QMP's.
Findings include:
- The "CAH Acquisition Company #5, LLC", titled "BOARD RESOLUTION APPROVING PHYSICIAN ASSISTANTS, ADVANCED REGISTERED NURSE PRACTITIONERS AND REGISTERED NURSES AS QUALIFIED MEDICAL PERSONNEL FOR PURPOSES OF CONDUCTING MEDICAL SCREENING EXAMINATIONS" , adopted 1/21/11, directs "....the Board of Directors of CAH ACQUISTION COMPANY #5, LLC ...has determined that Physician Assistants(PAs) ... are qualified ...to conduct such medical screening examination with the Emergency Department of the Hospital and as such may be designated as Qualified Medical Personnel (QMP) under this Act. The Board of Directors has determined that the scope of providing a medical screening examination (MSE) in the Hospital's Emergency Department is within the scope of licensure for physician assistants, ...as set forth in Kansas Physician Assistants Act (K.S.A. 65-28a01 to 65-28a12 inclusive), ...function under medically approved protocols; ... protocols define the limits of the non-physician ' s practice in providing a MSE and set forth objective criteria as to when a MSE must be provided by a physician ...are trained for the role and are reviewed ...on a regular basis ... the physician is ultimately responsible for any screening examinations conducted by a non-physician ...".
- The KANSAS STATE BOARD of HEALING ARTS, KANSAS STATUTES ANNOTATED and KANSAS ADMINISTATIVE REGULATIONs, Relating to the practice of PHYSICIAN ASSISTANTS, April 2012 "...under 65-28a08. Practice of physician assistant; direction and supervision of physician ...shall include medical services ...that are delegated by the responsible physician ....in a independent role with a responsible physician ...may perform those duties and responsibilities through delegated authority or written protocols ...authorized by the physician responsible for the physician assistant and only to the extent such acts are constituted with rules and regulations adopted by the board which relate to acts performed by a physician assistant under the responsible physician ' s direction and supervision ...under "100-28a-10. Supervision and direction adequacy .... 7. Review and authenticates each patient record of treatment provided by a physician assistant in an emergency situation ...The responsible physician shall perform the review and authentication of the patient record within 48 hours of the treatment ...".
- The "KANSAS-PHYSICIAN ASSISTANT's RESPONSIBLE PHYSICIAN and DRUG PRESCRIPTION PROTOCOL" under "#3." directed the responsible physician to be always available for communication with the PA within 30 minutes during the performance of patient service by the PA. Under "7 " The signature of the designated physician who shall routinely provide direction and supervision to the physician assistant in the temporary absence of the responsible physician is required ...8 ...In case of requested assistance or any pertinent clinical questions, practitioner will call designated physician above. Practitioner will also contact designated physician prior to supervising physician's absence ...dated and signed on 3/7/14.
The CAH's "Clinical Privileges-Physician Assistant" dated 2/13/14 and signed by the PA on 2/13/14 reviewed on 4/9/14 at 1:00pm in the hospital conference room lacked Physician's staff A's approval for requested Clinical Privileges, the Chief Executive Officers approval for Temporary Privileges, the Medical Staff Executive Committee Approval of Privileges and the Governing Boards Approval of Privileges.
- Policy titled "EMTALA- Qualified Medical Personnel Authorized to Perform Medical Screening Examinations; Accompanying Protocols" directs the physician assistant (PA) to consult with the physician prior to admitting any patient.
- Emergency Department Policy and Procedure titled "Scope of Service" dated 10/2013 reviewed on 4/9/14 at 1:15 pm directs ...A minimum of one Emergency Department Licensed Independent Practitioner is on duty or on call at all times. If the practitioner is on call they will have a 20 minute response time...
- Patient #3's medical record reviewed on 4/8/14 between 12:30pm to 4:30pm revealed an ED admission date of 4/6/14 at 8:56am with a diagnosis of foot injury, history of cerebral vascular accident (stroke) with left sided weakness and difficulty transferring. The PA performed the medical screening exam (MSE) and admitted patient #3 to the CAH. The medical record lacked responsible physician staff A's review and authentication of the medical within 48 hours. The medical record lacked evidence the PA followed the CAH's policy to consult with the physician prior to admitting patient #3 to the hospital.
- Patient #7's medical record reviewed on 4/8/14 between 12:30pm to 4:30pm revealed an ED admission date of 4/4/14 at 4:45pm with a diagnosis of right side pneumonia, dementia and outpatient antibiotic failure. The PA performed the MSE in the ED and admitted patient #7 to the CAH. The medical record lacked responsible physician A's authentication of the medical record within 48 hours. The medical record lacked evidence the PA consulted with the physician prior to admitting patient #7 to the hospital.
- The "April-14 Provider Call Schedule" reviewed in the front office on 4/8/14 at 11:30am revealed physician assistant (PA) staff D on call from 4/4/14 (Friday) 8:00am until 4/7/14 (Monday) 6:00am. The provider call schedule delegated physician A as the CAH's covering physician. The "On Call;" schedule reviewed on 4/9/14 at 11:40am at the nurses station dated April 5 and 6 listed PA staff D as on call with the CAH's physician staff A as second on call.
Medical staff A interviewed on 4/9/14 between 8:55am to 9:15am acknowledged they were the on call physician for staff D between 4/4/14 at 8:00am to 4/7/14 at 6:00am. Staff A verified they were approximately 165 miles away. Staff A verified the hospital policy directs PA staff D to notify them of any patient admission to the CAH. Staff A confirmed staff D failed to consult them of patient # 3's and 7's admissions to the CAH. Staff A verified that they were unaware of the 48 hour requirement to review and authenticate the medical records for patient #'s 3 and 7.
PA staff D interviewed on 4/9/14 between 8:15am to 8:30am in the conference room acknowledged they provided patient care services for the ED on Friday 4/ 4/14 from 8:00am to Monday 4/7/14 until 6:00am. Staff D verified the ED physician staff A was out of town approximately 165 miles away and would take about 2 hours and 45 minutes to return to the CAH. Staff D acknowledged the policy directs them to notify the on call physician for any patient admissions to the CAH. Staff D verified they failed to consult with physician staff A regarding patient # 3's and 7's admissions to the hospital. Staff D acknowledged that they failed to notify designated physician staff E of physician staff A's absence.
Contracted physician staff E interviewed per telephone on 4/10/14 at 12:35pm acknowledged they contracted with the CAH to provide on call physician service coverage for the ED when CAH physician staff was unavailable to consult or present to the ED when requested by the QMP's in a reasonable amount of time. Staff E confirmed that they had not been contacted by any of the CAH staff to be available to provide on call services for the ED in the past two or three months. Staff E acknowledged the CAH has a new physician and they have not provided on call coverage since physician staff A's and PA staff D's employment.
Administrative CAH Staff B interviewed on 4/8/14 between 4:00pm to 4:35pm acknowledged the PA was the on call provider for the weekend of 4/5/14 and 4/6/14. Staff B interviewed on 4/9/14 confirmed the CAH lacked approved Bylaws that included the EMTALA Requirements specific for physician supervision and oversight of the QMP's. Staff B acknowledged they were unaware of the Kansas requirement for the responsible physician to review and authenticate the medical records within forty eight hours for patient #'s 3 and 7 who were admitted to the CAH. Staff B confirmed the responsible physician was approximately 165 miles away from the CAH on Friday afternoon, 4/4/14 and Monday morning 4/7/14.

The Critical Assess Hospital (CAH) reported the Emergency Department (ED) treated 427 emergency cases for the last six months from October 2013 to March 2014. Based on medical record review, document review and staff interview the CAH failed to follow their policy and procedure to ensure the qualified medical personnel (QMP) consulted the on call physician for admissions and the CAH notified the designated physician of the responsible physician's inability upon request by the QMP to arrive at the CAH's emergency department (ED) in a reasonable amount of time for 8 of 8 patients treated in the ED by the QMP ( Patient #'s 1, 2, 3, 4, 5, 6, 7 and 8).
The CAH's failure to ensure the QMP followed the CAH's policy and procedures to ensure the QMP consulted the on-call physician and the on-call physician was available in a reasonable amount of time had the potential to affect all patients treated in the CAH's ED.
Findings included:
- Policy titled: EMTALA-Qualified Medical Personnel Authorized to Perform Medical Screening Examinations; Accompanying Protocols " dated October 23, 2013, directed that the qualified medical personnel (QMP) must be determined competent and will consult with the physician prior to transferring a patient to another hospital or admitting the patient. If a patient requires services that are beyond the QMP's scope of practice, demonstrated competency, or comfort level the QMP will request the physician to come to the hospital to evaluate and treat the patient.
- Policy titled "EMTALA-ON-Call Coverage Policy" dated October 23, 2013 and reviewed on 4/9/14 at 9:00am in the conference room revealed under "ED Physician Responsibilities" directed upon the request of the QMP the on call physician is to arrive at the ED as soon as possible.
- The "April-14 Provider Call Schedule" reviewed in the front office on 4/8/14 at 11:30am revealed physician assistant (PA) staff D on call from 4/4/14 (Friday) 8:00am until 4/7/14 (Monday) 6:00am. The provider call schedule delegated physician A as the CAH ' s covering physician. The "On Call" schedule reviewed on 4/9/14 at 11:40am at the nurses station dated April 5 and 6 listed PA staff D as on call with the CAH's physician staff A as second on call.
- Review on 4/8 and 9/14 in the conference room of eight ED medical records between 4/4/14 at 4:45pm and 4/7/14 at 2:45am revealed PA staff D admitted two patients (Patient #'s 3 and 7) to the hospital:
?Patient #3's medical record revealed an ED admission date of 4/6/14 at 8:56am with a diagnosis of foot injury, history of cerebral vascular accident (stroke) with left sided weakness and difficulty transferring. The PA performed the medical screening exam (MSE) and admitted patient #3 to the CAH. The medical record lacked evidence PA staff D consulted the on call physician staff A prior to the hospital admission of patient #3.
?Patient #7's medical record review revealed an ED admission date of 4/4/14 at 4:45pm with a diagnosis of right side pneumonia, dementia and outpatient antibiotic failure. PA staff D performed the MSE in the ED and admitted patient #7 to the CAH. The medical record lacked evidence PA staff D consulted the on call physician staff A prior to the hospital admission of patient #7.
? PA staff D triaged patient #1 and patient #4 as urgent, treated the patient and discharged them to home. PA staff D triaged patient # ' s 2, 5, 6 and 8 as non-medical emergencies, treated the patients and discharged them to home.
PA staff D interviewed on 4/9/14 between 8:15am to 8:30am in the conference room acknowledged they provided patient care services for the ED on Friday 4/ 4/14 from 8:00am to Monday 4/7/14 until 6:00am. Staff D verified the ED physician staff A was out of town approximately 165 miles away and would take about 2 hours and 45 minutes to return to the CAH. Staff D acknowledged the policy directs them to notify the on call physician for any patient transfers and admissions to the CAH. Staff D verified they failed to consult with physician staff A regarding patient #'s 3 and 7 admission to the hospital. Staff D verified the CAH has a contract with physician staff E for on call coverage when physician staff A is out of the area and unable to respond to the ED when requested to by the QMP's.
Physician Staff A interviewed on 4/9/14 between 8:55am to 9:15am in the conference room acknowledged they were the on-call physician for PA staff D on 4/4/14 at 8:00am until 4/7/14 at 6:00am. Physician staff A acknowledged that during this time frame they were approximately 165 miles away or about 2 hours and 45 minutes from the CAH. Physician staff A verified they were available by telephone but failed to receive notification or was consulted, as required by policy, by PA staff D regarding patient # 3's and 7's admissions to the hospital.
Contracted physician staff E interviewed per telephone on 4/10/14 at 12:35pm acknowledged they contracted with the CAH to provide on call physician service coverage for the ED when CAH physician staff was unavailable to consult or present to the ED when requested by the QMP's in a reasonable amount of time. Staff E confirmed administrative staff B had not contacted them to be available to provide on-call services for the ED in the past two or three months. Staff E acknowledged the CAH has a new physician and they have not provided on call coverage since physician staff A's and PA staff D's employment.