HospitalInspections.org

Based upon observation, record review, and interview, the Governing Body failed to ensure the operation of the Emergency Services Department and assure staffing of both nurses and physicians was provided to care for sick and injured patients that presented to the Emergency Department from October 1, 2022, to February 6, 2023. This resulted in 40 of 40 patients reviewed presenting to the Emergency Department during this time that received no stabilizing treatment, no diagnostic treatment, and no transfer arrangements for continued care. The deficient practices identified were determined to pose a severe risk to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Cross reference to Tag A0092 §482.12 (f)(1)

Cross reference to Tag A0093 §482.12 (f)(2)

Based upon observations, record reviews, and interviews with facility staff, the requirements of CFR §482.55 were not fully implemented in the facility. The facility failed to have organized services under the direction of qualified medical staff, integrate emergency services with other departments of the hospital, follow policies and procedures governing medical care provided in the emergency service department by responsible medical staff, supervise emergency service by qualified medical staff and meet written emergency procedures and needs anticipated by the facility. The Emergency Services Department was closed October 1, 2022. This resulted in 40 out of 40 patients selected from the central log that contained 58 patients total presenting to the Emergency Center for treatment during October 1, 2022, through February 6, 2023, to a closed emergency room with no staff available to implement the requirements of CFR §482.55. The deficient practices identified were determined to pose a severe risk to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Findings include:

Staff reported that on October 1, 2022, the facility was told by upper management that the ER (Emergency Room) was to be closed as per signed written statements obtained from Staff #2 CNO and Staff #3 House Supervisor.

On 2.6.2023 an observation was made that the sign outside near the roadway that had "EMERGENCY" printed in bold red lettering was covered with a white cover. An observation was made that the ER doors were blocked and locked preventing patient access for both ambulances and patients.

During the review of the central log, it was identified that 40 out of 40 patients selected from a list of 58 total patients had presented to the facility during the time the ER was closed. There was no nurse or physician assigned in the emergency department to meet the written procedures and needs anticipated by the facility. There was no medical record or MOT (Memorandum of Transfer) for any of these patients located at the facility that documented a MSE (Medical Screening Exam) had been performed which was a violation of facility policy and procedures governing medical care in the emergency department.

An interview was conducted on 2.6.2023 at 1:48 pm with Staff #3 who was an RN/House Supervisor. Staff 3# was asked what the procedure for patients that showed up to the ER seeking care. Staff #3 stated in part" We get vital signs and either call 911 or refer them to another facility like our freestanding ER across the parking lot."

Based on observation, review of documentation and interview, the governing body failed to insure the medical staff followed written policies and procedures for the Emergency Department resulting in 40 out of 40 patients selected for review from the central log that contained 58 patients being turned away from the Emergency Department with no MSE (medical screening exam) treatment or care by a physician as no physician or nurse was staffed in the emergency department from October 1, 2022, to February 6, 2023. The deficient practices identified were determined to pose a severe risk to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Findings include:

A review of facility policy revealed:

" Policy Title: Scope of Services - Emergency Room P&P#: ADMI.03
The Emergency Room will be staffed by a qualified Physician from the Medical Staff. The medical staff shall designate a "back-up" process should the in-house ER physician should be unable to respond due to unforeseen circumstances such as tending to another emergency.

An RN will be staffed to provide 24 hours/7 days a week to respond to individuals presenting to the ER Department. The "back up" is the house supervisor.
Operations of the ER Department shall be under the direction of the Medical Director whose qualifications and responsibilities shall be defined in the "Job Responsibilities ER Medical Director."

During an observational tour on the morning of 2.6.2023 the surveyor did not observe a physician or nurse assigned in the emergency room (ER).

In an interview on 2.6.2023 at 1:48 pm with Staff #3 who was asked if the emergency department had been staffed with nurses or physicians since October 1, 2022, Staff #3 stated in part "Altus Baytown Hospital ER has been closed since 10/01/2022. There have not been any medical or nursing staff scheduled in the ER. The last patient seen in the ER was on 09/29/2022."

In an interview on 2.6.2023 at 1:50 pm with Staff #2 who was also asked if the emergency department had been staffed with nurses or physicians since October 1, 2022, Staff #2 stated in part, "I am verifying that the one bay Emergency Room at Altus Baytown Hospital has not received emergency room patients since September 29, 2022. In addition, zero emergency room physicians or emergency room nurses have been scheduled to work for the past 3 months."

Based upon observation, record review, and interview, the hospital failed to ensure the operation of the Emergency Services Department. This resulted in no MSE (Medical Screening Exam), and no delivery of care based on current accepted standards for an emergency room for 40 out of 40 patients selected from 58 patients on the central log that presented to the ER (Emergency Room) during the period of October 1, 2022, to February 6, 2023. The deficient practices identified were determined to pose a severe risk to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Cross reference to Tag A1101 CFR §482.55(a)

Cross reference to Tag A1102 CFR §482.55(a)(1)

Cross reference to Tag A1103 CFR §482.55(a)(2)

Cross reference to Tag A1104 CFR §482.55(a)(3)

Cross reference to Tag A1110 CFR §482.55(b)

Cross reference to Tag A1111 CFR §482.55(b)(1)

Cross reference to Tag A1112 CFR §482.55(b)(2)

Based on a review of records and interviews, the facility failed to provide organized emergency services. The facility failed to follow facility policy for providing emergency services in the emergency department. The deficient practices identified were determined to pose a severe risk to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Findings include:

Facility policy titled: ED Patient Assessment P&P#: ED.11 stated in part,

" PURPOSE:
To establish guidelines for a basic nursing assessment and documentation in the Emergency Department (ED).
POLICY:
All patients will receive an assessment by a physician and a registered nurse, who will determine the patient's initial needs, changing needs and effectiveness of care/intervention.
ASSESSMENT:
1. Assessments will be performed by each discipline within their scope of practice, licensure laws, applicable regulations and certifications.
a. Assessment is the systematic collection and review of patient data. All assessment data from the multi-disciplinary team is utilized to determine and prioritize the care needs of the patient. The determination and prioritization of care is based upon the diverse and unique needs of the patient, including bio physiologic, cognitive, behavioral, psychological, spiritual, social/cultural data and past medical history. Additionally, the assessment will identify any factors that pose potential barriers to the patient reaching their goals.
2. The assessment process includes the following:
a. The collection of data through mechanisms such as: observation, interview, measurements, and diagnostic tests.
b. The data is analyzed to determine the care needs of the patient and to identify any additional information required.
c. Data is gathered from interviews and observations with patient/family/ significant others, medical record review and staff consultation.
d. Decisions are made and executed on the basis of the assessment.
e. Additional vital signs shall be obtained according to the patient's condition.
EMERGENCY DEPARTMENT NURSING
INITIAL ASSESSMENT:
1. A personal interaction between patient and staff member occurs upon arrival to the Emergency Room.
2. The patient's initial assessment, consisting of physical assessment and focused system review is taken
3. The following information will be documented in the initial assessment in the Emergency room: nurse, allergies, medications, height and weight (KG), functional screening/patterns, immunization status, nutritional screening, values/beliefs/cultural needs, barriers to learning, injury/fall risk and abuse assessment. The RN is responsible for performing the nursing assessment. The RN may delegate aspects of data collection to other ancillary staff. The RN must then analyze the data and set care priorities after obtaining a plan of care from the physician.
4. If during the initial assessment only partial data is obtainable, due to the patient's condition and lack of significant other, the assessment is marked appropriately as unknown. Additional data is collected as soon as feasible and documented, signed and dated on the initial assessment forms."

A review of the central log for the facility revealed that patients #1 thru #40 presented to the emergency department during the period of October 1, 2022, to February 6, 2023, and received no documented assessment by either a nurse or a physician. There was no creation of a medical record and no record of a reassessment based on the patients' changing needs.

An interview was conducted on 2.6.2023 at 3:35 pm with Staff #1 who confirmed that the facility had no medical records for patients #1 thru #40 to show that any assessment or care was provided by a nurse or physician.

Based on record review and interview the facility failed to ensure that Emergency Department Services were under the direction of a qualified member of the medical staff acting as ER (emergency room) Medical Director from October 1, 2022, to February 6, 2023. The deficient practices identified were determined to pose a severe risk to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Findings include:

Facility policy was reviewed and revealed:

"Policy Title: Scope of Services - Emergency Room P&P#: ADMI.03

POLICY:

For those Hospitals that provide emergency services onsite:
The Emergency Room will be staffed by a qualified Physician from the Medical Staff. The medical staff shall designate a "back-up" process should the in-house ER physician should be unable to respond due to unforeseen circumstances such as tending to another emergency.

An RN will be staffed to provide 24 hours/7 days a week to respond to individuals presenting to the ER Department. The "back up" is the house supervisor.

Operations of the ER Department shall be under the direction of the Medical Director whose qualifications and responsibilities shall be defined in the "Job Responsibilities ER Medical Director."

During the time the facility was closed, 40 out of 40 patients selected for review presented to the ER as evidenced by roster patient numbers #1 thru #40 who all presented to the facility during October 1, 2022, thru February 6, 2023, with no physician care and no MSE (medical screening exam) this was a violation of facility policy for sites with an Emergency Department.

During this time there was no qualified member of the medical staff assigned as the Medical Director of emergency services which was also a violation of facility policy.

An interview was conducted on 2.6.2023 at 1:48 pm with Staff # 3 who is the house supervisor, who stated in part, "There has been no staff assigned to the emergency department since October 1, 2022."

Based on record review and interview, the facility failed to ensure that the Emergency Department (ED) was fully integrated with other ancillary services located in the hospital in 40 out of 40 patient records selected for review. The facility failed to integrate the diagnostic capabilities for lab and radiology. The facility failed to provide pharmacological intervention from the pharmacy within the facility for patients that presented to the ER (emergency room) who may have benefited from pharmaceuticals for treatment during October 1, 2022 thru February 6, 2023. The deficient practices identified were determined to pose a severe risk to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Findings include:

Staff reported that the ER (emergency room) closed on October 1, 2022. This closure resulted in 40 patients selected for review from the central log containing 58 patients presenting to the ER for various ailments requesting service and treatment but were sent away to other facilities with no diagnostics or intervention provided by the facility even though the capabilities were in place within the facility such as lab, radiology, and pharmacy.

During an observational tour on 2.6.2023 it was noted that the ER (emergency room) was not staffed with a physician or nursing staff. Patients presenting to the facility would be unable to access the available services in the facility without a physician's order which could not be done when a physician is not present in the ER.

An interview was conducted on 2.6.2023 at 1:48 pm with Staff #3 who was an RN/House Supervisor. Staff 3# was asked what the procedure for patients that showed up to the ER seeking care. Staff #3 stated in part" We get vital signs and either call 911 or refer them to another facility like our freestanding ER across the parking lot."

Based on record review and interview the facility failed to follow and enforce policies and procedures to ensure that 40 out of 40 patients who presented to the ER (emergency room) on October 1, 2022, thru February 6, 2023, received appropriate MSE (medical screening exam) and transfers if needed. The deficient practices identified were determined to pose a severe risk to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Findings include:

Review of the policy and procedures titled "Medical Screening Exam P&P#: ED.12" revealed,

" PURPOSE:
To establish the process in which every patient is offered a medical evaluation by the physician.
POLICY:
This facility shall provide to each patient, without regard to the individual's ability to pay, an appropriate medical screening, examination, and stabilization within the facility's capability, including ancillary services routinely available to the facility, to determine whether an emergency medical condition exists and shall provide any necessary stabilizing treatment.
PROCEDURES:
A. Patient presents to Altus Community Health System with a perceived emergency medical condition.
B. Patient will be registered in the registration and / or EMR system.
C. The patient will be triaged by a registered nurse.
D. The patient will receive a medical evaluation by the emergency physician to determine whether an emergency medical condition exists.
1. If an emergency medical condition is determined to exist, the physician will explain the condition, it's emergent nature and possible consequences if left untreated and the recommended treatment plan with the patient and family.
a. The physician will discuss benefits and risks of care and / or refusal of care.
b. After the MSE determination is complete and when patient status allows, registration personnel will complete the registration process, providing it does not interfere with patient care or stabilization of the patient's condition.
c. If the patient refuses care, the physician will discuss leaving AMA with the patient and family. The AMA form will be explained, signed, and witnessed as appropriate.
d. The physician will provide instructions on further care and encouragement to return for worsening symptoms or condition.
e. Nursing and / or registration staff will provide discharge instructions, information on resources for healthcare, and clinics available in the community."

Review of the policy and procedures titled " EMERGENCY TRANSFER PROCESS P&P#: ADMO.03" revealed,

" PURPOSE:
To provide guidelines for facility personnel to follow when a patient requires transfer to a higher level of care to ensure the appropriate level of care for the patient.
POLICY:
It is the policy of Facility to transfer patients with the following conditions to a general acute care hospital:
1. Patients who have received CPR.
2. Any patient who's presenting medical condition the facility is not equipped to handle.
The Governing Body of Altus Community Health System has determined that there shall be on duty and available at all times at least one person qualified as determined by the medical staff (PHYSICIAN/ER MD/NP) to perform emergency medical screening examination and will determine if a transfer is needed.
A Certification Statement and Memorandum of Transfer shall be completed on all patients transferred to a higher level of care.
The transferring physician (PHYSICIAN/ER MD/NP) shall determine and order life support measures including equipment and personnel which are medically appropriate to stabilize the patient prior to transfer and to sustain the patient during transfer.
PROCEDURE:
In the event the situation eventuates into a transfer of a patient, the physician (PHYSICIAN/ER MD/NP) in charge of the emergency protocol will perform or delegate the following.
General Steps:
1. An ambulance or paramedics will be called to transport the patient.
2. The hospital will be called and notified of the emergency transfer.
3. The receiving physician will be notified.
4. The family will be informed.
5. A copy of the patient's medical record shall accompany the patient and at a minimum shall contain:
5.1 A brief description of the patient's medical history and physical examination;
5.2 A working diagnosis and recorded observations of physical assessment of the patient's condition at the time of transfer;
5.3 The reason for the transfer;
5.4 The results of all diagnostic tests, such as laboratory tests;
5.5 Pertinent X-ray films and reports;
5.6 Any other pertinent information.
Plan to Provide Patient Transfer Transportation Services:
1. The physician will indicate the mode of transportation to be used in the transfer, ensuring that the transfer is completed with the assistance of qualified personnel and transportation equipment.
2. If required by the patient's condition or per the physician's order, hospital personnel will contact local EMS to arrange for patient transfer transportation services.
Transfer Arrangements:
1. A Transfer Certification shall be completed, which will include:
1.1 A summary of the risks and benefits based on the information available at the time of transfer,
1.2 The medical benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient affecting the transfer.
2. The receiving hospital shall respond to the transferring hospital and transferring physician with the status of the transfer request within 30 minutes and will either accept or refuse the transfer. The time period begins to run at the time a member of the staff of the receiving hospital receives the call initiating the request to transfer.
2.1 The receiving hospital's policy may permit response to the transferring hospital and transferring physician within a period of time in excess of 30 minutes but no longer than one hour if there are extenuating circumstances for the delay. If the transfer is accepted, the reason for the delay shall be documented on the Memorandum of Transfer.
2.2 The response time may be extended before the expiration of the initial 30-minute period by agreement among the transferring hospital and transferring physician and the receiving hospital and receiving physician. If the transfer is accepted, the agreed extension shall be documented in The Memorandum of transfer (MOT).
2.3 A copy of the MOT is retained in the quality department filed separately from the medical record.
2.4 The Memorandum of Transfer shall contain the following information:
2.4.1 The patient's full name, if known;
2.4.2 The patient's race, religion, national origin, age, sex, physical handicap, if known;
2.4.3 The patient's address and next of kin, address, and phone number if known;
2.4.4 The names, telephone numbers and addresses of the transferring and receiving physicians;
2.4.5 The names, addresses, and telephone numbers of the transferring and receiving hospitals;
2.4.6 The time and date on which the patient first presented or was presented to the transferring physician and transferring hospital;
2.4.7 The time and date on which the transferring physician secured a receiving physician;
2.4.8 The name, date, and time hospital administration was contacted in the receiving hospital;
2.4.9 The signature, time, and title of the transferring hospital administration who contacted the receiving hospital;
2.4.10 The time and date on which the receiving physician assumed responsibility for the patient;
2.4.11 The time and date on which the patient arrived at the receiving hospital;
2.4.12 Signature and date of receiving hospital administration;
2.4.13 Type of vehicle and company used;
2.4.14 Type of equipment and personnel needed in transfers;
2.4.15 Name and city of hospital to which patient was transported;
2.4.16 Diagnosis by transferring physician; and 2.4.17 Attachments by transferring hospital.
Refusal of Transfer:
1. Reasonable steps shall be taken to secure the informed refusal of a patient refusing a transfer or a related examination and treatment or of a person acting on a patient's behalf refusing a transfer or a related examination and treatment. Reasonable steps include (and will be detailed:
1.1. A factual explanation of the increased medical risks to the patient reasonably expected from not being transferred, examined, or treated at the transferring hospital;
1.2. A factual explanation of any increased risks to the patient from not effecting the transfer; and
1.3. A factual explanation of the medical benefits reasonably expected from the provision of appropriate treatment at another hospital.
1.4 The informed refusal of a patient, or of a person acting on a patient's behalf, to examination, evaluation or transfer shall be documented and signed if possible by the patient or by a person acting on the patient's behalf, dated and witnessed by the attending physician or hospital employee, and placed in the patient's medical record.
Disclosure:
1. Patients who are being transferred shall be informed of any economic impact that will have to be considered, should the patient make a request to a specified receiving hospital.
CQI Committee Reporting:
1. Staff personnel shall prepare record reviews according to EMTALA Transfer Audit Form of all patients treated and/or transferred from the emergency treatment room as to the following:
1.1 Management of patient care.
1.2 Appropriate need for transfer.
1.3 Follow-up process.
1.4 The receiving hospital will be requested to send a discharge summary for that patient transferring Facility.
2. Review of all patients leaving AMA and prior to screening exam also will occur. The reviews will be conducted by the Medical Director and Chief Nursing Officer/ Director of Nursing to determine the appropriateness of transfers, timeliness, of service and completeness of documentation. Findings will be reported to QIC and Governing Board on a quarterly basis and trended for Process Improvement."

During the review of the central log, it was identified that 40 out of 40 patients selected from a list of 58 total patients had presented to the facility during the time the ER was closed. There was no nurse or physician assigned in the emergency department to meet the written procedures and needs anticipated by the facility. There was no medical records or MOT (Memorandum of Transfer) for any of these patients located at the facility that documented a MSE (Medical Screening Exam) had been performed which was a violation of facility policy and procedures governing medical care in the emergency department.

An interview was conducted on 2.6.2023 at 1:48 pm with Staff #3 who was an RN/House Supervisor. Staff 3# was asked what the procedure for patients that showed up to the ER seeking care. Staff #3 stated in part" We get vital signs and either call 911 or refer them to another facility like our freestanding ER across the parking lot."

An interview was conducted on 2.6.2023 at 3:35 pm with Staff #1 who confirmed that the facility had no medical records including MOT (memorandum of transfers) for patients #1 thru #40 to show that any assessment or care was provided by a nurse or physician to stabilize the condition prior to transfer.

Based on record review, observation and interview the facility failed to ensure the emergency services personnel requirements were met in 40 out of 40 patients selected for review as the ER (emergency room) was not staffed with nurses or physicians from October 1, 2022, to February 6, 2023.

Findings include:

A review of the central log showed 58 patients presented to the ER from October 1, 2022, to February 6, 2023, of which 40 out of 40 selected for review had no physician or nursing assessment performed as the facility has been without staff.

During an observational tour on 2.6.2023 it was noted that there was no physician or nursing staff assigned to the ER (emergency room) to provide any care or assessment to patients.

Staff reported that the ER (emergency room) has been closed since October 1, 2022.

In an interview on 2.6.2023 at 1:48 pm with Staff #3 who was asked if the emergency department had been staffed with nurses or physicians since October 1, 2022, Staff #3 stated in part "Altus Baytown Hospital ER has been closed since 10/01/2022. There have not been any medical or nursing staff scheduled in the ER. The last patient seen in the ER was on 09/29/2022."

In an interview with Staff #2 who was also asked if the emergency department had been staffed with nurses or physicians since October 1, 2022, Staff #2 stated in part, "I am verifying that the one bay Emergency Room at Altus Baytown Hospital has not received emergency room patients since September 29, 2022. In addition, zero emergency room physicians or emergency room nurses have been scheduled to work for the past 3 months."

Based on observation, record review and interviews the facility failed to ensure a qualified member of the medical staff was in the hospital and immediately available during all times the hospital makes emergency services available and can provide direction and/or direct care during the operating hours of the emergency department from October 1, 2022, to February 6, 2023. The deficient practices identified were determined to pose a severe risk to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Findings include:

During an observational tour on the morning of 2.6.2023 there were no physicians or nurses observed in the ER (emergency room).

A request was made for the schedules of the ER (emergency room) staff physicians from October 1, 2022, to February 6, 2023, to review and verify credentials. The facility was unable to provide a list of ER physicians because the emergency room has been closed since October 1, 2022, as reported by staff.

In an interview on 2.6.2023 at 1:48 pm with Staff #3 who was asked if the emergency department had been staffed with nurses or physicians since October 1, 2022, Staff #3 stated in part "Altus Baytown Hospital ER has been closed since 10/01/2022. There have not been any medical or nursing staff scheduled in the ER. The last patient seen in the ER was on 09/29/2022."

In an interview with Staff #2 who was also asked if the emergency department had been staffed with nurses or physicians since October 1, 2022, Staff #2 stated in part, "I am verifying that the one bay Emergency Room at Altus Baytown Hospital has not received emergency room patients since September 29, 2022. In addition, zero emergency room physicians or emergency room nurses have been scheduled to work for the past 3 months."

Based on a review of documentation and interviews with staff, the facility failed to provide staffing for the emergency department from October 1, 2022, thru February 6, 2023, which left the facility inadequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility for 40 out of 40 patients selected for review. The deficient practices identified were determined to pose a severe risk to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Findings include:

Facility policy was reviewed and revealed:

"Policy Title: Scope of Services - Emergency Room P&P#: ADMI.03
POLICY:
For those Hospitals that provide emergency services onsite:
The Emergency Room will be staffed by a qualified Physician from the Medical Staff. The medical staff shall designate a "back-up" process should the in-house ER physician should be unable to respond due to unforeseen circumstances such as tending to another emergency.
An RN will be staffed to provide 24 hours/7 days a week to respond to individuals presenting to the ER Department. The "back up" is the house supervisor.
Operations of the ER Department shall be under the direction of the Medical Director whose qualifications and responsibilities shall be defined in the "Job Responsibilities ER Medical Director."
PROCEDURE:
1. The hospital's medical staff will establish policies and procedures governing the general medical care provided in the emergency room department.
Policies and procedures to include:
1.2 ER Staffing
4.1 After nursing assessment is completed, the ER nurse will contact the ER MD on duty who provide Medical Screening Exam and determine if medical emergency is present. If medical emergency is present ERMD will provide stabilization, admit or transfer to appropriate facility."

During the time the facility was closed, 40 out of 40 patients selected for review presented to the ER during October 1, 2022, thru February 6, 2023, with no physician care, no medical record created, and no MSE (medical screening exam) this was a violation of facility policy for sites with an Emergency Department.

An interview was conducted on 2.6.2023 at 1:48 pm with Staff # 3 who is the house supervisor, who stated in part, "There has been no staff assigned to the emergency department since October 1, 2022."

Based on interview and record review, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements. The deficient practices identified were determined to pose a severe risk to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Cross reference to Tag A2403 CFR §489.20(r)(1)

Cross reference to Tag A2404 CFR §489.20(r)(2) and CFR §489.24(i)(1-2)

Cross reference to Tag A2406 CFR §489.24(a)

Cross reference to Tag A2407 CFR §489.24(d) (1-3)

Cross reference to Tag A2409 CFR §489.24(e)(1)-(2)

Based on document review and staff interview, the facility failed to ensure that a medical record was maintained for every individual who presented to the hospital for examination and/or treatment as there was no medical record maintained for 40 out of 40 patients selected for review that presented to the hospital emergency department from October 1, 2022, to February 6, 2023.

Findings included:

A review of the central log revealed 40 out of 40 patients that were selected for review presented to the Emergency Department between the dates of October 1, 2022, and February 6, 2023, requesting medical care or treatment.
The surveyor requested the medical records for these patients on 2.6.2023. The facility was unable to produce medical records for any of these patients.

A review of facility policy titled "Contents of the Medical Record P&P#: HIM.008" revealed in part,

" PURPOSE:
To outline the contents of a complete medical record.
SCOPE:
Each medical record shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course of treatment and the results accurately, and facilitate continuity of care among health care providers.
POLICY:
Altus Community Health System utilizes the format illustrated in Health Information Management policy "Medical Record Chart Order." The following guidelines shall be adhered to on the documentation and placement of the medical record. All entries in the medical record must be legible, signed, dated and timed.
PROCEDURES:
The attending practitioner is responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current.
1. The medical record will include, but not be limited to:
A. Identification data
B. Admitting diagnosis
C. Relevant past, family, and psychosocial histories
D. A system review
E. Current comprehensive history and physical examination
F. Provisional diagnosis or statement of problems
G. A plan of care
H. Physician's Orders
I. All required consents
J. Special reports such as laboratory (clinical / lab / pathology), cardiology, radiology
services, and other
K. Treatment
L. Progress Notes
M. Operative or procedure reports
N. Consultations
O. Condition on discharge
P. Discharge summary; final diagnosis
Q. Any patient/family instructions/education
R. When performed, an autopsy protocol "

An interview was conducted on 2.6.2023 at 3:35 pm with Staff #1 who confirmed that the facility had no medical records for patients #1 thru #40 to show that any assessment or care was provided by a nurse or physician.

Based on interview and record review the facility failed to provide a physician on-call list for the emergency room to review for compliance.

Findings include:

On the morning of 2.6.2023, in the facility conference room, the surveyor requested a Physician on-call list to review for emergency room coverage. The facility was unable to provide a list since the emergency room has been closed since October 1, 2022.

During an observational tour on the morning of 2.6.2023 the surveyor observed that there was no physician present in the ER (emeregency room) at the time of survey.

An interview was conducted on 2.6.2023 at 1:48 pm with Staff # 3 who is the house supervisor, who stated in part, "There has been no staff assigned to the emergency department since October 1, 2022."

Based on review of records and interviews the facility failed to perform and document an appropriate medical screening examination in the emergency department (ED) to determine if the patient was stable or had an emergency medical condition in 40 out of 40 patients that presented to the Emergency Department from the period of October 1, 2022, and February 6, 2023. The deficient practices identified were determined to pose a severe risk to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Findings include:

A review of the central log was used to identify 58 patients that presented to the ED (emergency department) during the periods of October 1, 2022, and February 6, 2023, during which time the ED had been closed as per upper management. This resulted in 40 out of 40 patients selected for review from the 58 total patients presenting for various complaints seeking medical care and treatment and being turned away with no MSE (medical screening exam) performed.

A review of facility policy titled "Medical Screening Exam P&P#: ED.12" revealed in part,

" PURPOSE:
To establish the process in which every patient is offered a medical evaluation by the physician.
POLICY:
This facility shall provide to each patient, without regard to the individual's ability to pay, an appropriate medical screening, examination, and stabilization within the facility's capability, including ancillary services routinely available to the facility, to determine whether an emergency medical condition exists and shall provide any necessary stabilizing treatment.
PROCEDURES:
A. Patient presents to Altus Community Health System with a perceived emergency medical condition.
B. Patient will be registered in the registration and / or EMR system.
C. The patient will be triaged by a registered nurse.
D. The patient will receive a medical evaluation by the emergency physician to determine whether an emergency medical condition exists.
1. If an emergency medical condition is determined to exist, the physician will explain the condition, it's emergent nature and possible consequences if left untreated and the recommended treatment plan with the patient and family.
a. The physician will discuss benefits and risks of care and / or refusal of care.
b. After the MSE determination is complete and when patient status allows, registration personnel will complete the registration process, providing it does not interfere with patient care or stabilization of the patient's condition.
c. If the patient refuses care, the physician will discuss leaving AMA with the patient and family. The AMA form will be explained, signed, and witnessed as appropriate.
d. The physician will provide instructions on further care and encouragement to return for worsening symptoms or condition.
e. Nursing and / or registration staff will provide discharge instructions, information on resources for healthcare, and clinics available in the community.
2. If an emergency medical condition is determined to NOT exist, the physician will discuss the plan of care and treatment options.
a. The registration personnel/House Supervisor will discuss the financial responsibility with the
patient for services or tests indicated.
b. The patient will be given the option to stay and continue care or seek alternative resources for healthcare services.
c. If the patient chooses to leave, the patient will be encouraged to return for worsening of symptoms or condition.
d. Prior to leaving the patient will be given a copy of the physicians recommended discharge instructions, healthcare resources and, clinics available in the community. "

An interview was conducted on 2.6.2023 at 1:48 pm with Staff # 3 who is the house supervisor, who stated in part, "There has been no staff assigned to the emergency department since October 1, 2022."

An interview was conducted on 2.6.2023 at 3:35 pm with Staff #1 who confirmed that the facility had no medical records for patients #1 - #40 to show that any assessment or care was provided by a nurse or physician.

Based on record review and interview with staff, the hospital failed to follow facility policy and failed to meet the requirements of an appropriate transfer in 40 of 40 records reviewed from October 1, 2022, to February 6, 2023.

Findings include:

During a review of the central log, the following requirements of an appropriate transfer were not met in 40 of 40 records reviewed:

- There was no memorandum of transfer signed by the transferring physician.

- No evidence of a Consent and Request with Risks and Benefits was completed.

- No evidence of a Physician Assessment and Certification was completed.

- No evidence of a Hospital Patient Transfer Form was completed or sent.

A review of facility policy titled " EMTALA P&P#: ED07" Stated in part,

" UNSTABLE PATIENTS:
10. An individual with an emergency medical condition which has not been stabilized may only be transferred for medical reasons or if the individual makes an informed request for a transfer:
a) For Medical Reasons with Physician Certification: If the treating physician certifies in writing on the "Transfer Summary Form" that, based on the reasonable risks and benefits to the patient, and based on the information available at the time of patient's transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks to the patient, and, if pregnant, the patient's unborn child from effecting the transfer. In the event an on-call or other physician has become involved in the care of the patient to the extent that he/she has assumed substantial responsibility for that patient, the physician shall also certify that the medical benefits outweigh the risks, and shall document such certification in the patient's medical record.
b) Informal request: The individual or a representative acting on the individual's behalf is first fully informed of the risks and benefits of the transfer. The transfer may then occur provided the individual or LRP:
c) Makes a request for the transfer; and acknowledges the request and his/her awareness of the risks and benefits of the transfer in writing on the "Transfer Summary Form."
STABLE PATIENTS:
11. Individuals with an emergency medical condition which has been stabilized may be transferred to another facility under one of the following conditions:
a) Transfer for Medical Reasons: If the treating physician recommends the transfer based on medical benefits and the individual provides informed consent to the transfer, the transfer may then occur if the patient or LRP consents to the transfer and acknowledges the reasons for the transfer on the "Transfer Summary Form."
b) Informed request for transfers: The individual requests a transfer for non-medical reasons after first being fully informed of the risks and alternatives to such a transfer. The transfer may then occur provided the individual or LRP:
c) Makes a request for the transfer and acknowledges the request and his/her awareness of the risks and benefits of the transfer in writing on the "Transfer Summary Form."
d) The treating physician who is responsible for the individual's care must declare that the patient is stable for transfer on the patient's "Transfer Summary Form."
PHYSICIAN CERTIFICATION
12. Physician certification is required for all transfers. This certification is required from the treating physician ordering the transfer and prior to the patient's transfer, noting that based on the
information available at the time of transfer, the medical benefits reasonable expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual and, in the case of a woman in labor, to the unborn child, from effecting the transfer. The certification shall include a summary of the risks and benefits upon which the certification is based and the reason(s) for the transfer.
a) If the treating physician is not physically present at the time of transfer, another physician can sign the certification as long as that physician is in agreement with the certification and the treating physician subsequently, countersigns the certification.
MEDICAL RECORDS
13. Medical records, laboratory and diagnostic reports, along with consultation notes, if applicable, must accompany all patients transferred. Reports that are not yet available at the time of transfer must be faxed to the recipient hospital as soon as they become available.
TRANSPORT BY QUALIFIED PERSONNEL
14. All transfers will be carried out through qualified medical personnel and equipment, as determined by the ED physician, including the use of necessary and medically appropriate life support measures during the transfer.
a) The mode of transportation will be documented on the Memorandum of Transfer (MOT). "

An interview was conducted on 2.6.2023 at 3:35 pm with Staff #1 who confirmed that the facility had no medical records including MOT (memorandum of transfers) for patients #1 thru #40 to show that any assessment or care was provided by a nurse or physician to stabilize the condition prior to transfer.