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Based on a review of Emergency Medical Services Documents, Emergency Department (ED) Policies and Procedures, ED Log, BC (Birthing Center/Obstetrics) Log, Medical Staff Bylaws, Medical Staff Rules and Regulations, Quality Assurance and Performance Improvement Plan (QAPI) and staff interviews it was determined that the facility failed to ensure that the Emergency Medical Treatment And Labor Act (EMTALA) Policies and Procedures were reviewed, revised or updated since 03/10, refer to A2400-A. The facility failed to include the ED Department into the facility wide QAPI Plan to ensure enforcement of the EMTALA policies and procedures, refer to A2400-B. The facility failed to ensure that patients would receive adequate pain control by posting a sign in the ED waiting room prohibiting specific medications and/or refills, refer to A2402-A. The facility failed to ensure all patients who presented to the ED were entered into the ED log, refer to A2405-A and failed to maintain a central log that included the BC patients who presented for an Medical Screening Exam (MSE), refer to A2405-B. The facility also failed to ensure one patient received stabilizing treatment before they were discharged home, refer to A2407.

Findings included:

A. Record review of the facility's ED policy and procedure manual showed that the last revised date for the manual was 03/29/10.

During an interview on 10/09/14 at 9:00 AM, Staff A, Registered Nurse (RN), Assistant Administrator/Patient Care Services, stated that he could not provide evidence that the ED EMTALA policies and procedures had been reviewed, revised or updated since their date of 03/10. He also stated that there was no policy and procedure for guidance on when policies and procedures were to be reviewed, revised or updated.

During an interview on 10/09/14 at 9:15 AM, Staff B, RN, Director of ED, stated that she had been Director of the ED for three years. She stated that soon after taking the position she had reviewed and approved the EMTALA Policies and Procedures in place. Staff B stated that the ED EMTALA Policies and Procedures had not been reviewed, revised or updated since that time.

B. During an interview on 10/08/14 at 10:20 AM, Staff B, RN, Director of ED, stated that the current QAPI measures for the ED were the core measures required for all hospitals. She stated that there was no written plan for other Quality Assessment and Performance Improvement (QAPI) projects to improve patient care in the ED related to high risk and/or high volume.

During an interview on 10/09/14 at 8:45 AM, Staff A, RN, Assistant Administrator, Patient Care Services, stated that the ED was not included in the hospital's QAPI annual Plan.

During an interview on 10/09/14 at 10:50 AM, Staff I, Director of Quality Assurance, stated that it was an oversight that the ED was not included in the facility's QAPI Plan.

Record review of the QAPI annual plan and minutes did not contain evidence that the hospital enforces its EMTALA Policies and Procedures.



27029

A. Based on observation and interview the facility failed to protect the patient's right to treatment for pain by posting a sign in the Emergency Department (ED) which stated that the facility could limit or withhold specific pain reducing drugs. This had the potential to affect all emergency room patients by discouraging patients from seeking pain relieving treatment.

Findings included:

Observation on 10/07/14 at 8:40 AM, showed a large sign posted by the door in the ED waiting room that stated the following:
"At the discretion of the emergency department physician, only very limited quantities of the following medications may be prescribed from the emergency room: Percocet, Percodan, Hydrocodone, Vicodin, Lortab, Ultram, Hydromorphone, Morphine, Dilaudid and Methadone [the listed pain medications are considered narcotics and have a higher analgesic (pain relief) potency and wider range of indications than any of the other currently available medications for pain control]. There will be no prescription refills on any of the above listed medications."

During an interview on 10/07/14 at 9:30 AM, Staff A, Registered Nurse (RN), Assistant Administrator, Patient Care Service (PCS), stated that the pain sign was posted approximately one year ago after seeing a similar sign posted in another facility's ED. After viewing the posted pain sign in another facility's ED it was decided the facility would post a similar pain sign in the facility's ED waiting area.


18018

A. Based on interviews, record and policy reviews, and the Birthing Center (BC) Logs the facility failed to ensure that the log identified 271 of 271 unscheduled BC patients who presented in the last six months seeking emergency services. The facility failed to log patients over 20 weeks gestation into the ED log before sending them to the OB department for care. This had the potential to affect all patients that presented to the BC to obtain a Medical Screening Exam (MSE) and were subsequently discharged back home.

Findings included:

1. Record review of the facility's policy titled, "Obstetric Patient (Unscheduled) Care," revised 03/29/10, showed the following direction for facility staff:
-To ensure timely medical screening exams and management of unscheduled obstetrical patients presenting to the emergency department or the birthing center.
-Patients presenting for obstetric conditions, other than scheduled procedures, will be logged in by the emergency department, or directly in the birthing center, if they present there initially.
-The patient with less than 20 weeks estimated gestation (pregnancy) would be evaluated in the emergency department.
-Patients with 20 weeks or greater estimated gestation and with obstetrical related complaints will be evaluated in the birthing center.

2. Record review of the BC's Log showed that staff documented in the log both scheduled and unscheduled patients presenting to the unit. The BC's Log did not differentiate between patients scheduled to be seen from those unscheduled patients seeking a MSE.

3. Record review of the facility's ED Log and BC Log showed that neither the information in the BC Log was included in the ED Log nor did the facility have a central log that contained information from both the ED and BC Logs.

During an interview on 10/07/14 at 9:35 AM, Staff A, Registered Nurse (RN), Assistant Administrator, Patient Care Services, stated that if an OB patient presented to the facility and is over 20 weeks gestation, they would be seen in the ED triage area and then sent to the BC.

During an interview on 10/08/14 at 4:40 PM, Staff G, RN, ED, stated that OB patients over 20 weeks gestation don't get logged into our area they get logged into OB for care.

During an interview on 10/08/14 at 2:53 PM, Staff H, RN, stated that:
-She had worked at the facility for 20 years and the BC has always had its own log book.
-The BC information is not contained within the facility's ED Log.
-All OB patients are logged into the BC Log if they are 20 or more weeks pregnant.
-Patients that are under 20 week's gestation are seen in the main ED.
-The BC and ED Logs have always been separate.

B. Based on a review of the BC's Log and staff interview, the facility failed to ensure that the BC Log contained all the elements required by the facility's Emergency Department (ED) Log for unscheduled patients and that log was incorporated into the central ED's Log. This had the potential to affect all patients that presented to the BC to obtain a Medical Screening Exam (MSE) and were subsequently discharged back home.

1. Record review of the facility's policy titled, "Register for Emergency Department," revised 03/29/10, showed the following direction for facility staff:
-The emergency department personnel shall enter each patient seeking treatment in the emergency department register. The following information will be noted:
-Time of admission and time of departure.
-Patient geographical information:
-Name;
-Age;
-Sex; and
-Address-including mailing address.
-Treatment given to patient.
-Diagnosis
-Disposition of the patient.
-Physician in attendance.
-Method of arrival to the emergency department.
-Condition on discharge.

2. Record review of the facility's Birthing Center Summary of Patient Services where staff documented both scheduled and unscheduled obstetric (OB) patient visits showed the log did not contain the following information:
-Patient geographical information: Address-including mailing address.
-Treatment given to patient.
-Diagnosis
-Physician in attendance.
-Method of arrival to the emergency department.
-Condition on discharge.
The BC's Log did not differentiate from patients that were scheduled to be seen from those patients that were unscheduled and seeking a MSE.

During an interview on 10/08/14 at 3:20 PM, Staff C, RN, Director of BC, stated that she knew the BC patients that presented to the unit for unscheduled MSE's and could hand count the patients from the last six months of logs. The total number of unscheduled patients that presented to the BC for a MSE was 271.





27029

Based on findings from document review and interviews, the facility's emergency department (ED) staff did not ensure that a patient's Emergency Medical Condition (EMC) was stabilized, within its capabilities, prior to the patient's discharge home.

Findings included:

Record review of Patient #16's discharged ED record showed she presented to the facility's ED on 09/26/14 at 3:07 AM, per ambulance with left wrist pain status post fall.

Review of the patient's ED Provider Report dated 09/26/14 at 3:21 AM, showed that Staff F, ED physician, documented that:
- The patient arrived to the facility per ambulance after tripping and falling at home.
- Musculoskeletal Findings: Swelling and deformity to the left wrist distal (away from the point of attachment) radius (long bones of the forearm). Left hand and fingers intact.
- Radiology: I have reviewed the wrist.
- ED Procedures: Fracture stabilization with a radial and ulnar gutter ocl splint (a fiberglass splint used to decrease movement to provide support and comfort through stabilization of an injury) until seen by the Orthopedic physician.
- Clinical Impression: Distal radius fracture, left.
- Coordination of Care: Case was discussed with the patient.
- Disposition: Home, self-care.
- Additional Instructions: Call the Orthopedic office first thing this morning to be seen.

Review of the patient's ED record showed that Staff F, ED physician, did not document that he consulted with the on-call Orthopedic physician to discuss this case.

Review of the facility's Orthopedic On-Call Schedule dated 09/26/14 showed the Orthopedic physician was on-call from 7 PM until 7 AM.

Review of the Radiology report dated 09/26/14 showed that the patient had a fracture involving the distal radius with a vertical (running lengthwise up or down) fracture line through the articulating (a way in which two or more things are joined) surface. There is displacement of the fragment anteriorly (at the front) and disruption of the joint space. There is marked soft tissue swelling of the wrist, especially laterally (coming from the side) anteriorly.

During an interview on 10/07/14 at 9:23 AM, Staff B, Registered Nurse (RN), ED Manager, stated that if a patient came in with a fracture and did not require surgery, the patient would be seen in the Ortho clinic for follow-up.

During an interview on 10/08/14 at 4:45 PM, Staff G, ED RN, stated that the call book informed staff if the doctor is available. Staff G stated that most often a broken limb will be too swollen to operate on at the time the patient presents and the patient will be referred to the doctor's office for follow-up.

During an interview on 10/08/14 at 5:00 PM, Staff E, ED Medical Director, stated that he had not had any issues with on-call specialist coming to the ED when requested. Staff E denied that neither the Orthopedic physician nor his assistant had refused to come to the ED when requested to come in. Staff E stated that the Orthopedic physician had always came into the ED when called. Staff E stated that he did not make appointments for the Orthopedic office but that he informed patients to follow-up with the Orthopedic physician.

During a telephone interview on 10/14/14 at 3:10 PM, Staff F, ED Physician, stated that:
- When a patient presents to the ED with complaints of possible fracture or breaks he reads the radiology report and treats them accordingly.
- He consults with the Orthopedic physician for surgical cases or cases he can't handle, for example, if he is not able to correct a dislocated shoulder.
- If the Orthopedic physician is on-site he will read the patient's radiology report and then comes to the ED.
- For non-surgical cases the fracture is stabilized and a splint applied.
- After the non-surgical case has been stabilized and splinted, he has the patient follow-up with the Orthopedic physician.
- Neither the Orthopedic physician nor his physician assistant had refused to see a patient even if it is not a surgical case when requested.
- The Orthopedic physician is very good to consult for both surgical and non-surgical cases.
- If the Orthopedic physician is not on-call he would stabilize the patient and transfer them if needed.

Review of Patient #16's ED record and telephone interview revealed that Staff F, ED Physician, believed that he had provided the patient with a proper Medical Screening Exam to rule out if an Emergency Medical Condition existed. Staff F stated per telephone interview that if a patient's fracture/break did not require immediate surgery, he would stabilize it and refer them to the Orthopedic physician for further evaluation. Document review showed that Staff F reviewed the patient's radiology report, stabilized the patient's left wrist fracture with a splint, provided pain medication and instructed the patient to follow-up with the Orthopedic physician later that same day.