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Based on document review and interview, the hospital did not comply with the requirements at 489.20(l). Specifically, the facility did not provide a medical screening exam (MSE) to determine if an emergency medical condition (EMC) existed. Please reference findings at Tag 2406. Additionally, the hospital's policies and procedures (P&P) and Medical Staff Bylaws/Rules & Regulations were not accurate and complete regarding EMTALA (Emergency Medical Treatment And Labor Act) requirements. This could lead to untoward patient outcomes.

Findings include:

-- Review of the hospital's P&P titled "Emergency Medical Condition, Medical Screening Examination and Stabilizing Treatment," last reviewed 2/14/19, indicated the steps necessary to accomplish the MSE and stabilizing treatment. "A MSE is an examination that will be afforded to every patient presenting with an emergency condition or perceived emergency condition to UHS (United Health Services) Chenango Memorial Hospital (CMH) ... ." EMTALA requirements specify any individual who comes to the ED must be provided a MSE within the capabilities of the hospital's ED to determine if an EMC exists or not.

-- Review of the hospital's P&P titled "Consultations and On-Call Duties to the ESD (Emergency Services Department)," last reviewed 11/19/18, stated "the ESD physician will be responsible to determine the appropriate on call specialist as warranted by the patient's condition and initiate contact with that physician. The ESD physician is responsible for determining time frame by which the on call physician must respond based on the patient's acuity." The P&P did not define response times for on call physicians.

-- Review of the hospital's P&P titled "On Call Coverage," last reviewed 9/2018, indicated the hospital's medical staff should be available when on call for one's own patients or on call covering other patients in a timely and appropriate manner. Such timeliness and appropriateness has many factors, including the type of patient being treated, severity of illness or condition and location of patient within the hospital or outpatient setting. The P&P did not define response times for on call physicians.

-- Review of the Medical Staff Rules and Regulations, last revised 11/2018, revealed that availability of the on call physician to the Emergency Department should "follow guidelines established in the New York State Health Code." The Medical Staff Rules and Regulations did not define response times for on call physicians.

Additionally, EMTALA requirements regarding how the hospital should respond to situations in which a particular physician specialty is not available, whether physicians on call to the ED are permitted to schedule elective surgery while on call, and/or whether physicians are allowed to be on call simultaneously at two or more facilities were not addressed in any hospital documents, including the ones noted above.

-- During interview of Staff A, Vice President of Quality and Outcome Improvements on 4/4/19 at 4:30 pm, he/she acknowledged the above findings.

-- Review of the hospital's P&P titled "Emergency Medical Condition, Medical Screening Examination and Stabilizing Treatment," last revised 2/14/19, indicated the Board of Directors of UHS (United Health Services) designates the following as Qualified Medical Personnel (QMP) for provision of MSEs: physicians privileged in this facility to practice medicine, Nurse Practitioners, licensed by the State of New York, operating within the scope of their authorized practice and privileged in this facility, Physician Assistants, licensed by the State of New York, operating within the scope of their authorized practice and privileged in this facility and Registered Nurses (RN), licensed by the State of New York, with one (1) or more years experience as a full-time nurse in an obstetrical unit of this or equivalent hospital, competent in fetal monitoring with approval of the Chairman of the Perinatal Committee to evaluate obstetrical patients in the absence of the immediate attendance of a physician. The P&P did not specify which individuals designated to perform MSEs as QMPs should be included in the hospital bylaws and medical staff rules and regulations.

-- Review of the hospital's P&P titled "Observation - Obstetrics Evaluation and Admission," last revised 5/2017, indicated a qualified evaluator is an RN who has completed the orientation to Labor & Delivery, who has completed the probationary period in this labor department and who has received the probationary evaluation to approve their ability to evaluate obstetrical patients in the absence of the immediate attendance of the obstetrical care provider. The P&P was inconsistent with the above EMTALA P&P.

-- Review of the Medical Staff Rules and Regulations, last revised 11/2018, did not identify health practitioners designated to perform MSEs as QMPs. EMTALA requirements specify a MSE must be conducted by an individual(s) determined by hospital bylaws or rules and regulations.

-- Review of Staff B's, Obstetric (OB) RN, personnel file there was no indication that he/she was approved by the hospital's governing body and the Chairman of the Perinatal Committee to provide MSEs as a QMP.

-- Review of Staff C's, OB RN, personnel file there was no indication that he/she was approved by the hospital's governing body and the Chairman of the Perinatal Committee to provide MSEs as a QMP.

-- During interview of Staff D, OB Nurse Manager on 4/4/19 at 2:50 pm, QMPs on the OB unit are RNs who are trained, oriented and work with experienced RNs.The experienced RNs act as preceptors and assess the RNs skills and sign off on a checklist. The nurse is then considered a QMP to provide a MSE. Nurses designated as QMP are not signed off as qualified by the OB Medical Department Director, it is an unofficial designation. The OB physicians in the department provide feedback on the QMP's skills. He/she acknowledged the above findings at the time of interview.

Based on document review and interview, the hospital failed to provide a medical screening exam (MSE) within the capability of the hospital's emergency department (ED) to a patient (Patient #1) who presented to the ED with a complaint of hip pain.This lack of a MSE could result in a poor patient outcome.

Findings include:

There was no medical record for Patient #1. Information obtained through Norwich Fire Department (NFD) EMS (Emergency Medical Services) PCR (Prehospital Care Report) dated 2/28/19 and ED staff interviews.

-- Review of NFD's PCR, revealed EMS responded to Norwich Rehabilitation facility on 2/28/19 at 4:10 pm for a 34-year-old female (Patient #1). The chief complaint was hip/pelvic pain. Norwich Fire Department was informed by the rehabilitation staff that Patient #1 had recent hip surgery and hardware from the surgery may not be in place correctly. The patient was assessed by EMS and the patient stated she had hip pain from recent surgery done at Chenango Memorial Hospital (CMH). Rehabilitation staff gave EMS paperwork on her medical history for the ED. Norwich Fire Department advised rehabilitation staff to contact CMH's ED with report from the facility. Patient #1 was advised and agreed to transport to CMH as this is where she had her original hip surgery. Patient #1 was transported via EMS; a brief report was called into CMH's ED by EMS. A registered nurse (RN) from CMH's ED spoke with EMS stating Patient #1 could not come to this location as she was to be transported to another hospital for an appointment there the next day. The RN was informed that EMS had already arrived at CMH's ED. Initially EMS was told by the RN that Patient #1 could not come into the ED but then changed his/her mind and allowed Patient #1 to enter the ED. Norwich Fire Department went to the ED Registration to get a "face sheet" (document with patient information) but there wasn't one because the RN did not want the patient to be seen in the ED. The ED RN asked EMS to take the patient back to Norwich Rehabilitation so the rehabilitation facility could find transportation for Patient #1 the next day. Norwich Fire Department agreed to this as long as the rehabilitation facility was also in agreement. The ED RN stated she spoke with the rehabilitation facility and they would accept the patient. Patient #1 was transported back to Norwich Rehabilitation on 2/28/19 at 4:58 pm.

-- Review of the hospital's policy and procedure (P&P) titled "Emergency Medical Condition, Medical Screening Examination and Stabilizing Treatment," last reviewed 2/14/19, indicated a MSE is an examination that will be afforded to every patient presenting with an emergency condition or perceived emergency condition to CMH and/or its clinical areas for emergency care that is on hospital property and within 250 yards of the main campus or clinical areas.

-- Review of the hospital's P&P titled "Triage, Prioritizing of Patients Seeking Care in the ED," last revised 7/2017, indicated the purpose of triage is to assign a priority level to patients seeking medical care in the ED. The RN will evaluate and categorize each patient upon arrival to the ED into one of five triage levels. The initial evaluation will include that information necessary to determine the level of triage. All information should be documented in the medical record.

-- During interview of Staff E, Access Care Representative, on 4/3/19 at 10:05 am and 2:00 pm, he/she revealed EMS brought Patient #1 to the ED and the ED Nurse Manager said the patient wasn't supposed to be here. Staff E put the patient's information into the computer but was then told the patient was not staying and cancelled the information in the computer.

-- During interview of Staff F, ED Nurse Manager on 4/3/19 at 2:15 pm, he/she revealed Patient #1 was supposed to be directly admitted to another hospital for hip repair surgery. The rehabilitation facility called the ED to let them know Patient #1 was coming to CMH for hip pain and needed surgery. Staff at CMH were trying to find out why Patient #1 was coming to the ED and spoke to Patient #1's orthopedics' physician assistant (PA). The PA had made arrangements for Patient #1 to be a direct admission to the other hospital for surgery the next day. Staff F met EMS and Patient #1 on the ambulance "apron" (entrance) and the patient came into the ED on the ambulance stretcher. The EMS personnel said they didn't speak to any staff at the rehabilitation facility when Patient #1 was picked up. Staff F called the rehabilitation facility's Director of Nursing informing him/her that the patient needed to go to the other hospital and EMS did not have means of transporting her there as EMS stated they only do transfers for emergency transports. The rehabilitation facility Director of Nursing accepted Patient #1 back to the rehabilitation facility and she was taken back to the facility. Patient #1 was not registered, triaged or seen by a provider in the ED. Staff F recalls telling registration not to register Patient #1 until he/she found out what was going on. There is no documentation of the patient being there.

-- During telephone interview of Staff G, ED RN, (worked shift Patient #1 presented to ED) on 4/3/19 at 3:45 pm, he/she revealed Patient #1 was brought to an ED room and was in the ED approximately 15 minutes.

-- During interview of Staff F on 4/4/19 at 3:05 pm, he/she acknowledged the above findings.