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Based on interviews, review of medical records and review of hospital documents, including policies and procedures, it was determined that the governing body failed to ensure the conduct of the hospital's Emergency Department, therefore, this CONDITION IS NOT MET.


Reference deficiencies written at Tag A1100
Reference deficiencies written at Tag A1101
Reference deficiencies written at Tag A1104
Reference deficiencies written at Tag A1110
Reference deficiences written at Tag A1112

Based on interviews, review of medical records and review of internal hospital documents, including policies and procedures, it was determined that the hospital failed to meet the emergency needs of all patients in accordance with acceptable standards of practice, therefore, this CONDITION IS NOT MET.


Reference deficiencies written at Tag A0043
Reference deficiencies written at Tag A1101
Reference deficiencies written at Tag A1104
Reference deficiencies written at Tag A1110
Reference deficiences written at Tag A1112

Based on interviews and review of documents including policies and procedures, it was determined that the governing authority of the hospital failed to assure that the hospital's emergency services organization and direction requirement were met. The hospital's failure to do so resulted in a lack of documented organization and organizational processes.

Findings include:

Emergency Department Organizational Chart

On October 10, 2018 at approximately 11 AM, the hospital was presented with a written list of requested documents. The first item requested was an organizational chart for the Emergency Department (ED).
At approximately 12:30 PM, the Regulatory and Accreditation Consultant (RAC) confirmed that the hospital did not have an organizational chart for the ED.

Later in the day, the RAC provided the investigator with a document titled "Emergency Department Organizational Chart". The RAC was asked if the document had been created that day, since it looked incomplete and was undated. The RAC responded that the chart was complete.
Review of the organizational chart showed that no physicians or mid-level practitioners, no staff nurses, and no technicians and/or assistants.
The "Emergency Department Organizational Chart" included 6 positions, one of which was noted to be vacant. Four (4) were nursing positions, one was the "Chief Medical Director" and one was an administrative assistant.

Emergency Department Policies and Procedures

On October 10, 2018 at approximately 11 AM, the hospital was presented with a written list of requested documents. One of the requested items was "all policies and procedures (P&Ps) that describe care in the ED". The RAC stated that the hospital did not have a way to identify P&PS specific to the ED and could not be assured that they were providing all relevant P&Ps. The RAC stated that they could provide a list of all P&PS for the hospital, and s/he would highlight those specific to the ED.
The list was provided and the RAC highlight several P&Ps. When the investigator noted that the EMTALA policy was not on the list, the RAC acknowledged that it was not on the list (although a hard copy of the EMTALA P&P had been provided). The RAC acknowledged that the list provided was incomplete and it was not possible to determine which other P&Ps might be missing from the list.

Reference deficiency written at Tag A1104

Based on interview, it was determined that the hospital failed to assure that policies and procedures governing medical care provided in the emergency service or department were established by, and were a continuing responsibility of, the medical staff. The hospital's failure placed all patients of the Emergency Department (ED) at risk for unmet care needs due to a lack of accurate and complete policies and procedures, approved by the medical staff.

Findings include:

Medical Staff Responsibility for Development of Policies and Procedures in the ED, and Continued Responsibility

On October 10, 2018 at approximately 11 AM, the hospital was presented with a written list of requested documents. One of the requests was for "documentation of how the hospital's medical staff establishes policies and procedures governing the medical care in the ED, and how ongoing/continuing assessment of medical care in the ED is performed".

As of 5:30 PM the same date, the Regulatory and Accreditation Consultant confirmed that the hospital could not provide the requested documentation.

Notification of Patients/Other of Critical or Significant Results

On October 10, 2018, at 2:10 PM, the ED Medical Director stated that s/he was familiar with the issues involved in the complaint under investigation, specifically that Patient #1 had not been notified of significant results of an imaging study. The ED Medical Director stated that s/he was aware of the issues, had been involved in review of the case and had discussed the issue with the ED physician who had provided care to Patient #1 during her/his visit to the ED.

The ED Medical Director was asked to describe the process in the ED for notifying patients/physicians of critical values that had been identified after the patients had left the ED. The ED Medical Director was able to describe the process, and the roles of physicians and mid-level practitioners, but stated that the process was not in writing and was not a formal policy.

The ED Medical Director stated that the process for notification relative to critical values would not have applied to the case of Patient #1 because the value was not considered "critical".

However, the Medical Director confirmed that the imaging findings for Patient #1 did meet criteria in the Imaging Department's policy and procedure"Reporting Critical Results in Imaging Policy" for notification, specifically:

"For Category Yellow/Important Findings
-Not urgent findings or unexpected significant findings: Not immediately life-threatening and/or not directly related to the requested procedure). For example - Exam List (new finding...) Unknown/Unsuspected mass or metastasis.
-The findings will be communicated with a responsible provider or appropriate designee within 72 hours of Radiologist's review..."

The results of the CT (computerized axial tomography) scan for Patient #1 stated:

"Impression:
1. Heterogeneously sclerotic skeleton suggesting diffuse skeletal metastases. Myeloproliferative disorder and metabolic bone disease less likely..."

The ED Medical Director stated that the finding did meet the "Category Yellow/Important Findings" criteria for notification within 72 hours, and that failure to notify the patient/family (who were still in the ED when the findings became available) was "inexcusable".

The ED Medical Director stated that s/he had met with the ED physicians, a contracted group of physicians, regarding the issue of notification of results, but s/he was unaware of any actions the hospital had taken in response to the issue(s).


Reference the deficiency written under Tag A 1101

Based on interview, it was determined that the hospital, and the medical staff, failed to determine what constituted adequate medical and nursing personnel for the Emergency Department. The failure placed all patients who received care in the ED at risk for unmet care needs or for care that did not meet specified standards of care.

Findings include:

On October 10, 2018 at approximately 11 AM, the hospital was presented with a written list of requested documents. One of the requests was for "Documentation that the medical staff has established criteria delineating the qualifications required for each category of ED services staff (ED physicians, specialist MD/DO, RNs, mid-levels, etc)".

The Regulatory and Accreditation Consultant (RAC) provided the following documents:

"Medical Staff Bylaws", adopted by the Medical Staff: October 24, 2011 and approved by the Board: November 1, 2010.

"Credentials Policy", adopted by the Medical Staff: August 24, 2009 and approved by the Board: August 28, 2009, Revised by MED May 24, 2010 and approved by Board June 6, 2010.

"Policy on Advance Practice Professionals". No dates or approvals were noted.

All documents above were tagged by hospital personnel to identify the location of the requested information; however, none of the documents contained information specific to personnel in the ED.

Documentation that the Medical Staff had established criteria specific to personnel in the ED had not been received at the close of the onsite investigation, at approximately 5:15 PM October 10, 2018, nor was the information received via email as of the morning of October 18, 2018.


The RAC confirmed that there was no documentation regarding what constituted adequate nursing personnel for the Emergency Department.

Reference deficiency written at Tag A1112

Based on interview, it was determined that the hospital, and the medical staff, failed to determine what constituted adequate medical and nursing personnel for the Emergency Department. The failure placed all patients who received care in the ED at risk for unmet care needs or for care that did not meet specified standards of care.

Findings include:

On October 10, 2018 at approximately 11 AM, the hospital was presented with a written list of requested documents. One of the requests was for "Documentation that the medical staff has established criteria delineating the qualifications required for each category of ED services staff (ED physicians, specialist MD/DO, RNs, mid-levels, etc)".

The Regulatory and Accreditation Consultant (RAC) provided the following documents:

"Medical Staff Bylaws", adopted by the Medical Staff: October 24, 2011 and approved by the Board: November 1, 2018.

"Credentials Policy", adopted by the Medical Staff: August 24, 2009 and approved by the Board: August 28, 2009, Revised by MED May 24, 2010 and approved by Board June 6, 2010.

"Policy on Advance Practice Professionals". No dates or approvals were noted.

Documentation that the Medical Staff had established criteria specific to personnel in the ED had not been received at the close of the onsite investigation, at approximately 5:15 PM October 10, 2018, nor was the information received via email as of the morning of October 18, 2018.


The RAC confirmed that there was no documentation regarding what constituted adequate nursing personnel for the Emergency Department.