HospitalInspections.org

Based on interview and review of hospital documents, it was determined that this critical access hospital with a dedicated emergency department failed to identify in hospital bylaws, or rules and regulations, which medical staff/ registered nurses were qualified to conduct medical screening examinations. The hospital also failed to develop and implement emergency department (ED) policies and procedure manuals for procedures related to the requirements of ?489.24 and the related requirements at ?489.20.

The hospital's failure to do so potentially contributed to Patient #1 not receiving a medical screening examination (MSE) to determine the presence of an emergent medical condition, and potentially placed other patients who present to the ED at risk for not receiving a medical screening examination.

Findings include:

Medical Staff Qualified to Perform Medical Screening Examinations

On 1/13/2014, the hospital Administrator and the Chief Nursing Officer were provided with a list of requested documents. One document requested was that which described which staff had been qualified to perform MSEs. The administrator stated that the qualifications were in the "Medical Screening Exam (MSE) policy and procedure.

The policy "Medical Screening Exam (MSE)" was reviewed and found to contain the following directive:

"POLICY:
The medical personnel that are qualified to provide the patient with a medical screening examination include:
A. Physicians
B. Physicians Assistants"

Nothing in the policy addressed which personnel were authorized to perform medical screening exams, the specific qualifications of the personnel, or what constituted a medical screening exam. The Administrator was asked to provide that portion of the hospital or medical staff bylaws that addressed who could perform MSEs.


The administrator provided a portion of the Medical Staff bylaws, which stated:

"Emergency Room Physicians
A. Physicians, in order to be granted Hospital Emergency Room privileges, shall be graduates of an approved medical or osteopathic school and be licensed in the State of Washington.
B. The physician must have completed an internship or a first year or internal medicine, family practice or emergency residency.
C. The physician must have completed a post-graduate ER rotation.
D. The physician must have current ACLS and ATLS certification.
E. The ER physician has limited medical and pediatric privileges, only emergency surgical privileges, and only emergency obstetrical privileges. They may write admitting orders and do admission history and physicals for patients admitted to the Hospital as long as this is requested by the patient's attending physician..."

"Independent Allied Health Professional...

A. Application for clinical privileges as an Independent allied Health Professional shall be generally processed in accordance with the procedures set forth in these Medical Staff Bylaws for delineation of privileges..."

The qualifications to perform MSEs were not addressed in the portions of the bylaws provided, and the Administrator confirmed that the bylaws did not contain any documentation of who was qualified to perform MSEs.

On 1/15/2014, the Medical Director for the hospital's Emergency Department (ED) Medical Staff was asked who was qualified to perform MSEs. S/he stated that the ED physicians were qualified to perform the exams, and the physicians' assistants were expected to follow the credentialing requirements for physicians. Discussion was held about the fact that the ED physicians were required to be graduates of medical or osteopathy schools and have completed a residency in one of 3 specialty areas, which were qualifications the allied health professionals did not have.

Policies and Procedures Related to EMTALA
The hospital Administrator and CNO were interviewed throughout the 4-day onsite investigation and were asked to provide the following policies and procedures. Information regarding policies and procedures in use, or not in existence, was obtained from the administrator and CNO.

EMTALA-No policy:
On 1/14/2014, the Chief Nursing Officer (CNO) stated that the hospital did not have an EMTALA policy. As of 1/16/2014, no policy and procedure, or other other document, had been provided to the investigator, which described for hospital personnel, the EMTALA regulation, or the hospital's responsibilities in assuring that the regulation was met.

EMTALA training-No policy:
On 1/14/2014, the CNO stated that the hospital did not have a policy that described the hospital's expectation for medical or nursing staff relative to education on the EMTALA regulation.

Triage- No policy:
On 1/15/2015, the Chief Nursing Officer and the Director of Quality confirmed that the hospital did not have a policy and procedure for the triage process in the ED. The hospital did have a policy and procedure for "telephone triage".

Nursing Assessment and Reassessment - No Policy
The CNO confirmed that there was not a policy and procedure for nursing assessment and reassessments in the ED. S/he also confirmed that there also was not a policy for house-wide nursing care.

Based on interview, review medical records, review of hospital policies and procedures and review of internal hospital documents, it was determined that the hospital failed to provide an appropriate medical screening examination to Patient #1.

The hospital's failure to develop and implement accurate policies and procedures regarding medical screening examinations, and the failure to adequately train the Emergency Department staff to those policies, placed all patients who presented to the hospital with potentially emergent medical conditions at risk for undiagnosed and untreated medical emergencies.

Findings include:

Patient #1
Patient # 1 stated that she had had a miscarriage. She stated she went to the ED on 01/10/2014 for emergency care, and at the time her " pants were soaked " with blood about halfway down to her knees. She stated that she told the staff in the ED that she had had a miscarriage and was bleeding.

She stated there were 2 staff people in the ED at the time, a man who was sitting at a desk and a woman who was standing. The patient stated that the people in the ED told her that they would not refuse her care, but that it would be "wiser " if she went to a nearby hospital. Both staff told the patient that their hospital did not have an "OB " doctor and it would take longer to transport her to the other hospital than if she just drove herself.

Patient #1 confirmed that she did not receive an evaluation in the ED, did not have vital signs taken, and no one looked at her bloody clothing.

No medical record was generated for Patient #1's visit to the ED. No record of the patient's visit was recorded on the ED log, no incident report was generated and the patient did not fill out an AMA (against medical advice) form.

Patient #1 stated that she and her family member then drove to another hospital several miles away. She stated she was triaged immediately and saw a physician immediately. She stated that she went to the operating room the same morning and was discharged the next morning.

Physicians' Assistant #1
On 1/14/14, interviewed by phone the Physicians' Assistant (PA) #1 who was on duty 1/10/2014 when Patient #1 presented to the ED. S/he stated that s/he did recall the patient, but had no more information beyond what s/he had provided in an email to the Medical Director of the Skyline ED. The email was forwarded to this investigator on 1/14/2014 at 12:52 pm, by the ED Medical Director.

The email, which had been sent to to the physician on Jan. 14, 2014 at 12:01 PM stated:
" ...When the patient learned there was no obstetrician immediately available on site she decided to leave without being seen to go to another facility."

The PA stated that the patient stated " I think I'm having a miscarriage ... " S/he stated that they (s/he and the nurse on duty) told the patient they would do a screening, but the patient did not want to wait. S/he stated s/he only saw the patient as she walked by and the patient was only in the ED 1 or 2 minutes and left.

When PA #1 was asked to describe what constituted a medical screening examination, s/he stated " the medical screening examination is to be provided to any patient who presents, if the patient is willing to be examined, to see if an emergency condition exists. If an emergency condition exists the patient is to be stabilized to the best of their ability and then transferred if another facility has availability".

Physicians' Assistant (PA) #2

PA #2 was interviewed on 1/14/2014, and asked to describe who could perform medical screening exams in the hospital and what constituted a medical screening exam. S/he stated that there had been a lack of consensus about who can perform the exams in the ED. He stated that the ED Medical Director, has directed the providers that whichever physician or physicians' assistant is on duty in the ED was the person who was supposed to perform the exam.

Registered Nurse (RN) #1

RN #1 was interviewed on 1/14/2014, and the RN stated that s/he did recall Patient #1. S/he stated that she was on duty the day Patient #1 had come to the ED accompanied by another person. The RN #1 stated that the patient said she had had a miscarriage several months prior and had declined to have a D&C (Dilation and Curettage is a brief surgical procedure in which the cervix is dilated and a special instrument is used to scrape the uterine lining) at the time of the miscarriage. The RN stated that there was a small area of blood on the crotch of the patient's pants. [She demonstrated with her hands an area approximately 4" in diameter].

RN #1 stated that PA #1 was present while the patient was in the ED. S/he confirmed that no triage of the patient was performed, no vital signs were taken and no medical screening exam was performed. S/he stated s/he just talked with the patient and then the patient left.

The RN #1 was asked to describe what would happen if a patient presented to the ED and required a service the hospital could not provide. She stated that in that circumstance, the hospital would tell the patient that they did not have the ability to care for the patient, but they could check the patient in and have the doctor see them. Then, they would arrange for a transfer if necessary.

Registered Nurse (RN) #2

RN #2 was interviewed on 1/14/2014 and asked to describe what constituted a medical screening exam. S/he stated that "they" had had many discussions about that issue and s/he was still unclear. The RN stated that, depending upon the patient, a medical screening examination could be only taking the patient ' s vital signs, or it could be a full workup.

The RN stated that it is in hospital policy that only physicians and physician assistants do medical screening examinations at the hospital. S/he stated that RNs do not do medical screening exams at the hospital, but s/he thinks they can do them elsewhere.