The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PUTNAM COUNTY MEMORIAL HOSPITAL 1926 OAK STREET, PO BOX 389 UNIONVILLE, MO 63565 Feb. 12, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on interview, record and policy review, the facility failed to follow their policies and procedures when staff did not perform a Medical Screening Exam (MSE) by Qualified Medical Personnel (QMP) for two patients (#4 & #34) within the facility's capabilities to determine if a psychiatric/medical Emergency Medical Condition (EMC) existed. This occurred for two patients (#4 & 34) out of 67 Emergency Department (ED) medical records reviewed from June 2013 to February 2014. The facility census on the initial survey on 01/09/14 was 11 that included six on the Inpatient Psychiatric Unit (IPPU) and the census on the extended survey on 02/12/14 was 13 that included eight on the IPPU. The average daily census for the ED was five and the average monthly census was 140.

Findings included:

1. Record review of the facility's policy titled, "Medical Screening Examination" last reviewed 03/13, showed the following direction for facility staff:
-The hospital must provide for an appropriate medical screening examination within the capabilities of the hospital's Emergency Department, which may not be delayed or denied in order to obtain financial information/verification.
-If the patient is determined to have an Emergency Medical Condition (EMC) the hospital is required to provide treatment until the patient is stabilized.
-Definition of Medical Screening Examination: A documented ongoing process during which the physician or nurse practitioner determines with reasonable clinical confidence whether an EMC does or does not exists for an individual in a non-discriminatory manner. The documentation must reflect continued monitoring according to the patient's needs and must continue until the patient is stabilized or appropriately transferred.
-Definition of Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the patient in serious jeopardy.
-Qualifications of the Screening Personnel:
a. Registered Nurse to do the initial triage assessment and report findings to the physician and/or nurse practitioner; and carry out the orders of the physician and/or the nurse practitioner. The Registered Nurse will follow emergency room Protocols until the physician or nurse practitioner arrives.
b. emergency room on -call physician or nurse practitioner (NP) to do the examination, order testing if necessary, determine whether an emergency medical condition exists, and order stabilizing treatment and transfer if necessary.
c. Completed orientation and credentialing for the Emergency Department.

2. Record review of the facility's policy titled "emergency room Screening" last reviewed 03/13, showed the following direction for facility staff:
-The physician on-call is expected to see all presenting patients in the emergency room who need medical attention. It is up to the on-call physician to arrange proper backup coverage if he cannot see the patient.
-Qualification of Screening Personnel:
a. Currently certified Registered Nurse or physician.
b. Completed orientation and credentialing for the emergency room .
-Medical Screening Evaluation: The process by which a physician and/or the RN evaluates the patient as necessary to determine if any underlying Emergent condition may exist.

3. Record review of the facility's undated "Medical Staff By-Laws/Rules and Regulations", showed the document did not designate the type of practitioner who is qualified to perform a MSE, also known as a Qualified Medical Personnel (QMP) that is capable of performing a MSE to determine if a patient has a medical/psychiatric EMC.
The record review showed that medical staff had not approved Nurse Practitioners (NP) as QMP to perform MSE to determine if a patient has a medical/psychiatric EMC.

4. During an interview on 01/08/14 at 2:10 PM, Staff C, RN, Director of Nursing (DON), confirmed that the facility did not have documentation designating which staff were QMP's that could perform a MSE to determine if a EMC existed.

5. Record review of Patient #4's ED medical chart showed the following information:
-The patient's Face Sheet showed she presented to the facility's ED on 11/08/13 at 11:07 PM, with complaints of ingesting eye glass cleaner and threatening self harm.
-ED staff documented the patient presented to the ED accompanied by long term care (LTC) staff.
-At 11:15 PM, staff notified Staff F, Chief of Staff, ED/IPPU, Medical Director, and Staff E, NP, of the patient's arrival.
-At 11:15 PM, Staff E, NP, arrived and had first contact with the patient. The patient was not examined by a physician.
According to the November 2013 ED Physician On-Call List, Staff F was on-call on 11/08/13 from 6 PM until 6 AM and not Staff E.

6. Record review of Patient #34's ED medical chart showed the following information:
-Staff documented that she presented to the facility's ED on 10/24/13 at 1:30 PM, with complaints of verbal/physical aggression towards others accompanied by LTC staff.
-At 2:15 PM, staff documented they notified Staff E, NP, the patient had arrived to the ED.
-At 2:55 PM, staff documented Staff E here to do exam on patient.

7. Record review of the facility's undated Medical By-Laws/Rules and Regulations did not recognize NP as QMP that could perform MSE to determine if a patient had a medical/psychiatric EMC.
Staff E had submitted an application for credentialing/privileges to practice as a NP at the facility but to date the medical staff had not agreed to allow her to provide care and services to patients seeking care at the facility and she was not on the ED On-Call Physician Schedule.

8. During an interview on 01/07/14 at 1:30 PM, Staff F, Chief of Staff, ED/IPPU Medical Director stated that:
-The on-call physician must present per policy and procedure within 30 minutes of being notified and we all come in or that would be grounds for dismissal.
-She uses "telepresence" via a robot when she doesn't need to be present in person to assess ED or acute care patients.
-Staff E, NP, was doing some coverage in the IPPU for admissions, H&P's (History and Physical) and physical assessments in the ED.
-Staff O, Psychiatrist, was a contracted psychiatrist from St. Louis, Missouri and admitted patients from that location by telephone.
-Staff G, ED Physician, medically cleared all psych patients admitted to the IPPU.

9. During an interview on 01/08/14 at 9:35 AM, Staff E, NP, stated that the night Patient #4 presented to the ED, Staff F, Chief of Staff, ED/IPPU Medical Director, was scheduled on-call for the ED not her.

10. During a telephone interview on 02/13/14 at 11:00 AM, Staff P, Former Director of the IPPU stated that:
-Psychiatric patients were not being screened in the facility's ED.
-When Staff L, ED Physician was on-call for the ED, Staff E, NP was to see psychiatric patients that presented to the ED.
-Staff F would not sign the agreement for Staff E to see psychiatric patients that presented to the facility's ED.

11. During a telephone interview on 02/26/14 at 11:35 AM, Staff M, RN, ED Nurse, stated that:
-She was working when Patient #4 presented to the ED from the LTC facility.
-She called Staff F, Chief of Staff, ED/IPPU Medical Director, that the patient had presented to the ED (Staff F was on-call for the ED from 6 PM to 6 AM on 11/08/13).
-She stated that Staff F reported that she thought Staff E, NP, was seeing psychiatric patients that presented to the ED.
-She stated that Staff P, Former IPPU Director, called her and informed her that Staff G, ED Physician, would see the patient in the ED.
-After talking to Staff P, she called Staff C, RN, Director of Nursing (DON), to see who was to see psychiatric patients that presented to the ED.
-Staff C returned her call and informed her that Staff F would be seeing the patient per telemedicine.
-When Staff F called the ED, she informed Staff F that Staff P and Staff E were in the ED and Staff F spoke with Staff P per telephone.
-At that time it was being decided if Staff E, was going to be allowed to see patients in the ED and Staff F (Chief of Staff, ED/IPPU Medical Director), told her it would be "OK" for Staff E to see Patient #4 in the ED.
-After Staff F spoke with Staff P on the telephone, Staff E ordered laboratory test and assessed the patient.
-The decision to use telemedicine would be made on a case by case basis determined by Staff F and that Staff F is the only physician that utilized telemedicine to see patients.
-Staff F, Staff G, L, T and U, ED Physicians, are the only recognized QMP to see patients in the ED.
VIOLATION: ON CALL PHYSICIANS Tag No: C2404
Based on interview and record review the facility failed to maintain a physician On Call Schedule to meet the needs of patients presenting to the Emergency Department (ED).The facility also failed to have policies and procedures in place to address changes in the physician On Call provider response and/or availability to meet patient needs in the ED.These failures increased the risk of harm to all patients presenting to the Emergency Department (ED) with an emergency medical condition (EMC). The average daily census for the ED was five and the average monthly census was 140.

Findings included:

1. Record review of the facility's undated Medical Staff By-Laws did not address the ED On-Call Physician's schedule, changes in the schedule or maintenance of the schedule.

2. During an interview on 02/10/14 at 1:55 PM, Staff F, Chief of Staff, ED/Inpatient Psychiatric Unit (IPPU) Medical Director, stated that she was responsible for the ED On-Call Physician Schedule. She also stated that there was no policy and procedure pertaining to the ED On-Call Physician Schedule. Staff F stated that if changes needed to be made they were handwritten on the schedule posted in the ED.

3. Record review of the ED Physician On-Call Schedules for the months of 07/13 through 01/14 did not list Staff E, Nurse Practitioner (NP), on the schedules; however, a comparison of the ED Physician On-Call Schedule and the ED Log showed the following:
- On 10/16/13 at 7:01 PM Staff F, Chief of Staff, ED/IPPU Medical Director, was on call but Staff E, signed the ED log as the examining practitioner.
- On 10/16/13 at 8:14 PM Staff F, was on call but Staff E signed the ED log as the examining practitioner.
- On 10/25/13 at 4:03 PM Staff F, was on call but Staff E signed the ED log as the examining practitioner.
- On 11/08/13 at 11:07 PM Staff F, was on call but Staff E signed the ED log as the examining practitioner. These changes were not noted on the posted ED Physician On-Call Schedule.

4. Record review of the ED On-Call Physician schedule for the month of January 2014 showed Staff L, ED Physician, on call for the dates and times of 01/10/14 at 6:00 PM through 01/12/14 at 6:00 AM. Compared to the ED Log for those dates and times, Staff L was not on call and Staff T, ED Physician, signed the log as the physician on call in the ED. Further review showed the January ED On-Call Physician schedule named Staff G, ED Physician, on call from 01/16/14 at 6:00 AM through 01/17 at 6:00 PM, however when compared to the ED Log for those dates and time Staff F, Chief of Staff, ED/IPPU Medical Director, signed as the physician on call in the ED. These changes were not noted on the posted ED Physician On-Call Schedule.

5. During an interview on 01/07/14 at 1:30 PM, Staff F, Chief of Staff, ED/IPPU Medical Director, stated that Staff L, ED Physician, was not comfortable providing emergency room services to psychiatric patients. She stated that there was a verbal agreement made with Staff B, Chief Operating Officer (COO), that she, Staff G, ED Physician, or Staff E, NP, would medically clear the patients when Staff L was on call. She stated that Staff E did some coverage in the [ED] unit and completed patients History and Physical (H&P) and Medical Screening Exams (MSE's) in the ED.

6. During an interview on 01/08/14 at 9:35 AM, Staff E, NP, stated that Staff L, ED Physician, was not comfortable treating psychiatric patients in the ED and she had been told by Staff B, COO, that she would be required to be on-call in the ED for psychiatric patients when Staff L was the on-call physician. She also stated that her application for credentialing and privileges had not been approved by the Medical Staff.

Record review of the credentialing file for Staff E, NP, showed she was neither credentialed nor privileged by the hospital's Medical Staff to provide care to patients as an NP.

7. During an interview on 01/09/14 at 8:10 AM, Staff L, ED Physician, stated that he was not comfortable treating psychiatric patients that presented to the ED because the majority of the patients were being transferred there by Staff O, Psychiatrist, from nursing homes without any paperwork or History and Physical (H&P). He stated that he had a conference call with Staff B, COO, Staff G, ED Physician, Staff I, IPPU Manager, and Staff J, physician. He stated that he expressed his concerns to everyone on the call and it was determined that he would not be required to examine or treat psychiatric patients that presented on call. He stated that he was unaware that policies and procedures had not been updated to reflect the agreement and there was no other written agreement stating the results of the conference call. He stated that he was on call one weekend per month from 6:00 PM Friday to 6:00 AM Monday morning for a total of 60 hours.

8. During an interview on 01/09/14 at 1:35 PM, Staff N, President of the Hospital Board, stated that Staff B, COO, called him almost every day but he was unaware of the problems surrounding the ED and psychiatric departments. He stated that he did not know that Staff L, ED Physician, did not see psychiatric patients in the ED when he was on-call.

9. During an interview on 02/10/14 at 1:55 PM, Staff F, Chief of Staff, ED/IPPU Medical Director, stated that she was not on the conference call when Staff L stated he was uncomfortable treating psychiatric patients in the ED. She also stated that Staff E, NP, was never on the ED On-Call Physician schedule. She had no explanation as to why Staff E was allowed to evaluate and/or treat patients in the ED when her application for credentialing/privileges had not been approved by the Medical Staff. She also stated she did not know why the changes to the ED On-Call schedule had not been noted on the posted schedules in the ED.

10. During an interview on 02/10/14 at 1:25 PM, Staff D, RN, ED Nurse Manager, stated that when Staff L, ED Physician, worked he did not take psychiatric patients but the NP was to see them. She stated that the current physician on-call schedule does not reflect who will do psychiatric assessments when Staff L is scheduled on-call for the ED.

11. During an interview on 02/10/14 at 1:45 PM, Staff Q, ED staff RN, stated that when Staff L, ED Physician, was the physician on-call, there were pre-arranged arrangements for another physician to cover for psychiatric patients but he did not know who it was. He stated that the physician on-call schedule should reflect what physician is covering psychiatric patients when Staff L is working.

12. During an interview on 02/12/14 at approximately 12:30 PM, Staff F, Chief of Staff, ED/IPPU Medical Director, stated that to her knowledge the facility does not have policies or procedures for the ED physician on-call schedule, changes to the schedule, or guidance to providers for response times and/or their availability to meet patient needs in the ED.
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
Based on interview, record and policy review, the facility failed to perform a Medical Screening Exam (MSE) by a recognized Qualified Medical Personnel (QMP) for two patients (#4 & #34) within the facility's capabilities to determine if a medical/psychiatric Emergency Medical Condition (EMC) existed. This occurred for two patients (#4 & #34) out of 67 Emergency Department (ED) medical records reviewed from June 2013 to February 2014. The average daily census for the ED was five and the average monthly census was 140.

Findings Included:

1. Record review of the facility's undated "Medical Staff By-Laws/Rules and Regulations", showed the document did not designate the type of practitioner who is qualified to perform MSE, also known as a Qualified Medical Personnel (QMP) that is capable of performing a MSE to determine if a patient has a medical/psychiatric EMC.

2. Record review of Patient #4's ED medical chart showed the following information:
-The patient's Face Sheet showed she presented to the facility's ED on 11/08/13 at 11:07 PM, with complaints of ingesting eye glass cleaner and threatening self harm.
-ED staff documented the patient presented to the ED accompanied by long term care (LTC) staff.
-At 11:15 PM, staff notified Staff F, Chief of Staff, ED/IPPU, Medical Director, and Staff E, NP, of the patient's arrival.
-At 11:15 PM, Staff E, NP, arrived and had first contact with the patient. The patient was not examined by a physician.
According to the November 2013 ED Physician On-Call List, Staff F was on-call on 11/08/13 from 6 PM until 6 AM and not Staff E.

3. Record review of Patient #34's ED medical chart showed the following information:
-Staff documented that she presented to the facility's ED on 10/24/13 at 1:30 PM, with complaints of verbal/physical aggression towards others accompanied by LTC staff.
-At 2:15 PM, staff documented they notified Staff E, NP, the patient had arrived to the ED.
-At 2:55 PM, staff documented Staff E here to do exam on patient.
-The medical record showed no documentation by a physician.

4. Record review of the facility's undated Medical By-Laws/Rules and Regulations did not recognize NP as QMP that could perform MSE to determine if a patient had a medical/psychiatric EMC.

During an interview on 01/08/14 at 9:35 AM, Staff E, NP, stated that she had submitted an application for credentialing/privileges to practice as a NP at the facility but to date the medical staff had not approved the application.

During an interview on 02/10/14 at 1:55 PM, Staff F, Chief of Staff, ED/IPPU Medical Director, confirmed that Staff E, NP, had submitted an application for credentialing/privileges to practice as an NP at the facility but the medical staff had never approved the application. Staff F allowed Staff E to provide care and services to patients seeking care at the facility and she was not on the ED On-Call Physician Schedule.

5. During an interview on 01/07/14 at 1:30 PM, Staff F, Chief of Staff, ED/IPPU Medical Director stated that:
-The on-call physician must present per policy and procedure within 30 minutes of being notified and we all come in or that would be grounds for dismissal.
-She uses "telepresence" via a robot when she doesn't need to present in person to assess ED or acute care patients.
-Staff E, NP, was doing some coverage in the IPPU for admissions, H&P's (History and Physical) and physical assessments in the ED.
-Staff O, Psychiatrist, was a contracted psychiatrist from St. Louis, Missouri and admitted patients form that location by telephone.
-Staff G, ED Physician, medically cleared all psych patients admitted to the IPPU.

6. During an interview on 01/08/14 at 9:35 AM, Staff E, NP, stated that
the night Patient #4 presented to the ED, Staff F, Chief of Staff, ED/IPPU Medical Director, was scheduled on-call for the ED not her.

7. During an interview on 01/08/14 at 2:10 PM, Staff C, RN, Director of Nursing (DON), stated that the facility did not have documentation designating which staff were QMP's that could perform a MSE to determine if a EMC existed.

8. During an interview on 02/10/14 at 1:55 PM, Staff F, Chief of Staff, ED/IPPU Medical Director, stated that she made out the ED physician on-call list and schedule and Staff E, NP, had never been scheduled on-call for the ED.

9. During a telephone interview on 02/13/14 at 11:00 AM, Staff P, Former Director of the IPPU stated that:
-The facility lacked screening by ED physicians for psychiatric patients and some of the ED physicians refused to see psychiatric patients when they came to the facility's ED.
-Psychiatric patients were not being screened in the facility's ED.
-When Staff L, ED Physician was on-call for the ED, Staff E, NP was to see psychiatric patients that presented to the ED.
-Staff F would not sign the agreement for Staff E to see psychiatric patients that presented to the facility's ED.

10. During a telephone interview on 02/26/14 at 11:35 AM, Staff M, RN, ED Nurse, stated that:
-She was working when Patient #4 presented to the ED from the LTC facility.
-She called Staff F, Chief of Staff, ED/IPPU Medical Director, that the patient had presented to the ED (Staff F was on-call for the ED from 6 PM to 6 AM on 11/08/13).
-She stated that Staff F reported that she thought Staff E, NP, was seeing psychiatric patients that presented to the ED.
-She stated that Staff P, Former IPPU Director, called her and informed her that Staff G, ED Physician, would see the patient in the ED.
-After talking to Staff P, she called Staff C, RN, Director of Nursing (DON), to see who was to see psychiatric patients that presented to the ED.
-Staff C returned her call and informed her that Staff F would be seeing the patient per telemedicine.
-When Staff F called the ED, she informed Staff F that Staff P and Staff E were in the ED and Staff F spoke with Staff P per telephone.
-At that time it was being decided if Staff E, was going to be allowed to see patients in the ED and Staff F (Chief of Staff, ED/IPPU Medical Director), told her it would " OK " for Staff E to see Patient #4 in the ED.
-After Staff F spoke with Staff P on the telephone, Staff E ordered laboratory test and assessed the patient.
-The decision to use telemedicine would be made on a case by case basis determined by Staff F and that Staff F is the only physician that utilized telemedicine to see patients.
-Staff F, Staff G, L, T and U, ED Physicians, are the only recognized QMP to see patients in the ED.