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.

BATH COMMUNITY HOSPITAL 106 PARK DRIVE- PO DRAWER Z HOT SPRINGS, VA 24445 Feb. 7, 2014
VIOLATION: ORGANIZATIONAL STRUCTURE Tag No: C0240
Based on the systemic nature of the standard-level deficiency related to determining, implementing and monitoring policies the CAH's governing body failed to substantially comply with this condition.
VIOLATION: GOVERNING BODY Tag No: C0241
Based on interviews and record reviews, it was determined that the Governing Body for the CAH failed to assure adherence to the policies and procedures adopted by the CAH with respect to physician responsibilities related to patients who present to the CAH's emergency department, entitled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," which was in effect November 18, 2013.

Findings:

Patient #14 arrived at the CAH Emergency Department under an Emergency Custody Order (ECO) and was triaged by nursing staff at 12:55 p.m. on November 18, 2013. The ED physician evaluated the patient at 2:00 p.m. and ordered various laboratory tests and an X-ray. The ED physician did not make a determination about whether or not Patient #14 had an emergency medical condition. There is no documentation that the CAH's professional healthcare staff performed any further assessment of Patient #14. Instead, the CAH permitted an employee of the Community Service Board (CSB), an unrelated entity, to evaluate Patient #14. The CSB employee was not a physician, nor was the employee designated under the CAH's bylaws as a QMP (Qualified Medical Personnel) to evaluate patients. The CSB employee failed to document the employee's assessment of Patient #14 in the medical record, including the results of the assessment and plans for admitting or transferring the patient.

The CAH's EMTALA Policy and Procedures state, "...[a]n appropriate medical screening to determine whether or not an emergency medical condition exists must be performed by an Emergency Department physician or other qualified medical personnel, as set forth in Hospital's Bylaws. For purposes of providing medical screening examinations, the Hospital's Bylaws designate the following persons as qualified medical personnel: physicians and nurse practitioners." Although physicians and nurse practitioners are generally authorized to perform a medical screening examination under the CAH's EMTALA policy, the policy specifically requires a physician to perform the screening when the situation involves an individual with psychiatric or substance abuse problems. The policy and procedures state, "[r]esponsibility for providing an appropriate screening, stabilizing treatment and making transfer decisions for individuals with psychiatric or substance abuse problems rests with the physician." The CAH's EMTALA policy makes no mention of any involvement by the CSB or its employees, or of any process for designating CSB employees as QMPs.

The CAH Policy entitled, "Psychiatric Care and Substance Abuse Care Provisions," that was in effect November 18, 2013 was also reviewed and does make reference to a CSB role, but this policy is not consistent with the CAH's EMTALA policy. The "Psychiatric Care and Substance Abuse Care Provisions" policy specifies the following among other things:

"c. Emergency Custody Order
i. Community Services Board (CSB) will be notified of an Emergency Custody Order (ECO) and the patient's need for an evaluation.
ii. CSB will work in cooperation with the Sheriff's Office
and/or magistrate to obtain ECO.
iii. CSB will evaluate the patient to determine the need for TDO."

Use of the CSB as called for in the "Psychiatric Care and Substance Abuse Care Provisions" policy put the CAH in the position of not being able to satisfy its obligations under EMTALA, since CSB employees who performed assessments on behalf of the CAH were not designated QMPs whose qualifications were examined by the CAH, nor were they under the supervision of the CAH's medical director, nor were they required by the CAH to document in the patient's clinical record the services they provided or the arrangements they made for discharge or transfer of the patient.
VIOLATION: PROVISION OF SERVICES Tag No: C0270
Based on the systemic nature of a standard-level deficiency related to the CAH (Critical Access Hospital) governing body's responsibility to ensure that a contractor of services provides services that enable the CAH to comply with all applicable conditions and standards, the CAH failed to be in substantial compliance with the requirements governing the provision of services.
VIOLATION: CLINICAL RECORDS Tag No: C0300
Based on the systemic nature of the standard-level deficiency related to the requirements for the CAH's (Critical Access Hospital) clinical records system to be complete and accurate, the CAH failed to comply with this condition.
VIOLATION: RECORDS SYSTEM Tag No: C0302
Based on interviews and record reviews, it was determined that the CAH failed to maintain a complete, accurately documented, and readily accessible record for 1 of 20 sampled patients (Patient #14) and this failure was as a result of a systematic policy of not requiring evaluation services that were being provided in the CAH by the CSB (Community Service Board) to be documented in patients' clinical records.

Findings:

Patient #14 presented on November 18, 2013 at 12:55 under an Emergency Custody Order (ECO). As a result of the ECO, the Community Services Board was notified and responded by assigning a CSB employee to travel to the CAH to evaluate Patient #14 for purposes of the ECO.

The clinical record identifies the following timeline of events upon the arrival of the CSB evaluator:
3:20 p.m. "[CSB employee] here talking to [Patient #14's parent]."
3:20 p.m. "[Patient #14] has remained very cooperative [with] care. Deputy [at] bedside."
3:26 p.m. "[CSB employee] in [with] [Patient #14] talking to [him/her]."
4:15 p.m. "[CSB employee] calling to find placement for [Patient #14]."
5:00 p.m. "[CSB employee] spoke with [name of hospital] they advised change of shift. Awaiting on call back."
5:45 p.m. "[Three separate facilities] no beds available. Attempting [abbreviation for a hospital]."
6:26 p.m. ECO complete. Deputy advised [Patient #14]. [CSB employee] advised [Patient #14]. Deputy left. No bed available. Patient will [follow up] in a.m. [with] [CSB]. [Patient #14] agreed.

Despite the documentation demonstrating the CSB employee had evaluated Patient #14 and was looking for an inpatient bed for Patient #14 from approximately 3:10 p.m. to 6:30 p.m. on November 18, 2013, there was no documentation in Patient #14's clinical record regarding the nature of the evaluation the CSB employee had performed of Patient #14 at the CAH. The only documentation written by the CSB employee contained in Patient #14's clinical record was a signed Progress Note the CSB employee had written dated November 18, 2013 at 6:30 p.m., "Clinician assessed client and he presented as decompensating. Client has [history] of bipolar disorder. Client's ECO ran out and [he/she] agrees to follow up with [the local Community Service Board] on 11/19/13 for Crisis Stabilization."

Patient #14's ED clinical record failed to include evidence of documentation concerning the evaluation performed by the CSB employee. Neither the physician's documentation nor the nurse's documentation included details of the evaluation performed by the CSB employee. The CSB employee's documentation was not complete as it failed to provide any details of the evaluation and search for an inpatient bed the CSB employee had performed between 3:10 p.m. to 6:30 p.m. on November 18, 2013. Additionally, the CSB employee's documentation did not include details of his/her assessment to indicate what type of screening exam the patient received.

On February 5, 2014 at 1:47 p.m., an interview was conducted with the Supervisor for the CSB employee who evaluated Patient #14 on November 18, 2013, the CSB Clinical Director, and the CSB Executive Director. During this interview, these CSB representatives explained the normal process when a CSB employee is called to respond to a CAH in the event of an ECO. The CSB representatives specifically explained the CSB employee acts as a "pre-screener." The CSB representatives further explained that during the evaluation process the "pre-screener" is "constantly talking [with the] doctor." Patient #14's ED clinical record failed to include evidence of documentation concerning communications between the CSB employee and the physician.

During this same interview on February 5, 2014 at 1:47 p.m., the Supervisor for the CSB employee who evaluated Patient #14 on November 18, 2013 described the process of how the CSB evaluator must fill out a "Pre-Screener Form." It was determined that no such "Pre-Screener Form" was contained in the clinical record for Patient #14. Nor was there any documentation describing the evaluation by the CSB employee other than the short entry at 6:30 p.m. identified above. Thus, it was determined that documentation of the CSB evaluation and search for an inpatient bed performed between approximately 3:10 p.m. to 6:30 p.m. on November 18, 2013 existed but, was not contained in the clinical record for Patient #14. Interview with the CAH's Vice President of Nursing and Vice President of Quality at 2:30 p.m. on February 5, 2014 revealed that hospital staff had asked CSB for additional documentation concerning the evaluation that the CSB employee had performed on Patient #14 in the CAH but CSB refused to provide the documentation and further stated that the CSB attorney would not allow CSB to provide such documentation to the CAH.

Cross refer to 42 C.F.R. 485.635(c)(4)(ii) Services provided through agreements or arrangements. Based on interviews and record reviews, it was determined that CAH failed to properly oversee the evaluation services that were being provided by the Community Service Board in its CAH to Patient #14 and such lack of oversight resulted in a failure to maintain complete, accurately documented, and readily accessible records.