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.

Based on observation, interview and medical record review Tri County Hospital failed to ensure all entries in the medical records were complete for 6 (#2, #3, #10, #11,#12, #21) of 33 patients sampled.

The investigation was conducted in conjunction with CCR# , CCR# , CCR# and . A review of the medical records reviewed revealed records that were not completed accurately and completely.

PATIENT #2 Date of Admission 07/03/2013
Cut his finger off in machine
Hospital Authorization and Release of Information " unable to sign " witnessed by staff name
not title.
Transfer Record 07/03/2013 partially completed.
An interview with the Risk Manager designee, on 07/09/2013 at 11:50 revealed she asked the Registered Nurse (RN), Emergency Department (ED) to fill out a transfer form today (07/09/2013) for Patient #2 who was transferred on 07/03/2013. She stated she asked the RN to fill out a transfer form so the business office could close the account. No diagnosis was on the account either, so most of this was requested for billing purposes. The Risk Manager (RM) designee asked the RN to fill out another transfer form, as it appeared the transfer form went with Patient #2. The RM stated she asked the RN to fill out the transfer form so the business office could close the account. She further stated, no diagnosis was on the account either, so most of this was requested for billing purposes. The Director of Nursing was present in the interview and instructed her on " Late entry " and what needed to be done if the record needed information. The DON informed the RM designee that a transfer was never done.
An interview with the ED physician on 07/09/2013 at 12:45 PM revealed he called the transfer center and talked with the physician at the receiving hospital. He stated the patient refused to go by ambulance. The finger was packed on ice and sent with the patient. The ED physician was asked for documentation of the call to the receiving hospital(hospital #3). He stated he did not document the call at the time and did not compete a transfer form. He stated the patient should have gone by ambulance if the finger was to be reattached.
A review of the Physician ' s note of 07/03/2013 revealed the patient cut right digit off on machine at work at first metacarpal. Log rolled on top of finger. Plan: Send patient to hospital #3 (the receiving hospital) to possibly have finger reattached. Finger is on ice. Tetanus toxoid given.

PATIENT #3 Date of Admission 06/30/2013 Two charts were opened for this patient on 06/30/2013.
Chief Complaint: 0805 Loss of feeling on left side of face with swelling on back side of head behind left ear. Complained of migraine and blurry vision. Seen by physician at 0845. Physician ' s notes indicated injuries were from an altercation. The physician ' s order was for a CT of the face today at hospital #2 and return here today. The nurses noted indicated the patient called for a ride to hospital #2 and will return with report of CT scan for Dr. Martin to review. The notes indicated the patient was waiting for a ride. At 1105 the patient was discharged .

At 1700 the patient returned for recheck of outpatient CT scan. The report indicated the patient had multiple facial fractures. Patient to be transferred to hospital #3 for further workup and evaluation. 2208 transferred to hospital #3 ER by EMS. Delay due to transport - no ambulance in the area. A review of the TriCounty Hospital Williston emergency room physician ' s assessment form revealed only the name, age, date and MR number were recorded. No notes were made by the physician. The Physician Certification statement for non-emergency ambulance transportation dated 06/29/2013 indicated the patient requires monitoring by trained personnel during transport. A verbal order at 1900 for Lortab 5 mg PO not signed by physician.

PATIENT #10 Date of Admission 07/05/2013
Chief Complaint: 16 yo (year old) 8 months pregnant. Contractions 5 minutes apart. 1st baby. Water not broke.
Impression:8 months pregnancy. 5 minute contractions. Transferred to hospital #3 Reason: services not available at facility. Labor and Delivery.
The Physician Certification statement for Non-Emergency Ambulance Transportation dated 07/05/2013 did not include a Diagnosis. Item 3. Medical Necessity Information was not completed.
The Transfer Record Form consent was blank.
The Physician Transfer Authorization form did not have the patient ' s name or identifying information. Section #3 The risks and possible complications of transfer was not completed. The form was signed in the section for Physician ' s Signature but was illegible.
The Authorization for Release of Medical Record Information was not labeled with patient ' s identifying information and was not completed. The signature of patient section stated " minor " and Signature of patient representative stated " Unable to sign " 07/05/2013 at 1850.
The Advance Directive Information form dated 07/05/2013 was crossed through and labeled " minor " and signature of patient " Unable to sign " .
A Hemlock was shown as started at 1850. An order for NS (Normal Saline) bolus was not documented as given.

PATIENT #11 Date of Admission 07/04/2013
Impression: Rt. Humeral Head Fracture S/P (status post) fall.

Authorization to Release of Medical Record Information was not labeled with patient ' s identifying information and was not completed. " Unable to Sign dated 07/04/2013 at 1122.

The TriCounty Hospital Williston Authorization and release of Information had no patient identifiers.
The nurses ' documentation form page 4 stated the patient back from x-ray. The Tri County Hospital Williston physician form did not include an order for an x-ray but the physician noted the result as Right Humeral Head Fracture.

The Physician Certification Statement for Non-Emergency Ambulance Transportation did not include a diagnosis. Item 3. Medical Necessity Information was not completed.
The Physician Transfer Authorization Section #3 the risks and possible complications of transfer was not completed.

PATIENT # 12 Date of Admission 07/04/2013
Chief Complaint Vomiting, diarrhea, abdominal pain and headache per triage. 5 months pregnant
Transfer to hospital #2.
Physician Transfer Authorization Section #3 the risks and possible complications of transfer incomplete
The Physician Certification Statement Item 3. Medical Necessity Information was not completed.

PATIENT #21 Date of Admission 06/26/2013
Chief complaint: Right lower quadrant pain 7/10
Physician Orders: X-ray KUB (kidneys, ureters, bladder), HL (heplock), NS (normal saline) 1000 ml over 1 hour.
Impression: RLQ (right lower quadrant) pain R/O appendicitis
No orders were found for the following:
Urinalysis, SGOT, SGPT, Amylase, Lipase, CBC, Basic Metabolic Panel results were reported.
The disposition was not completed.

The Physician Certification Statement dated 06/26/2013 did not have a diagnosis.
Physician Transfer Authorization dated 06/26/2013 Section 3 the risks and possible complications of transfer incomplete.

A review of the policy and procedure titled: Documentation dated May 2011 revealed:
A) Entries in the Emergency Department Patient Care Record shall be dated and signed legibly by the licensed person who is responsible for their clinical accuracy.
B) Verbal or telephone orders may be given by physicians on emergency basis, accepted and transcribed by the nursing staff. The ordering physician must verify and countersign the orders within twenty-four hours.
D) Evidence of required documents, such as, informed consents, leaving against medical advice, restraints or conscious sedation shall be incorporated into the Emergency Department Patient Care Record.
E) It is required that all nursing interventions be documented on the Emergency Department Patient Care Record and re-assessment every 2 hours or often as clinically indicated.
F) Correction of documentation errors in the ED patient care record shall be corrected by entering this into Meditech.

C. It is required that all interventions, diagnoses and procedures be documented in the Emergency Department Patient Care Record:
Time that the provider evaluates the patient
Time of diagnostic test (i.e. EKG, Chest X-Ray, CT, Ultrasound, Lumbar Puncture, ABG's Labs, Pelvic Exam, etc.)
Time of Procedures

D. Administration of medications by any route, IV therapy and IV medications.
The RN/LVN will record the time, medication, IV solution, dose rate, route, site, catheter size, pump use.

J. Discharge/Transfer
Documentation of specific verbal and printed instructions given to the patient
Time of discharge/transfer will be recorded at the time the patient leaves the department as well as the patient's destination
How patient left will be documented (i.e. walk, wheelchair, ambulance)
Referrals will be documented on all patients at time of discharge
Discharge assessment will be performed on all patients and will re-address patients chief complaint
After care instructions will be given to each patient at time of discharge, printed by the physician from the exit writer.

Based on observation, interview and medical record review Tri County Hospital failed to ensure the policies and procedures for emergency access were followed for 2 (#1, #4) of 33 patients sampled.


On 07/08/2013 at 10:05 AM patient #1 was observed walking with crutches into a triage room with Registered Nurse (RN), ED. The patient was not in the Emergency Department after triage. At 10:25 AM an interview with the ED RN revealed she explained she did not get a history or anything but said patient #1 ' s foot looked broken. She told the patient she might have to be transferred to hospital #2 for treatment. The patient would be billed at both hospitals. The patient made an " informed choice " The RN stated she chose not to have 2 bills, and decided to go elsewhere. She stated the patient left without being seen by a physician. She stated she did not document the nurse ' s notes. She would go do her documentation.

On 07/08/2013 at 10:40 AM an interview with the CEO revealed the policy of the hospital was the patient is to sign in, be triaged, registered, or brought right in, and has a medical screening. He stated, " It was totally unacceptable for the patient not to be seen by a physician for a medical screening " .

On 07/08/2013 at 2:15 PM an interview with the Chief of Staff, Emergency Department Physician, revealed he was the only physician in the emergency department from 7 AM until 7 PM on 07/08/2013. He was not made aware of patient #1 with a possible broken foot. He stated the hospital policy was the patient was to be triaged and then seen by a physician for a medical screening.

An interview at 4:15 PM with the Emergency Department Medical Director, revealed he sees all patients presenting to the emergency department for a medical screening exam. Nurses are not allowed to determine if the patient is a medical emergency or not. He stated all patients coming to the emergency department are seen by the physician after triage.

Further interview with the ED RN, on 07/09/2013 at 11:00 AM revealed the RN has been employed at the facility since April 2013. She stated she has been a nurse for 23 years. She stated she had no Emergency Department experience. She acknowledged the chart had a chief complaint of a possible broken right foot but the assessment was not done and documentation of an assessment was not completed on the Primary nurse assessment form. She stated she had not received EMTALA or emergency access training. She did not know the triage levels and had to refer to a paper with the triage levels to determine which level of care a patient needs. She stated she made a huge error in judgement and can ' t correct it at this point. She did not realize she was making a mistake.

A review of the medical record for Patient #1 revealed documentation on the Triage/ER Flow Sheet that the Chief complaint was: Possible broken right foot. Dropped X-box 360 on it last night. LWBS. (Left without being seen). The documentation notes revealed the patient informed that she may need to be transferred to another facility if she had a broken bone. But that we would be able to determine that for her and transfer her there or get all the necessary papers together and sent her to whichever hospital she desired. She made an informed choice to not be seen here but to go to hospital #2 herself and not rack up " 2 bills. "
A review of the Emergency Department sign in log shows the patient signed in with no time noted. A review of the Central log of 07/08/2013 revealed the patient was not logged into the emergency department log as seeking medical treatment and a disposition was not noted.

A review of the medical record from the hospital #2 revealed Patient #1 went to their emergency department with a complaint of a right foot injury after dropping an Xbox on top of right foot. The patient is uninsured. She reported inability to bear weight due to right foot pain and pain with walking. She was seen on 07/08/2013 at 11:25 AM by the Physician ' s Assistant. A history and physical, allergies, vital signs, x-ray of the foot, 3 views (right foot) was completed at 11:34 AM.
The exam showed: Foot: normal pulses, no [DIAGNOSES REDACTED], ttp to dorsum of right foot over 1st to 5th mid to distal metatarsal with visible swelling and bruising to this area, ttp with visible bruising to right 2nd to 5th toes,, greatest to 3rd and 4th toes with limited ROM due to swelling and pain of foot. Capillary refill appropriate. Contusion with abrasion to dorsum of foot over distal 3rd and 4th metatarsals.
Splint Application right lower extremity: short leg posterior splint to right lower extremity, buddy tape to 3rd toe with adjacent toe.

Impression: Closed fracture of proximal phalanx, right 3rd toe. Contusion/abrasion to dorsum of right foot, right foot, toe crush injury. discharged home 1317. Follow up with podiatry.

On 07/08/2013 a review was being made in the Emergency Department log and a request was made for the medical record for Patient #4 who was shown as signed into the Emergency Department needing meds and a disposition in the emergency department. The Medical Records Director, informed the surveyors she was not able to locate an Emergency Department medical record and only had a clinic record. She furnished the clinic record with the same MR # dated 06/19/2013. A review of the record revealed the patient came in with a chief complaint of anxiety, pain in teeth today. She was seen by a physician in the clinic within the hospital and medications prescribed. Assessment: Anxiety, Panic Attacks, Severe Dental Carries, Tension Headaches. Plan: Cipro 500 mg PO BID for 10 days, Tramadol 50 mg 2 tabs every 6 hours as needed for pain.

On 07/09/2013 an interview with Admissions Clerk, Emergency Department revealed at one point she would tell the patient that there is a clinic on site. She said the patients don 't read the information posted in the Emergency Department (sign posted about clinic). When she was taking them over to the clinic, they were not being triaged or screened first prior to going to the clinic. If the triage is done first, then she sees them and processes the admission to the Emergency Department. She provided the surveyors with a memo to the Admission Staff from the CEO dated June 18, 2013, stating:
Please be advised that all patients that are processed through the emergency room and deemed Non-Emergent by the Medical staff after triage will be transferred to the clinic during working hours.
This will cut down on non-emergent cases backlogging the emergency room and leaving room for true emergencies.

On 07/09/2013 at 5:00 PM the Director of Nursing revealed the staff needed training in emergency access and EMTALA and she was unable to locate the training in the personnel files.

A review of the facility policies and procedures relating to emergency services revealed:
Policy and Procedure titled Log, Emergency Department Visits dated May 2011 stated a log will be kept as part of the documentation of patients seen in the Emergency Department.
A. Responsible Persons:
ED Nurse, Paramedic Unit Specialist
B. Frequency/occasion: Every registered Emergency Department patient
(2) The ED log will be reviewed with the sign in sheet at the end of each shift.
Determine if sign in sheet matches ED log - If patient pending, pass report to next shift
If patient left AMA, is documentation complete
if patient left without being seen (LWBS) is documentation complete.

Emergency Medical Conditions under EMTALA that is a danger to the patient or unborn fetus, or could result in a risk of loss of function or impairment if the patient is not treated promptly. These conditions include:
1. Undiagnosed , acute pain which is sufficient to impair the normal functioning
2. Pregnancy with contractions
3. Substance abuse symptoms
4. Psychiatric disturbances including severe depression, insomnia, suicidal ideation or attempt, dissociative state, inability to comprehend danger or care for self.
A. All patients presenting to Tri County Hospital Williston for a non-scheduled visit and seeking care must be accepted and evaluated regardless of the patient ' s ability to pay. EMTALA absolutely prohibits delaying a medical screening exam or stabilization treatment to inquire about a patient ' s financial information or payment source.
B. All patients shall receive a medical screening exam that includes providing all necessary testing and services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic.
C. Tri County Hospital-Williston will not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to deteriorate due to the natural process of their medical condition, they are legally unstable according to EMTALA standards.
D. Tri County Hospital-Williston will not transfer patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient. A transfer of a patient to another facility may only be for reason of medical necessity.
E. If a patient is to be transferred for medical necessity, the following guidelines must be followed.
1. A physician certification that the risks of transferring the patient are outweighed by the potential benefits. The individual risks and benefits must be discussed with the patient or responsible party and documented in the patient ' s medical record. There must be supporting documentation in the medical record.
2. The patient or responsible party gives written consent for transfer.
3. The receiving hospital must give acceptance in advance. The acceptance must be documented in the medical record, including the name of the receiving facility and the physician agreeing to accept the transfer.
4. The patient must be transferred by an appropriate medical transfer vehicle.
F. Copies of the medical record, x-rays and laboratory test will accompany the patient when transferred. In the event copying the records could jeopardize the patient, the records may be sent on a STAT basis to the receiving facility as soon as completed.