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.

NORTH SHORE MEDICAL CENTER - 81 HIGHLAND AVENUE SALEM, MA 01970 April 5, 2016
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on interviews and records reviewed Hospital Campus A failed to maintain a Central Log of Patient #1 who arrived to the Emergency Department (ED) by ambulance on 3/25/16.

Findings include:

1.) The Ambulance Service Report, dated 3/25/16 at 12:56 A.M., indicated Patient #1 arrived at Hospital Campus A and staff placed Patient #1 into a room in the ED.

2.) The policy titled Examination, Treatment and Transfer of Patients to other facilities, EMTALA, dated 5/2012, indicated Hospital A maintained a Central Log of all individuals who came to the Hospital for an emergency medical condition.

3.) Hospital Campus A's Emergency Department Central Log, dated 3/25/16, indicated the Hospital Campus did not register Patient #1.

4.) The Surveyor interviewed the Vice President for Quality and Safety at 10:20 A.M. on 4/5/16. The Vice President for Quality and Safety said Hospital Campus A did not register Patient #1 when Patient #1 came to Hospital Campus A's Emergency Department, on 3/25/16 (Therefore the Hospital Campus did not have Patient #1 registered on the Central Log).
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interviews, records reviewed of 30 sampled patients, review of Medical Staff Bylaws Rules and Regulations, and review of the policy titled Medical Staff EMTALA, review of the policy titled Examination, Treatment and Transfer of patients to other Facilities EMTALA, and interviews Hospital Campus A failed to assure that the Hospital Campus A provided Patient #1 with an appropriate medical screening examination when Patient #1 arrived to Hospital Campus A's Emergency Department (ED) by ambulance, on 3/25/16.

Findings include:

1.) The Ambulance Service Report, dated 3/25/16, indicated an Ambulance Service responded to a Police Department call for an intoxicated adolescent approximately at 1:00 A.M. on 3/25/16. The Ambulance Service Report indicated Ambulance Service Staff notified Hospital Campus A of the ambulance's arrival to Hospital Campus A and placed Patient #1 into a room in the ED.

2.) The Surveyor interviewed ED Physician #1 at 12:00 P.M. on 4/7/15. ED Physician #1 said Patient #1 looked well and wanted to expedite the transfer to Hospital Campus B because Patient #1 would be better served in Hospital Campus B's pediatric emergency department. Physician #1 said she did not perform a medical screening examination.


3.) Medical Staff Bylaws and Rules and Regulations, dated 11/3/15, indicated all persons presenting to the Hospital or on Hospital property who request medical care for an emergency condition (or whom a request was made or who showed symptoms indicating a possibility of an emergency medical condition) would receive an appropriate medical screening examination to determine if that person had an emergency medical condition.

4.) The policy titled Medical Staff EMTALA, dated 5/28/15, indicated all persons presenting to Hospital A's dedicated emergency department or who were on Hospital property seeking care for an emergency medical condition, (or for whom a request was made or who showed symptoms indicating possibility of an emergency medical condition), shall receive an appropriate medical screening examination within the capabilities of the Hospital, by qualified medical person to determine if that person had an emergency medical condition.

5.) The policy titled Examination, Treatment and Transfer of Patients to other Facilities EMTALA, dated 5/2012, indicated all persons presenting to the Emergency Department seeking care for an emergency medical condition would receive an appropriate medical screening examination.

6.) The Surveyor interviewed the Vice President for Quality and Safety at 10:20 A.M. on 4/5/16. The Vice President for Quality and Safety said the Hospital Campus A did not provide Patient #1 with an appropriate medical screening examination to determine if Patient #1 had an emergency medical condition when Patient #1 came to Hospital Campus A's Emergency Department, on 3/25/16. The Vice President for Quality and Safety said Hospital Campus A did not create a medical record for Patient #1 when Patient #1 came to Hospital Campus A's Emergency Department, on 3/25/16.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on interviews, records reviewed of 30 sampled patients, review of Medical Staff Bylaws Rules and Regulations, and review of the policy titled Medical Staff Emergency Medical Treatment And Labor Act (EMTALA) Hospital Campus A failed to assure that if an emergency medical condition existed, A provided stabilizing treatment, when Patient #1 came to the Emergency Department (ED) on 3/25/16.

Findings include:

1.) The Ambulance Service Report, dated 3/25/16, indicated Patient #1 was brought to Hospital Campus A's ED for psychiatric problems that needed evaluation.

2.) Medical Staff Bylaws and Rules and Regulations, dated 11/3/15, indicated if the Hospital determined that a patient had an emergency medical condition the person's condition would be stabilized prior to transfer.

3.) The policy titled Medical Staff EMTALA, dated 5/28/15, indicated all patients would be transferred when medically necessary, once the patient was stabilized and transfer requirements were met.

4.) The policy titled Examination, Treatment and Transfer of patients to other Facilities EMTALA, dated 5/2012, indicated patients would be transferred when medically necessary and transfer requirements were met.

5.) The Ambulance Service Report, dated 3/25/16, indicated when Patient #1 was at Hospital Campus A, a physician told the Ambulance Service staff to take Patient #1 to Hospital Campus B and the Ambulance Service staff took Patient #1 to Hospital Campus B.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on interviews, review of 30 sampled records, review of the policy titled Examination, Treatment and Transfer of Patients to Other Facilities EMTALA, and the policy titled Physician Authorization for Transfer, Hospital Campus A failed to assure an appropriate transfer was agreed by Hospital Campus B.

Findings include:

1.) Medical Staff Bylaws and Rules and Regulations, dated 11/3/15, indicated if the Hospital determined that a patient had an emergency medical condition the person's condition would be stabilized prior to transfer.

2.) The policy titled Examination, Treatment and Transfer of patients to other Facilities EMTALA, dated 5/2012, indicated patients would be transferred when transfer requirements were met.

3.) The Ambulance Service Report, dated 3/25/16, indicated Patient #1 was brought to Hospital Campus A for evaluation of a possible emergency medical condition. The Ambulance Service Report indicated when the ambulance was on the property of Hospital Campus B, a nurse supervisor, at Hospital Campus B, told the Ambulance Service staff Hospital Campus B would not accept Patient #1, and return to Hospital Campus A, because Hospital Campus A violated the Emergency Medicine Treatment and Labor Act (EMTALA).

4.) The Surveyor interviewed ED Physician #1 at 12:00 P.M. on 4/7/15. ED Physician #1 said she wanted to expedite the transfer to Hospital Campus B because Patient #1 would be better served in Hospital Campus B's pediatric emergency department.

5.) The Surveyor interviewed the Vice President for Quality and Safety at 10:20 A.M. on 4/5/16. The Vice President for Quality and Safety said that there was no physician-to-physician communication about Patient #1's transfer from Hospital Campus A to Hospital Campus B.

6.) The document titled Physician Authorization for Transfer, dated 7/2007 a blank sample form, indicated a physician would verify that the receiving facility agreed to accept the transfer.