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NYE REGIONAL MEDICAL CENTER 825 ERIE MAIN ST (AKA SOUTH MAIN) TONOPAH, NV Aug. 23, 2012
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on record review and staff interview, the facility failed to maintain an emergency room central log that identified each individual who presented to the emergency room and did not identify the treatment received and disposition for 5 of 20 patients (#9, #10, #12, #15, #17).

Findings include:

Review of emergency room logs from July and August of 2012 revealed Patients #9, #10, #12, #15, and #17's names were missing from the log.

The emergency room log did not consistently identify the patient's chief complaint and did not identify whether the patient was treated or refused treatment or whether the patient was transferred, admitted or discharged .

During an interview on 8/20/12, with the Director of Nurses (DON), she revealed the facility switched over to electronic records on 7/1/12. The DON reported the facility was not aware the needed data was missing from the log until August 2012, and the facility went back to using the paper emergency room logs on 8/8/12 to make sure they were collecting the needed data.

On 8/20/12 the Assistant Administrator was interviewed and revealed the emergency room logs from 7/1/12 to 8/7/12 were incomplete. The Assistant Administrator was later able to collect additional data to supplement the emergency room log.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the facility failed to provide an on site physician within the 30 minutes response time identified in hospital policy for 1 of 20 patients and failed to have a written policy and procedure in place to respond to situations in which an on-call physician was not available for 1 of 20 patients (Patient #15).

Findings include:

Patient #15

Summary of Events:

Patient #15 (MDS) dated [DATE] at 4:20 AM complaining of shortness of breath, substernal chest pain radiating to his left arm, dizziness, weakness and lethargy. The patient arrived in the emergency room via ambulance with an intravenous solution of normal saline initiated by the paramedics. The patient was alert and oriented.

Record review revealed Patient #15 had laboratory work including Troponin I, Myoglobin level, complete blood count, CPK level, Hepatitis panel, Magnesium level and a Basic Metabolic Panel within two hours after presentation to the emergency room . The patient also received an EKG (Electrocardiogram) and a chest x-ray within the first two hours following presentation to the emergency room . The patient was placed on a cardiac monitor immediately upon arrival to the emergency room .

Patient #15 was admitted from the emergency room to the acute hospital at 9:30 AM. Review of the patient's Emergency Department Note, written by Physician #3, revealed the patient was diagnosed as having chest pain, palpitations, rhabdomyolysis, acute hepatitis and an abnormal electrocardiograph. The patient was admitted for cycling of cardiac enzymes and serial EKGs. His urine was to be alkalinized for the rhabdomyolysis and he was to have a 2D stress echo.

Patient #15 was discharged from the hospital on [DATE] with diagnoses including rhabdomyolysis, chest pain, hepatitis, iron excess and dehydration.

Emergency MD Response /On-Call Issues:

Record review revealed the patient's Emergency Department Form did not identify the time the on call physician was notified and did not identify the time the physician responded in the space where notification and response time were required on the form.

Review of the Chartlink Physician Orders section of Patient #15's records revealed the physician issued verbal orders that were documented at 4:50 AM. Review of the nursing progress notes revealed the physician came in to the emergency room to see the patient at 7:00 AM.

On 8/20/12 at approximately 5:15 PM, Registered Nurse (RN), Employee #5, was interviewed. The RN examined Patient #15's Emergency Department Form from his 7/26/12 visit. The RN reported she mistakenly left the physician notification and response time documentation area of the form blank. The RN reported the physician responded via phone when called regarding the patient's arrival in the emergency room . The RN reported the physician gave verbal orders at that time. The RN reported the physician did not come in to the emergency room to see the patient during her shift. The RN reported she left the hospital at 5:30 AM. The RN confirmed no other physicians were present in the emergency room or in the hospital.

RN, Employee #5, reported the nurses were instructed to identify the time the physician responded as the time the physician gave verbal or written orders. The RN confirmed she would record the physician response time by documenting the time physician gave verbal orders over the phone. The RN reported during the night shift, the physicians were responding to notification of a patient's arrival within 30 minutes by giving verbal orders over the phone. The RN reported the physician response time varied according to patient acuity and could vary from one hour to two hours.

On 8/21/12 at approximately 3:00 PM, the Director of Nurses (DON) was interviewed and confirmed response time was identified as the time the physician gave orders including verbal orders over the phone. The DON reported physician arrival could be within 30 minutes or could take one to two hours. The DON reported all patients presenting to the emergency room were seen by the physician but all patients were not seen within 30 minutes. The DON reported the nurses were not to document the physician arrival time in the emergency room even though the hospital policy indicated they would do so. The DON reported the facility Medical Director did not want the physician arrival time in the emergency room to be documented.

The DON reported the hospital registered nurses were not trained to be Qualified Medical Personnel (QMPs) capable of doing the medical screening examinations. The hospital's plan of correction following the initial EMTALA complaint dated 7-6-12, revealed the hospital would not amend its by-laws to allow registered nurses to perform the medical screening examinations.

The DON reported she relieved RN, Employee #5 on 7/26/12 and provided care to Patient #15. The DON confirmed the physician did not arrive in the emergency room until 7:00 AM.

On 8/22/12, Licensed Practical Nurse (LPN), Employee #6, was interviewed. The LPN reported the physician response time was identified as the time the physician gave orders, not the time the physician arrived to see the patient.

On 8/22/12, RN, Employee #7, was interviewed and reported the physician response time was to be identified as the time the physician gave orders, not the time the physician arrived to see the patient.

Review of the hospital policy entitled "Physician On-Call" reference #2302b effective 3/1/02 and revised 7/28/09 revealed "EMTALA requires facilities to adopt policies and procedures establishing a reasonable amount of time for the on-call physician to respond to the emergency Department. A reasonable amount of time for Nye Regional Medical Center will be thirty (30) minutes. The ED (Emergency Department) nurse notifying the on-call physician will document the time the physician was notified on the ED chart. The ED nurse will document the time the on-call physician responded to the ED."

Review of the hospital by-laws did not define a required physician response time.

Review of the physician schedules for July and August of 2012 revealed physicians were scheduled to cover the emergency room from 11 to 14 days at a time. The schedule did not identify a back-up physician.

On 8/21/12, the Assistant Administrator was interviewed and reported the hospital did not have a written policy and procedure to respond to situations where the on-call physician was not available. The Assistant Administrator reported she would call one of the other physicians on staff.

On 8/22/12 at 9:55 AM, Physician #3, the Hospital Administrator, was interviewed and confirmed the hospital did not have a written policy addressing how to respond if the on-call physician was not available. The physician confirmed the physician response time was defined as the time the physician gave verbal orders over the phone or, it was the time the physician was in the emergency room and gave orders.