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 interview and record review, the provider failed to consistently maintain documentation of the collection and tracking of quality indicators and other aspects of performance that assess processes of care, hospital service and operation. Specifically, documentation of ED quality indicator tracking and reporting was inconsistent.


Review of the "ED Quality Management/ Performance Improvement Plan" (effective date 7/12) notes that data to monitor patient care activities for variances and trends are collected and reviewed monthly. QM worksheets related to the reviews will be maintained by the QM/PI committee, and will serve to demonstrate the data retrieved. Findings and results of monthly reviews are to be discussed at the multidisciplinary staff meeting. Data to be collected and reviewed include: patients leaving against medical advice (AMA); patients leaving before physician examination (LBE); patients with an unscheduled return to the ED within 48 hours; patients receiving thrombolytic therapy; patient transfers; patients requiring restraints; patient related incident reports; patient concern reports/ Situation Assessments; patients noted to have an x-ray interpretation discrepancy; patients noted to have an EKG discrepancy; and nursing documentation review on a random set of patients.

Department of Emergency Medicine monthly meeting minutes for the period December 2013- May 2014 were reviewed. The scheduled January 2014 meeting was cancelled. Minutes of the December 2013, February and March 2014 meetings documented that reviews of ED patients who left AMA or were transferred was conducted. There was no data or additional information provided. Meeting minutes of the March 2014, April 2014 and May 2014 DEM meetings noted that due to time constraints, there was no discussion of QM issues.

The Associate Director (AD) of the ED was interviewed on 6/19/14 at 1:40 pm. The AD said that the facility's ED electronic medical record (EMR) system functionality includes monitoring of clinical metrics, quality assurance/ performance improvement tracking, and billing/ coding. The AD said that daily spreadsheets documenting inpatient admissions and patient transfers are maintained. The AD stated that he collects data regarding quality indicators and provides the information to the ED Director. The AD said that the data is available on the EMR system and he did not always maintain hard copies of the information. The AD said that data concerning patients leaving before physician exam was not being formally reviewed. The AD demonstrated the ED EMR metrics for the surveyor. The AD reported that the percentage of patients who left before physician exam was 0.9%, based on data from June 1- present (6/19/14). The AD said that ED nursing personnel follow up via telephone with all patients who left before physician exam.

The Nursing Director of Emergency Services was interviewed on 6/18/14 at 10:00 am and provided information concerning ED quality assurance and performance improvement activities. "Performance Improvement Summary" for the Department of Emergency Services for the first quarter of 2014 was reviewed. Improvement projects include "door to first provider time", "door to 12-lead EKG time for patients who arrive with a chief complaint of chest pain", and core measure CAUTI and appropriateness of foley catheter insertion in the ED. Data and project summaries were documented. In addition to the current projects, sepsis screening and door to admission disposition time will be added in quarter three of 2014.

The Director of Performance Improvement was interviewed on 6/19/14 at 11:30 am and provided information concerning ED reporting of quality assurance and performance improvement activities. "Performance Improvement Initiatives" (revised 5/14/14) documented the previously referenced ED measures, department goals and end of year results for 2012 and 2013.
Based on record review and interview, the provider's medical staff failed to maintain complete documentation of the appraisals of its members. Specifically, provider performance appraisals and training required for medical staff reappointment were incompletely documented.


ED Provider A's credential file was reviewed. Provider A was reappointed to the Medical Staff on 9/18/12. The file did not contain documentation of facility mandated education.

ED provider B's credential file was reviewed. Provider B was reappointed to the Medical Staff on 3/5/14. The file did not contain specific documentation of the Provider B's current clinical competence.

Medical Staff Bylaws (amended 3/19/14) Article 6 Medical Staff Appointment (, requires "A written record of all matters considered in each practitioner's periodic reappointment appraisal must be made part of the permanent files of the Organization".

The Associate Director (AD) of the ED was interviewed on 6/19/14 at 1:40 pm. The AD stated that all ED medical staff personnel are employed by a professional organization which contracts with the hospital to provide ED medical staffing services. The AD said that all ED providers undergo credentialing at hire and recredentialing periodically. Continuing medical education (CME) and mandatory education including EMTALA training is provided by the employer. The AD demonstrated the organization's education database. Information concerning mandatory 2013 course completion (EMTALA, HIPAA update) was available. The AD stated that not all of the organization's recredentialing information was provided to the facility, but was available.

The Chief Medical Officer (CMO) was interviewed on 6/19/14 at 3:30 pm. The CMO reviewed the providers' files and confirmed the documentation deficiencies.