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.

PENN HIGHLANDS CLEARFIELD 809 TURNPIKE AVE CLEARFIELD, PA 16830 Feb. 24, 2015
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
Based on review of facility documents and staff interviews (EMP), it was determined that Penn Highlands Clearfield failed to adopt written policies and procedures to respond to situations in which a particular specialty service is not available.

Findings include:

1) Review of the On-Call schedules dated September 1, 2014 to present for specialties offered by Penn Highlands Clearfield included but was not limited to; Oncology/Hematology, Pediatrics, Gynecology, Surgery, Orthopedics, Facial Trauma, Ophthalmology, Cardiac, Nephrology, Podiatry and ENT. It was noted that the Surgery Call coverage during the weekdays was not consistent, and that there was no Call coverage on every Saturday and Sunday during that time period.

2) An interview was conducted with EMP7 on February 24, 2015, at 11:10 AM. EMP7 revealed, "We call Dubois transfer line and ask for a surgeon on call. Essentially the hospital would not be open if we did not have Dubois to take our On-Call. We do not have an On-Call policy."

3) An interview was conducted with EMP6 on February 24, 2015. EMP6 confirmed the facility does not have an On-Call policy or procedure in place. EMP6 also stated that there is no policy as to minimum On-Call requirements for limited Specialties.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on a review of facility documents, closed medical records (MR), and staff interviews (EMP), it was determined that Penn Highlands Clearfield failed to include one of one (PT1) on the Emergency Department Log.

Findings include:

Review of facility policy Emergency Medical Screening, Treatment, and Transfer Policy, dated December 8, 2014, was conducted and revealed, "... Policy: The Penn Highlands Clearfield ED Physicians are responsible to provide a Medical Screening Exam (MSE) and appropriate treatment to patients coming to the Penn Highlands Clearfield ED for emergency care. ... A. Presenting For Care And Medical Screening Examination (1) A central log on each individual who comes to the Penn Highlands Clearfield Emergency Department seeking assistance and whether he or she received treatment, refused treatment, was transferred, admitted and treated, stabilized and transferred or discharged is maintained by the Penn highlands Clearfield Emergency Department. ... ."

1) An interview was conducted with EMP4 on February 23, 2015, at 2:25 PM. EMP4 revealed, "I came in at the tail end. The Physician just came in from the ambulance doors. [The physician] told the ambulance to go to Dubois. When [the physician] came in, I was at the desk, and the Physician made the statement that this was just a Band-Aid station with a defibrillator. I could not tell if [the physician] saw the patient in the ambulance (PT1) ... ."

2) An interview was conducted with EMP3 on February 23, 2015, at 2:10 PM. "The ambulance called in. They had a pregnant girl (PT1) with syncope. The doctor said, 'why didn't you tell me.' When the ambulance pulled in, [the physician] went outside and said the patient should go to DuBois. I went to the Charge Nurse and said this was a questionable EMTALA violation because they pulled up under the canopy. They were on our property."

3) A telephone interview was conducted with EMP1, on February 24, 2015, at 10:45 AM. "The patient (PT1) was 27 weeks pregnant, vomiting and weak. I went out to talk to ambulance crew and advised the patient that we don't have Obstetric care at this facility. I recommended that [they] get [the patient] to a facility as soon as possible for Obstetrical care, specifically fetal monitoring. I spoke to the medics and checked on the patient's vital signs."

4) Review of the Emergency Department Log dated February 12, 2015, at 12:07 AM through February 12, 2015, 11:11 PM, failed to reveal the name of PT1.

5) An interview with EMP6 on February 23, 2015, at 10:30 AM confirmed that PT1's name was not present on the Log.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on a review of facility documents, closed medical records (MR), and staff interviews (EMP), it was determined that Penn Highlands Clearfield failed to follow their adopted policies related to providing a medical screening examination for one of one patients (PT1).

Findings include:

Review of facility policy Emergency Medical Screening, Treatment, and Transfer Policy, dated December 8, 2014, was conducted and revealed, "... Policy: The Penn Highlands Clearfield ED Physicians are responsible to provide a Medical Screening Exam (MSE) and appropriate treatment to patients coming to the Penn Highlands Clearfield ED for emergency care. If the patient requires services or a level of care not provided within the facility, the ED Physician shall provide direction to transfer the patient to an appropriate facility to receive further care if needed. Procedure: A. Presenting For Care And Medical Screening Examination (1) A central log on each individual who comes to the Penn Highlands Clearfield Emergency Department seeking assistance and whether he or she received treatment, refused treatment, was transferred, admitted and treated, stabilized and transferred or discharged is maintained by the Penn Highlands Clearfield Emergency Department. (2) Any individual who comes to the Penn Highlands Clearfield Emergency Department requesting Examination or treatment will be provided with an appropriate MSE. (3) An individual will also be considered to have come to the Penn Highlands Clearfield Emergency Department if the individual is on Penn Highlands Clearfield property (including its parking lot, driveway, or sidewalk) and is requesting care for what may be an emergency condition or someone has requested care on his or her behalf. Penn Highlands Clearfield property and grounds, define as an area that is 250 yards around the Hospital building ... a) Emergency Situation: 1) All hospital personnel have the responsibility to respond to any incident that occurs within 250 yards of Penn Highlands Clearfield (i.e. Parking lots) ... (4) The MSE shall include any ancillary services routinely available to the Penn Highlands Clearfield Emergency Department. The MSE must be similar for patients presenting with similar symptoms. (5) In providing a medical screening examination, Penn Highlands Clearfield does not discriminate against any individual because of diagnosis ... (6) The purpose of the MSE is to determine if an individual is experiencing an emergency medical condition a) An "emergency medical condition" is a condition manifesting symptoms (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) which, in the absence of immediate medical attention, is likely to cause serious dysfunction or impairment to a bodily organ or function or serious jeopardy to the health of the individual or unborn child. ... B. NO DELAY IN SCREENING OR EXAMINATION (1) There will be no delay in providing a medical screening examination or follow-up treatment for an emergency medical condition in order to inquire about the patient's method of payment or insurance status ... ."

Review of Penn Highlands Clearfield Medical Screening Examination policy and procedure dated June 2014, revealed, "Procedure: A. Purpose and Extent. The purpose of the Medical Screening Examination is to determine whether or not the patient has a medical emergency ... The extent of the Medical Screening Examination will be detailed enough to allow a determination of whether the patient has an emergency medical condition ... A medical screening examination in the Emergency Department may be performed by an Emergency Department physician, another physician, or a non-physician practitioner, including certified physician assistants and certified registered nurse practitioners who are qualified to conduct such examination ("qualified medical personnel"). B. Required Documentation elements of the Medical Screening Examination. Documentation requirements include, at a minimum, an appropriate history and physical examination, mental status evaluations if indicated, impression and diagnoses. ... D. Patients Presenting by Ambulance. All such individuals will be transferred directly to a treatment room in the Emergency Services Area ... ."

Review of the Emergency Department policy and procedure dated November 2014, revealed, "... V. Hours of Operation ... B. Physician Coverage Penn Highlands Clearfield Emergency Department is staffed by an experienced Emergency Department Physician on a twenty-four hour, seven days a week basis. Consultations are available within approximately thirty minutes by members of the Medical and Surgical Staff of Penn Highlands Clearfield ... VI. Utilization of the Emergency Department ... A. Admission to the Emergency Department 1. Types and Methods of Admissions/Walk ups A customer who presents to the Emergency Department with a health concern undergoes an initial assessment by a Registered Nurse. A determination is made at that time as to whether the patient's condition is stable or unstable. If it is determined that the customer's condition is stable, they are triaged and escorted to the appropriate treatment area of the Emergency Department ... II. Obstetric Patients Pregnant females that present to the Registration area and are having pregnancy related complications but are NOT in labor will be seen by the Emergency Department Physician and consult made to OB/GYN by the Emergency Department Physician after exam. Pregnant females who are unsure if they are in labor will be seen by the Emergency Department physician for a medical screening exam. After the MSE, the physician will make the determination if the patient is to remain in the Emergency Department under his care for emergent treatment, stabilization and/or delivery or the need for transfer to an appropriate acute care facility with Obstetrical and/or NICU services ... K. Documentation Penn Highlands Clearfield Emergency Department uses the Healthmatic Electronic Documentation System. All patients who are examined and treated in the Emergency Department are entered into the system and their visit documented electronically ... 5. Evaluation Phase ... B. Physician Responsibilities ... 3. Decision making mechanisms in determining the appropriate disposition of the patient based on the Evaluation Phase ... D. Evaluatory Disposition ... 1. Discharge to Home Customers may be discharged to home with a referral for follow-up care such as seeing their primary care physician, a specialist, Home Health, Case management, social services, recheck in the emergency department, or an outside agency referral. 2. Transfer to another Facility Customers may be transferred to another facility for further medical care that is beyond the scope of practice or services rendered at Clearfield Hospital ... ."
Review of Management of the Obstetrical Patient Presenting to the Emergency Department policy and procedure dated March 2014, revealed, "Purpose: To rapidly evaluate the Obstetrical Patient presenting to the Emergency Department to determine stability and/or imminence of birth prior to transport to an acute care facility with Obstetrical services. Policy: It is the policy of Penn Highlands Clearfield to facilitate transfer of all stable Obstetrical patients presenting with labor to an appropriate care facility with Obstetrical services. Procedure: 1. Patients presenting to Registration with greater than 22 weeks gestation pregnancy related complaints to include, but not limited to, contractions, rupture of membranes, back pain, vaginal bleeding, to include but not limited to postpartum hemorrhage and abdominal trauma, will be taken directly to an E.D. bed and categorized as ESI level 2 to facilitate transfer to appropriate acute care facility. Triage of patient will be completed in the room followed by medical screening and evaluation by the physician ... ."
1) An interview was conducted with EMP4 on February 23, 2015, at 2:25 PM. "I came in at the tail end. The Physician just came in from the ambulance doors. [The physician] told the ambulance crew to go to Dubois. When [the physician] came in, I was at the desk, and the Physician made the statement that this was just a Band-Aid station with a defibrillator. I could not tell if [the physician] saw the patient in the ambulance (PT1) ... ."

2) An interview was conducted with EMP3 on February 23, 2015, at 2:10 PM. "The ambulance called in. They had a pregnant [patient] (PT1) with syncope. The doctor said, 'why didn't you tell me.' When the ambulance pulled in, [the physician] went outside and said the patient should go to DuBois. I went to the Charge Nurse and said this was a questionable EMTALA violation because they pulled up under the canopy. They were on our property."

3) A telephone interview was conducted with EMP1, on February 24, 2015, at 10:45 AM. "The patient (PT1) was 27 weeks pregnant, vomiting and weak. I went out to talk to ambulance crew and advised the patient that we don't have Obstetric care at this facility. I recommended that [they] get [the patient] to a facility as soon as possible for Obstetrical care, specifically fetal monitoring. I spoke to the medics and checked on the patient's vital signs."

4) Documentation provided to surveyors confirmed that a documented medical screening examination was not completed relative to PT1.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on a review of facility documents, closed medical records (MR), and staff interviews (EMP), it was determined that Penn Highlands Clearfield failed to follow their adopted policies related to transfer of patients to another medical facility, for one of one patients (PT1), and for an additional eight patients in eight of eight medical records reviewed (MR26, MR27, MR28, MR29, MR30, MR31, MR32 and MR33).

Findings include:

Review of facility policy Emergency Medical Screening, Treatment, and Transfer Policy, dated December 8, 2014, "... Policy: The Penn Highlands Clearfield ED Physicians are responsible to provide a Medical Screening Exam (MSE) and appropriate treatment to patients coming to the Penn Highlands Clearfield ED for emergency care. If the patient requires services or a level of care not provided within the facility, the ED Physician shall provide direction to transfer the patient to an appropriate facility to receive further care if needed ... E. Patient Transfers To A Medical Facility... b) Based on the information available at the time of transfer, the physician determines that the medical benefits to be received at another medical facility outweigh the risk to the patient of being transferred (including, in the case of a woman in labor, the risks to the unborn child) and a certification to this effect is signed by the physician ("physician-initiated transfer') ... (4) When a physician imitates the transfer, the Emergency Department physician completes the Penn Highlands Clearfield Emergency Department Transfer form, which must include a summary of the risks and benefits of transfer. The Emergency Department Transfer Form is completed by the transferring physician. Reasonable steps are also taken to secure the written consent of the patient to the transfer ... (5) In all cases of patient transfer, consent of the receiving hospital must be obtained and documented in the patient's medical record before transfer. This consent is to include that the receiving hospital has available and qualified personnel to provide treatment to the patient. The patient's condition must also be documented in the medical record prior to the transfer. (6) Copies of the patient's medical record, including, but not limited to, symptoms, preliminary diagnosis, treatment provided, test results, and informed written consent or transfer certification, is sent with the patient to he receiving hospital ... (7) The transfer of a patient is carried out by qualified personnel using transportation equipment appropriate for the patient's medical condition ... ."

Review of Penn Highlands Clearfield policy entitled Transfer Process Policy: "It is the policy of Penn Highlands Clearfield (PHC) to refer patients to other facilities for care when the hospital is unable to provide the services required for patient care. Referrals for alternative care can be made for, but not limited to, the following ... 5. Mental Health referrals A. Psychiatric treatment ... Procedure: 2. Other transfers: a. The physician will evaluate the patient to determine need/stability for transfer to another facility. B. The physician will arrange for a receiving facility, a receiving physician, and determine the personnel required for transfer. The physician will complete the certification for transfer once the above have been determined. The physician will also write transfer orders for patients leaving via ambulance. The physician will request that copies of medical records be sent ... ."

Review of Emergency Department policy and procedure dated November 2014, revealed, "... V. Hours of Operation ... B. Physician Coverage Penn Highlands Clearfield Emergency Department is staffed by an experienced Emergency Department Physician on a twenty-four hour, seven days a week basis. Consultations are available within approximately thirty minutes by members of the Medical and Surgical Staff of Penn Highlands Clearfield ... VI. Utilization of the Emergency Department ... A. Admission to the Emergency Department 1. Types and Methods of Admissions/Walk ups A customer who presents to the Emergency Department with a health concern undergoes an initial assessment by a Registered Nurse. A determination is made at that time as to whether the patient's condition is stable or unstable. If it is determined that the customer's condition is stable, they are triaged and escorted to the appropriate treatment area of the Emergency Department ... II. Obstetric Patients Pregnant females that present to the Registration area and are having pregnancy related complications but are NOT in labor will be seen by the Emergency Department Physician and consult made to OB/GYN by the Emergency Department Physician after exam. Pregnant females who are unsure if they are in labor will be seen by the Emergency Department physician for a medical screening exam. After the MSE, the physician will make the determination if the patient is to remain in the Emergency Department under his care for emergent treatment, stabilization and/or delivery or the need for transfer to an appropriate acute care facility with Obstetrical and/or NICU services ... K. Documentation Penn Highlands Clearfield Emergency Department uses the Healthmatic Electronic Documentation System. All patients who are examined and treated in the Emergency Department are entered into the system and their visit documented electronically ... 5. Evaluation Phase ... B. Physician Responsibilities ... 3. Decision making mechanisms in determining the appropriate disposition of the patient based on the Evaluation Phase ... D. Evaluatory Disposition ... 1. Discharge to Home Customers may be discharged to home with a referral for follow-up care such as seeing their primary care physician, a specialist, Home Health, Case management, social services, recheck in the emergency department, or an outside agency referral. 2. Transfer to another Facility Customers may be transferred to another facility for further medical care that is beyond the scope of practice or services rendered at Clearfield Hospital ... ."
Review of Management of the Obstetrical Patient Presenting to the Emergency Department policy and procedure dated March 2014, revealed, "Purpose: To rapidly evaluate the Obstetrical Patient presenting to the Emergency Department to determine stability and/or imminence of birth prior to transport to an acute care facility with Obstetrical services. Policy: It is the policy of Penn Highlands Clearfield to facilitate transfer of all stable Obstetrical patients presenting with labor to an appropriate care facility with Obstetrical services. Procedure: 1. Patients presenting to Registration with greater than 22 weeks gestation pregnancy related complaints to include, but not limited to, contractions, rupture of membranes, back pain, vaginal bleeding, to include but not limited to postpartum hemorrhage and abdominal trauma, will be taken directly to an E.D. bed and categorized as ESI level 2 to facilitate transfer to appropriate acute care facility. Triage of patient will be completed in the room followed by medical screening and evaluation by the physician ... ."
1) Review of the Ambulance Trip Sheet (OTH1) for PT1 revealed, "... Patient was taken to Penn Highlands Clearfield ER ... It was agreed by all parties that patient would be better off being evaluated at Dubois facility. At this point transport was continued to Penn Highlands Dubois ... ."

Interview with EMP5 on February 23, 2015, at 11:05 AM, related to PT1, revealed that Triage cannot be completed in the back of an ambulance and that Transfer Certification needs to be completed.

2) During a review of Clearfield Hospital Transfer Form Physician Certification And Authorization, it was noted to include the option for the mode of transportation, the accepting hospital, accepting physician, benefit of transfer, risk of transfer, physician certification and the informed consent. It was also noted that the form contained a place for the physician signature and the patient signature.

A focused review of eight Emergency Department medical records for behavioral health patients seeking evaluation at Penn Highlands Clearfield Emergency Department, revealed that eight of eight medical records (MR26, MR27, MR28, MR29, MR30, MR31, MR32 and MR33) had documentation in the Physician's Disposition indicating that the patients were discharged directly to a psychiatric facility. The medical records contained no documented evidence that the Transfer Form Physician Certification And Authorization was completed by the Emergency Department physicians.

A review of discharge or transfers data with Chief Complaint: Mental Health Evaluation; Suicidal Thoughts, Emergency Department Patients with Disposition of Discharge or Transfer Date of Service: January 1, 2015 through February 23, 2015, revealed that 18 of the 30 patients were discharged directly to another health care facility.

During an interview with EMP6, on February 24, 2015, at approximately 11:00 AM, EMP6 confirmed that the transfer forms were not completed for 18 of 30 medical records. EMP6 continued by stating that no transfer arrangements are made by the facility because the Crisis Intervention Staff locate an accepting facility. EMP6 also stated that the patients are discharged directly to a psychiatric facility.