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.

UPMC ST MARGARET 815 FREEPORT ROAD PITTSBURGH, PA 15215 July 13, 2012
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
Based on review of facility policy and other documents, and staff interview (EMP), it was determined the facility failed to maintain a list of individual physicians who are on call as required and failed to develop policies and procedures to ensure emergency services are available to meet the needs of patients if the facility elects to permit on call physicians to have simultaneous on-call duties.

Findings include:

Review of UPMC Policy and Procedure "Emergency Medical Treatment and Active Labor Act (EMTALA)" reviewed December 30, 2011, revealed, "...V. Procedure...11. Each UPMC hospital's Emergency Department shall maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an Emergency medical Condition."

Review of UPMC St. Margaret Emergency Department "EMTALA/COBRA Policy & Procedure" reviewed July 2011 revealed, "...UPMC St. Margaret EMTALA Guidelines...UPMC St. Margaret's emergency department will provide an on-call physician specialty list which includes all specialties privileged at this hospital. The on-call list will be posted in the emergency department and a record of all on-call lists shall be maintained for 5 years."

Review of UPMC St. Margaret Emergency Department "Physician Rotation and Referral Coverage" policy reviewed September 2010 revealed, "...3. ...d) The list of physician rotations is approved by each Chief of Service yearly. An alternative physician shall be designated by the physician on rotation when necessary and this alternate is to be called in the absence of the physician on rotation. e) Listings are maintained by and posted in the Emergency Department: Medical - Medical Officer of the day; Family Health Center - Medical officer of the day; Surgical; Orthopedic; Ear, Nose and Throat; Urology; Plastic Surg.; Ophthalmology; Obstetrics/Gynecology; Cardiovascular Surgery; Neuro Surgery."

1. On July 11, 2012, at approximately 9:15 AM review of facility "On-Call Schedules" for the months of January - June 2012 revealed on 88 of 182 days a group service was identified for neurology on-call services; on 182 of 182 days a group service was identified for orthopedic on-call services; and on 31 of 182 days a group service was identified for ophthalmology on-call services rather than an individual physician.

2. During an interview at 9:40 AM on July 11, 2012, EMP18 confirmed the above findings and stated, "This call schedule is a compilation of lists provided by each physician or physician group. The HUC (Health Unit Coordinator) puts this together in the ED. We don't have any more specific information for these specialties [neurology, orthopedics and ophthalmology]. If we needed to consult a doctor from those specialties we would just call the answering service and they would let us know who is on that day."
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Review of UPMC Policy and Procedure "Emergency Medical Treatment and Active Labor Act (EMTALA) reviewed December 30, 2011, revealed, "...V. Procedure...13. Each UPMC Hospital shall maintain policies and procedures to (a) respond to situations in which a particular specialty physician is not available or if the on-call physician is not able to respond due to circumstances beyond his or her control; and (b) provide that emergency services are available if the hospital elects to permit its on-call physicians to schedule elective surgery during the time that they are on call or permit physicians to participate in simultaneous on-call service."

1. On July 11, 2012, at approximately 10:55 AM a request was made of EMP2 to provide a facility specific written policy and/or procedure that addresses the information in the above identified UPMC policy.

2. At 2:30 PM on July 11, 2012, EMP1 stated, "We don't have any policies that address this [information in above UPMC policy regarding on-call physicians having simultaneous obligations]."
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on review of facility policy and other documents, and staff interview (EMP), it was determined the facility failed to maintain a complete log of all persons presenting to the facility seeking emergency treatment.

Findings include:

Review of the UPMC policy "Emergency Medical Treatment and Active Labor Act (EMTALA)" reviewed December 30, 2011, revealed, "V. Procedure...12. Each hospital facility shall maintain a central log in the Emergency Department identifying each individual that seeks emergency medical treatment at that facility, and indicate whether they refused treatment, or whether they were transferred, admitted , or discharged . These logs shall be retained for three (3) years."

Review of the UPMC St. Margaret Emergency Department "EMTALA/COBRA Policy & Procedure" reviewed July 2011 revealed, "...EMTALA Definitions...2. Central Log is a log that the hospital maintains of all individuals who come to its emergency department seeking assistance and the disposition of all such individuals. The purpose of the central log is to track the care provided to each individual presenting to the hospital for an emergency medical condition."

1. On July 10, 2012, at approximately 12:00 PM, review of an ambulance report dated June 27, 2012, revealed, "03:56 After arrival at the SMMH ER, ER staff and PD [police department] informed pt's mother and [EMS crew] that, due to assailant arriving at the ER first, pt had to be transported elsewhere for his own safety and that of the ER staff."

2. On July 10, 2012, at approximately 2:00 PM, review of the facility ED log from June 26 - 28, 2012, revealed no documented evidence that the above identified patient was listed on the ED log.

3. The above findings were confirmed by EMP1 at the time of the observation.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on review of facility policy and other documents, and staff interview (EMP), it was determined the facility failed to ensure that all patients presenting to the Emergency Department (ED/ER) for emergency services receive a medical screening examination (MSE) within the capabilities of the department; and the facility failed to define within their bylaws or rules and regulations which individuals are determined qualified to perform the MSE.

Findings include:

Review of the UPMC policy "Emergency Medical Treatment and Active Labor Act (EMTALA)" reviewed December 30, 2011, revealed, "...V. Procedure 1. If an individual seeking emergency medical care comes to the hospital's Dedicated Emergency Department, physicians or other Qualified Medical Person (QMP) shall offer a Medical Screening Exam to such person."

Review of the UPMC St. Margaret Emergency Department "EMTALA/COBRA Policy & Procedure" reviewed July 2011 revealed, "...UPMC St. Margaret EMTALA Guidelines: All patients presenting to UPMC St. Margaret's Emergency Department for non-scheduled visit and seeking care must be accepted and evaluated regardless of the patient's ability to pay. All patients shall receive a medical screening examination that includes providing all necessary testing and on-call services within the capacity of the hospital to assure medical stability."

1. On July 10, 2012, at approximately 12:00 PM a review of an ambulance record dated June 27, 2012, revealed, "...03:56 After arrival at the SMMH ER, ER staff and PD [police department] informed pt's mother and [EMS crew] that, due to assailant arriving at the ER first, pt had to be transported elsewhere for his own safety and that of the ER staff. Pt's mother angrily agreed to transport to [second receiving hospital]. 04:07 On arrival at [second receiving hospital ED], report was given and care was transferred to the ER staff, without incident..."

2. On July 10, 2012, at 1:15 PM during an interview OTH1 confirmed the above findings and stated that the identified patient was not examined by any staff from St. Margaret ED between the time the ambulance arrived at that facility and the time it left to transport the patient to the second receiving hospital.
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Review of the UPMC policy "Emergency Medical treatment and Active Labor Act (EMTALA) reviewed December 30, 2011, revealed, "...IV. Definitions...5. Qualified Medical Person ("QMP") is defined as a licensed physician or other appropriately qualified individual as determined by each hospital in their respective by-laws or rules and regulations."

Review of the St. Margaret Bylaws of the Medical Staff revised September 20, 2011, and the Medical Staff Rules and Regulations revised May 24, 2011, revealed no documentation identifying which credentialed staff are qualified to perform a MSE.

1. On July 11, 2012, at approximately 2:30 PM EMP1 confirmed that the Medical Staff Bylaws and Rules and Regulations do not identify specifically who is qualified and/or meets the requirements of ?482.55 of this chapter concerning emergency services personnel and direction.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure all elements of the physician certification were documented in the medical record prior to transfer for four of eight patients transferred from the facility Emergency Department (MR41, MR42, MR43 and MR44).

Findings include:

Review of the UPMC policy "Emergency Medical Treatment and Active Labor Act (EMTALA) reviewed December 30, 2011, revealed, "...V. Procedure...Following the Medical Screening Exam, a patient may be transferred if requested by the patient or their representative, after being notified of the risks and benefits of the transfer. If the hospital determines that it does not have appropriate medical and/or staffing resources to properly stabilize the patient, transfer to an appropriate facility may be made if a physician certifies in writing that the medical benefits of the transfer are expected to outweigh the risks of transfer; or if a QMP [Qualified Medical Person] certifies in writing that the benefits of transfer are expected to outweigh the risks of transfer, and such certification is co-signed by a physician. When a patient is transferred the consent of the receiving hospital to accept the transfer must first be obtained and documented in the medical record. In the case of transfer from a UPMC facility, the UPMC facility shall send to the receiving facility, copies of all pertinent medical records available at the time of transfer, and affect the transfer through qualified personnel and transportation equipment."

Review of the UPMC "Transfer Form" revised June 2010 revealed the form contains different sections requiring completion prior to transfer of a patient to another facility. Items for completion include whether an Emergency Medical Condition (EMC) was identified and if the patient was stable or not; the reason for transfer; risk and benefit for transfer; mode of transportation and care required during transport; identity of receiving facility accepting person; signature of transferring physician; accompanying documentation and a section for patient signature of consent to transfer.

1. On July 11, 2012, at approximately 1:00 PM, review of the Transfer Form for MR41 did not document the emergency medical condition that was identified, whether the patient was stable at the time of transfer, did not include the risks and benefits of transfer to another facility, the mode of transport and services required during transport and did not indicate whether the medical record was available to the receiving facility. Additionally, there was no written documentation of patient consent to transfer.

2. On July 11, 2012, at approximately 1:15 PM, review of MR42 revealed Transfer Form did not contain a signature of the patient or responsible person, indicating consent to transfer to another facility.

3. On July 11, 2012, at approximately 1:30 PM, review of MR43 revealed the Transfer Form did not document the emergency medical condition that the patient required treatment for and whether MR43 was stable at the time of transfer. Continued review of the Transfer Form revealed there was no documentation of the risks and benefits of transfer, the mode of transport and required treatment during transport and whether documentation was available to the receiving site.

4. On July 11, 2012, at approximately 1:45 PM, review of MR44 revealed the Transfer Form did not contain documentation of the patient's emergency medical condition and did not indicate whether the patient was stable for transfer. The form also did not contain information related to the risks and benefits of transfer, the mode of transfer and medical treatment required during transfer; whether the medical record was available to the receiving hospital and consent to transfer by the patient or the responsible person was not documented.

5. The above information was confirmed by EMP3 at the time of each review.

6. On July 13, 2012, at 10:55 AM EMP2 and EMP7 confirmed the facility had no other policy addressing the physician certification for transfer.