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REGIONAL HOSPITAL OF SCRANTON 746 JEFFERSON AVENUE SCRANTON, PA 18501 June 29, 2015
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on review of facility documents, medical records (MR), and staff interview (EMP) it was determined the facility failed to ensure a physician reviewed the evaluation, orders, treatment, and testing by the physician assistant prior to the patient's discharge from the Emergency Department for three of five medical records reviewed (MR1, MR2 and MR3) and failed to ensure the patient arriving in the Emergency Department via ambulance was triaged on presentation and assigned the appropriate Emergency Severity Index (ESI) acuity level for one of five medical records reviewed (MR1).

Findings include:

1) Review on June 29, 2015 of facility policy "Scope of Practice: Physician Assistants," dated August 25, 2014, revealed "Statement: Physician Assistants are members of the Allied Health Professional care team, qualified by academic and clinical training, who function in an expanded medical support role to the physician in the provision of medical care, and who work under the direction, supervision and responsibility of an approved Physician Assistant Supervisor and/or Substitute Physician Assistant Supervisors as per the written agreement and as registered with the Pennsylvania State Board of Medical Licensure, as well as in accordance with the Medical Staff By-Laws and Credentialing Manual Policies and Procedures of [this area is blank on the facility policy] Physician Assistants exercise judgement within their areas of competence and participate directly in the medical care of patients under the Supervision and/or direction of an approved Primary or Substitute Physician Assistant Supervisor member of the Medical Staff, performing functions to the extent delineated by the Medical Staff. The physician Assistant must be currently licensed and certified by the Pennsylvania State Board of Medical Education and Licensure to practice as a Physician Assistant. PAs' are dependent practitioners who are required to function under the direction of a physician. ... Required Supervision- Inpatient Setting / Outpatient Setting: Inpatient Supervision: all inpatient supervision of a physician assistant shall be under the supervising of the Physician Assistant Supervising Physician. Where multiple physicians simultaneously are involved in any one case, the PA will be supervised and responsible to only one physician (the approved Supervising Physician, and/or Primary PA Supervisor, and/or Substitute PA Supervisor). The appropriate approved physician must review and countersign all the work of the PA within a period of 24 hours. Outpatient Supervision: should be directed in such a way that the Supervising Physician and the PA should discuss the case of a patient and render treatment as soon as possible. This will include clinical impressions, the necessary referral and/or consultations, education of patient and treatment plans. ..."

Review on June 29, 2015, of MR1 revealed the patient arrived in the Emergency Department (ED) via ambulance on March 27, 2015, at 5:30 PM via ambulance. The patient was seen, evaluated, treated and discharged by EMP6, a physician's assistant. The patient was discharged by EMP6 on March 27, 2015, at 9:15 PM. Documentation revealed OTH1, a physician, co-signed the orders written by EMP6 on March 31, 2015. OTH2, a physician, reviewed and co-signed the orders written by EMP6 on April 8, 2015. There was no documentation a physician reviewed the results of the laboratory tests or the CT scan for MR1 prior to the patient's discharge from the ED.

Review on June 29, 2015, of MR2 revealed the patient was admitted to the ED on March 27, 2015, with the complaint of lower back pain. The patient was seen, evaluated, treated, and discharged by EMP6, a physician's assistant. OTH1 reviewed the orders written by EMP6 on March 31, 2015. OTH2 reviewed the orders written by EMP6 on April 8, 2015.

Review on June 29, 2015, of MR3 revealed the patient was admitted to the ED on March 27, 2015, with the complaint of abdominal pain with nausea and vomiting. The patient was seen, evaluated, treated, and discharged by EMP6, a physician's assistant. OTH1 reviewed the orders written by EMP6 on March 31, 2015. OTH2 reviewed and co-signed the orders written by EMP6 on April 8, 2015.

Interview on June 29, 2015, at approximately 11:00 AM with EMP2 confirmed there was no documentation a physician reviewed the laboratory tests, CT scan, and orders written by EMP6 prior MR1's discharge. Further interview with EMP2 confirmed there was no documentation the orders written by EMP6 for MR2 and MR3 were reviewed by the physician prior to the patients discharge from the ED.

Interview on June 29, 2015, at approximately 11:30 AM with EMP5 confirmed EMP6 was not privileged to review medical test results and discharge patients without the confirmation and review by a physician.

2) Review on June 29, 2015 of the facility policy and procedure "Triage Assessment of Patients - Five Tier," last reviewed August 28, 2014, revealed "Purpose: To determine patient acuity To identify severity of illness or injury To assure patients with highest acuity are seen first To determine number of expected resources to reach a disposition decision To determine placement placement in appropriate treatment areas. Policy: Triage will involve a rapid, directed patient assessment which provides an assignment of an acuity level for each patient arriving in the unit. The assessment should include subjective and objective data appropriate to the presenting signs and symptoms to determine acuity level. A Registered Nurse will perform the patient assessment to determine triage acuity. Acuity levels will be based on the Emergency Severity Index (ESI) algorithm found in attachments A and B. See Attached ... B: High risk situation is a patient you would put in your last open bed. Severe pain / distress is determined by clinical observation and/or patient rating of greater than or equal to 7 on 0-10 pain scale. (Note: When patients report a pain rating of 7/10 or greater, the triage nurse may triage the patients as ESI level 2, but is not required to assign a level-2 rating. .."

The attached algorithm documented the following: "requires immediate life-saving intervention? A yes 1 [ESI 1] no high risk situation? or confused / lethargic / disoriented? or severe pain/distress B yes 2 [ESI 2] how many different resources are needed? C none 5 [ESI 5] one 4 [ESI 4] many 3 [ESI 3] ..." Continued review of the algorithm documented a grid of "danger zone vitals? D no 3 [ESI 3] consider 2 [ESI 2].

Review on June 29, 2015, of MR1 revealed the patient arrived in the Emergency Department (ED) on March 27, 2015, at 5:30 PM via ambulance. The chief complaint was abdominal pain. The patient was taken from the ambulance, registered and placed in the waiting area. Triage was completed at 6:16 PM. The patient's pain was 8/10. ESI level III was assigned to the patient.

Interview on June 29, 2015 at approximately 1:00 PM with EMP4 confirmed the complainant was taken from the ambulance, registered and placed in the waiting area. EMP4 confirmed patients brought in by ambulance were to be triaged upon arrival. EMP4 provided no explanation why MR1 was placed in the waiting area on arrival and triaged at 6:16 PM. EMP4 confirmed with a pain level of 8/10 MR1 should have been triaged as ESI level 2.