HospitalInspections.org

Based on interviews of facility staff, ER physicians, review of the ER Patient Log and review of Medical Staff Bylaws, Rules and Regulations, Hospital A failed to provide a Medical Screening Examination (MSE) for two (2) of twenty-three (23) patients in the sample, [Patient Identifier (PI) #1] and PI #2.

1.) PI #1 presented to this facility's ER for evaluation and treatment of chest wall pain on 08-04-10. On this day there was not a scheduled ER physician working in Hospital A's ER (the schedulted ER physician refused to work until he was paid by the Owner/Administrator of Hospital A related to nonpayment of past days worked in the ER). Hospital A's Owner/Administrator instructed (via e-mail) the hospital's physicians on staff that if one of their (physicians on staff) patients presented in the ER, they, as the primary care physician (PCP) would have to come to the ER to conduct the MSE and treatment of said patient, and, if the patient did not have a PCP then the On Call Physician (for admissions of unattached patients) would have to come to the ER to conduct the MSE and treatment of said patient. PI #1's PCP, EI #2, was notified of PI #1's presentation to Hospital A's ER. EI #2 refused to come to the ER to conduct PI #1's MSE and treatment. PI #1 was offered to have the local ambulance service called for transporting to Hospital B's ER which PI #1 refused. PI #1 did not receive a MSE at Hospital A prior to leaving this facility (Hospital A).

2.) Review of the ER Patient Log for the date 08-04-11 revealed that PI #2, presented to Hospital A's ER at 4:58 AM when the ER was closed (related to ER physician refusing to work until paid by the Owner/Administrator of Hospital A due to to nonpayment of past days worked in the ER)... PI #2 presented with the chief complaint of nausea, vomiting, anc chest pain. Although the ER was "CLOSED" and without an ER physician, two Registered Nurses remained in the ER around the clock to triage and assist patients with transportation (calling 911/ambulance service) to (Hospital B). PI #2 was transported to Hospital B by ambulance for an appropriate MSE and treatment.

Hospital A failed to provide an appropriate MSE for two patients, PI #1 and PI #2, who presented to Hospital A's ER for evaluation and treatment of a possible medical emergency. Hospital A's failure to provide a MSE for PI #1 and PI #2 was directly related to Hospital A not ensuring adequate ER physician staffing was present on a 24 hour basis for the ER.

The findings include:

1. The following information was reported by the facility to the Alabama Department of Public Health on 8-04-11 that Hospital A's ER was closed as of 17:30 on 08-03-11 by the ER physician (EI #1) due to non-payment (by the Administrator/Owner of Hospital A). Also reported was that PI #1 presented to Hospital A's ER (which was open for business without a scheduled ER physician working) and did not receive a MSE.

"On 08-4-11, (PI #1) presented to the ER at (Hospital A) with complaints of chest pain and discomfort. The Triage Nurse contacted the patient's PCP (EI #2) with the patient's presenting complaints and requested the doctor come to the ER to assess the patient (PI #1). (EI #2) reportedly refused to come to the ER and directed the Triage Nurse to send the patient (PI #1) to (Hospital B). The patient (PI #1) left the ER without having a MSE and reportedly refused the Triage Nurse's offer to call an ambulance for transport."

Review of the ER Patient Log for the date 08-04-11 revealed that another patient, PI #2, presented to Hospital A's ER at 4:58 AM when the ER was closed (related to ER physician refusing to work until paid by the Owner/Administrator of Hospital A due to to nonpayment of past days worked in the ER)... PI #2 presented with the chief complaint of nausea, vomiting, anc chest pain. Although the ER was "CLOSED" and without an ER physician, two Registered Nurses remained in the ER around the clock to triage and assist patients with transportation (calling 911/ambulance service) to (Hospital B). PI #2 was transported to Hospital B by ambulance for a MSE and treatment.

2. MEDICAL STAFF BYLAWS, RULES & REGULATIONS

The Medical Staff Bylaws, Rules and Regulations (revised April 2004) was reviewed during the survey (08-08-11 through 08-10-11). The following was noted under "Emergency Cases."

2. Patients seen in the Emergency Room who do not have an attending physician will be referred to a Medical Staff member for continuing treatment of care.

3. The Chief of Staff/designee shall provide for the availability of a Medical Staff physician for emergency care in the event that the attending physician or alternate is not available or if the patient presented to the Emergency Room does not have an attending physician.

5. Each patient presented tot he Emergency Room will be assessed within thirty (30) minutes of arrival and appropriate medical care initiated as required.

6. The Medical Staff shall adopt a method of providing medical coverage int eh Emergency Room. Such plan shall include a method of ensuring necessary and adequate availability of physician specialists through an Emergency Room Call Roster. The Emergency Room Call Roster will consist of the following priorities for call by the Emergency Room physician:
a. Physician on call;
b. Physician on call for the next twwenty-four (24) hours; c. Chief of Staff; and
d. Any member of the medical staff.

7. It is the responsibility of the physician on call to:
a. Ensure the availability to respond in a tmely manner to calls from the Emergency Room physician.
b. Arrange for back-up (substitute) coverage as indicated.

3. INTERVIEWS

*EI #1/ER physician, working in Hospital A's ER on 08-03-11, was interviewed on 08-08-11 at 5:00 PM stating "I am behind from when I'm supposed to have been paid, about $14,200. I got paid for today's shift, a twenty-four shift. That's what we do now, get paid before we start working our shift, otherwise we won't get paid. On 8-3-11, I was scheduled to work a twenty-four shift. I told the Administrator that she would have to wire money into my bank account today (8-3-11) if she wanted me to work the entire twenty-four shift. That day I checked my account several times and there was no deposit. The CNO (EI #3), was e-mailing and calling the Administrator about this because (Owner/Administrator) was not present in the hospital.. The CNO (EI #3) told me that she informed (Owner/Administrator) that if I didn't get the money wired to my account by 5:00 PM (8-3-11) that I would leave and close the ER for the remainder of my shift. The CNO (EI #3) said that (Owner/Administrator) said that she had wired the money to my account that afternoon but I never got it. The CNO (EI #3) did tell (Owner/Administrator) that I had not received the wire deposit... Before closing the ER I spoke with the Chief of Staff and consulted with him about what I should do and he agreed with me... There were to be no patients in the ER or coming through the door (at 5:00 PM on 08-03-11). Everyone (all physicians on staff, ambulance services, police department, etc.) had to be notified. I spoke with all the primary physicians on staff that the ER would be closed after 5:00 PM except for Dr. (name left out). I left him (Dr.) a message about the ER closing. I told them (CNO and other nurses) to post signs on the doors that the ER was closed temporarily..."

*EI #3 (CNO) was interviewed on 8-9-11 at 10:45 AM stating "I wasn't here that Thursday and Friday (8-4-11 and 8-5-11) (was scheduled off with vacation days). I don't know what (Owner/Administrator) did about not having an EE physician for the evening/night of 080-3-11 and day of 08-04-11. On 08-03-11 (EI #1/ER physician) said that if he didn't get paid by wire transfer (into his bank account) or a cashier check (on the afternoon of 08-03-11) that he was leaving at 5 PM (on 8-3-11). (EI #1/ER physician) scheduled to work the ER on 08-03-11 from 7 AM to 08-04-11 7 AM. At 4:15 PM we (EI #1/ER physician and myself) got (Owner/Administrator) on the phone. She (Owner/Administrator) said she had wired the money to (EI #1/ER physician's) bank account. I said '(Owner/Administrator) (EI #1/ER physician) just checked his bank account before we called you and it's (money) not there' meaning that she didn't wire the money. I called the Chief of Staff to inform him of the situation which (EI #1/ER physician) had already done. I called our other ER service (provides ER physicians) that we use for coverage. (ER service / ER physicians) said that unless they get paid something like $16,000 they would not send anyone (ER physician). I sent (Owner/Administrator) an e-mail that we did not have an ER physician for 08-03-11 after 5 PM and would have to close the ER. I left a message with the Director of Medicare Other Unit, Division Health Care Facilities, Bureau of Health Provider Standards, Alabama Department Public Health (ADPH), phone number on 08-03-11 at 4:45 PM to let the STATE know that we did not have an ER physician ant the ER would be closed..."

"We posted a sign on the front entrance of the hospital, the ER entrance and the door of the ER Department after (EI #1/ER physician) left the ER. We also put a sign on the sign by the road that's lit up that says we have an ER. We were told by CMS that this had to be done the last time it (no physicians for the ED) happened (June 2011)."

NOTICE!!

THE EMERGENCY ROOM
OF (HOSPITAL B)
IS TEMPORARILY

CLOSED!!

PLEASE SEEK MEDICAL CARE AT
THE NEXT CLOSEST MEDICAL
FACILITY UNTIL FURTHER NOTICE.

"We notified EMA (Emergency Management Agency) who notified the three dispatch centers, all ambulance companies, (name of city) Police Department, major industry plants, (name of city) Nursing Home, and (technology laboratory) that our ER was closed temporarily. I tried to notify the radio station to make a public announcement but all I got was the answering machine. (Hospital B) is 30 miles south of us..."

"I e-mailed (Owner/Administrator) that I had called (Director of Medicare/Other and that she (Owner/Administrator) needed to call (Director of Medicare/other) first thing Thursday morning (08-04-11). (EI #4/ER Manager) was working the ER that day (08-03-11 and 08-04-11) but is not responsible for staffing the ER physicians. (Owner/Administrator) is responsible for scheduling the ER physicians. (Different ER physician) was scheduled to work the ER Thursday (08-04-11) (24 hours) and Friday (08-05-11) (24 hours) but he said that he wasn't going to work until he got paid (EI #1/ER physician)... I sent an e-mail to (Owner/Administrator)... about having to close the ER because we didn't have a physician and to call the STATE to make sure this message had been received and who else we needed to call."

"The ER was never unattended by nursing. Two nurses were present to bring the patient into the ER, assess, stabilize and call 911 and make arrangement for the patient to go to another ED. I wasn't here that Thursday and Friday so I don't know what Anne Thompson decided to do about ER physician coverage. I don't know how it was communicated to all the physicians that if a patient of theirs came to the ER that they had to come to the ER to see that patient. (EI #2/physician on staff) was on call last week (08-001-11 through 08-07-11) for unattached patient admits. That's not the same as covering the ER if the ER physician doesn't show up or not come in. Since 08-04-11 all active staff physicians except for two, changed from active staff to courtesy staff (are not obligated to take call)."

"Over the last six months, actually longer than that, (Owner/Administrator) is the only one who controls the money. She (Owner/Administrator) has to approve, release of cash/money before we can place an order for supplies. We make her (Owner/Administrator) very aware of supplies, drugs, anything we need. (Owner/Administrator) is usually not here. We communicate mainly by e-mail and by phone... Our physicians on staff say they will no longer admit here (Hospital A) because of supply issues and lack of nursing staff since Surgery and Med Surg Departments have been closed (08-05-11)."

*EI #4/ER Nurse Manager was interviewed on 08-09-11 at 9:30 AM stating "The patient, (PI #1) came to the ER on 08-04-11 saying that (EI #2/ physician on staff) sent her to the ER. The patient had complaints of chest pain but was in no distress. I called (EI #2/physician on staff) secretary (office) who said that the patient (PI #1) was told to go to the ER to be evaluated and treated. (EI #2/physician on staff) said 'I told her (PI #1) to go to (Hospital B's) ER not (Hospital A's) ER. She (PI #1) had an appointment yesterday (08-03-11) and did not keep her appointment and I'm not coming to the ER to examine and treat her (PI #1)). She (PI #1) can go to (Hospital B). (EI #2/physician on staff) said that this patient didn't keep her appointment and hasn't kept other appointments, was non complainant... (EI #2/physician on staff) stated 'I'm not coming to the ER to see her (PI #1) when she (PI #1) could have stayed at the office and be seen.' The patient (PI #1) said she had chest pain that started one week ago, that she had lifted her child and this was causing her (chest) pain. This patient did not appear to be in distress and I did triage her. [Note that when at (Hospital B) the patient no longer experienced pain/discomfort and said that she (PI #1) was sore from exercising...] I told the patient (PI #1) that I would call an ambulance to take her to (Hospital B). The patient (PI #1) said she had her children and she would just drive to (Hospital B). We do not have a full time ER doctor today (08-04-11) and (EI #2/physician on staff) was not able to come to the ER to see her (PI #1) and that (EI #2/physician on staff) had told her (PI #1) to go to (Hospital B's) ER. The patient (PI #1) said that if she had realized that she would have driven there (Hospital B) first."

"I called the (Owner/Administrator) and told her what happened. She (Owner/Administrator) said that she called (EI #2/physician on staff) and that (EI #2/physician) wasn't happy because (Owner/Administrator) informed her (EI #2/physician) about the protocol for full time physicians seeing their own patients in the ER. (Medical Director/Chief of Staff, Orthopedic Surgeon) said that he was made aware of this by e-mail that morning (08-04-11) from (Owner/Administrator), that the physicians were seeing their own patient's in the ER and that for patient's that didn't have a PCP, that the physician on call for unattached patient admissions would see these patients which would be (EI #2/physician on staff). All the full time physicians' rotate taking unattached patients if they (patient) come to the ER and need to be admitted."

"We didn't have an ER physician starting after 5 PM on 08-03-11, morning and early afternoon of 08-04-11 until (a different physician on staff) came and worked the ER (came and ripped the signs off the doors). We kept our staff (nursing) in the ER even though we didn't have a ER physician. We did what was in our scope of practice (for the patients presenting to the ER) and call an ambulance..."

*EI #2/physician on staff (PI #1's primary care physician) was interviewed on 08-08-11 at 3:20 PM stating "I was contacted that morning (8-04-11) by (Owner/Administrator) that I was on call for the ER (08-04-11) because there was no ER physician for the ER. I told (Owner/Administrator) that morning that I couldn't work the ER, that I would have an office full of patients and I could not be in both places at once... My office is miles down the road. To come and see a patient in the ER coming from my office, screen and treat the ER patient then go back to my office would delay me seeing patients, having patients upset with me... I was on call last week (08-01-11 through 08-07-11) for unattached patients who needed to be admitted to the hospital. The Medical Staff Bylaws, Rules and Regulations say that in the ER we are to be as back up for the ER physician, not replace the ER physician. ER physicians (EI #1/ER physician and other ER physician) were not getting paid which is why they (ER physicians) did not work their schedule (days to work in ER, 08-03-11 starting at 5:30 PM, 08-04-11, and 08-05-11) which they told (Owner/Administrator) would happen if she (Owner/administrator) didn't pay them (ER physicians). Now she (Owner/Administrator) pays the ER physicians (EI #1/ER physician and other ER physician) first (before the ER physician starts his shift). There's gaps in the schedule (ER physicians schedule to cover the ER) and nothing is done to get it covered... We, the physicians on staff at (Hospital A), had an emergency meeting. We, (physicians on staff) except for (Chief of Staff and (other physician on staff), decreased our privileges from active staff to courtesy staff. We (physicians on staff) told (Owner/Administrator) that we did not feel that we could admit patients to this hospital related to the way she was managing this hospital... Not being able to keep the ER open because the ER doctors haven't been paid..."

"About this patient (PI #1) of mine that brought herself to the ER here. She (PI #1) had an appointment to see me a couple of days before (08-04-11) and she was a no show. (PI #1) was a walk-in (office) that morning (08-04-11). She was not in any distress. I told her, I directed her to (Hospital B's) ER. I told her (PI #1) not to go to (Hospital A's) ER because I knew that they (Hospital A) didn't have an ER physician. I told (EI #4/ER Manager) (ER at Hospital A) that I saw the patient in my office that morning and directed her to (Hospital B's) ER. (PI #1) is non complainant, won't keep her appointments or follow my recommendations. I did say (to EI #4/ER Manager) that she (PI #1) did not keep her previous appointments with me and that she (PI #1) did not display any acute distress. I did tell (EI #4/ER Manager) that I was not going to come to the ER to see this patient... (see above) and that she should go to (Hospital B's) ER..."



These deficiencies were written as a result of the investigation of Complaint #AL00024855.


Susan A. Reed, RN