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Based on a review of Emergency Medical Services Documents, Emergency Department (ED) logs, Medical Records, Bylaws of the Professional Staff, Rules and Regulations Professional Staff, Medical Staff credentialing files and interviews, it was determined the facility failed to:

- maintain a list of physicians on call to provide in accordance with the resources available to the hospital, treatment necessary to stabilize the emergency medical condition of four patients (#8, #9, #12 and #13) of 25 patient charts reviewed. Refer to A-2404 for examples.

- ensure six patients (#4, #5, #21, #22, #24, and #25) of 25 patient ED charts reviewed, received an appropriate medical screening exam (MSE) sufficient to determine whether an emergency medical condition (EMC) existed. Refer to A-2406 for examples.

- ensure four patients (#8, #9, #12, and #13) of 25 patient ED charts reviewed received within the hospital's capabilities, appropriate stabilizing treatment for their emergency medical condition. Refer to A-2407 for examples.







17863

Based on interview, record review and facility memorandum review, the facility failed to maintain a physicians On Call Schedule to meet the needs of patients presenting to the Emergency Department (ED) with an Emergency Medical Condition (EMC) and/or those patients that may require a physician to continue their care by admission to the facility for four patients (#13, #9, #8 and #12) of 25 patients reviewed. The facility also failed to have On-Call Schedule Policies and Procedures in place. These failures increased the risk of harm to all patients who presented to the ED with an EMC. The facility's ED average daily census over the prior six months was 46 and the average monthly census was 1423. The ED census was 11. The facility census was two.

Findings included:

1. Although requested, no on-call list was provided by the facility.

Record review of a facility memorandum dated 06/25/14 showed that the facility did not have any specialist including surgeons on-call for the ED.

2. Record review of facility policies showed no Policy or Procedures for on-call physicians for the ED.

Review of the facility website showed surgeries were performed Monday through Friday with orthopedics (bone), gynecology (female reproductive system), podiatry (feet/ankle), ophthalmic (eye) and urology (urinary tract system and male reproductive system) and general surgery services offered.

During an interview on 11/04/15 at 9:18 AM, Staff G, ED Physician, stated that there was not an on-call roster for ED because they did not admit patients to the facility. Staff G stated that the facility was unable to care for medical or unscheduled surgical patients.

During an interview on 11/05/15 at 10:05 AM, Staff J, ED Nurse Manager, stated that there was no on-call roster because medical and or surgical patients were not admitted to the facility. He stated that only scheduled surgeries were cared for Monday through Friday. Staff J stated that all medical and/or surgical patients that needed continued care were transferred.

During a telephone interview on 11/30/15 at 10:22 AM, Staff V, Chief Executive Officer, stated that about a year a ago he made the decision to not admit patients to the medical floor. He stated that the census was one to two patients a week and it was economically impossible to employ physicians to care for so few patients. The facility performs scheduled surgeries Monday through Friday for Gynecological Podiatric, Ophthalmic, Urological surgeries but no physicians are on call for these services. The Anesthesiologist (physician who administer medication to a patient during surgery) and Certified Registered Nurse Anesthetists (specially trained nurses who administer medication to patient during surgery) are also not on call. Staff V also stated there were six physican members on the medical staff including sugeons with priviledgs for orthopedics, gynecology, podiatry, ophthalmic, urology and general surgery.

3. Record review of Patient #13's ED medical record showed the following:
- The encounter sheet (created and/or updated upon registration with the patient's information) on 10/19/15 at 4:33 PM, documented the patient presented and complained of abdominal pain, bruising and swelling in the abdominal area where earlier that same day she had a non-emergent surgical procedure at Ozarks (Ozarks Community Hospital) on her liver and gallbladder.
- On 10/19/15 at 5:07 PM, Staff BB, ED Registered Nurse (RN), documented an elevated heart rate, elevated respiratory rate and cool pale skin.
- On 10/19/15 at 6:25 PM, Staff W, ED Physician, documented the patient had acute (severe) post-operative bleeding (unexpected bleeding that continued or recurrent bleeding after a surgical procedure), and that the patient had acute anemia (severe low red blood cells) and would be transferred to another facility.
- Staff W discussed the patient's condition with Staff X, Surgeon, who performed the surgical procedure earlier the same day on the patient at Ozarks. Staff W also discussed the patients transfer with Staff DD, ED physician, at the receiving hospital (Facility B).
- On 10/19/15 the Certificate of Transfer signed by Staff W, stated that the diagnosis and reason for transfer was "post-op bleeding" and the benefit for transfer was "care by surgery" and that the patient's condition was stable. It was determined that the patient required post-operative surgical in-patient care. Staff X who performed the surgical procedure at Ozarks was not on call nor were any of the facility surgeons on-call for emergent or non-emergent surgical procedures.

4. Record review of Patient #9's ED medical record showed the following information:
- The patient presented to the ED on 05/02/15 at 4:53 AM and complained of abdominal pain, nausea, vomiting, fever and diarrhea.
- On 05/02/15 from 5:44 AM to 9:16 AM, Staff R, ED Physician, documented assessment findings and a diagnosis of Appendicitis (inflammation of the appendix, a small pouch attached to the colon and often requires a non-emergent common surgery to remove the appendix if it is not abscessed) and that the patient would be transferred to Facility C.
- Staff R contacted Staff Y, Surgeon from Facility C, and discussed the transfer of the patient for a surgical procedure.
- Staff R signed the patient's Certificate of Transfer on 05/02/15 and the patient was transferred by ambulance to Facility C at 9:08 AM for "definitive surgical care".
The patient required in-patient care by a surgeon. The facility did not have physicians on-call and available to admit for in-patient treatment of Patient #9's medical condition.

5. Record review of the medical record of Patient #8 showed she presented to the ED on 06/30/15 with intractable vomiting (repeated vomiting that resists medical treatment) for the past 36 hours. The ED assessment showed she was treated with Zofran for nausea and Dilaudid for pain.

Record review of the Adult Emergency Provider Record dated 06/30/15 at 4:50 AM showed the patient had intractable nausea and vomiting and a possible small bowel obstruction (the intestine is blocked which prevents food, fluid or gas to move through the intestine and causes pain.)

Record review of the Certificate of Transfer dated 06/30/15 showed the patient was sent to another facility for intractable vomiting and small bowel obstruction vs ileus (a blockage of the intestines caused by lack of peristalsis (the pumping action of the intestines that moves food through the digestive system) for treatment with intravenous (IV) fluids and current medical condition. The facility did not have physicians on-call and available to admit for in-patient treatment. The patient was transferred at 11:26 AM.

6. Record review of the medical chart of Patient #12 showed he presented to the ED by ambulance on 10/06/15 at 3:15 PM for complaints of sharp intermittent pain in his abdomen and two episodes of vomiting. The ED assessment showed he was given IV fluids, Zofran for nausea, Toradol, Fentanyl and Dilaudid for pain.

Record review of the Adult Emergency Provider Record dated 10/06/15 at 4:00 PM showed the patient had reported sudden onset (of pain) at about 10:00 AM of all over severe steady abdominal pain with nausea and two episodes of vomiting. Physical examination showed the patient had very mild tenderness with some (abdominal) distension (bloating).

A Computed Tomography (CT), scan (an imaging method that uses x-rays to create pictures of cross sections of the body) showed the patient had Pancreatitis, an inflammation of the Pancreas.

Further documentation showed the patient's care had been transferred to a second provider at 5:30 PM who re-examined the patient and reviewed the CT scan and labs. The provider spoke with the receiving hospital and transferred the patient.

Record review of the Certificate of Transfer dated 10/06/15 showed the facility sent Patient #12 to another facility for Acute Pancreatitis for inpatient treatment not available at this facility. The facility did not have physicians on-call and available for in-patient treatment. The patient was transferred at 9:45 PM.




17863

Based on interview, record review and policy review the facility failed to provide a medical screening examination (MSE) by a qualified medical professional (QMP) for six patients (#4, #5, #21, #22, #24 and #25) of 25 patient charts reviewed. The facility's Emergency Department (ED) average daily census over the prior six months was 46 and the average monthly census was 1423. The facility census was two.

Findings included:

1. Record review of the facility's policy, "Medical Screening Examination", reviewed 06/2015 showed:
-A medical screening examination will be performed on every patient that presents to the Emergency Room to determine if the patient has a emergency medical condition or is in active labor.
-If a medical emergency is present the patient will be taken to a room and the ED provider (physician or nurse practitioner) will be notified immediately.
-This facility provides screening and stabilizing treatment within the scope of its abilities, as needed, to the individuals with emergency conditions who come to the hospital for examination and treatment.
-If the patient is deemed of an urgent or emergent nature during the triage process the patient will be examined by an ED provider.
-When a patient has a triage status of non-urgent and the medical screening examination reveals no emergency the patient may be referred to their primary care provider (PCP) or dentist.

2. During an interview on 11/04/15 at 2:40 PM, Staff B, Chief Experience Officer (CEO) stated that the Rules and Regulations and the Bylaws do not state who is qualified to perform a MSE.

3. During an interview on 11/05/15 at 9:15 AM, Staff S, ED Physician, stated that he knew patients presented to the ED and left without being seen by an ED physician. He stated that it did not make sense to see patients during clinic hours (non-holiday, weekday business hours) when their PCP's were in their offices and could see them. He further stated that the ED nurses sent patients to their PCP's office based on their nursing judgement and that he believed the nurses were capable of making the decisions.

4. Record review of the facility's job description for ED RN's showed no required responsibilities, expectations, qualification by education, training, experience or duties which qualified them as a QMP.

5. Record review of the facility's undated document, "Rules and Regulations Professional Staff", showed no designation of the person(s) qualified to perform a MSE.

6. Record review of the facility's document, "Bylaws of the Professional Staff", dated 10/14/15 showed no designation of the person(s) qualified to perform a MSE.

7. Record review of Patient #4's medical record showed the following:
- The patient arrived to the ED on 10/13/15 at 9:00 AM, complained of hives and was assigned to Staff R, ED Physician;
- Staff T, ED RN, documented in the ED assessment notes, disposition section (final arrangement or transferring of care) "Pt (patient) sent to PCP";
- Staff R, while on duty at the time the patient was admitted to the ED, did not perform a MSE or any type of evaluation of the patient before the patient was sent to a PCP; and
- Discharge instructions dated 10/13/15, instructed the patient to contact the patient's PCP if they had questions after discharge.

8. Record review of Patient #5's medical record for the date of 10/15/15 showed the following:
- The encounter sheet dated 10/15/15 (created and/or updated upon registration with the patient's information) documented the chief complaint as "right leg, left heel pain and back pain" and Staff R, ED Physician was the provider;
- Staff R, while on duty at the time the patient was admitted to the ED, did not perform a MSE or any type of evaluation of the patient before the patient was sent to the PCP; and
- Discharge instructions dated 10/15/15, instructed the patient to contact the patients PCP if they had questions after discharge.

9. Record review of Patient #21"s medical record showed the following:
- On 08/03/15 at 1:05 PM, the patient presented to the ED, and complained of pain throughout her right hip and knee rated at a level 10 (from a pain scale of zero to 10 with 10 as the worse pain experienced by the patient);
- Staff G, ED Physician was the ED provider assigned on the patients visit encounter form;
- On 08/03/15 at 2:05 PM, Staff H, ED RN, documented in the ED assessment disposition section, "Patient sent to PCP office";
- Staff G, while on duty at the time the patient was admitted to the ED, did not perform a MSE or any type of evaluation of the patient before the patient was sent to the PCP; and
- Discharge instructions dated 08/03/15, instructed the patient to contact the PCP if they had any questions after discharge.

10. Record review of Patient #22's medical record showed the following:
- On 08/05/15 at 11:57 AM, the patient presented to the ED, and complained of back pain at a level of seven (on a scale of zero to 10) due to an injury;
- Staff AA, ED Physician was the ED provider on the patient's visit encounter form;
- On 08/05/15 at 1:00 PM, Staff H, ED RN, documented in the ED assessment notes disposition section, "Patient sent to PCP office";
- Staff AA, while on duty at the time the patient was admitted to the ED, did not perform a MSE or any type of evaluation of the patient before the patient was sent to the PCP; and
- Discharge instructions dated 08/05/15, instructed the patient to contact the PCP if they had any questions after discharge.

11. Record review of Patient #24's medical record showed the following:
- On 10/20/15 at 2:05 PM, the patient presented to the ED, and complained of right knee pain and Staff G, ED Physician was assigned as the ED provider;
- On 10/20/15 at 3:05 PM, Staff T, ED RN, documented in the ED assessment notes disposition section, "Patient sent to PCP office";
- Staff G, while on duty at the time the patient was admitted to the ED, did not perform a MSE or any type of evaluation of the patient before the patient was sent to the PCP; and
- Discharge instructions dated 10/20/15, instructed the patient to contact the PCP if they had any questions after discharge.

12. Record review of Patient #25's medical record showed the following:
- On 05/04/15 at 1:56 PM, the patient presented to the ED, and complained of cough, congestion and sore throat;
- Staff H, ED RN, documented in the ED assessment notes that the patient had a chronic (long standing with frequent recurrence) history of asthma (a condition that causes narrowing of the airway and breathing difficult);
- On 05/04/15 at 2:45 PM, Staff H documented in the ED assessment notes disposition section, "Patient sent to PCP";
- Staff G, ED Physician while on duty at the time the patient was admitted to the ED, did not perform a MSE or any type of evaluation of the patient before the patient was sent to the PCP; and
- Discharge instructions dated 05/04/15, instructed the patient to contact the PCP if they had any questions after discharge.











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27727

Based on interview, record review and policy review, the facility failed to provide necessary stabilizing treatment when an emergency medical condition (EMC) existed for four patients (#13, #9, #8 and #12) of 25 patient charts reviewed. The facility had the capability and capacity to admit and treat these patients with unstable EMCs. These failures had the potential to cause harm to all patients who presented to the emergency department (ED) with a emergency medical condition and delay stabilizing treatment due to transferring to another facility. The average daily census for the ED was 46, the average monthly census was 1,423 and the total number of patients transferred to other facilities was 109 during the last six months. The facility inpatient census was two.

Findings included:

1. Review of the facility's policy titled, "Medical Screening Examination", showed:
-That a medical screening examination will be formed on every patient that presents to the Emergency Room to determine if the patient has an emergency medical condition or is in active labor.
-The medical screen examination is completed regardless of age, diagnosis, financial status, race or color.
-If a medical emergency is present the patient will be taken to a room and the ER provider will be notified immediately.
-This facility provides screening and stabilizing treatment within the scope of its abilities, as needed to the individuals with emergency conditions who come to the hospital for examination and treatment.

2. During an interview on 11/30/15 at 10:22 AM, Staff V, Chief Executive Officer stated that there were six physician members on the medical staff including surgeons with privileges for performing orthopedic, gynecologic, podiatry, opthalmic, urological and general surgeries. capabilities.

3. Record review of Patient #13's ED medical record showed the following:
- The encounter sheet (created and updated upon registration with the patient's information) on 10/19/15 at 4:33 PM, documented the patient presented and complained of abdominal pain, bruising and swelling in the abdominal area where earlier that same day she had surgery on her liver and gallbladder at Ozarks Community Hospital.

- On 10/19/15 at 5:07 PM, Staff BB, ED, Registered Nurse (RN) documented an elevated heart rate, elevated respiratory rate and cool pale skin.
- On 10/19/15 at 6:25 PM, Staff W, ED Physician, documented the review and conclusion of diagnostic testing and determined that the patient had acute (severe) post-operative bleeding (unexpected bleeding that continued or recurrent bleeding after a surgical procedure), and that the patient had acute anemia (severe low red blood cells) and would be transferred to another facility.
- Staff W discussed the patient's condition with Staff X, Surgeon, who performed the surgical procedure (earlier the same day on the patient at Ozarks Community Hospital) and then contacted Staff DD, ED Physician at another facility (Facility B) who agreed to accept the transfer of the patient.
- On 10/19/15 documentation of the diagnosis and reason for transfer was "post-op bleeding" and the benefit for transfer was "care by surgery" on the Certificate of Transfer signed by Staff W. Staff W documented the time of transfer was 12:09 AM on 10/20/15, approximately 7 1/2 hours after patient # 13 presented to the ED with an emergency medical condition.
-The facility had the capability and capacity to provide stabilizing treatment.

3. Review of Patient #9's ED medical record showed the following information:
- The patient presented to the facility's ED on 05/02/15 at 4:53 AM and complained of abdominal pain, nausea, vomiting, fever and diarrhea.
- The patient reported his pain level was a six on a pain scale of zero to ten (with 10 being the worse pain experienced by the patient);
- Diagnostic abdominal imaging tests performed on 05/02/15 showed findings suggestive of appendicitis.
- On 05/02/15 from 5:44 AM to 9:16 AM, Staff R ED Physician, documented assessment findings and review of diagnostic findings and conclusion of the diagnosis of Appendicitis (inflammation of the appendix, a small pouch attached to the colon) and that the patient would be transferred to Facility C, approximately 4 hours and 20 minutes after presenting to the ED with an emergency medical condition.
- Staff R signed the patient's Certificate of Transfer on 05/02/15 and the patient was transferred by ambulance to Hospital C at 9:08 AM for "definitive surgical care."
-The facility had the capability and capacity to provide stabilizing treatment.


4. Review of Patient # 8's medical record showed she presented to the ED on 06/30/15 with intractable vomiting (repeated vomiting that resists medical treatment) for the past 36 hours. The ED assessment showed she was treated with Zofran for nausea and Dilaudid for pain.

Review of the Adult Emergency Provider Record dated 06/30/15 at 4:50 AM showed the patient had intractable nausea and vomiting and a possible small bowel obstruction (the intestine is blocked which prevents food, fluid or gas to move through the intestine and causes pain.)

Review of the Certificate of Transfer dated 06/30/15 showed the patient was transferred to another facility for intractable vomiting and small bowel obstruction vs ileus (a blockage of the intestines caused by lack of peristalsis (the pumping action of the intestines that moves food through the digestive system) for treatment with intravenous (IV) fluids and current medical condition. The patient was transferred at 11:26 AM to receive stabilizing treatment approximately 6 1/2 hours after presenting to the ED with an emergency medical condition.
The hospital had the capability and capacity to provide stabilizing treatment to this patient.

5. Review of Patient # 12's medical record showed he presented to the ED by ambulance on 10/06/15 at 3:15 PM for complaints of sharp intermittent pain in his abdomen and two episodes of vomiting. The ED assessment showed he was given IV fluids, Zofran for nausea, Toradol, Fentanyl and Dilaudid for pain.

Record review of the Adult Emergency Provider Record dated 10/06/15 at 4:00 PM showed the patient had reported sudden onset (of pain) at about 10:00 AM of all over severe steady abdominal pain with nausea and two episodes of vomiting. Physical examination showed the patient had very mild tenderness with some (abdominal) distension (bloating). The ED documentation showed the patient's care had been transferred to a second provider at 5:30 PM who re-examined the patient and reviewed a CT scan (an imaging method that uses x-rays to create pictures of cross sections of the body), which showed the patient had Pancreatitis, an inflammation of the Pancreas. The provider spoke with the the receiving hospital and arranged transfer for the patient.

Record review of the Certificate of Transfer dated 10/06/15 showed the patient was sent to another facility for Acute Pancreatitis for "in-patient treatment not available here" approximately 6 1/2 hours after presenting to the ED with an emergency medical condition. The facility had the capability and capacity to provide stabilizing treatment for this patient's emergency medical condition.

During an interview on 11/04/15 at 10:05 AM, Staff J, ED Nurse Manger, stated that patients were not admitted to the in-patient floors from the ED. He stated that all patients were transferred to other facilities.

During a concurrent interview on 11/04/15 at 1:15 PM, Staff J, ED Manager and Staff U, ED Information Specialist, stated that patients who came to the ED and needed any kind of surgery, emergency or non-emergent, or any type of consultation were transferred to a hospital that provided the services because the facility did not provide in-patient care or any type of patient care beyond the emergency service (for patients who presented through the ED). Staff J stated that during the week days, the only patients that were admitted to the in-patient medical units were surgical patients who had undergone scheduled procedures and only required a very short stay. Patients who presented to the ED and needed in-patient admission for medical or surgical care were not admitted.

During a telephone interview on 11/30/15 at 10:22 AM, Staff V, Chief Executive Officer, stated that about a year a ago he made the decision to not admit patients to the medical floor. The census was one to two patients a week and it was economically impossible to employee physicians to care for so few patients.