HospitalInspections.org

Based on observation, interview, and record review the facility failed to ensure the Medical Bylaws Rules and Regulations was implemented when,
1. A. The Emergency Department (ED, also known as Emergency Room (ER), an area in the hospital open 24/7 that treats patients with illnesses and injuries requiring immediate care.) Physician (ED Physician 1) left the ED on 8/1/24 at 10:00 AM and the ED was "left uncovered" (from 10:00 AM to 1:00 PM) for three (3 hours) while the facility was on "diversion (when the ED is temporarily unable to accept new patients and will redirect ambulances to other hospitals). One ED Nurse Practitioner (ED/NP, also called Allied Health Professionals, an Advance Practice Provider) was on site in the ED and one Hospitalist 1 (physician who practices hospital medicine) came to the ED (to provide physician coverage) during the diversion until the ED Physician 3 arrived 1:00 PM.

1.B. One patient (Patient 1) was still in the ED awaiting transfer to the Intensive Care Unit (ICU, area in the hospital where patients with severe or life-threatening receive care and close monitoring) without the "hand off (means "signing out patient to the next provider)" to the next ED Physician (Physician 3) who arrived at 1:00 PM on 8/1/24.

These deficient practices had the potential to negatively impact the quality of care rendered to patients and could not ensure patient's safety.

2. Hospitalist 1 did not have evidence of Influenza (known as flu, is a contagious viral infection that affects the air passages of the lungs) vaccination or declination during the 2023 flu season.

3. Hospitalist 1 did not have evidence Tuberculosis Screening (a process used to detect whether an individual has been infected with the Mycobacterium tuberculosis [TB] that can cause infection in the lungs or other tissues) was completed on Initial appointment (a permission granted to a physician to render specific patient care service in the hospital), on 10/18/23.

Failure to ensure staff providing care to the patients was adequately vaccinated /received proper immunization had the potential to place the patients at risk of exposure to communicable diseases (illnesses caused by viruses or bacteria that people spread to one another through contact with contaminated surfaces, bodily fluids, blood products, insect bites, or through the air).

Findings:

1. A. During the Entrance Conference group interview on 8/19/24, at 9:41 AM, with the Chief Executive Officer/Administrator, Chief Health Officer (CHO), Emergency Services Department Director (ESD), Corporate Quality Director CQD), Associate Chief Operating Officer (ACOO), Chief Nursing Officer (CNO), Administrator Nursing Supervisor (ANS), Quality Analyst (QA), Clinical Data Analyst (CDA), CHO stated, the ED Providers (ED Physicians, NPs, and the ED Medical Director (EDMD) belonged to the Contracted Group of Providers (CGoP) for the hospital. The ESD stated, when the ED Physician 1 left the ED, the ED went on "diversion" from 10:00AM till 1:00 PM on 8/1/24, the reason for the "diversion" was there was no ED Physician in-person onsite in the ED, and the Providers present were the Hospitalist 1 and the ED/NP 1 until the ED Physician 3 arrived at 1:00 PM on 8/1/24. The ESD stated, the Hospitalist 1 did not have the "competency" and "training" of an ED Physician and one patient (Patient 2) was brought in by the ambulance during the diversion because of "delay in communication" between the hospital and the County.

Record review of the document titled, "Narrative of the Investigation", dated 8/1/24 indicated, the diversion started at "10:29 AM" until "12:53 PM" on 8/1/24.

In an interview on 8/19/24, at 10:10 AM, with the CHO, CHO stated, he was part of the CGoP for the hospital and member of the Medical Staff. CHO explained, the ED Physician 1 started her shift in the ED on 7/31/24 at 6:30 PM and her shift was supposed to end at 6:30 AM on 8/1/24, and the ED Physician 2 was scheduled and supposed to come on 8/1/24 at 6:30 AM but "called in sick". The CHO stated, the ED Physician 1 stayed, the ED/NP 1 started her shift at 9:00 AM, and the ED Medical Director (EDMD 1) called him (CHO) to request the Hospitalist 1 to come to the ED to provide physician coverage. The CHO further stated, when the ED Physician 1 left the ED on 8/1/24 at 10:00 AM, there was no on-site ED Physician, only the Hospitalist 1 and the ED/NP 1 were present, the Hospitalist 1 was "not an ED Physician", and the ED/NP 1 "worked independently", but if an ambulance came it would need a physician to do the assessment and the medical management of the patient. The CHO stated, the Hospitalist 1 have the skills to manage patients and he was doing the due process before the ED Physician 3 arrived, however, if a physician was not credentialed, for example a pediatric patient or a pregnant woman came in the ED, the Hospitalist 1 may be able to do the assessment, but it's "not in his scope of practice", "it's not in his specialty", it will be an assessment to make sure the patient was stable. The CHO stated, at this time the Hospitalist 1 was on vacation and could not be reached for an interview, the ED Physician 1 no longer work for the hospital, and the EDMD 1 whose first day to work as Medical Director for the ED on 8/1/24, no longer work in the hospital. The Regional Director for the CGoP has taken over the position and was now the Interim EDMD 2 beginning 8/2/24.

Review of the facility's Medical Bylaws Rules and Regulations, with the last revised date of 2/8/23 indicated, "ARTICLE XVII, MEDICAL SCREENING EXAM, 17.1 For all patients presenting to xxx (name of Hospitals 1 and 2) Emergency Room, a licensed physician or allied health professional with Emergency Medicine privileges at xxx (name of Hospitals 1 and 2) will perform the medical screening exam."

In an observation and interview on 8/19/24, at 11:53 am, with the ESD with the Corporate Quality Director (CQD) present, the ED located on level 1 (one) of the hospital was observed. The ESD stated, the ED has 12 rooms, and the census was 10 including one "14-year-old". The ESD further stated, "walked -in" patients were triaged in the Triage area located in the "front", and the patients with higher acuity were in the "main" ED. Two Providers were present on 8/19/24, one ED Physician 4 and one ED/NP 1.

In an interview on 8/19/24, at 12:34 PM, with the ED Registered Nurse (ED/ RN 1), ED/RN 1 stated, she worked in the ED on 8/1/24, morning shift. ED/RN 1 stated, when the ED Physician 1 left the ED on 8/1/24 the Hospitalist 1 came to the ED to provide physician coverage. ED/RN 1 stated, she transferred one patient out with "bleed" who was evaluated by ED Physician 1 before the diversion. The ED/RN 1 stated, she recalled there was one patient (Patient 1) who "coded (medical emergency)" and was evaluated by the ED Physician 1 before she left the ED on 8/1/24.

Record review of "ER (Emergency Room Log Report (ERLR)" dated 8/1/24 indicated, Patient 1 was admitted to the ED on 8/1/24 at 8:20 AM with the chief complaint of weakness, "critical", discharged from the ED on 8/1/24 at 11:03AM, and was transferred out to the ICU.

In an interview on 8/19/24, at 12:54 PM, with the ED/NP 1 stated, ED/NP 1 stated, she was NP since 2014, she was part of the CGoP who provided coverage for the ED, her shifts usually start at 12 noon but was asked to come early and she came at 9:00 AM on 8/1/24. When she arrived, the day shift Physician (ED Physician 2) who was supposed to come was not there, the ED Physician 1 was still in the ED, and told her (ED/NP 1) she had "gone thru" all patients in the ED and have to leave. The Hospitalist 1 came to the ED to provide physician coverage after the ED Physician 1 left. The ED/NP 1 stated, as member of the CGoP, "we have a responsibility as a company to provide safe care and as a nurse, "you can't abandon your patients", and there was a system to contact the site manager if unable to work. During the diversion, one patient (Patient 2) was brought by the ambulance due to congestive heart failure (CHF, means weak heart), tested positive for Covid (contagious disease caused by a virus), and eventually was transferred out to the ICU.

Record review of the ERLR dated 8/1/24 indicated, Patient 2 arrived in the ED on 8/1/24 at 11:23 AM with the chief complaint of shortness of breath, "Condition: Critical", and was transferred out to the ICU on 8/1/24 at 5:14 PM.

In a phone interview on 8/21/24, at 2:02 PM, with the Interim EDMD 2, Interim EDMD 2 stated, he was the Regional Director for the CGoP and worked 30 years in his career. The Interim EDMD 2 stated, the ED Physician 1 was an "independent" staff employed by the CGoP for the hospital. The ED was "left uncovered" when the ED Physician 1 left the ED on 8/1/24, although there was one NP present, the ED Physician 1 should have stayed (till the next ED physician arrived) and not leave the ED without coverage, it's the most "appalling" thing for a physician to do.

In a concurrent interview and record review 8/23/24, at 12:30 PM, with the ESD, the ERLR dated 8/1/24, was reviewed. ESD stated, on 8/1/24 the ED Physician 1 evaluated total of four (4) patients including Patient 1 who was brought in by the ambulance at 8:20 AM and was transferred out to the ICU at 11:03 AM. After the ED Physician 1 left, one patient (Patient 2) was brought in by the ambulance and additional five (5) walked-patients (Patients 3, 4, 5, 6, and 7) presented to the ED during the diversion period (from 10:29 Am to 12:5 PM on 8/1/24).

Record review of the ERRL dated 8/1/24 indicated, there were five (5) patients who presented to the ED during the diversion period: Patient 3 arrived at 10:29 AM with the chief complaint of abdominal pain, and was discharged to home at 10:59 AM. Patient 4 arrived at 10:55 AM with the chief complaint of chest, covid positive, and was discharged to home at 11:54 AM. Patient 5 arrived at 11:55 AM with the chief complaint of "unable to eat for seven (7) days" and was discharged to home at 2:21 PM. Patient 6 arrived at 12:01 with the chief complaint of "urine pain" and was discharged to home at 12:55 PM. Patient 7 arrived at 12:41 PM with the chief complaint of "right hand pain" and was discharged to home at 1:41 PM.

In an interview on 8/22/24, at 11:37 AM, with the Chief of Staff (CoS), CoS stated, on 8/1/24 he received report the ED Physician 2 did not show and the ED Physician 1 left the ED. The CoS stated, he expected the ED Physician 1 should have stayed until "someone came over," it was "appalling" to leave patients, it's as "abandonment" of care, and it's "against the code of ethics". The Hospitalist 1 went to the ED, it was a "patch" to fill in, (to provide doctor coverage), but it was a "weak gap". There was the ED/NP 1 but "they should not be put in that position", that was the "best we can do" at that moment because the ED did not have an ED Physician. When asked if the EDMD 1 should have shown up after the ED Physician 1 left, CoS nodded his head and stated, he (EDMD 1) should have shown up in the ED on 8/1/24.

Review of the facility's Medical Bylaws Rules and Regulations, with the last revised date of 2/8/23 indicated, "3.3 Basic Responsibilities of Staff Membership. Each member of the Medical Staff shall: 3.3.1 Provide for continuous care of their patients and, in their absence, delegate the responsibility for that care only to other qualified Medical Staff members. 3.3.2 Comply with the provisions of these Bylaws, Department Rules and Regulations, policies of the Medical Staff and policies and rules of the Hospital applicable to members of the Medical Staff. ... . 3.3.4 Be present to provide the care for which they charge. ... ."

1.B. In a concurrent record review and interview on 8/23/24, at 12:38 PM, with the ESD and the CHO, the Emergency Medicine Evaluation Note (EMEN) for Patient 1 done by the ED Physcian1, dated 8/1/24 at 9:01 AM, was reviewed. The EMEN indicated, Patient 1 came with the chief complaint of "syncope (fainting or passing out), had "syncopal posturing (sudden drop in blood pressure and heart rate due to quick change of position), "CPR (cardiopulmonary resuscitation, life saving measures)" was started and was "ventilated (life supports that helps a person breathe)." The ESD stated, Patient 1 was still in the ED when the ED Physician 1 left at 10:00 AM and the patient was transferred out to the ICU at 11:03 AM. Further review of the EMEN indicated, "Patient was discussed with hospitalist and intensivist." The CHO stated, hand off meant "signing out patient to the next provider" and after he verified the ED practice of "hand off" with the on duty ED Physician 4, the expectation was to document on the patient's medical record, she/he was signing out the care to the next (ED) Physician.

Review of the facility's Medical Bylaws Rules and Regulations, with the last revised date of 2/8/23 indicated, "ARTICLE XX, ... RULES AND REGULATION OF THE MEDICAL STAFF OF xxx (name of Hospital 1). 1. ADMISSION AND DISCHARGE OF PATIENTS, a. The Hospital shall accept patients for care and treatment of disease for which there are appropriate physical facilities and appropriately trained staff. ... b. For all patients presenting to xxx (name of Hospitals 1 and 2) Emergency Room, a licensed physician with privileges xxx (name of Hospitals 1 and 2) will perform the medical screening exam. ... e. The attending physician shall be responsible for the overall management of the patient. Whenever these responsibilities are transferred to another staff member, a note shall be entered on the order sheet of the medical record. f. Each physician shall be responsible for providing continuous care to all of his patients. ... ."



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2. During a concurrent record review and interview on 8/22/24, at 1:20 PM, with Medical Staff Credentialing Coordinator (MSCC) 1, Hospitalist 1's Credential File (CF, a comprehensive collection of documents and records that verify qualifications of the physician) was reviewed. The CF indicated the Initial Appointment for Hospitalist 1 was on 10/18/23. The CF contained Hospitalist1's Medical History that includes TB Screening indicating it was administered on 6/16/23 and expired on 6/16/24, and the annual "Tuberculosis Individual Risk Assessment Questionnaire (a TB screening tool used to determine a person's risk for TB infection) was completed on 7/23/23. MSCC 1 stated TB screening is required annually. MSCC 1 acknowledged Hospitalist 1's TB screening was expired and did not have a current TB screening.

3. During a concurrent record review and interview with MSCC 1 on 8/22/24 at 2:23 PM, Hospitalist 1's "Individual Immunization (a process by which a person becomes protected against a disease through vaccination) Compliance Report (IICR)," which included influenza vaccination, dated 7/10/23, was reviewed. MSCC 1 stated the influenza vaccination was completed and administered on 11/17/22 and Hospitalist 1 was due for annual influenza vaccination on 9/1/23. MSCC 1 further stated if physicians refused influenza vaccination, the "Influenza Vaccination Declination Form/2022-23 [2023] (IVDF)" must be completed and signed. MSCC 1 stated Hospitalist 1 did not have a completed and signed IVDF. MSCC 1 stated, "We don't have a current up to date flu shot (vaccination) on our records (for Hospitalist 1)."

During a concurrent interview and review of the facility's policy and procedure, titled "Employee Health Requirements 2024 (EHR 2024)," on 8/23/24 at 12:36 PM, the CHO verified the EHR 2024 should be implemented by the facility. The EHR 2024 indicated "The following documentation should be submitted to the Medical Staff Office along with new appointment application for [Hospital's name]. These requirements apply to all directed new hired Healthcare Workers (HCW), affiliated physicians, contract personnel, students, and volunteers ... Influenza vaccine - Documentation to support immunization during flu season. Usually, influenza season runs between October and March OR Declination form following Joint Commission (an accreditation group that develops and upholds patient safety and care standards for hospitals and other healthcare organizations) standards ([Hospital's name] can provide form if needed). The EHR 2024 further indicated, "Latent Tuberculosis (it means a person is infected with the TB bacteria but has no symptoms of the disease) Screening - Screening within the prior 12 months (PPD [purified protein derivative, a solution administered under the skin to test for TB] or a blood test) AND [Hospital's name] TB questionnaire (use the most recent version provided by [hospital's name]). No outside versions accepted. In absence of a latent TB screening test in the past 12 months a 2 (two) -step PPD (a method used to detect latent TB infection that involves two separate skin tests conducted a few weeks apart) may be required ..."

Review of facility's policy and procedure, titled "Credentialing and Privileging Process for the Medical Staff and Allied Health Professionals," with last revision dated 1/2023, indicated "Policy: this applies to all licensed independent practitioners applying for initial appointment and reappointment to the Medical Staff or AHP (Allied Health Professionals) of [Hospital's name] ...Procedure ...Privileging and Approval Process ...II. Reappointment Application ...3. The applicant shall submit a complete application that shall include, but not limited to the following: ...l. Recent TB test result ...Flu vaccination record ..."

Review of facility's "Medical Staff Bylaws Rules and Regulations," with last revision dated 2/2023, indicated "MEDICAL STAFF MEMBERSHIP ... 3.3 Basic Responsibilities of Staff Membership. Each member of the Medical Staff shall ... 3.3.2 Comply with the provisions of these Bylaws, Department Rules and Regulations, policies of the Medical Staff and policies and rules of the Hospital applicable to members of the Medical Staff."