HospitalInspections.org

Based on a review of facility documents, and staff interviews (EMP), it was determined that Penn Highlands Clearfield failed to maintain On Call lists with the names of physicians and contact information, failed to include a clear delineation of On-Call coverage responsibilities; that is when each hospital participating in the plan is responsible for On-Call coverage, and failed to ensure documentation of an annual assessment of the Community Call Plan by the participating hospitals.

Findings:

Review of Penn Highlands Clearfield policy entitled "Medical Staff On-Call Policy", dated March 2020, revealed "Policy: The Penn Highlands Clearfield Hospital (PHC) and its Medical Staff arrange and provide emergency on-call coverage directly and through a community call arrangement with Penn Highlands DuBois (PHD). The community call arrangement between PHC and PHD includes a schedule of on-call responsibilities at each hospital that guides patient disposition, as well as an annual assessment of the community call arrangement itself. Purpose: The purpose of this policy is to provide for the preparation of a monthly emergency on-call schedule for applicable medical specialities, to provide guidance to on-call physicians, and to provide direction to physicians and hospital staff when emergent services are required by on-call physicians. Procedure: On-Call Schedule 1. The Penn Highlands Physician Network (PHPN) practice managers, on behalf of the Hospital, is responsible for developing a monthly on-call schedule for specialists comprised of employed physicians that includes the name and relevant contact information of each Active/Active Affiliate Staff physician in the department who is required to fulfill on-call duties. On-call schedules will be prepared by PHPN and maintained by the Medical Staff Professional. Copies of the on-call schedule will be provided to on-call physicians by the Medical Staff Professional and PHPN, and will be posted and available on-line via Hospital Forms. For Active/Affiliate Staff physicians not employed by PHPN and required to fulfill on-call duties, a monthly on-call schedule will be submitted to the Medical Staff Professional and will be posted and available on-line via Amion. 2. The on-call schedule will include, the following specialties: Hospitalist, Gynecology, General Surgery, Orthopedic Surgery, Ophthalmology, Cardiology, and Psychiatry. On call-coverage for these specialities will be provided by a PHC physician, and dates that are not covered by a PHC physician will be covered via a community call arrangement with PHD physicians. Specialties with a limited number of PHC physicians, consulting staff, and other specialties, may be included based on the availability and the nature of the service. 3. PHC Physicians must provide, in advance, dates to the Medical Staff Professional when he/she will be out-of-town/signed-out and, therefore, unavailable for on-call service. Changes to the final on-call schedule must be communicated to the Medical Staff Professional and PHPN Practice Manager (if applicable), and must include the name of a replacement. Response to Call 4. When a PHC on-call physician is contacted by the Emergency Department and requested to respond, the physician must: (a) be available, by telephone, within 30 minutes; and (b) respond in person, if so requested, within a reasonable time period. Generally, response is expected within 60 minutes. The Emergency Department physician, in consultation with the on-call physician, will determine whether the patient's condition requires the on-call physician to see the patient as soon as possible. The determination of the Emergency Department physician will be controlling and will be recorded in the medical record. (c) When the community call arrangement with PHD is utilized, the PHD staff will follow the policy and medical staff bylaws of their institution. 5. If the scheduled on-call physician is unable to respond due to circumstances beyond the physican's control, the Emergency Department physician will determine whether to attempt to contact another specialist on the Medical Staff or arrange for a transfer pursuant to this Policy. Alternative On-Call support and Transfer Arrangements. 6. On an ongoing basis and in conjunction with the PHC Medical Executive Committee, the department chief/medical director of each specialty described in Section 2 will determine the monthly on-call responsibilities for each applicable physician and will develop the on-call schedule in advance each month. For dates when no PHC physician is available to provide on-call coverage for the specialties described in Section 2, on-call coverage will be provided by PHD in accordance with a community call arrangement which will also be considered by the PHC department chiefs, medical directors and the Medical Executive Committee. This arrangement will cover all patients at, or arriving at, PHC from any location in the PHC service area, including the primary locations of Clearfield, Curwensville, Lawrence Township and adjacent municipalities of Clearfield and Centre counties. 7. Patients who must be cared for by the PHD on-call physician will be transferred to PHD if necessary, or to another facility if requested by the patient. Transfers to PHD will be completed in accordance with the Transfer Agreement between PHC and PHD. Regardless of an Emergency Department patient's final disposition and/or transfer, all patients who present to PHC will receive a Medical Screening Examination (MSE) and stabilizing treatment by appropriate PHC providers in accordance with PHC policy: Emergency Medical Screening, Treatment and Transfer. 8. PHC patients who require emergency services by a specialist who is not available via call-coverage at PHC, such as specialties with limited numbers of PHC specialists, will be transferred to PHD or another appropriate facility in accordance with the process described in Section 7 above. 9. Representatives from PHC and PHD will review all aspects of the community call program with all EMS providers in the PHC service area, and will update EMS providers as changes to the program occur. Representatives from PHC and PHD will also review the performance of the community call program on an ongoing and annual basis, modifying as necessary. Concurrent Call/Elective Surgery 10. Notwithstanding an on-call physician's obligation to respond when on call, the on-call physician may perform elective surgery or other patient care services at the hospital while on call, or may be on call at another hospital. If emergent patient services are needed during this time, the hospital and/or Emergency Department staff will provide a Medical Screening Examination (MSE) and stabilizing treatment by appropriate PHC providers in accordance with PHC policy: Emergency Medical Screening, Treatment and Transfer, and either arrange for appropriate transfer of the patient if necessary or hold the patient until the on-call PHC physician is available ... ." This policy was noted to contain a signature page, which included signatures as noted below:
Approved by the PHC (Penn Highlands Clearfield) Medical Executive Committee on March 17, 2020, with Signature of the President of the Medical Staff.
Approved by the PHD (Penn Highlands DuBois) Medical Executive Committee on March 9, 2020, with Signature of the President of Medical Staff.
Approved by President of PHC, on March 23, 2020, with signature of President.
Approved by President of PHD, on March 17, 2020, with signature of President.
1. A telephone interview was conducted with EMP1, EMP4, EMP16, EMP3, EMP2, and EMP17 Penn Highlands Clearfield/DuBois, on August 4, 2020, at approximately 12:15PM. A review of Penn Highlands Clearfield Provider Call Schedules dated January 1, 2020- July 31, 2020, was completed.
Review of the Legend of all On Call Schedules reviewed, was noted to define "PD" as PH DuBois Transfer Center.
During review of the schedules revealed the following:
January 2020: Schedule indicated that "PD" covered days for GYN, Orthopedics, Facial Trauma Call, Podiatry Call, ENT Call, and Maxillofacial Call.
February 2020: Schedule indicated that "PD" covered days for GYN and Podiatry.
March 2020: Schedule indicated that "PD" covered days for GYN and Podiatry, Facial Trauma Call, ENT, Maxillofacial Call, Vascular Surgery Call and Pulmonology Call.
April 2020: Schedule indicated that "PD" covered days for GYN, Facial Trauma Call, Podiatry Call, ENT Call, Maxillofacial Call, Vascular Surgery Call, and Pulmonology Call.
May 2020: Schedule indicated that "PD" covered days for GYN, Facial Trauma Call, Podiatry Call, ENT Call, Maxillofacial Call, Vascular Surgery Call, and Pulmonology Call.
June 2020: Schedule indicated that "PD" covered days for GYN and Podiatry Call, and Facial Trauma Call, ENT Call, Maxillofacial Call, Vascular Surgery Call, and Pulmonology Call.
July 2020: Schedule indicated that "PD" covered days for GYN, General Surgery Call, and Podiatry Call, and Facial Trauma Call, ENT Call, Maxillofacial Call, Vascular Surgery Call, and Pulmonology Call.
During the telephone interview on August 4, 2020, EMP17 stated that the On Call schedules were changed as Emergency Department initiated calls were to go through the transfer center, so that the Emergency Department did not contact providers directly that were on call.
2. During review of the On Call Schedules, it was noted that Facial Trauma Call, ENT Call, Maxillofacial Call, Vascular Surgery Call and Pulmonology Call were not included in the Community Call arrangement as outlined in the facility's Medical Staff On Call Policy.
3. Surveyor also requested evidence that an annual assessment of the Community Call Plan, as described in their Medical Staff On Call Policy, has been completed. Surveyor was only provided with evidence of review of the plan, via Medical Executive Committee Meeting Minutes for Penn Highlands Clearfield dated March 17, 2020, and for Penn Highlands DuBois, dated March 9, 2020. but no evidence of assessment of the Plan.

Based on a review of facility documents and staff interview (EMP), it was determined that Penn Highlands Clearfield failed to maintain a Control Register, as described in their adopted policies, of individuals who present to their Emergency Department (ED) seeking assistance for one of one patients identified (PT1)

Findings:

"Control Register", reviewed June 2020, revealed "... Policy: A Control Register is continuously maintained and includes the following information: 1. Date of Emergency Department visit. 2. Time of patient's arrival. 3. Patient's name. 4. Attending physician and family physician ... 5. Sex of patient. 6. Classification of patient base on triage Emergency Severity Index Classification. 7. Patient's diagnosis. 8. Mode of entry ... 9. The patient's room number, if admitted. 10. If patient is transferred. 11. Dead on arrivals and cardiac arrests are noted. 12. Time of departure. 13. Insurance approval number if applicable. 14. RN initials of the primary nurse providing patient care. Procedure: All patients receiving care in the Emergency Department are entered into the control register each shift by the Unit Secretary."

Review of facility policy entitled "Emergency Medical Screening, Treatment and Transfer Policy', reviewed July 2020, revealed "Purpose: To provide guidance to the Penn Highlands Clearfield Emergency Department (ED) staff and physicians in the care of patients presenting to the ED according to the regulations established. Policy: The Penn Highlands Clearfield ED Physicians, certified physician assistants, or certified registered nurse practitioners are responsible to provide a Medical Screening Exam (MSE) and appropriate treatment to patients coming to the Penn Highlands Clearfield ED for emergency care. If the patient requires services or a level of care not provided within the facility, the ED physician shall provide direction to transfer the patient to an appropriate facility to receive further care if needed. Procedure: A. Presenting for care and medical screening examination. (1) A central log on each individual who comes to the Penn Highlands Clearfield Emergency Department seeking assistance and whether he or she received treatment, refused treatment, was transferred, admitted and treated, stabilized and transferred or discharged is maintained by the Penn Highlands Clearfield Emergency Department. (2) Any individual who comes to the Penn Highlands Clearfield Emergency Department requesting Examination or treatment will be provided with an appropriate MSE. (3) An individual will also be considered to have come to the Penn Highlands Clearfield Emergency Department if the individual is on Penn Highlands Clearfield property (including its parking lot, driveway, or sidewalk) and is requesting care for what may be an emergency condition or someone has requested care on his or her behalf. Penn Highlands Clearfield property and grounds, defined as an area that is 250 yards around the Hospital building, but does not include other areas or structures of the main hospital building that are not a part of the Hospital, such as physician offices, or other entities that participate separately in Medicare. a) Emergency Situation: 1) All hospital personnel have the responsibility to respond to any incident that occurs within 250 yards of Penn Highland Clearfield (i.e. Parking lots) 2) Personnel responding to an incident will practice within their scope. 3) 911 center should be called to request EMS response. 4) If the patient refuses transport to the Emergency Department, then EMS will follow their own policy for patient refusal ... (4) The MSE shall include any ancillary services routinely available to the Penn Highlands Clearfield Emergency Department. The MSE must be similar for patients presenting with similar symptoms. (5) In providing a medical screening examination, Penn Highlands Clearfield does not discriminate against any individual because of diagnosis, financial status, race, color national origin, or handicap. (6) The purpose of the MSE is to determine if an individual is experiencing an emergency medical condition a) An "emergency medical condition" is a condition manifesting symptoms (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) which, in the absence of immediate medical attention, is likely to cause a serious dysfunction or impairment to a bodily organ or function or serious jeopardy to the health of the individual or unborn child ... ."

1. Facility Statement documentation from EMP3, revealed "... This statement reflects what the patient (PT1) told EMP3 when the patient arrived at the ED (second visit) ... PT1 states ... family doctor ... told (them) to go to Clearfield and have labs and x-rays done in the ED to be sure (they) did not have any injuries related to the falls ... PT1 states they came to the hospital. (PT1's family member) came in and requested assistance from EMP9. Per EMP9, (they) went out to vehicle to check what the situation was. EMP9 states the (Patient's family member) states PT1 was to come here to have labs and x-rays done in the ED ... PT1 did state they did tell EMP9 that (they were) here for the ED, but was told by EMP9 that (they) may need to get an ambulance to help (PT1) out ... ."

2. Surveyor requested to view Penn Highland Clearfield video footage of patient's (PT1) initial presentation to the facility on May 18, 2020. The video footage, noted that on
Monday May 18, 12:42 PM: Vehicle pull up at ED/Registration Entrance. PT1 noted to be in front passenger seat of vehicle. The vehicle with PT1 pulled away from the facility at 13:00. Four individuals were noted to have interaction with PT1 between 12:47 and 12:58.

3. Review of the Ambulance Trip Sheet relative to PT1(MR23) revealed "... May 18, 2020 ... Description: The crew arrived at the patient and noted (PT1) to be sitting in the front seat of ... vehicle just outside of the Clearfield EMS building. (PT1) is noted to be anxious and crying. (PT1) does not appear to be in distress but visible scared and upset ... Patient was noted to be extremely upset, embarrassed, and crying thinking nobody will help (them) and (they) will continue falling ... Chief Complaint ... Epigastric pain, chest pain (non cardiac) bruising, unsteady gait with noted weakness, frequent falls, obesity ... History of Present Illness. This ... patient of ... presented today at this EMS facility after (family member) stated that they had went to the doctors' office and nobody would help (their) mother out of the SUV because (they were) a fall risk. Then they went to the PH Clearfield Hospital as directed by the doctors' office and ... asked for assistance getting (their) mother out of the vehicle ... was told by an employee that they could not help because (PT1) was a high risk fall and that (PT1) needed to come in by stretcher and to go home and call EMS and have them transport ... The EMS stretcher was brought to the patient's side of the vehicle. The patient was assisted under (their) arms to exit the vehicle by crew x 2. (PT1) was then able to pivot to the be seated on the EMS stretcher ... legs were assisted to the EMS stretcher and (PT1) was comfortable in a semi-fowlers position. The patient was then covered with blankets and was secured with stretcher straps ... and side rails x 2. The patient then wheeled to the ambulance where ... was safely loaded and secured for transport for further interventions ... Cardiac monitor ... and pulse ox placed on the patient to obtain vitals and continued monitoring throughout transport. Patient's breathing noted to be fast due to ... crying and anxiety. Patient was able to rate ... pain, intermittent at the epigastric area and more just aching tenderness with palpation ... Patient remains stable. Crew continues to talk with patient ... Patient co-operative and able to relate (their) anguish ... transport to Penn Highlands Clearfield ED ... The patient was safely unloaded and was wheeled into the ED via the EMS stretcher with one crew at each end of the stretcher for safety. Crew directed to ED #2. The patient was taken to room 2 in the ED. All EMS monitoring equipment was removed from the patient and ... was moved from the EMS stretcher to the ED bed via sheet left by crew x 2 and staff x 1. Patient was placed in a semi-fowlers position of comfort per the patient with ... side rails up and locked. A patient report and copy of the patient transfer was provided to the receiving nurse ... at the patient's bedside. All patient care was released to the staff at the ED and no further patient care was required of this crew ... This issue with the patient being turned away from the hospital earlier by unknown staff on the Admission side of Hospital was discussed with EMP3 to handle the situation further. The patient was left conscious, alert, and oriented to person, place, time and events ... Patient was much calmer and able to speak without crying. Patient still unable to rate pain or describe, just stating ... was ... sore ... "

4. Interview with EMP3 on July 28, 2020, at 11:30 AM revealed, "I was assisting in the ER that day. We received an ambulance patient, (they were) triaged and placed in a bed. (The patient) was telling (their) story and said that (they) was just here but couldn't get out of (their) car. I said, 'Excuse me?' (The patient) said (they) went to the clinic in ... to see the doctor, but couldn't get out of (their) car there. (The patient) was there to get testing done. (The patient) called (their) family doctor who told (the patient) to go to the ER ... There was a miscommunication between the screener and the patient as to whether (the patient) was coming to the ED to be seen or coming for testing as an outpatient. (The patient) needed (their) X-rays ... Both outpatient and ER patients come through the ED entrance. (The patient) was there for an ER visit, yes ... ."
5. Review of the ED Log dated May 18, 2020, revealed that the patient was not entered in the ED Log, upon this initial presentation to the ED.

Based on a review of facility documents, medical record (MR), and staff interview (EMP), it was determined that Penn Highlands Clearfield failed to ensure that a medical screening examination was provided for one of one patients who presented to the Emergency Department. (PT1-MR23)

Findings:

Review of facility policy entitled "Emergency Medical Screening, Treatment and Transfer Policy', reviewed July 2020, revealed "Purpose: To provide guidance to the Penn Highlands Clearfield Emergency Department (ED) staff and physicians in the care of patients presenting to the ED according to the regulations established. Policy: The Penn Highlands Clearfield ED Physicians, certified physician assistants, or certified registered nurse practitioners are responsible to provide a Medical Screening Exam (MSE) and appropriate treatment to patients coming to the Penn Highlands Clearfield ED for emergency care. If the patient requires services or a level of care not provided within the facility, the ED physician shall provide direction to transfer the patient to an appropriate facility to receive further care if needed. Procedure: A. Presenting for care and medical screening examination. (1) A central log on each individual who comes to the Penn Highlands Clearfield Emergency Department seeking assistance and whether he or she received treatment, refused treatment, was transferred, admitted and treated, stabilized and transferred or discharged is maintained by the Penn Highlands Clearfield Emergency Department. (2) Any individual who comes to the Penn Highlands Clearfield Emergency Department requesting Examination or treatment will be provided with an appropriate MSE. (3) An individual will also be considered to have come to the Penn Highlands Clearfield Emergency Department if the individual is on Penn Highlands Clearfield property (including its parking lot, driveway, or sidewalk) and is requesting care for what may be an emergency condition or someone has requested care on his or her behalf. Penn Highlands Clearfield property and grounds, defined as an area that is 250 yards around the Hospital building, but does not include other areas or structures of the main hospital building that are not a part of the Hospital, such as physician offices, or other entities that participate separately in Medicare. a) Emergency Situation: 1) All hospital personnel have the responsibility to respond to any incident that occurs within 250 yards of Penn Highland Clearfield (i.e. Parking lots) 2) Personnel responding to an incident will practice within their scope. 3) 911 center should be called to request EMS response. 4) If the patient refuses transport to the Emergency Department, then EMS will follow their own policy for patient refusal ... (4) The MSE shall include any ancillary services routinely available to the Penn Highlands Clearfield Emergency Department. The MSE must be similar for patients presenting with similar symptoms. (5) In providing a medical screening examination, Penn Highlands Clearfield does not discriminate against any individual because of diagnosis, financial status, race, color national origin, or handicap. (6) The purpose of the MSE is to determine if an individual is experiencing an emergency medical condition a) An "emergency medical condition" is a condition manifesting symptoms (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) which, in the absence of immediate medical attention, is likely to cause a serious dysfunction or impairment to a bodily organ or function or serious jeopardy to the health of the individual or unborn child ... ."

1. Facility Statement documentation from EMP3, revealed "... This statement reflects what the patient (PT1) told EMP3 when the patient arrived at the ED (second visit) ... PT1 states ... family doctor ... told (them) to go to Clearfield and have labs and x-rays done in the ED to be sure (they) did not have any injuries related to the falls ... PT1 states they came to the hospital. (PT1's family member) came in and requested assistance from EMP9. Per EMP9, (they) went out to vehicle to check what the situation was. EMP9 states the (Patient's family member) states PT1 was to come here to have labs and x-rays done in the ED ... PT1 did state they did tell EMP9 that (they were) here for the ED, but was told by EMP9 that (they) may need to get an ambulance to help (PT1) out ... ."

2. Surveyor requested to view Penn Highland Clearfield video footage of patient's (PT1) initial presentation to the facility on May 18, 2020. The video footage, noted that on
Monday May 18, 12:42 PM: Vehicle pull up at ED/Registration Entrance. PT1 noted to be in front passenger seat of vehicle. The vehicle with PT1 pulled away from the facility at 13:00. EMP6, EMP7, EMP9, and EMP12, were noted to have interaction with PT1 between 12:47 and 12:58.

3. There was no documentation that the PT1 received a Medical Screening Examination on this first presentation to the Emergency Department on May 18, 2020.
4. Review of the Ambulance Trip Sheet relative to PT1 revealed "... May 18, 2020 ... Description: The crew arrived at the patient and noted (PT1) to be sitting in the front seat of ... vehicle just outside of the Clearfield EMS building. (PT1) is noted to be anxious and crying. (PT1) does not appear to be in distress but visible scared and upset ... Patient was noted to be extremely upset, embarrassed, and crying thinking nobody will help (them) and (they) will continue falling ... Chief Complaint ... Epigastric pain, chest pain (non cardiac) bruising, unsteady gait with noted weakness, frequent falls, obesity ... History of Present Illness. This ... patient of ... presented today at this EMS facility after (family member) stated that they had went to the doctors' office and nobody would help (their parent) out of the SUV because (they were) a fall risk. Then they went to the PH Clearfield Hospital as directed by the doctors' office and ... asked for assistance getting (their parent) out of the vehicle ... was told by an employee that they could not help because (PT1) was a high risk fall and that (PT1) needed to come in by stretcher and to go home and call EMS and have them transport ... The EMS stretcher was brought to the patient's side of the vehicle. The patient was assisted under (their) arms to exit the vehicle by crew x 2. (PT1) was then able to pivot to the be seated on the EMS stretcher ... legs were assisted to the EMS stretcher and (PT1) was comfortable in a semi-fowlers position. The patient was then covered with blankets and was secured with stretcher straps ... and side rails x 2. The patient then wheeled to the ambulance where ... was safely loaded and secured for transport for further interventions ... Cardiac monitor ... and pulse ox placed on the patient to obtain vitals and continued monitoring throughout transport. Patient's breathing noted to be fast due to ... crying and anxiety. Patient was able to rate ... pain, intermittent at the epigastric area and more just aching tenderness with palpation ... Patient remains stable. Crew continues to talk with patient ... Patient co-operative and able to relate (their) anguish ... transport to Penn Highlands Clearfield ED ... The patient was safely unloaded and was wheeled into the ED via the EMS stretcher with one crew at each end of the stretcher for safety. Crew directed to ED #2. The patient was taken to room 2 in the ED. All EMS monitoring equipment was removed from the patient and ... was moved from the EMS stretcher to the ED bed via sheet left by crew x 2 and staff x 1. Patient was placed in a semi-fowlers position of comfort per the patient with ... side rails up and locked. A patient report and copy of the patient transfer was provided to the receiving nurse ... at the patient's bedside. All patient care was released to the staff at the ED and no further patient care was required of this crew ... This issue with the patient being turned away from the hospital earlier by unknown staff on the Admission side of Hospital was discussed with EMP3 to handle the situation further. The patient was left conscious, alert, and oriented to person, place, time and events ... Patient was much calmer and able to speak without crying. Patient still unable to rate pain or describe, just stating ... was ... sore ... "

5. Interview with EMP3 on July 28, 2020, at 11:30 AM revealed, "I was assisting in the ER that day. We received an ambulance patient, (they were) triaged and placed in a bed. (The patient) was telling (their) story and said that (they) was just here but couldn't get out of (their) car. I said, 'Excuse me?' (The patient) said (they) went to the clinic in ... to see the doctor, but couldn't get out of (their) car there. (The patient) was there to get testing done. (The patient) called (their) family doctor who told (the patient) to go to the ER ... There was a miscommunication between the screener and the patient as to whether (the patient) was coming to the ED to be seen or coming for testing as an outpatient. (The patient) needed (their) X-rays ... Both outpatient and ER patients come through the ED entrance. (The patient) was there for an ER visit, yes ... ."
6. Review of the ED Medical Record (MR23), dated May 18, 2020, revealed that PT1 subsequently presented to the Hospital via ambulance and was then received a medical screening examination.