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Based on Bylaws of the Medical Staff review, policy and procedure review, clinical record review, Emergency Department Provider Calendar review, Physician e-mail review, and interview, it was determined the facility failed to follow the Bylaws of the Medical Staff in that 14 (#1, #3-#9, #13-#17, and #20) of 20 (#1-#20) patients reviewed, who presented to the Emergency Department, did not have a medical screening exam conducted by a physician as required in the Bylaws of the Medical Staff.

This facility failed to ensure that a physician was on staff in the Emergency Department on a 24 hour basis to perfomr appropriate medical screening examination on individuals presenting for examination of a medical condition as required by the Bylaws of the Medical Staff.

Failure to ensure patients were provided with an appropriate medical screening examination by a physician, this facility failed to be in compliance with its bylaws and the patients failed to receive the level of care mandated by the facility. The failed practice affected Patient #1, #3-#9, #13-#17, and #20 and had the potential to affect all patients presenting to the Emergency Department.

Findings:

A. Review of the Bylaws of the Medical Staff with an approved date of 05/09/12 showed the following for Emergency Services:

1. Emergency Room coverage will be assigned to Active Staff physicians on a rotating basis, as coordinated by the Chief of Staff, and the Medical Staff will be responsible for establishing policies and procedures for this area.

2. An appropriate medical record, signed by the attending physician, shall be kept for every patient receiving emergency services, and be incorporated in the patient's Hospital record, if one already exists. The record shall at least include the following: ...

a. Pertinent history of the injury or illness, including details of first aid or emergency care given prior to the patient's arrival at the Hospital.

b. Description of significant clinical, laboratory and x-ray findings.

c. Diagnosis.

d. Treatment given.

e. Condition of patient on discharge or transfer.

f. Final diagnosis, including instructions given to the patient and/or the family relative to necessary follow-up care.


B. The above findings were confirmed in an interview with the Director of Nursing on 02/14/19 at 2:45 PM. The Director of Nursing confirmed the Bylaws of the Medical Staff with an approved date of 05/09/12 were the most current bylaws.

C. Review of Patient #1's clinical record on 02/15/19 showed, the patient presented to the Emergency Department on 02/14/19 at 10:55 AM. Nursing Note (no time provided) showed, "Explained to parents no provider in ER (Emergency Room)." There was no evidence that a medical screening exam was conducted by a physician to determine if an emergent condition existed. There was no evidence stabilizing treatment was provided. The findings were confirmed in an interview with the Emergency Room Supervisor on 02/15/19 at 12:55 PM.

D. Review of Patient #3-#9, #13-#17, and #20's clinical record on 02/15/19 showed a medical screening exam was performed by an APN rather than a physician as required per the Bylaws of the Medical Staff.

E. The above findings were confirmed in an interview with the Emergency Room Supervisor on 02/15/19 at 12:55 PM.

F. Review of the facility's "Policy and Procedure Manual for Critical Access Hospitals Emergency Department" with a signature date of 03/28/18, a policy titled, "Emergency Department Category of Service," with a revision date of 2010, showed the Emergency Department was categorized as providing Level IV service offering emergency treatment 24 hours a day. At least one physician was to be on duty in the emergency room 24 hours a day.

G. The above findings were confirmed in an interview with the Director of Nursing on 02/15/19 at 9:20 AM.

H. Review of the February 2019 Emergency Department provider calendar on 02/14/19 showed an Advanced Practice Nurse (APN) or a Physician was scheduled for each day. Review of the February 2019 NP/MD (Nurse Practitioner/Physician) Back-Up calendar showed Physician #4 was listed as the back-up physician for APN #1 (Corporate Nursing Officer) and APN #2.

I. Review of an email from Physician #2 sent to the Owner on 02/11/19 showed, "Dear (Owner). It has been a trend at your side delaying payments for Doctors, Nurses and other staff at DQMC (De Queen Medical Center). This email is referring to most of your physicians who were kind enough to schedule shifts at your hospital without being certain of the timely reimbursement as a gesture to keep the hospital running, some were even kinder to continue working without being paid hoping that you will honor your word and promises for them to be compensated for all the time they spent working and maintaining the operation of the hospital, yet you continue to delay and even deny their payments in an very unprofessional manner. At this time we as the main group of physicians working at DQMC regret to inform you that starting today 02/11/2019 (we) will not cooperate with you in running the ED (Emergency Department) at your hospital, unless we get fully reimbursed for all the delayed unpaid hours. It's your full responsibility to find alternate coverage for all the scheduled shifts at ED. We all stand as one body and we all hope that you return to your senses and look at this entire case with appreciation rather than denial." Physician #1, #2 and #3's names were listed on the email.

J. In an interview with the Director of Nursing and the ER Supervisor on 02/14/19 at 8:40 AM, the ER Supervisor stated, the Emergency Department no longer has provider (APN or Physician) coverage. The Director of Nursing stated, no physician was willing to cover the Emergency Department due to financial concerns. The ER Supervisor stated, the facility went on "diversion" as of 02/14/19 at 8:15 AM when APN #1 left the facility. The Director of Nursing stated, Physician #1 and #5 refused to staff the ER. The Director of Nursing stated the Chief of Staff (Physician #4) resigned as of 02/13/19.

K. In an interview with the Director of Nursing and ER Supervisor on 02/15/19 at 8:55 AM, the ER Supervisor stated the Emergency Department did not have provider coverage at this time. The Director of Nursing stated that if a patient presented to the Emergency Room, the staff would inform the patient a provider was not available for treatment. The ER Supervisor stated that if the patient felt their condition was an emergency, the staff would ask the patient if they wanted the staff to call 911.

L. In a telephone interview with the Director of Nursing on 02/19/19 at 8:30 AM, she stated the facility did not have provider coverage. The Director of Nursing confirmed the facility had not had provider (APN or Physician) coverage since 02/14/19 at 8:15 AM.

Based on Bylaws of the Medical Staff review, policy and procedure review, clinical record review, and interview, it was determined the facility failed to ensure stabilizing treatment was provided for 1 (#1) of 20 (#1-#20) patients who presented to the Emergency Department. The failed practice did not ensure the patient received medical treatment according to the patient's presenting symptoms. The failed practice affected Patient #1 and had the potential to affect all patients seen in the Emergency Department.


Findings:

A. Review of the Bylaws of the Medical Staff with an approved date of 05/09/12 showed the following for Emergency Services:

1. Emergency Room coverage will be assigned to Active Staff physicians on a rotating basis, as coordinated by the Chief of Staff, and the Medical Staff will be responsible for establishing policies and procedures for this area.

2. An appropriate medical record, signed by the attending physician, shall be kept for every patient receiving emergency services, and be incorporated in the patient's Hospital record, if one already exists. The record shall at least include the following:

a. Pertinent history of the injury or illness, including details of first aid or emergency care given prior to the patient's arrival at the Hospital.

b. Description of significant clinical, laboratory and x-ray findings.

c. Diagnosis.

d. Treatment given.

e. Condition of patient on discharge or transfer.

f. Final diagnosis, including instructions given to the patient and/or the family relative to necessary follow-up care.

B. The above findings were confirmed in an interview with the Director of Nursing on 02/14/19 at 2:45 PM. The Director of Nursing confirmed the Bylaws of the Medical Staff with an approved date of 05/09/12 were the most current bylaws.

C. Review of the facility's "Policy and Procedure Manual for Critical Access Hospitals Emergency Department" with a signature date of 03/28/18, a policy titled, "Emergency Department Category of Service," with a revision date of 2010 showed, the Emergency Department was categorized as providing Level IV service offering emergency treatment 24 hours a day. At least one physician was to be on duty in the emergency room 24 hours a day.

D. The above findings were confirmed in an interview with the Director of Nursing on 02/15/19 at 9:20 AM.

E. Review of Patient #1's clinical record on 02/15/19 showed, the patient presented to the Emergency Department on 02/14/19 at 10:55 AM related to being sent home from school with a fever (102.5* F). Nursing Note (no time provided) showed, "Explained to parents no provider in ER (Emergency Room). Contacted (Named Clinic), appointment for 1:20 PM. Parents verbalized understanding." There was no evidence that a medical screening exam was conducted by a physician to determine if an emergent condition existed. There was no evidence stabilizing treatment was provided. The findings were confirmed in an interview with the Emergency Room Supervisor on 02/15/19 at 12:55 PM.