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Based on interview, record review and review of policies and procedures, it was determined the facility failed to provide appraisal and initial treatment of medical emergencies that occur at the hospital between the hours of 5:00PM- 6:30 AM. The cumulative effect of these sytemic practices resulted in the facility's inability to ensure patients' needs would be met.

Findings:

See A 0093

Based on review of policies, review of medical records and staff interviews the governing body failed to ensure the hospital policy and staff did not rely on 9-1-1 to substitute for the hospital's emergency response requirements for emergency care after 5:00 pm until 6:30am and failed to ensure the policy was followed for the transfer of one of eleven patients reviewed (Patient #11). This deficient practice had the potential to affect all patients receiving care from this facility. The facility had 487 inpatients out of 9,487 operative cases performed through November 2013. The facility provides general surgery and specialties such as orthopedics, otolaryngology, podiatry, gastroenterology, plastic surgery, gynecology, pain management, ophthalmology and imaging services.

Findings:

1) The facility was toured with Staff B on 12/02/13 at 12:10 PM. Twenty-nine inpatient rooms were observed during the tour of which four were occupied. Two registered nurses (RNs) were observed caring for the four patients admitted to inpatient beds. A code blue emergency button was noted in all rooms toured.

Staff B was interviewed at the time of the tour on 12/02/13 at12:10 PM and was asked to describe the facility's protocol for emergency situations. Staff B reported that all RNs caring for inpatients are required to be certified in advanced cardiovascular life support (ACLS) and pediatric advanced life support (PALS). Registered nurses initially call 911 if a code blue occurs after hours between 05:00 PM and 06:30 AM. The attending physician and hospitalist are also notified. According to Staff B, hospitalists are on call 24 hours a day, 7 days per week.

Staff C, an Inpatient unit registered nurse, was interviewed on 12/04/13 at 11:00 AM. According to Staff C, in an emergency situation, someone calls 911 and nurses work together to stabilize the patient and get them ready to transfer. The Staff C also indicated that the hospitalist is notified of the situation. The nurse denied there had been any emergency situations to his/her knowledge but stated, "I would assume the hospitalist would come in but in a true emergency situation, the patient would have already been transferred before the hospitalist got here."

2) Ten medical records reviewed contained a Consent of Disclosure of Onsite Physician Services that was signed by all 10 patients. The disclosure listed the following points: 1. "The hospital does not have an onsite physician after normal business hours Monday through Friday (7 am-5 pm) weekends and holidays." 4. "The hospitalist is on call 24/7 and makes rounds at least once a day." 5. "Your physician is readily available by telephone and will be contacted in the event that he/she is needed."

3) Review of the facility policy titled "Code Blue Procedure" on page 3 of 4 under subtitle "TriHealth Evendale Hospital" revealed "The emergency cart will be brought to the code area. Between the hours of 5:00 PM-6:30 AM, the outside 911 emergency medical system will be activated. The RN in charge of code team will facilitate and direct transport to an outside emergency department (ED) for stabilizing care and treatment." The facility failed to ensure the Doctor (onsite or on call) directly provided appraisals of emergencies between 5:00 PM -6:30 AM as opposed to having 911 provide the appraisal.

4) Review of the facility policy titled "Transfer of a Patient to Another Facility" revealed "Hospital personnel will contact a transport service to arrange transportation as required."

Review on 12/05/13 of a document (no title) that contained a list of patient transfers to other inpatient hospitals revealed a total of 8 patients for 2013. Documentation from the list revealed that on 10/23/13, Patient #11, a 70 yr old, began to cough brown bile and mucous during an upper endoscopy/colonoscopy procedure . The procedure was discontinued and an X-ray was performed in the post care unit that revealed a lower lobe infiltrate. The documentation on the transfer list revealed that anesthesia spoke with the patient's primary care doctor and made the decision to transfer by car.

This finding substantiates substantial allegation number OH00072249.