HospitalInspections.org

Based on review of facility documents and staff interviews (EMP) it was determined that Brookville Hospital failed to follow adopted policies by ensuring that the Emergency Department was staffed with at least one physician for four of four patients who had presented to the Emergency Department for treatment, and failed to adopt policies and procedures which clearly defined responsibilities for physicians to respond, examine, and treat patients, when the scheduled physician cannot respond due to circumstances beyond his/her control.

Findings:

Review of "Brookville Hospital Medical Staff Bylaws, Rules, and Regulations", dated June 2012, revealed, "... 3.1-10 Patient Care. All Practitioners appointed to the Medical Staff shall provide continuous care and supervision to all patients within the Hospital for whom they have responsibility ... 4.6 Emergency Medical Staff. The Emergency Medical Staff shall consist of those physicians employed or contracted by the Hospital to provide Medical Staff coverage for the Emergency Room ... Article IX. Clinical Departments. 9.1 Clinical Departments and Sections. The Medical Staff of Brookville Hospital is departmentalized. The current clinical Departments of the Medical Staff are A. Medicine B. Surgery ... 9.4 Functions of Departments. 9.4-1 General Functions. Departments fulfill administrative, collegial and quality of care maintenance and assessment functions ... 9.4-2 Administrative Functions. Each Department will assure that its members contribute their professional views and insights to the formation of the Medical Staff and Hospital policies and plans, will communicate formulated policies and plans back to its members for implementation, and will coordinate the professional services of it's members with those of other Departments and clinical units and with Hospital and Medical Staff support services ... 10.2 Responsibility, Authority and Reporting Obligation of Departmental Officers ... E. Each Department Chairman shall be responsible for: 1. All clinically related activities of the Department. 2. All administratively related activities of the Department unless provided by the Hospital. 4. The coordination and integration of interdepartmental and intradepartmental services. 5. The development and implementation of policies and procedures that guide and support the provision of services. 6. The recommendations for a sufficient number of qualified and competent persons to provide care/service ... 9. The continuous assessment and improvement of the quality of care and services provided ... 11.8 Emergency/Ambulatory Care Function. The Emergency/Ambulatory Care Committee shall be responsible for the oversight of the Emergency Room and the Ambulatory Care Facilities of the Hospital. It shall perform the following functions in connection with the Emergency Room and the Ambulatory Care Facilities: 1. Quality and Appropriateness of Patient Care ... Rules and Regulations of the Medical Staff of Brookville Hospital ... I. Emergency Room Medical Records. 1. A medical record shall be created and maintained for each patient seeking emergency care. The Emergency Room medical record shall contain the following information: (A) Patient identification (B) Time and means of arrival (C) History and Physical Examination (D) Patient Vital signs (E) Emergency care given to patient prior to arrival (F) Diagnostic and therapeutic orders (G) Clinical observations and results of treatment (H) Reports of procedures and tests (I) Diagnostic impressions (J) Communications with family physician, if known (K) Final disposition (L) Patient's condition on discharge or transfer (M) Patient instructions for follow up care (N) Patient leaving against medical advice when applicable 3. The Emergency Room medical record shall be authenticated by the Emergency Room physician on duty who treated the patient ... O. 1. All physicians employed by the Hospital to work in the Emergency Room shall be required, as part of their appointment to the Medical Staff, to respond to and treat all emergencies in the Hospital. Said emergencies shall include, but not be limited to, cardiac arrests, precipitous obstetrical deliveries, and seriously ill patients in the absence of the attending physicians. 2. In those instances when a member of the Medical Staff is present with an ill patient for which an Advanced Life Support trip has been dispatched by the local ambulance service, said Medical Staff member shall discuss the case with the Medical Command physicians once radio or telephone contact has been made by the Paramedics at the scene. If the Medical Staff member is actively involved in the emergency care of the patient, he shall communicate with the Medical Command physician at the earliest opportunity ... ."
Review of the ED policy entitled "Medical Direction", dated February 28, 2013, revealed, "... Medical direction for the Emergency Department is by the Medical Staff via the Medical Director of the Department ... In the absence of the Medical Director, his designee assumes the overall responsibility for direction. The Director has the authority and responsibility for implementing established policies and for providing overall direction in the continuing operation of the department. The Director assures that quality, safety and appropriateness of emergency patient care and monitored and evaluated and that appropriate actions based on findings are taken. The medical director or a qualified designee contributes to the inservice education of Emergency Department Personnel."

Review of the ED policy entitled "Classification and Hours of Operation", dated February 28, 2013, revealed, "... The Emergency Department is classified as a Level II Emergency Department, which offers emergency care 24 hours a day with at least one physician experienced in emergency care on duty in the emergency area, and with specialty consults available by members of the medical staff. Initial consultation through two-way voice communication is utilized. The hospital's scope of service includes capabilities for managing physical and related emotional problems with provision for patient transfer to another facility when needed."

Review of the ED policy entitled "Physician Staffing", dated March 25, 2013, revealed, "Purpose: To define physician coverage of the Emergency Department. Policy: The physicians are employees of Brookville Hospital, and are active members of the medical staff in the event of unavailable Brookville Hospital Emergency Room Physicians; the hospital will use a Locum agency. At least one physician per shift must meet the requirements for Medical Command based on the Pennsylvania Department of Health Guidelines. Physician staffing is based on review of historical volume and acuity trends. Physicians are qualified based on current competence and experience in emergency medicine ... Procedure: Persons requesting care in the Emergency Department are examined by the Emergency Department physician ... The Emergency Department physician is responsible for the care of each patient's general medical condition."

Review of the ED policy entitled "Purpose and Goals of Emergency Department", dated February 28, 2013, revealed, "1. To assure prompt and efficient medical and nursing care to the victims of accidents and those who have experienced illness of sudden and/or serious nature. Medical and nursing care provided addresses Psychosocial as well as physical needs of the patients. 2. To provide and area in which emergency instrumentation and equipment is available for immediate use for adult and pediatric patients. 3. To provide support facilities for patients who are already hospitalized ... 7. To provide emergency services consistent with the community-based emergency plan ... ."

Review of the ED policy entitled "Scope of Service," dated March 25, 2013, revealed, "It is the function of the Emergency Department to provide twenty-four hour care to individuals who require treatment of illness and injury, initially presenting as an outpatient. Qualified medical and nursing personnel provide expertise in managing life threatening as well as serious illness and injury ... I ... It is the function of the Emergency Department to deliver 24-hour quality care for patients suffering emergent, urgent and non-emergent illness or injury ... II ... A. Services provided: 1. Triage of patients by acuity 2. Medical evaluation by acuity 3. Nursing Care 4. Emergency treatment of acute illness or injury 5. Patient stabilization, admission, transfer or discharge ... VI. Patient Population ...D. Any patients presenting to the Emergency Department will be treated by Brookville Hospital personnel ... ."

Review of the ED policy entitled "Organization," date February 28, 2013, revealed, "Purpose: To define organization of the department. Policy: 1. Emergency Department Director: The Medical Director of the Emergency Department is responsible for carrying out established policy and for the overall medical care in the area, as well as for orientation, scheduling and supervising of emergency physicians. He is responsible for assuring that a quality assurance program is implemented ... ."

1) An interview was conducted with EMP2 on April 4, 2013, at 9:40 AM. EMP2 stated "I was the Administrator On Call. I received a call at 2:30 in the morning from nursing. ... that the physician scheduled to come in that day at 7:00 AM, had called in ill, that the physician was unable to work. I directed the nursing staff to call ... our contracted company. Our Medical Director was out of the country and OTH16 was covering for him. The nursing staff contacted DRMC (DuBois Regional Medical Center) to call OTH16 who was covering. The current ED physician that was here, was on a twenty-four hour shift, and [their] shift was up at 7:00 AM. It was the physician that was replacing [them] at 7:00 AM, that called off. OTH6 ... from DRMC called and advised the physician in the ED that [they] could not stay, that it was unsafe ... We contacted several other physicians at that time, and could not get anyone to come in ... I can tell you that we do not have a formalized process in place for when this occurs. So on this day we did not have a physician in the Emergency Department from 7:00 AM to 11:43 AM."
2) An interview was conducted with EMP3 on April 4, 2013, at 9:50 AM. EMP3 was queried to events that occurred on March 30, 2013. EMP3 stated "...I wasn't here when there was no physician coverage but was when the doctor called in sick. The Clinical Care Coordinator (kind of like a supervisor) called the Administrator on call, EMP2. EMP6 took the call from the doctor. EMP6 called DuBois Regional Medical Center (DRMC). At six AM, the shift was still not covered. I absolutely saw a problem with this ... A couple of weeks ago we had this almost happen again. It was a near miss. OTH30 came in ... [They] used to be one our ED docs ... We have had some holes in the schedule with ... as of late, I heard they dropped them ... ."
3) An interview was conducted with EMP4 on April 4, 2013, at 2:30 PM. "...We only have one doctor here. What happens if [they] should go down? The doctor called off, [they were] very sick. We were all very nervous about the situation. We didn't have a lot of patients and the ones we did were low level, fours or fives. We were on the phone all morning trying to find coverage ... We never said we would not treat, but that we would help them find care. We told them that we would bring them in and take vital signs, triage, and make them comfortable on a limited basis. We told them that due to circumstances beyond our control, we can't have a doctor see you now. At that point people weren't interested in much else. There was no way they wanted to stay if there was no doctor. People didn't have any interest in coming through the doors, once they knew we didn't have a doctor ... ."
4) An interview was conducted with OTH16 on April 5, 2013, at approximately 11:15 AM. OTH16 stated "Basically, Brookville has a contract with an independent company to staff their Emergency Department at Brookville Hospital. They supply the Medical Director for the Emergency Department. The Emergency Department Medical Director at Brookville Hospital is OTH22, [they are] part of the contracted service. If [they are] not available [the independent company] has a Regional Director OTH23 ... Basically OTH22 was out of town or the country. OTH22 did not make that known and did not have a back-up plan. I was not covering for OTH22. I was unaware that OTH22 was out of town. If OTH22 would have called and made arrangements for me to cover ... I probably would have ... I was never asked to be the Emergency Department Medical Director nor do I have a contract which states I will provide this service ... ."

Based on review of facility documents and staff interviews it was determined that Brookville Hospital failed to maintain their Central Log for all patients who presented to the Emergency Department.

Findings:

Review of "Brookville Hospital ... Policy#: EMR-12 Title: Control Register" revealed, "... Purpose: To provide a source of statistical information. Information obtained from the Register will aid in planning staffing for the Emergency Department. Information from the Register may be used for department and institutional census statistics. Information will also be useful in planning health care services for the community. Information obtained from the Control Register can also be used as a guide in selecting record for quality and appropriateness of services provide. Policy: A Control Register is continuously maintained and includes the following information. 1. Date of Emergency Department visit 2. Time of patient arrival 3. Patients name and Medical Record number 4. Attending physician and family physician ... 5. Age range .... 6. Sex of the patient. 7. Classification of patient based on triage classification 8. Patients diagnosis and complaint 9. Mode of entry (ambulatory, wheelchair, ambulance, etc) 10 Disposition 11. Time of departure Procedure: 1. All patients receiving care in the Emergency Department are entered into the Control Register each shift utilizing the Medhost electronic medical record system. 2. In the event of electronic medical records system is unavailable the Control Register will be entered manually by the Emergency Room Staff on form titled Emergency Department Control Register during electronic medical records downtime a. The Emergency Department Control Register during electronic medical records downtime will be entered manually by the ER Register Clerk or ER staff. ... b. The Medhost Downtime Emergency Department Control Registry form will be forwarded to the ER Manager daily. "This policy was reviewed by the Policy Integration Team on February 2013.

1) Review of the "Emergency Department Daily Log" revealed that on March 30, 2013, there was a gap in the Log.

2) The facility produced a "Brookville Emergency Room Diversion Record" dated March 30, 2013, with information for four patients who presented to their Emergency Department during the period of time that they were without a physician present. It was noted that these four patients were not entered into the Emergency Department "Daily Log Detail."
The Diversion Record indicates that a patient presented to the ED at 8:50 AM, with documentation that the"patient came from a Doctor's office, with abnormal kidney problems. Family angry & left; at 9:50 AM,"
A patient presented with complaint of "ear infection-headache-cough; at 9:55 AM,"
A patient presented with complaint of "Eye problem - Pain; at 9:57 AM,"
A patient presented with "Right Arm Pain; at 11:35 AM."

3) An interview with EMP4 was conducted on April 4, 2013, at approximately 2:30 PM, revealed, " ... We told them that due to circumstances beyond our control, we can't have a doctor see you now. At that point people weren't interested in much else. There was no way they wanted to stay if there was no doctor. I kept track of their names, phone number and what their problem was so that we could follow up later. We told them that they didn't have to provide us with any information. These patients information was not placed on our ED Central Log. ... ."

Based on review of facility documents and staff interviews (EMP) it was determined that Brookville Hospital failed to provided medical screening examinations for four of four patients that presented to the Emergency Department seeking medical treatment.

Findings:

Review of "Brookville Hospital ... Policy #: EXE-01-09 Title: EMTALA Compliance (Transfer of Patients)" revealed, "... Purpose: ... This policy and procedure further provides for stabilizing care to patients in and on all hospital grounds and property both on and off the main hospital campus. For purpose of this policy, emergency medical condition includes a patient in active labor and the unborn child. IT SHALL BE THE POLICY OF BROOKVILLE hospital To: 1. Perform a medical screening exam when a patient presents to the hospital requesting medical assistance to determine if the patient has an emergency medical condition, regardless of the patient's ability to pay. If it has been determined that the patient has an emergency medical condition: a. stabilizing treatment will be initiated within the capabilities of the staff and facilities available at the hospital b. a specialist from the hospital's ... c. and/or arrangements will be made for transfer of the patient to a facility where appropriate treatment may be obtained. ... Definitions: Emergency Medical condition means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pan) that the absence of immediate medical attention could reasonably be expected to result in: a. serious jeopardy to the health of the individual (or, with respect to a pregnant woman, the health of the woman or the unborn child) b. serious impairment to bodily function c. serious dysfunction of any bodily organ or part; or 2. With respect to a pregnant woman who is having contractions: a. that there is adequate time to effect a safe transfer to another hospital before delivery; b. or the transfer may pose a threat to the health or safety of the woman or the unborn child. Stabilizing means, with respect to tan Emergency Medical Condition as defined in subparagraph 1 above: 1. to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result or occur during the transfer of the individual from a facility; or, 2. With respect to an Emergency Medical Condition involving a pregnant woman, that the woman has delivered (including placenta). Procedure: Initial Medical Screening Procedures An initial triage assessment is completed by a Registered Nurse. A medical screening examination is performed by the ED Physician. It includes a history, vital signs, an examination of the injury and a medical assessment to determine whether an acute medical emergency exists.... The initial medical screening examination is performed uniformly on all patients who come to the Emergency Department requesting medical care. The following guidelines are considered in the initial medical screening examination: a. Chief symptom: chronic condition or acute onset b. Vital signs c. Mental state: evidence of change; emotional status d. General appearance e. Degree of pain - utilizing pain scale rating f. Skin - evidence of dehydration, poor perfusion g. Physical exam findings - cardiovascular, respiratory, gastrointestinal, genitourinary and musculoskeletal h. Past medical history i. Current medication regimen and allergies j. Ability to walk k. Pregnancy: Is the patient near term? ... ."

1) Review of the "Emergency Department Daily Log" revealed that on March 30, 2013, there was a gap in the Log.
2) The facility produced "Brookville Emergency Room Diversion Record" dated March 30, 2013, with information for four patients who presented to their Emergency Department during the period of time that they were without a physician present. It was noted that these four patients were not entered into the Emergency Department "Daily Log Detail."
The Diversion Record indicates that a patient presented to the ED at 8:50 AM, with documentation that the"patient came from a Doctor's office, with abnormal kidney problems. Family angry & left; at 9:50 AM,"
A patient presented with complaint of "ear infection-headache-cough; at 9:55 AM,"
A patient presented with complaint of "Eye problem - Pain; at 9:57 AM,"
A patient presented with "Right Arm Pain; at 11:35AM."

3) An interview was conducted with EMP2 on April 4, 2013, at 9:40 AM. "I was the Administrator On Call. I received a call at 2:30 in the morning from nursing. ... that the physician scheduled to come in that day at 7:00 AM, had called in ill, that the physician was unable to work. ... We contacted several other physicians at that time, and could not get anyone to come in. ... So on this day we did not have a physician in the Emergency Department from 7:00 AM to 11:43 AM."