HospitalInspections.org

Based on review of records and interviews, the hospital failed to comply with 489.24 in that:

1) 15 of 20 patients (Patient # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, and 20) who presented between 11/13/09 and 01/25/10 were not provided an appropriate medical screening examination in the Emergency Department (ED) to determine whether or not an emergency condition existed. These 15 patients were assessed and/or treated by PA#1 (Physician Assistant) who was not determined qualified by hospital bylaws or the medical staff rules and regulations.

The Medical Staff Rules & Regulations (section A. 10) attached to Bylaws of The Medical Staff dated August 2002 noted, "the following individuals are designated to be 'Qualified Medical Providers' and are authorized to perform 'medical screening exams' as defined in the Emergency Medical Treatment and Labor Act (EMTALA)."
However, no individuals were designated to be "Qualified Medical Providers."

The Bylaws of The Medical Staff, Article VIII, Allied Health Professionals, required:
(item 8.2) " All activities undertaken by AHP ' s shall be ...in conformity with these Bylaws and Medical Staff Rules and Regulations ..."

(item 8.1) "In order to be eligible to provide specified services..., an individual must...document qualifications, physical and mental health status, training, experience and current competence... "

Review of PA #1 ' s Personnel File revealed the Job Description for Physician Assistant dated 11/01/05 did not address duties and responsibilities of the PA for the ED. The personnel file did not have any ED competencies documented for PA #1.

During an interview on the morning of 02/24/10, Physician #2 was asked how he monitored the care provided by the mid-level practitioner when Physician #2 was on call. He stated, " I review the charts of the Physician Assistant (PA) and the Nurse Practitioner (NP). " He was then asked whether he reviewed the appropriateness of care provided by the PA or NP. He said " No. "
Cross refer to tag A 2406

2) 4 of 4 patients (Patient # 1, 2, 3, and 4) examined by PA #1 in the ED between 12/14/09 and 02/24/10 were not provided further medical examination and/or treatment to stabilize their medical condition within the capabilities of the hospital.

Patient #1, age 84, presented on 12/28/09 at 8:55 am by ambulance; the ambulance record noted "vomiting blood, bloody diarrhea and a syncopal episode."
ED record noted hemoglobin was 10 (normal range 12-16), hematocrit was 29.3 (normal range 36-46), prothrombin time was 60.5 (normal range 9-12), international normalized ratio was 6.227 (normal range 1-3), and fecal occult blood was positive.
Physician Assistant (PA) #1 assessed this patient and treated her with intravenous normal saline, then discharged.

The medical record at hospital B noted that patient #1's family transported the patient in private vehicle to hospital B where she was admitted, underwent further medical examination and treatment for gastrointestinal bleed.

Patient #2, age 88, presented by family car on 1/25/10 with chief complaint of " dizzy and weakness " and episode of decreased blood pressure at home. ED record noted her past medical history included a pacemaker and antihypertensive medication.
PA #1 assessed this patient and treated her with intravenous normal saline, then discharged.

Patient #3, age 77, presented at 13:05 on 12/30/09 with the chief complaint of irregular heart beat, shortness of breath (SOB) with exertion and palpitations. ED record showed a past medical history of heart disease and hypertension. A 12 lead electrocardiogram performed on admission showed atrial fibrillation with a heart rate of 135.
PA #1 assessed this patient and treatment included Cardizem IVP (intravenous push), "NS at 30 cc/hr," Digoxin po (by mouth), and Coumadin po. Heart rate was 102 when discharged.

Patient #4, age 64, presented by ambulance on 12/14/09 at 2:00 pm with the chief complaint of SOB and weakness. ED record showed a past medical history which included asthma and apnea. Arterial Blood Gases showed ph 7.32 (normal range 7.35-7.45), PCO2 73 (normal range 35-45), PO2 94 on 5 lpm (liters per minute) of oxygen (normal range 80-100 on room air). PA #1 assessed this patient and discharged her without treatment or discharge instructions.

The hospital had beds and staff available for inpatient admission and/or observation on 12/14/09, 12/28/09, 12/30/09, and 01/25/10, when patients # 1, 2, 3, and 4 were in the ED. This hospital routinely provides medical services for patients in need of internal medicine services.
Cross refer to tag A 2407

3) Patient # 1 was not provided medical treatment within the hospital's capacity prior to discharge.

Patient #1, age 84, presented on 12/28/09 at 8:55 am by ambulance. Ambulance record noted " vomiting blood, bloody diarrhea " and " syncopal episode. "
ED record noted hemoglobin was 10 (normal range 12-16), hematocrit was 29.3 (normal range 36-46), prothrombin time was 60.5 (normal range 9-12), international normalized ratio was 6.227 (normal range 1-3), and fecal occult blood was positive.
Patient #1 ' s home medications included Coumadin (a blood thinner).
Blood pressure on arrival was 151/76, and decreased to 112/75 one hour later (9:55 am).
Physician Assistant (PA) #1 assessed this patient and treated her with intravenous (IV) "NS 650 cc" which infused from 10:30 am to 11:05 am. Patient #1 was discharged 20 minutes after the IV fluid was stopped (11:25 am) with discharge instructions for gastrointestinal bleeding.

The medical record at hospital B noted that patient #1's family transported this patient in a private vehicle from Comanche County Medical Center to hospital B, located in another town 30 miles away; hospital B was the closest hospital to Comanche County Medical Center. Patient #1 was admitted to hospital B with blood pressure of 95/47. During the stay at hospital B, she underwent further medical examination and treatment for gastrointestinal bleed, including administration of four units packed red blood cells and two units fresh frozen plasma.

The hospital had beds and staff available for inpatient admission and/or observation on 12/28/09 when patient # 1 was in the ED. This hospital routinely provides medical services for patients in need of internal medicine services.
Cross refer to tag A 2409

Based on review of records and interviews, 15 of 20 patients (Patient # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, and 20) who presented between 11/13/09 and 01/25/10 were not provided an appropriate medical screening examination in the Emergency Department (ED) to determine whether or not an emergency condition existed. These 15 patients were assessed and/or treated by PA#1 who was not determined qualified by hospital bylaws or the medical staff rules and regulations.

Findings:

The Medical Staff Rules & Regulations (section A. 10) attached to Bylaws of The Medical Staff dated August 2002 noted, "the following individuals are designated to be 'Qualified Medical Providers' and are authorized to perform 'medical screening exams' as defined in the Emergency Medical Treatment and Labor Act (EMTALA)."
However, no individuals were designated to be "Qualified Medical Providers."

The Bylaws of The Medical Staff, Article VIII, Allied Health Professionals, required:
(item 8.2) " All activities undertaken by AHP ' s shall be ...in conformity with these Bylaws and Medical Staff Rules and Regulations ..."

(item 8.1) "In order to be eligible to provide specified services..., an individual must...
"document qualifications, physical and mental health status, training, experience and current competence... "

Review of PA #1 ' s Personnel File revealed the Job Description for Physician Assistant dated 11/01/05 did not address duties and responsibilities of the PA for the ED. The personnel file did not have any ED competencies documented for PA #1.
PA#1 was not designated as a "Qualified Medical Provider" (QMP) nor approved by the Governing Board as a QMP to perform medical screening examinations to determine whether an emergency condition exists.

During an interview on the morning of 02/24/10, Physician #2 was asked how he monitored the care provided by the mid-level practitioner when Physician #2 was on call. He stated, " I review the charts of the Physician Assistant (PA) and the Nurse Practitioner (NP). " He was then asked whether he reviewed the appropriateness of care provided by the PA or NP. He said " No. "

Patient #1 presented on 12/28/09 with a chief complaint of vomiting blood, bloody diarrhea and syncopal episode. Physician Assistant (PA #1) assessed this patient and discharged home.

Patient #2 presented on 01/25/10 with a chief complaint of dizzy and weakness. PA #1 assessed this patient and discharged home.

Patient #3 presented on 12/30/09 with a chief complaint of irregular heart beat, shortness of breath (SOB) with exertion and palpitations. PA #1 assessed this patient and discharged home.

Patient #4 presented on 12/14/09 with a chief complaint of SOB and weakness. PA #1 assessed this patient and discharged home.

Patient #5 presented on 12/23/09 with a chief complaint of left elbow arm pain. PA #1 assessed this patient and transferred to a higher level of care with a left distal humerus fracture.

Patient #6 presented on 12/30/09 with a chief complaint of abdominal pain, depression and anxiety. PA #1 assessed this patient and discharged home.

Patient #7 presented on 11/18/09 with a chief complaint of shoulder pain and urinary complaints. PA #1 assessed this patient and discharged home.

Patient #8 presented on 12/23/09 with a chief complaint of abdominal pain and fever. PA #1 assessed this patient and transferred patient to a higher level of care with possible acute appendicitis.

Patient #9 presented on 12/30/09 with a chief complaint of epigastric pain. PA #1 assessed this patient and discharged home.

Patient #10 presented on 12/02/09 with a chief complaint of unable to hear fetal heart tones at physician office. PA #1 assessed this patient and discharged home after pelvic exam and monitoring fetal heart tones.

Patient #11 presented on 11/18/09 for chief complaint of chest pain. PA #1 assessed this patient and transferred to a higher level of care with acute angina.

Patient #13 presented on 11/13/09 with a chief complaint of abdominal pain. PA #1 assessed this patient and discharged home.

Patient #14 presented on 11/13/09 with a chief complaint of headache. PA #1 assessed this patient and discharged home.

Patient #15 presented on 11/13/09 with chief complaint of sore throat and fever. PA #1 assessed this patient and discharged home.

Patient #20 presented on 12/03/09 with chief complaint of diarrhea. PA #1 assessed this patient and transferred to a higher level of care.

Based on review of records and interviews, 4 of 4 patients (Patient # 1, 2, 3, and 4) examined by Physician Assistant #1 in the emergency department (ED) between 12/14/09 and 02/24/10 were not provided further medical examination and treatment to stabilize their medical condition within the capabilities of the hospital.

Findings:

Patient #1, age 84, presented on 12/28/09 at 8:55 am by ambulance. Ambulance record noted " vomiting blood, bloody diarrhea " and " syncopal episode. "
ED record noted hemoglobin was 10 (normal range 12-16), hematocrit was 29.3 (normal range 36-46), prothrombin time was 60.5 (normal range 9-12), international normalized ratio was 6.227 (normal range 1-3), and fecal occult blood was positive.
Patient #1 ' s home medications included Coumadin (a blood thinner).
Blood pressure on arrival was 151/76, and decreased to 112/75 one hour later (9:55 am).
Physician Assistant (PA) #1 assessed this patient and treated her with intravenous (IV) " NS 650 cc " which infused from 10:30 am to 11:05 am. Patient #1 was discharged home 20 minutes after IV fluid was stopped (11:25 am) with discharge instructions for gastrointestinal bleeding.

The medical record at hospital B noted that patient #1's family transported the patient in private vehicle from Comanche County Medical Center to hospital B, located in another town 30 miles away (closest hospital to Comanche County Medical Center). Patient #1 was admitted with blood pressure of 95/47. During the stay at hospital B, she underwent further medical examination and treatment for gastrointestinal bleed, including administration of four units packed red blood cells and two units fresh frozen plasma.

In an interview on the morning of 02/24/10, PA #1 was asked if the on call physician examined the patient. PA #1 stated " No. "
In an interview on the morning of 02/24/10, Physician #2 was asked if he was the physician on call for the ED the morning of 12/28/09. He stated, " Yes. " He was asked if he examined Patient #1 on the morning of 12/28/09 in the ED. He stated, " No. "

Patient #2, age 88, presented by family car on 1/25/10 with chief complaint of " dizzy and weakness " and episode of decreased blood pressure at home. ED record noted her past medical history included a pacemaker and antihypertensive medication.
PA #1 assessed this patient and treated her with IV " NS 250 cc Bolus then 100 cc/hr " with a total of 475 cc infused over approximately 2 ? hours. During Patient #2 ' s stay, her blood pressure ranged from 111/60 on admission, to 126/62 during IV infusion, to 119/44 on discharge. Patient #2 was discharged home, after a three-hour ED stay, with instructions for hypotension.

Patient #3, age 77, presented at 13:05 on 12/30/09 with the chief complaint of irregular heart beat, shortness of breath (SOB) with exertion and palpitations. ED record showed a past medical history of heart disease and hypertension. Home medications included Amlodipine (calcium channel blocker used to treat high blood pressure and chest pain), Losartan (used for hypertension), and Nitroglycerin (used for chest pain). A 12 lead electrocardiogram performed on admission showed atrial fibrillation with a heart rate of 135.
PA #1 assessed this patient and treatment included Cardizem IVP (intravenous push), "NS at 30 cc/hr," Digoxin po (by mouth), and Coumadin po. Patient #3 was placed on a cardiac monitor. The cardiac monitor strips continued to show irregular heartbeat with rates ranging from 137 to 102 at discharge. Patient #3 was discharged home, after a two hour twenty minute ED stay, with instructions for atrial fibrillation.

Patient #4, age 64, presented by ambulance on 12/14/09 at 2:00 pm with the chief complaint of SOB and weakness. ED record showed a past medical history which included asthma, apnea, GERD (gastroesophageal reflux disease) and Fibromyalgia. Arterial Blood Gases showed ph 7.32 (normal range 7.35-7.45), PCO2 73 (normal range 35-45), PO2 94 on 5 lpm (liters per minute) of oxygen (normal range 80-100 on room air).
PA #1 assessed this patient and discharged her home, after a two hour forty minute ED stay, without treatment or discharge instructions.

During an interview on the morning of 02/24/10, Physician #2 was asked how he monitored the care provided by the mid-level practitioner when Physician #2 was on call. He stated, " I review the charts of the Physician Assistant (PA) and the Nurse Practitioner (NP). " He was then asked whether he reviewed the appropriateness of care provided by the PA or NP. He said " No. "

The hospital had beds and staff available for inpatient admission and/or observation on 12/14/09, 12/28/09, 12/30/09, and 01/25/10, when patients # 1, 2, 3, and 4 were in the ED. This hospital routinely provides medical services for patients in need of internal medicine services.

Based on review of records and interviews, Patient # 1 was not provided medical treatment within the hospital's capacity prior to discharge.

Findings:

Patient #1, age 84, presented on 12/28/09 at 8:55 am by ambulance. Ambulance record noted " vomiting blood, bloody diarrhea " and " syncopal episode. "
ED record noted hemoglobin was 10 (normal range 12-16), hematocrit was 29.3 (normal range 36-46), prothrombin time was 60.5 (normal range 9-12), international normalized ratio was 6.227 (normal range 1-3), and fecal occult blood was positive.
Patient #1 ' s home medications included Coumadin (a blood thinner).
Blood pressure on arrival was 151/76, and decreased to 112/75 one hour later (9:55 am).
Physician Assistant (PA) #1 assessed this patient and treated her with intravenous (IV) " NS 650 cc " which infused from 10:30 am to 11:05 am. Patient #1 was discharged 20 minutes after the IV fluid was stopped (11:25 am) with discharge instructions for gastrointestinal bleeding.

The medical record at hospital B noted that patient #1's family transported this patient in a private vehicle from Comanche County Medical Center to hospital B, located in another town 30 miles away; hospital B was the closest hospital to Comanche County Medical Center. Patient #1 was admitted to hospital B with blood pressure of 95/47. During the stay at hospital B, she underwent further medical examination and treatment for gastrointestinal bleed, including administration of four units packed red blood cells and two units fresh frozen plasma.

In an interview on the morning of 02/24/10, PA #1 was asked if the on- call physician examined the patient. PA #1 stated " No. "
In an interview on the morning of 02/24/10, Physician #2 was asked if he was the physician on call for the ED the morning of 12/28/09. He stated, "Yes." He was asked if he examined Patient #1 on the morning of 12/28/09 in the ED. He stated, "No."

During an interview on the morning of 02/24/10, Physician #2 was asked whether he reviewed the appropriateness of care provided by the PA for patient #1. He said "No."

The hospital had beds and staff available for inpatient admission and/or observation on 12/28/09 when patient # 1 was in the ED. This hospital routinely provides medical services for patients in need of internal medicine services.