HospitalInspections.org

Based on observations, review of facility policy, and staff interviews (EMP), it was determined the facility staff failed to post conspicuously in the emergency department or in places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than the traditional emergency departments, a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital participates in the Medicaid program under a State plan approved under Title XIX.

Findings include:

Review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated "April 19, 2010" revealed "9. The facility shall post conspicuous signage that identifies the rights of the individual under EMTALA with respect to examination and treatment for Emergency Conditions and indicates the hospital's participation in the Medicare and Medicaid programs."

1) Tour of the facility Emergency Department on May 17, 2010, at 9:30 AM revealed one Emergency Medical Treatment and Active Labor Act (EMTALA) sign in an area. The sign was located before entering the waiting area. Further tour revealed no other signage in the entrance, admitting area, waiting room, or treatment areas.

Interview with EMP5 on May 18, 2010, at 12:15 PM confirmed the above findings and revealed "Yes that is the only one [sign] we have."

Based on a review of Medical Staff Rules and Regulations, facility policy and facility documentation, and staff interview (EMP), it was determined that the facility failed to have individual physicians listed as on-call and failed to have policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control.

Findings Include:

Review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated "April 19, 2010" revealed "11. Each UPMC hospital's Emergency Department shall maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an Emergency Medical Condition"

Review of "UPMC McKeesport Medical Staff Rules and Regulations" dated "11/4/09" revealed "III. On-Call Responsibilities: ... The on-call list can be used to retrospectively identify call obligations."

1) Review of facility on-call list from December 2009 to May 2010, revealed the Obstetrical and Gynecological and the Orthopedic on-call schedule had groups listed and not individual physicians.

Interview with EMP5 on May 17, 2010, at 11:15 AM confirmed the above findings and revealed "Yes it is a group, we call their answering service and they call who ever is on call."
____________________________________

Review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated "April 19, 2010" revealed "13. Each UPMC hospital shall maintain policies and procedures to (a) respond to situations in which a particular specialty physician is not available or if the on-call physician is not able to respond due to circumstances beyond his or her control; and (b) provide that emergency services are available if the hospital elects to permit its on-call physicians to schedule elective surgery during the time that they are on call or permit physicians to participate in simultaneous on-call service."

1) A request was made to review a policy and procedure on May 17, 2010, at approximately 1:00 PM for how the On-call Physicians respond to situations in which a particular specialty is not available or if the on-call physician is not able to respond and/or has scheduled elective surgery during the time they are on call. None was provided.

Interview with EMP10 on May 17, 2010, at 2:10 PM confirmed the above findings and revealed "No we do not have one [policy and procedure to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control].

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined that the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exits for two of two patients (MR1 and MR28).

Findings include:

Review of "UPMC McKeesport Medical Staff Rules and Regulations ...Approved Board of Directors: 11/4/09" revealed " ... 3.1 Medical Staff Rules and Regulations EMTALA Compliance ... 1. The Medical Screening Exam: A Licensed Independent Practioner (LIP) is required to perform a medical screening examination for all individuals presenting to the Emergency Department."

Review of "UPMC McKeesport Emergency Department Policy and Procedure Manual Subject: Medical Screening Examination ... Reviewed: 7-08" revealed "Purpose: To provide guidelines for Emergency Department ('ED') personnel for their performance of an appropriated medical screening examination. ... Policy: It is the policy of UPMC McKeesport to provide an appropriate medical screening examination for any individual presenting to the emergency Department to determine if an emergency medical condition exists, regardless of the individual;s medical condition, race, color, national origin, handicap, financial status, or lifestyle. Procedure: 1. Any individual who comes to the emergency Department area of UPMC McKeesport, a medical examination or treatment will be triaged in accordance with hospital policy, and will then be escorted to the appropriate area in the Emergency Department as the case may be; where further assessment and a medical screening examination will be performed with respect to such individual. ... 2. If the individual refuses consent to examination, the procedures outlined in the hospital's policy, 'Refusal of Examination or Treatment' must be followed. 3. Medical Screening Examination: The purpose of the medical screening examination is to determine if the individual has an emergency medical condition. a. Screening Examinations Performed in the Emergency Department: Licensed physician working in the Emergency Department, who have been granted privileges to treat patients in conformity with the bylaws of the hospital and the hospital staff shall perform medical screening examinations within the capabilities of the Emergency Department, including those ancillary services routinely available to the Emergency Department."

Review of "UPMC Policy and Procedure Policy: HS-LE0007 ... Subject: Emergency Medical Treatment and Active Labor Act (EMTALA) Date: April 19, 2010" revealed "I. Policy It is the policy of UPMC to comply with all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA) ... II. Purpose The purpose of this policy is to set forth hospitals' requirements under EMTALA. III. Scope This policy applies to all domestic UPMC hospitals. Each hospital may develop its own procedures for implementing this policy, provided that such procedures are consistent with the policy. IV. Definitions ... 2. Emergency Medical Condition is a 'medical condition manifesting itself by acute symptoms of sufficient severity (including sever pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment of bodily functions; serious dysfunction of any bodily organ or part ... 3. Medical Screening Exam (MSE) is an appropriate exam within the capability of the hospital to determine whether an emergency medical condition exists. ... V. Procedure 1. If an individual seeking emergency medical care comes to the hospital's Dedicated Emergency Department, physicians or other Qualified Medical Person (QMP) shall offer a Medical Screening Exam to such person. ... 4. If the patient or their representative refuses a medical examination an/or treatment, the physician or other designated professional staff shall note the type of examination and/or treatment refused in the Emergency Department log and the medical record, where available, and shall take reasonable steps to secure a written informed refusal by the patient or their representative."

Review of "UPMC McKeesport Policy and Procedure Emergency Department Manual Subject: Assessment of the Pediatric Patient ... July 2009" revealed "Policy: It is the policy of UPMC McKeesport to identify the process of nursing assessment for the pediatric patient, ages greater than thirty-one days of life through twelve years of age, presenting to the Emergency Department (ED). All pediatric patients presenting to the ED will receive a medical screening examination by the ED attending physician, in adherence with the Emergency Medical Treatment and Active Labor Act."

1) Review of facility documentation on May 17, 2010 at approximately 1:00 PM revealed that on March 8, 2010, a patient presented to the Emergency Department accompanied by parents with chief complaint of a request for drug testing due to patient's weight loss, loss of interest and irritability. Further review of facility documentation dated March 8, 2010, revealed "Info by mother, triage RN [EMP23] spoke with parents while signing in pt, told mother we don't do general drug testing here, to go to PCP, mother highly upset and left."

Interview with EMP10 on May 17, 2010 at 10:30 AM confirmed the above findings and revealed "The nurse [EMP23] was a seasoned nurse. [EMP23] self reported ... to the supervisor."

2) Review of MR1 on May 17, 2010 at 11:00 AM revealed that a pediatric patient presented to the Emergency Department with a reported chief complaint of behavioral health issues. Review of the "Emergency Department Triage Assessment" revealed no documented evidence of a triage assessment, except for documentation of the "Date", "Time" and "Wt. [weight]."

Continued review of "Progress Notes" for MR1 revealed a progress note completed by EMP19. Further review of this note revealed "It was requested by the triage RN that I speak [with] [the patient's] [parent] re: (regarding) a [psychiatric] assessment. ... [The parent] said that [they] called [an outside agency] and was referred to our ED to see a psychiatrist. I told [the parent] that I can do a child assessment and pt (patient) would see the MD in our ED but when assessment was complete we would call [another hospital] and transfer there if [the parent] wanted a child psychiatrist to assess. [The parent] declined to stay for assessment electing to go directly to [another hospital] to save time."

3) Interview with EMP19 on May 17, 2010, at approximately 1:05 PM confirmed the findings in MR1 and revealed "The nurse in triage should have filled out the [Emergency Department Triage Assessment] ... [EMP23] should have done the triage." During further interview, EMP19 was asked "Did you offer a medical screening exam?" and EMP19 stated "I told [the parent] that we could assess the child but there was someone waiting outside for them and they did not want to stay ... I don't know if [EMP23] offered an exam." During additional interview, EMP19 was asked "Did you attempt to obtain something in writing that the parent refused a medical screening examination?" and EMP19 stated "No."