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Based on review of facility documents, medical records (MR), and interview with staff, it was determined the facility failed to ensure treatment was administered only upon written and signed order of the practitioner for one of 28 medical records reviewed (MR2).

Findings include:

Review on July 12, 2012, of the "Mid-Valley Hospital Medical Staff Rules and Regulations," last reviewed October 12, 2006, revealed "... Physician's Orders Diagnostic and therapeutic orders shall be written by medical staff members, by physicians in training status and by other individuals within the authority of their clinical privileges. A Verbal Order shall be considered to be in writing if dictated by a physician to an on-duty RN or duly authorized person, i.e., respiratory therapist, physical therapist or pharmacist, functioning within his sphere of competence and signed by the responsible practitioner. All Phone Orders shall be signed by the appropriately authorized person to whom dictated, with the name of the practitioner per his own name. The responsible practitioner shall authenticate such orders at the next visit or within 24 hours. ..."

Review on July 12, 2012, of MR2 revealed the patient presented to ED on June 24, 2012, with right shoulder pain following a fall. The initial reading of the x-ray of the right shoulder revealed a contusion (bruise) of the shoulder following a fall at home. The patient was discharged with instructions to wear a sling. On June 27, 2012, a nurse found a variance/diagnostic follow-up report of the right humerus for MR2 that revealed a minimally displaced comminuted (splintered) fracture of the humerus. MR2 was contacted and presented to the ED for a sling and swathe (immobilization of the shoulder for further support), instruction in the application, and a follow up scheduled with an orthopedic physician. There was no documentation of a physician order for this care. Continued review revealed a late entry was entered into the medical record on July 12, 2012.

Interview with EMP4 on July 12, 2012 at approximately 11:30 AM confirmed the physician verbally ordered the sling and swathe and an orthopedics follow up for MR2 when the variance was discovered on June 27, 2012. EMP4 confirmed the the verbal order was not written on June 27, 2012. EMP4 confirmed the verbal order was entered as a late entry on July 12, 2012.

Interview with EMP3 on July 12, 2012, at approximately 11:45 AM confirmed the verbal order for MR2 was not written on June 27, 2012. EMP3 also confirmed the order was entered as a late entry on July 12, 2012.

Interview with EMP1 on July 12, 2012 at approximately 2:00 PM confirmed there was no documentation of a verbal physician order written on June 27, 2012 for MR2.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to perform a medical screening examination for one of 28 medical records reviewed (MR6) and failed to ensure that all patients presenting to the Emergency Department were registered for one of 28 medical records reviewed (MR2).

Findings include:

1) Review on July 12, 2012, of the facility's "Board of Trustees Bylaws," dated reviewed June 2011, revealed "Article I ... General Scope 1.1 Purpose ... The purposes, goals, and objectives of the Board of Trustees of Mid-Valley Hospital shall be to: 1.1(a) Support, manage and furnish facilities, personnel and services; provide diagnosis, medical, surgical and hospital care, outpatient care and other hospital and medically related services to sick, injured or disabled persons; provide well-care programs as appropriate and feasible, without regard to race, color, sex, national origin or disability. 1.1(b) Provide appropriate facilities and services to best serve the needs of patients; ... 1.1(f) Manage or participate in, so far as hospital policy, circumstances and available funds may permit, activities designed to promote the general health of the community; 1.1(g) Guard against any activity in or on behalf of the Hospital having, or tending to have, an undesirable effect upon the Hospital or the services it renders; ...3.10 Responsibilities ... 3.10(e) In consultation with the MEC, the Corporation wand he CEO, formulating programs for efficient delivery of care, compliance with applicable law (including Medicare regulations and other applicable regulations) and development, review and revision of policies and procedures ..."

Review on July 12, 2012, of the facility's "Medical Staff Rules and Regulations," dated revised September 8, 2010, revealed "Emergency Care ... 8. When individuals present to the emergency department requesting examination/treatment of a medical condition, the hospital will provide for an appropriate medical screening examination by the emergency room physician, within the capability of the hospital's emergency department."

Review on July 12, 2012, of facility's policy and procedures "Emergency Medical Treatment and Labor Act (EMTALA)," dated reviewed May 12, 2011, revealed Policy: It is the responsibility of all employees of Mid-Valley Hospital to be familiar with the EMTALA requirements and to specifically outline the responsibilities of MVH emergency department as it pertains to EMTALA ... Responsibilities: The Emergency Medical and Treatment and Labor ACT imposes emergency care requirements on hospitals operating emergency departments and participating in the federal Medicare program. The Act states that in the case of a hospital that has an emergency department, and individual presents to the hospital or its campus in need of and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital must provided for an appropriate medical screening examination within the capability of the hospital's emergency department, to determine whether or not an emergency medical condition exists ..."

Review on July 12, 2012, of MR6 revealed the patient presented to the Emergency Department (ED) on February 25, 2012, at 00:55 AM with symptoms of agitation and intoxication. Review of the physician documentation revealed the police brought the patient to the Mid-Valley ED for a medical health examination (MHE) after verbalizing suicidal ideation. The patient was aggressive and agitated. The patient was removed from the ED by the police and taken to another facility. Continued review of physician documentation revealed the patient had alcohol intoxication and "MHE not performed" Further review revealed that the police officer noted the environment (the ED is a very small area) was not safe and secure and assumed responsibility and removed the patient from the ED and transferred MR6 to another facility for a psychiatric evaluation.

Interview with EMP3 on July 13, 2012 confirmed a medical screening examination was not performed by the physician for MR6.

2) Review on July 12, 20112, of the facility's policy "Patient Registration," dated reviewed March 2010, revealed "I. Policy: An absolute vital part of the registration process is avoiding violations against EMTALA, the federal "anti - dumping" law concerning emergency room admissions. EMTALA says that, before a patient gets a medical screening exam (MSE), we must not do anything to delay or discourage the patient from being treated and it requires us to treat all Emergency Department patients the same regardless of their ability to pay for services. This policy is to be followed to avoid EMTALA violations during the patient registration process in the Emergency Department. (ED) II. Procedure: A. Patient enters the Emergency Department ... Upon determining that a patient is at Mid-Valley Hospital for Emergency Room Services, all registration clerks are to notify the Emergency Department staff that there is a new patient present. Patient will be triaged. Triage is the clinical assessment of the individual's presenting signs and symptoms at the time of arrival the Hospital in order to prioritize when the individual will be seen by a physician. Never is the registration of a patient to delay triage or MSE."

Review on July 12, 2012, of the facility's policy and procedure "Client Registration," dated reviewed March 2010, revealed "Client registration is in general recognized as the direct responsibility of personnel of the Admissions Office. ... To ensure delivery of emergency services in an orderly manner, prevent treatment delay and enhance client privacy, the following guidelines govern the information gathering process for client registration: 1. All clients presenting to the Emergency Department are directed immediately to the attention of the professional nursing staff for initial triage prior to initiation and completion of registration information. ..."

Review on July 12, 2012, of MR2 revealed the patient had presented to the ED on June 24, 2012, with right shoulder pain following a fall. The initial reading of the x-ray of the right shoulder revealed a contusion (bruise) of the shoulder. The patient was discharged with instructions to wear a sling. On June 27, 2012, a nurse found a variance/diagnostic follow-up report of the right humerus for MR2 that revealed a minimally displaced comminuted (splintered) fracture of the humerus. MR2 was contacted and presented to the ED on June 27, 2012, for a sling and swathe (immobilization of the shoulder for further support), instruction in the application, and a follow up scheduled with an orthopedic physician. There was no documentation of registration or triage for MR2 for June 27, 2012.

Interview with EMP4 on July 12, 2012, at approximately 11:30 AM confirmed MR2 returned to the ED for further treatment and instruction on June 27, 2012. EMP4 confirmed the practice of the ED staff for patients returning for further treatment following discharge was to bring the patient back to the ED for care without registering them.

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure variances in radiological reports were handled as required by facility policy and in a timely manner for one of 28 Emergency Department medical records reviewed (MR2).

Findings include:

Review of facility policy and procedure "Misinterpretation of X-Ray Films," dated reviewed June 2012, revealed "... B. When films are misinterpreted by the Emergency Department Physician, the Radiologist will document correct reading on patient x-ray request, stating if it is a 'major' or 'minor' variance and immediately fax it to the Emergency Department. When the transcriptionist types the report, it is immediately faxed along with the patient request to the ED. The transcriptionist will document date and time on reports and call the ED to make them aware of the fax transmission."

Review on July 12, 2012, of MR2 revealed the patient had presented to the Emergency Department (ED) on June 24, 2012, with right shoulder pain following a fall. The initial reading of the x-ray of the right shoulder revealed a contusion (bruise) of the shoulder. The patient was discharged with instructions to wear a sling. On June 27, 2012, a nurse found a variance/diagnostic follow-up report of the right humerus for MR2 that revealed a minimally displaced comminuted (splintered) fracture of the humerus. MR2 was contacted and presented to the ED on June 27, 2012, for a sling and swathe (immobilization of the shoulder for further support), instruction in the application, and a follow up scheduled with an orthopedic physician.

Review of the facility document "Variance/Diagnostic Follow-Up" for MR2 revealed on June 24, 2012, at 2107 the report stated "official x-ray minimally displaced comminuted fracture of humerus greater tuberosity." There was no documentation the transcriptionist called the ED to notify them of the variance. There was no documentation by the Radiologist noting the variance as a "major" or "minor" variance.

Interview with EMP4 on July 12, 2012 at approximately 11:30 AM confirmed the variance report was discovered on June 27, 2012, and the patient was called to report to the ED for further treatment. EMP4 confirmed it was the practice of the Radiology Department to call the ED when a variance report was faxed to the ED. EMP4 further confirmed the discovery of the report was three days after the patient initially sought treatment in the ED.

Interview with EMP3 on July 12, 2012, at approximately 11:45 AM confirmed a variance in the reading of the x-ray for MR2 occurred on June 24, 2012. EMP3 confirmed the Radiology Department calls the ED when they are faxing a variance report.

Based on review of facility policy and procedures, medical records (MR), and interview with staff, it was determined the facility failed to ensure that effective nursing care plans were implemented in one of one restraint medical record reviewed (MR1).

Findings include:

Review on July 12, 2012, of the facility policy and procedure "Restraints,"dated reviewed February 20, 2012, revealed " The patient plan of care should indicate that restraints are in use and refer the caregiver to the Restraint Flow Sheet..."

Review on July 12, 2012, of MR1 revealed the patient was admitted June 22, 2012, and discharge June 28, 2012. Continued review of MR1 revealed a physician order for "soft wrist restraints to 4 [sic] extremities" on June 24, 2012, and June 25, 2012, at 1330 PM. Further review of MR1 revealed no documentation that a nursing care plan for restraints was implemented for this patient.

Interview with EMP1 on July 13, 2012 at approximately 4:00 PM confirmed that the nursing care plan for restraints was not implemented while this patient was in restraints.