Based on a review of medical records (MR), facility documents and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow adopted policies to ensure that patients triaged as Emergency Severity Index (ESI) 3, received hourly vital signs as per their policy, in nine of 17 medical records. (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, and MR9). Findings Include: Review of Conemaugh Memorial Medical Center ... PolicyStat ID: 92 ... Last Reviewed: May 2016 ... Policy Area: Emergency Department ... Department of Emergency Services Triage Process ... "Purpose: To provide guidelines for a quick, initial assessment of every patient who presents to the Emergency Department and to assume early identification of those who are eligible for Fast Track and allows the RN to begin advanced Triage protocols. Process: 1. All patients who come to the Emergency Department for care are triaged, either at bedside or in he [sic] triage area. At times, ambulance patients will be directed to Triage based on Medical Command report. 2. Triage responsibilities are: a) completing the reason for visit and assigning a Triage acuity level b) obtaining vital signs ... f) initiate the advanced Triage protocols as appropriate. 3. The Triage nurse is responsible for monitoring patient condition and updating them on delays while in the Waiting Room, working with the Triage Tech and Pt Advocate to keep patients and families informed regarding delays. ... ." Review of Conemaugh Memorial Medical Center ... PolicyStat ID: 32 ... Last Reviewed: August 2016 ... Policy Area: Emergency Department ... DEM Vital Sign Assessment ... Documentation of of Vital Signs/Patient Assessment Protocol: 1. Temperature, pulse, heart rate, respirations, blood pressure and pulse oximetry are taken on all patients upon arrival to the Department of Emergency Medicine (DEM). ... 4. Emergency Severity Index (ESI) Level 1 patients should have vital signs monitored and documented at least every 15 minutes or more frequently based on patient condition or provider request. This includes a documented set of vital signs within 15 minutes of departing the DEM to inpatient bed, special procedure are (cath lab, GI lab, IR), OR, or transfer to another facility. 5. ESI Level 2 and 3 patients should have vital signs monitored and documented at least every 60 minutes. The last set of vital signs before patient departure should be captured within 30 minutes of leaving the DEM. ... ." 1) MR1 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival 1310 ... Chief Complaint: Fall, back, knee injury ... Triage Priority: 3 ... Time: 1310 ... Temp: 36.9 Pulse: 77 RR: 18 BP: 170/72 ... Additional Orders ... Time: 1410 36.6 69 88 136/64 ... 1510 36.4 78 94 124/59 1610 36.2 72 90 130/62 ... Time Seen by Provider: [blank] ... Diagnosis: [blank] ... Check out time: 1755 ... Disposition: ... LWOT [box marked with x] ... ." EMP3 confirmed that MR1 failed to reveal documented evidence that the patient had additional vital signs taken at 1710 while in the ED Waiting Room prior to leaving before being examined by a provider. 2) MR2 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival: 1914 ... Time in Room: 0020 ... Chief Complaint: Cough, Hx Lung Transplant ... Triage Priority: 3 ... Time: 1914 ... Temp: 37.1 Pulse: 103 RR: 18 BP: 108/65 ... Time Seen by Provider: 0025 ... Diagnosis: PNA ... Check out time: 0845 ... Disposition ... Transfer ... ." EMP3 confirmed that MR2 failed to reveal documented evidence that the patient had any additional vital signs taken while in the ED Waiting Room prior to being examined by a provider. 3) MR3 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival: 1504 ... Time in Room: 1958 ... Chief Complaint: R Facial Droop since 10/2 ... Triage Priority: 3 ... Time: 1504 ... Temp: 36.4 Pulse: 109 RR: 16 BP: 188/99 ... Additional Orders ... Time: 1604 36.8 94 90% 158/71 ... Time Seen by Provider: 2004 ... Diagnosis Facial Droop R/O CVA ... Check out time: 0150 ... Disposition ... Admit ... ." EMP3 confirmed that MR3 failed to reveal documented evidence that the patient had additional vital signs taken at 1800 and 1900 hours while in the ED Waiting Room prior to being examined by a provider. 4) MR4 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival: 1508 ... Time in Room: 1959 ... Chief Complaint: RLE Pain ... Triage Priority: 3 ... Time: 1508 ... Temp: 36.5 Pulse: 75 RR: 18 BP: 131/89 ... Additional Orders ... Time: 1608 36.7 110/72 71 100% 20 ... 1709 36.5 112/75 90 100% 20 ... Time Seen by Provider: 2003 ... Diagnosis Suspect DVT ... Check out time: 2323 ... Disposition ...Discharge ... ." EMP3 confirmed that MR4 failed to reveal documented evidence that the patient had additional vital signs taken at 1800 and 1900 hours while in the ED Waiting Room prior to being examined by a provider. 5) MR5 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival: 1533 ... Time in Room: 2015 ... Chief Complaint: Weakness BLLE Swelling ... Triage Priority: 3 ... Time: 1533 ... Temp: 36.5 Pulse: 57 RR: 18 BP: 104/52 ... Additional Orders ... Time: 1633 Not in waiting room ... 1733 36.4 60 98% 18 100/61 ... 2000 36.6 59 99% 20 111/59 ... Time Seen by Provider: 2022 ... Diagnosis: [blank] ... Check out time: 2200 ... Disposition: [blank] ... ." EMP3 confirmed that MR5 failed to reveal documented evidence that the patient had additional vital signs taken at 1800 and 1900 hours while in the ED Waiting Room prior to being examined by a provider. 6) MR6 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival: 1632 ... Time in Room: [blank] ... Chief Complaint: Abd injury ... Triage Priority: 3 ... Time: 1632 ... Temp: 36.7 Pulse: 106 RR: 16 BP: 118/77 ... Time Seen by Provider: [blank] ... Diagnosis: [blank] ... Check out time: 1935 ... Disposition: LWOT [box marked with x] ... ." EMP3 confirmed that MR6 failed to reveal documented evidence that the patient had any additional vital signs taken at 1730 and 1830 hours while in the ED Waiting Room prior leaving the facility before being examined by a provider. 7) MR7 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival: 1705 ... Time in Room: 2257 ... Chief Complaint: Shaky ... Triage Priority: 3 ... Time: 1705 ... Temp: 36.8 Pulse: 106 RR: 16 BP: 141/93 ... Additional Orders ... 1805 36.9 111 140/87 99% 18 ... 2000 37.0 105 139/96 98% 18 ... P 93 BP 137/83 O2 100 RA 2325 ... Time Seen by Provider: 2306 ... Diagnosis: dizziness anxiety ... Check out time: 0300 ... Disposition: discharged ... ." EMP3 confirmed that MR7 failed to reveal documented evidence that the patient had additional vital signs taken at 1900, 2100 and 2200 hours while in the ED Waiting Room prior to being examined by a provider. 8) MR8 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival: 1836 ... Time in Room: 2305 ... Chief Complaint: R Leg Swollen Pain ... Triage Priority: 3 ... Time: 1836 ... Temp: 37.0 Pulse: 86 RR: 16 BP: 126/81 ... Additional Orders ... 2015 36.7 88 18 146/77 95% ... 2130 36.7 80 18 141/75 93% ... Time Seen by Provider: 2310 ... Diagnosis: PE DVT Hx of SAH ... Check out time: 0236 ... Disposition: Admit ... ." EMP3 confirmed that MR8 failed to reveal documented evidence that the patient had additional vital signs taken at 1930 and 2230 hours while in the ED Waiting Room prior to being examined by a provider. 9) MR9 ER Facesheet dated October 3, 2016, revealed, "... Time of Arrival:1857 ... Time in Room: 0011 ... Chief Complaint: Abd Pain ... Triage Priority: 3 ... Time: 1857 ... Temp: 37.1 Pulse: 100 RR: 16 BP: 108/67 ... Additional Orders ... 2030 37.0 85 18 106/65 100% ... Time Seen by Provider: 0015 ... Diagnosis: Colitis Nausea ... Check out time: 0329 ... Disposition: Discharge ... ." EMP3 confirmed that MR9 failed to reveal documented evidence that the patient had additional vital signs taken at 2100, 2200 and 2300 hours while in the ED Waiting Room prior to being examined by a provider.

Based on a review of facility documents and staff interviews (EMP), it was determined that Conemaugh Memorial Medical Center failed to have policies and procedures to address situations when an On-Call physician could not respond for conditions beyond his/her control, and failed to identify the specific Pediatrician name and contact information on the Emergency Department Specialty On-Call schedule. Findings: A review of PolicyStat ID: 0. LifePoint Health ... Approved 12/17/2013 LL.031, EMTALA-Provision of On-Call Coverage. Scope: All company-affiliated facilities including hospitals and any entities operating under the hospital's Medicare Provider number including, but not limited to, the following: All Clinical Departments ... Emergency Department ... Purpose: To be eligible to participate in Medicare, federal law requires hospitals to "maintain a list of physicians who are on call for duty after initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition, 42 U.S.C.A. 1359cc(a)(1)(l). A participating facility or an on-call physician is subject to a penalty if the on-call physician fails or refuses to appear within a reasonable period of time when notified by an Emergency Department physician that his or her services are needed and the Emergency physician orders a transfer because he or she determines that without the service of the on-call physician the benefits of transfer outweigh the risk of transfer. 59 Fed. Reg. , at . This policy is to ensure that the Emergency Department is prospectively aware of which physicians, including specialists and sub-specialist, are available to provide screening and treatment necessary to stabilize individuals with emergency medical conditions in order to meet the healthcare needs of the community ... Procedure: Please refer to the EMTALA - Medical Screening Policy LL.026 for a complete list of definitions pertaining to this policy. 1. The hospital is responsible for adopting and enforcing an EMTALA policy that ensures compliance with his requirements of EMTALA to maintain a list of physicians who are on call after the initial examination to provide treatment necessary to stabilize an individual with an "emergency medical condition. The Medical Staff Bylaws or appropriate policy and procedure should define: the responsibility of on-call physicians to respond, examine and treat patients with emergency medical conditions; and actions to be taken when a practitioner fails to respond, including initiation of Chain of Command. 2. The hospital shall be responsible for developing an on-call rotation schedule in advance that includes the name and contact information for each physician on call for each specialty or sub-specialty and the dates/time that they are on call. On-call rotation schedules shall be maintained in the Emergency Department. Physician group names by themselves should not be listed to identify physicians who are on call. Individual physicians names must be used. 3 ... The hospital must have policies and procedures to be followed when a particular specialty is not available to provide on-call services or when the scheduled on-call physician cannot respond because of situations beyond his/her control ... ." 1) An interview was conducted with EMP5 on November 13, 2015, at approximately 12:30 PM. "We do not have a policy to be followed when an On Call physician cannot respond. I looked in the Bylaws and there is nothing that addresses this situation. I thought that the Emergency Department had a policy regarding this. We are meeting with DLP lawyers next week to review the Bylaws. I will bring this to their attention." 2) An interview with EMP16 on November 13, 2015 at approximately 1:20 PM. "We currently do not have a policy to address when a physician cannot respond. We are adding language in the Bylaws to address the Chain of Command that we follow when an On-Call physician is unable to respond." 3) A a random review of the physician On-Call schedules was conducted from October 4, through November 7, 2015, it was revealed that Pediatrics was identified as a group practice 26 days out of 35 days reviewed. There were 9 days that the facility did identify a specific Pediatrician On-Call, however, they failed to have the physician's contact information documented on the On-Call schedule for 5 of 9 days. 4) A review of facility documentation from EMP30 on November 19, 2015, at 1:07 PM revealed, "... I checked the On Call schedules from October 4 through November 7. I can see what you were talking about regarding only listing the Group name 'FMC' or 'PCS'. There should be the name of the physician present beside that listing. ... ."

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that Conemaugh Memorial Medical Center failed to maintain a Central Log consistent with their adopted policies and processes. Findings include: Review of facility policy LifePoint Health LL.029. EMTALA - Central Log approved December 5, 2013, revealed, "... Purpose: To identify and document each individual who either comes to the Dedicated Emergency Department seeking treatment for any medical condition or presents on Hospital property or premises seeking care for an emergency medical condition. ... Procedure ... 3. The Central Log must include, directly or by reference, patient logs from all departments of the Hospital that are considered Dedicated Emergency Departments, such as Labor and Delivery. ... 5. The Log must contain: the name of the individual who comes to the Emergency Department seeking assistance; and whether the individual: refused treatment; was refused treatment; was transferred; was admitted and treated; was stabilized and transferred; or was discharged . 6. A Log entry should be made at the first point of contact. This would normally take place at Triage and be finalized after the medical screening and/or any necessary treatment and stabilization, and if necessary, transfer, to address the emergency medical condition. ... ." Review of the Obstetrics Department Triage Area-Log Form revealed a notation across the top right hand side "... Staff: It is very important that you document a reason for the visit. Documentation of outpatient or observation status is required. To be compliant with EMTALA laws, please document method of release of patient from facility ... ." The Triage Area-Log Form was also noted to have specific columns entitled "Disposition at D/C" and "Reason for Visit." 1) A review of the Triage Area - Log Form for the months of August 2015 through November 12, 2015, revealed the Log did not consistently indicate the patient's reason for visit and disposition at discharge. 2) An interview was conducted on November 12, 2015, at approximately 1:45 PM with EMP3. "I try to remind the staff to fill the Log out completely, but after the review I can see the inconsistencies." 3) A review of the electronic Emergency Department Log was conducted to ascertain completeness of required elements. The Log was extensive, therefore, a sample dated November 1, 2015 through November 2, 2015, was specifically reviewed. The headings listed at the top of the Log included: Pt Identification; Patient Name; Room Identification; Disposition; Discharge Diagnosis; Chief Complaint; Admit Type; admitted Time; Bed Assignment Date; MD 1st Seen Date; Triage Date; MD Decision to Discharge; Disposition Date; ... and Patient Category. The Log revealed that the patient, MR1, was admitted to the Emergency Department on November 1, 2015 at 12:31 PM. The patient's Chief Complaint was documented as "Evaluation." The patient was triaged at 12:28 PM and the provider saw the patient at 1:30 PM. The provider decision to discharge was incorrectly documented as November 3, 2015 at 10:32 AM. It was noted that the Log indicated that MR1 disposition was documented as being a Discharge not as a Transfer, with an incorrect disposition date/time of November 3, 2015 at 10:32:55 AM. Continued review of the Log revealed inconsistencies and gaps in the data that was required to be documented. 4) An interview with EMP10 conducted on November 12, 2015, at approximately 2:15 PM confirmed the above findings.

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that Conemaugh Memorial Medical Center failed to provide a medical screening examination for 4 of 11 patients who presented for emergency medical care to the Obstetrical Department (MR 12, MR13, MR14, MR15), failed to ensure the designation of Qualified Medical Personnel was set forth in Governing Body approved Medical Staff Bylaws/Rules and Regulations, and failed to adopt Registration processes for unscheduled patients who present to the Obstetric Department, to ensure that a medical screening is not delayed. Findings include: A review of facility policy Life Point Health LL.026, EMTALA - Medical Screening and Treatment of Emergency Medical Conditions, approved December 4, 2013, was conducted. "Purpose: To ensure that individuals coming to an affiliated Hospital's Dedicated Emergency Department seeking assessment or treatment for a medical condition, or coming to Hospital Property requesting (or obviously requiring) treatment for an Emergency Medical Condition receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Labor Act (EMTALA) ... Policy: Any individual who comes to the Hospital property or premises requesting examination or treatment is entitled to and shall be provided an appropriate medical screening examination performed by a physician or other Qualified Medical Personnel to determine whether or not an Emergency Medical Condition exists. ... Procedure: l. Definition ... ii. Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor. Such screening must be done within the facility's capability and available personnel, including on-call physicians. The Medical Screening Examination must be performed by a Physician or other Qualified Medical Personnel. The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred. Triage does not constitute a Medical Screening Examination ... Qualified Medical Person or Personnel, or "QMP," means an individual other than a licensed physician who has demonstrated current competence in the performance of Medical Screening Examinations and been approved by the main Hospital provider's Governing Board as qualified to administer one or more types of Medical Screening Examination and complete/sign a certification for transfer in consultation with a physician. The categories of non-physician practitioners who may be designated as QMPs is set forth in Medical Staff Bylaws or Rules and Regulations and approved by the governing body of the Hospital. Ad hoc QMP designations of other categories of non-physician practitioners are not permissible ... Who May Perform MSE. A Medical Screening Examination may be performed by an Emergency Department physician, another physician, or a non-physician practitioner who is qualified to conduct such examination (Qualified Medical Personnel) or (QMP) and approved by the Hospital's Governing Board: ... b. A Qualified Medical Person may conduct the Medical Screening Examination provided the individual is: i. Determined qualified by Hospital medical staff bylaws, rules and regulations which are approved by the Hospital's governing body ... ." A review of the facility's policy entitled, Laboring and Non Laboring Obstetrical Patient Triage: presenting to Emergency Department/or transfer to Labor and Delivery Triage, dated July 2015 revealed, "Purpose: To provide appropriate assessment and treatment for the obstetric patient who presents in an unannounced manner to the hospital for emergency care. Unscheduled Obstetrical Patient: Any obstetric patient who presents to the hospital's department of Emergency of Medicine (DEM) or Labor and Delivery Unit (L&D) unanticipated. Regardless of whether the patient has an attending physician, or whether the physician has been notified Labor and Delivery that the patient is coming, the hospital will provide a screening exam and provide necessary treatment within a timely manner. Policy: A provider or a qualified RN will perform the medical screening examination for all patients who present to the dedicated Emergency Department and/or Labor and Delivery Unit for emergency care. The Obstetric Registered Nurse with demonstrated competency can perform the assessment and relay information to the on call physician and/or midwife for further orders. 1. A pregnant patient who presents 24 weeks or greater gestation by date and/or history with a non pregnancy related complaint will be evaluated in the DEM. The provider on call will be notified to determine if the patient should be sent to Labor and Delivery for fetal monitoring, further assessment and treatment and then sent to Labor and Delivery. The staff will call prior to escorting the patient to Labor and Delivery. 2. A pregnant patient who presents 16 weeks or greater gestation by date and/or history with signs of imminent delivery or with pregnancy related complaints will be escorted directly to Labor and Delivery. The staff will call the Labor room prior to bringing the patient. Such complaints include but are not limited to: Urinary Tract Infection ... Vaginal bleeding with or without pain ... Back pain ... Contractions ... Pre-eclamptic symptoms: a. Elevated Blood Pressure b. Headache c. Altered or blurred vision d. Epigastric Pain e. Abdominal indigestion f. Swelling 3. Obstetrical patient who presents 24 weeks or greater by date and/or history with a potentially life threatening condition or who needs emergency evaluation will be seen in the DEM. Obstetrical staff can monitor the patient in the DEM until the patient is stable for transfer to L&D. Such complaints include but are not limited to: Acute trauma... Cervical spine injury ... Severe respiratory distress ... Chest Pain ... Condition that does not allow transfer to L&D ... Active Seizures ... OB Procedure: A. The unscheduled OB patient arrives at the hospital via the DEM or the L&D unit. B. Registration takes place. The registration clerk may ask basic information to register the patient, such as a name, birth date, and Social Security number, but this cannot delay the nurse's assessment and care of the patient. C. The Obstetric RN performs the following assessment and medical screening exam for labor status: Initial maternal vital signs, maternal history, and physical assessment, including contractions and cervical dilatation as appropriate. Assessment of fetal well-being by Doppler or external fetal monitor. D. The nurse notifies the physician or nurse midwife of assessment findings and any other pertinent data gathered during the assessment and implements orders as directed. E. If the patient is not in labor and her chief complaint remains, the patient's provider can come and evaluate the patient, or give orders to transfer patient to the Emergency Department for a medical screening exam and further treatment. F. Any patient who is discharged to home while still pregnant will receive information about when to return to the hospital or contact her care provider in discharge instructions. G. If the physician orders a transfer for the patient, the certificate of transfer is completed by the obstetric RN and is countersigned by the attending physician within 24 hours ... ." A review of the facility's policy entitled Care of Patient in Obstetric Triage, dated January 2014, revealed, "Policy: Obstetric patients at 16 weeks of gestation or greater, through 6 weeks postpartum, will be evaluated in the Obstetric Triage Unit in accordance with Emergency Medical Treatment and Labor Act (EMTALA) regulations. Patients less than 16 weeks gestation or with a non-obstetric emergency will be triaged in the Department of Emergency Medicine. Final determination is left to the discretion of the OB Provider. The purpose is to provide evaluation and or testing of the obstetrical patient to ensure the best possible outcome ... B. Common patient evaluations appropriate for a triage bed include but are not limited to: Cerclage ... non stress tests ... rule out labors, ruptured membrane status ... PIH work-up ... Monitoring Post amniocentesis ... Evaluation of non acute medical complaints such as N/V, abdominal pain, trauma ... IV hydration ... obstetrical complaints ... ." A review of the Job Description for an RN, Obstetrics, was completed. It was noted that the description did not include that performance of a medical screening examination, related to labor, by a qualified RN. 1) A review of the Obstetrical Log dated August 2015 to November 12, 2015, was completed. A sample of 11 medical records were chosen from the Log for review. In addition, the facility's schedule book for the same time period was reviewed, to ensure medical records that were selected were unscheduled patients. It was noted that all 11 medical records were unscheduled (MR12-MR22). 2) Review of MR12, MR13, MR14, MR15, revealed these patients presented unscheduled, as outpatients. There was no documented evidence that a medical screening examination was completed by a physician or a non physician practitioner who who is qualified to conduct such an examination, once labor was ruled out. Review of each medical record revealed that each patient was discharged home from the Obstetrical Unit. 3) Review of MR12 revealed the patient presented with complaints of abdominal and back pain, and tightening. Interview with EMP20 on November 13, 2015, revealed that labor was ruled out and the patient was discharged to home. EMP20 also confirmed that there was no documentation in the medical record that the patient received a medical screening examination by a provider. 4) Review of MR13 revealed the patient presented with complaints of abdominal and back pain, nothing timeable, and the patient stated they had been sick recently, and may not have been drinking as much as they should have. Interview with EMP20, on November 13, 2015 confirmed that there was no documentation in the medical record that the patient received a medical screening examination by a provider. 5) Review of MR14, revealed the patient presented stating that they fell against bathtub and began having abdominal and back pain. Interview with EMP20 on November 13, 2015 revealed that there was no documentation in the medical record that the patient received a medical screening examination by a provider. 6) Review of MR15, revealed the patient presented with irregular lower abdominal pain and sharp pain in the vaginal area. Documentation also revealed the patient has a chronic headache, had spots before, and was to see a Neurologist soon. Nursing documentation revealed the patient was medicated with Percocet for constant, sharp, head pain, and that Macrobid was started. Interview with EMP20, on November 13, 2015 revealed that there was no documentation in the medical record that the patient received a medical screening examination by a provider. 7) Review of the Medical Staff Bylaws/Rules and Regulations, dated October 19, 2015 failed to designate Obstetrical Registered Nurses as Qualified Medical Personnel. 8) An interview with EMP3 on November 12, 2015, at approximately 2:35 PM, in the presence of EMP2 revealed that the nurse never acts independently without physician contact. EMP3 stated that the nurses assess for cervical changes and contractions, and that a physician and a midwife are On Call. EMP3 stated that verbal Discharge Orders are received. EMP3 stated that to rule out labor, contraction patterns, and vaginal exam is done, and this information is communicated to the provider. EMP3 stated that they don't recall seeing RN's listed in medical documents stating that they can perform medical screening exams. 9) An interview with EMP5 on November 12, 2015 at 11:45 AM was conducted. EMP5 confirmed the Medical Staff Bylaws/Rules and Regulations dated October 19, 2015 failed to designate Obstetrical Registered Nurses as Qualified Medical Personnel. "The By-laws or Rules and Regulations do not say anything about nurses doing examinations, only talks about the medical staff." 10) A tour of the Obstetrics Department was conducted on November 12, 2015 at approximately 1:40 PM. During the tour a patient presented to the OB Registration desk. Surveyors observed EMP4 query the patient as to whether or not they were able to stand in order to be registered. 11) An interview with EMP17 on November 13, 2015 at approximately 1:20PM revealed, relative to the OB Registration process, that the Front Desk in the OB Department is staffed Monday through Friday from 7:00 to 3:00. EMP17 stated that unscheduled patients present, and registration information is collected, including insurance information, prior to the Triage nurse being contacted in the Obstetric Department.

Based on a review of medical records (MR), facility documentation and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to ensure a safe transfer with qualified medical personnel in 3 of 9 Emergency Department transfers (MR1, MR4 and MR6). Findings Include: Review of Rules & Regulations of the Medical Staff of Memorial Medical Center, revised and approved Board October 27, 2015. "Rule 1. Patient Care. 1. Admission and Discharge of Patients. A. The Memorial Medical Center shall accept all patients within the capabilities of the Medical Center who present themselves for care and treatment regardless of race, religion or national origin. ... I. Patient Transfers - Patients are to be transferred from the following areas, on any given date, prior to any elective admissions that same day: 1. Emergency Department to appropriate bed area; ... J. Suicidal Patients - Consideration must be given to taking all necessary precautions in caring for suicidal patients, including placing them in maximum-security areas. ... ." Review of Life Point Health LL.027. EMTALA-Transfer Policy dated December 5, 2013. "... Purpose: To ensure that a patient requesting or requiring a transfer for further medical care and follow-up in connection with treatment for an emergency medical condition is transferred appropriately. Policy: Each hospital must have written guidelines outlining the requirements for an appropriate transfer to another facility in accordance with federal and state laws. Any transfer of an individual with an emergency medical condition must be initiated by a physician order with the appropriate physician certification. The transfer of a patient shall not be predicted upon arbitrary, capricious or unreasonable discrimination based upon race, religion, national origin, age, sex, physical condition or economic status. ... Procedure: ... 3. The four requirements of an appropriate transfer must be met before a patient can be transferred to a second facility: a. The transferring hospital must, within its capability, provide treatment to minimize the risks to the health of the individual or unborn child; b. The receiving hospital must have available space and qualified personnel for the treatment of the individual, and must have agreed to accept the transfer and provide appropriate treatment; c. The transferring hospital must send copies of all available medical records pertaining to the individual's emergency medical condition to the hospital where the patient is being transferred. ... d. The transfer must be carried out through the use of qualified personnel and transportation equipment, including those life support measures that may be required during transfer. The physician at the sending hospital has the responsibility of determining the appropriate mode, equipment and attendants for the transfer. Patients should not be transferred by private vehicle, for risk management purposes. ... The transferring hospital should document its communication with the receiving hospital, including the date and time of the transfer request and the name of the person accepting the transfer; If the transfer is requested by the patient, the request must be in writing and must indicate the reason(s) for the request as well as indicate that the patient is aware of the risks and benefits of the transfer; The patient has been informed of the hospital's obligation to provide an emergency medical screening and the necessary stabilizing treatment; The receiving facility: a) has available space and qualified personnel for the treatment of the individual, and b) has agreed to accept the transfer of the individual and to provide appropriate medical treatment; and The individual agrees to the transfer. ... 9. The physician at the transferring hospital has the responsibility to determine appropriate mode of transportation, equipment and attendants necessary to effect a transfer to a receiving or recipient facility. ... ." (jb) Review of Consent For Treatment In The Department of Emergency Medicine policy and procedure dated December 2014. "... Minors. Minor patients may or may not establish consent. A minor who understands the nature and consequences of treatment is capable of consenting if the minor is 18 years of age or older, graduated from high school, has married, has been pregnant, needs diagnosis or treatment of pregnancy or venereal disease, or is 14 years of age or older and requests psychiatric treatment. In emergency situations treatment may be rendered without consent if in the opinion of the attending physician involved, an attempt to secure consent would result in a delay of treatment which could seriously increase the risk to the minor's life or health. ... ." Review of Purchase of Transport Services for ... Transport Service revealed, "... This agreement is made between Conemaugh Memorial Medical Center ... and ...Transport Service for the provision of patient transportation 24 hours per day, 7 days per week ... for transfers from Conemaugh Memorial Medical Center to a specified destination in a safe, reliable and effective manner complying with medical, legal, and patient requirements. II. Definitions: 1) Basic Van- transport of a patient with or without a wheelchair. 2) Basic Invalid Coach- transport of a patient via litter. 3) Ambulance Rental - transport of a patient by ambulance with personnel from Conemaugh Memorial Medical Center accompanying the patient. 4) BLS transport - patient requires transport with Emergency Medical Technician and requires basic life support care measures. No personnel from Conemaugh Memorial Medical Center accompany the patient. 5) ALS transport - patient requires transport with Paramedic and requires advanced life support care measures. No personnel from Conemaugh Memorial Medical Center accompany the patient ... VI. Responsibilities of Provider. V. The transport service will supply suitable and safe transportation for all transports ... 6) All transport personnel are expected to conduct themselves in a professional manner in both conduct and appearance. Interactions with patients, health care professionals and general public are expected to be courteous and respectful in alignment with MMC's CARING Values ... 8) Transport personnel shall be duly licensed and certified, and shall maintain that status while performing services for and on behalf of MMC. MMC has the right to request proof of licensure and certifications upon request. 9) Transport service will provide upon request a criminal background check on personnel providing services for MMC. MMC may have the right to bar an individual from providing service to or for MMC for 'cause' ... 11. Attendance at quarterly meetings to be held by the transport personnel and the hospital personnel to discuss quality assurance issues and opportunities for improvement ... VII. Responsibilities of the Hospital 1) MMC personnel, under the direction of a physician, will determine the mode of transport. ... ." (kw) 1) MR1, MR4 and MR6 revealed no documented evidence that suicidal patients all under the age of 18 were transferred in the company of a parent, a guardian or a responsible adult, in addition to the ... Transport Service driver. MR1, MR4 and MR6 also revealed inconsistencies between the mode of transportation that was documented in the Nurses Notes and the mode of transportation documented on the Transfer Consents. 2) MR1 ER FACESHEET dated November 11, 2015 revealed, "... Time of Arrival: 1231 ... Time in Room: 1323 ... Age: 13 ... Chief Complaint: Eval ... Triage Priority: 3 ... Time: 1235 ... Additional Orders: PAC called ... 2242: Bactrim DS PO x 1, Hydroxyzine 50mg PO x 1, Prazosin 1 mg PO x 1 ... Time Seen by Provider: 1350 ... Condition: Stable ... Check out time: 0206 ... Disposition: ... Transfer ... Diagnosis: [blank] ... ." MR1 emergency room physician documentation dated November 11, 2015 revealed, "... Chief Complaint: Is evaluation. History of Present Illness: [Patient] is a [AGE]-year-old who presents from the ... Home, states that patient has been suicidal for 5 years and this afternoon was found to be in bed with a belt from a robe tied around their neck in a bow. ... Diagnostic Impression: 1. Suicidal ideation. ... Disposition: Admit to Psychiatry and transfer with a bed search underway. ... ." MR1 ER Primary Nurse Note dated November 11, 2015 revealed, "... 0206: Pt transported to Southwood with ... Transport Service. Southwood called & updated with ETA. ... ." MR1 Memorial Medical Center Transfer Consent To Acute Care Hospital dated November 1, 2015 at 10:35 PM revealed, "... Person Completing: [EMP28] ... Mode of Transportation: Ambulance: BLS ... ." 3) MR4 ER FACESHEET revealed, "Date: 10/26/2015 ... Time of Arrival: 1332 ... Time in Room: 1335 ... Age: 15 ... Chief Complaint: Eval ... Triage Priority: 3 ... Time: 1332 ... Time Seen by Provider: 1345 ... Condition: Stable ... Diagnosis: 1. Suicidal Ideation ... Check out time: 0942 ... Disposition: Observation ... Primary Nurse Note revealed ... 0850: Pt to be transferred to Latrobe Hospital. Awaiting precert. ... 0942: Report to ... receiving facility ... Transport Service here to transport. ... . MR4 Memorial Medical Center Transfer Consent: To Acute Care Hospital ... Mode of Transportation: Ambulance: BLS. ... ." 4) MR6 ER FACESHEET revealed, "Date: 07/30/2015 ... Time of Arrival: ... 1830 ... Time in Room: 1837 ... Age: 14 ... Chief Complaint: evaluation ... Triage Priority: 3 ... Time: 1830 ... Time Seen by Provider: 1841 ... Condition: Stable ... Diagnosis: 1. SI ... Check out time: 0153 ... Disposition: Transfer ... MR6 Primary Nurse Note revealed, ... 0117: ... Transport Service notified. Will transport pt ... MR6 Memorial Medical Center Transfer Consent: To Acute Care Hospital ... Mode of Transportation: Ambulance: BLS. ... ." 5) Facility documentation from EMP30 dated November 19, 2015 at 11:34 AM revealed, "... Per our conversation regarding chaperones/family accompaniment, I couldn't find any documentation to show that chaperones or family members went with MR1, MR4 or MR6. 6) A telephone interview was conducted with EMP27 on November 6, 2015, at 2:30 PM. "... We regularly use the van for all patient transports. Families could follow behind the van. A second telephone interview was conducted with EMP27 on November 17, 2015 at approximately 3:20 PM. "... The physician doesn't tell us how they want the patient to go. The mode of transportation and arrangements are determined by us, the Psychiatric Assessment Coordinators." 6) A telephone interview was conducted with EMP28 on November 6, 2015, at 3:14 PM. "... I made the arrangements for transport, that was around 10:00 or 11:00 PM. We transfer children to other facilities on a daily basis. Several of these children have gone with just a van driver. Their parents can follow behind. ... Transport Service does not normally allow the parents to ride with them. Normally it's just the patient and the driver. ... Transport Service is our 'go to' for transport. Their driver could not get to us until after dropping off another patient. I don't think there was any reason why we had to send the patient out at 2:00 AM, but they had already been there so long and the ER was ready to have the patient move on." A second telephone interview was conducted with EMP28 on November 16, 2015, at 10:20 AM. "... Transport Service is our 'go to' transport company. The doctors tell us, the PACs, to arrange for patient transportation. They don't specify how they want the patients to go. There is an option on the Consent to Transfer to select 'ambulance' and I do believe that it was checked on MR1. I checked BLS because I thought it was the least restrictive. MR1 didn't have a medical need, they just needed a driver." 7) An interview was conducted with EMP10 on November 12, 2015, at approximately 12:45 PM. "... EMP9, the patient's primary nurse had another patient who required an ICU transfer. EMP9 saw the patient and their Care Giver from the ... Residence home walking out to get in the van. EMP9 thought that since the ... Residence Care Giver was carrying the patient's bags, that they were going to ride along with the patient ... We have no specific policy related to the transfers of minors. ... It happens with other under age children, we have been sending them with just the driver transporting." 8) A telephone interview was conducted with EMP9 on November 17, 2015, at 8:10 AM. "MR1's legal guardian, ... , was never present. I guess I assumed that the ... Residence Care Giver was going along with patient. The ... Residence staff was carrying the patient's belongings. ... I do not typically document who accompanied the patient when they are being transferred. ... ."

Based on a review of the patient's medical record (MR1), facility documents, and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted Emergency Department policies to ensure that Triage and reassessment procedures were implemented in one of one medical record (MR1). Findings Include: A review of PROCESS: DEPARTMENT OF EMERGENCY SERVICES, TRIAGE PROCESS, and PURPOSE: policy and procedure revealed, "... To provide guidelines for a quick, initial assessment of every patient who presents to the Emergency Department and to assure early identification of those with emergency problems. It also identifies those who are eligible for Fast Track and allows the RN to begin advanced Triage protocols. PROCESS: 1. all patients who come to the Emergency Department for care are triaged, either at bedside or in he [sic] triage area. At times, ambulance patients will be directed to Triage based on Medical Command report. 2. Triage responsibilities are: a) completing the reason for visit and assigning a triage acuity level. B) obtaining vital signs, accurate patient weight (all children must be weighed). C) obtain tetanus history if applicable. D) last normal menstrual period on all age appropriate females. E) obtain and document medications and allergies e) [sic] initiate the advanced triage protocols as appropriate. 3. The Triage nurse is responsible for monitoring patient condition and updating them on delays while in the Waiting room, working with the Triage tech and pt. advocate to keep patients and families informed regarding delays. ... ." A review of Documentation of Vital Signs/Patient Assessment Protocol ED policy and procedure revealed, "... 4. Triage acuity 1 patients should have VS monitored and documented at least every 30 minutes, more frequently based on their condition or physician request. Patient assessment for these patients is ongoing to determine changes in condition and must be documented in the note at least every hour or more often if warranted. ... 6. All other patients should have VS monitored every 2 hours and documented as well as a brief pt assessment. ... Patient assessments done in the Emergency Department are centered on the Chief Complaint. It is expected that the reassessments include an updated evaluation of these systems and complaints as well as any additional areas of concern. Repeat assessments should include a statement about the patient's general appearance and comfort level. ... Vital signs refer to blood pressure and pulse. Patients that require cardiac monitoring must have a rhythm strip on admission to the ED and every 4 hours after if admitted to a monitored area. ... ." 1) Review of MR1 ER Facesheet dated May 6, 2015, revealed, "... Time of Arrival: 1723 ... Room: 29 ... Time in Room: 2118 ... Chief Complaint: Chest Pain ... Triage Priority: [blank] ... Time: 1725 ... Temp 36.7 ... Pulse 131 ... RR 18 ... BP 118/65 ... O2Sat 95% ... ... ." MR1 "DEM Vital Signs/EKG Strips dated May 6, 2015, revealed that the patient was in bed "ER 29" with a set of vital signs documented at 10:45 PM. The initial set of vital signs were documented at 5:25 PM in triage. There were no vital signs, cardiac monitor assessments or reassessment of patient condition documented from 5:25 PM until 10:45 PM. 2) A telephone interview was conducted with EMP6 on June 1, 2015, at 9:00 AM. EMP6 confirmed the above and revealed, "There was no Triage score assigned to the patient." 3) A review of electronic mail documentation from EMP6 dated June 1, 2015, at 3:42 PM revealed that there was no reassessment until the patient was taken into a cubicle.