Based on a review of facility documents, and staff interview (EMP), it was determined the facility failed to ensure that physician names were identified with contact information, for each day on call, on the General Surgery Call Schedules, and failed to adopt a Community Call Plan, as described in their adopted policy. Findings include: A review of Penn Highlands Elk, Medical Staff On-Call Policy, effective date October 2015, revealed, "... Policy: The Penn Highlands Elk Hospital (PHE) and its Medical Staff arrange and provide emergency on-call coverage directly and through a Community Call arrangement with Penn Highlands DuBois (PHD). The Community Call arrangement between PHE and PHD includes a schedule of on-call responsibilities at each hospital that guides patient disposition, as well as an annual assessment of the Community Call arrangement itself. Purpose: The purpose of this policy is to provide for the preparation of a monthly emergency on-call schedule for applicable medical specialties, to provide guidance to on-call physicians, and to provide direction to physicians and hospital staff when emergent services are required by on-call physicians. Procedure: On-Call Schedule 1. The Penn Highlands Practice Network (PHPN) practice managers, on behalf of the hospital, are responsible for developing a monthly on-call schedule in collaboration with applicable physicians that includes the name relevant contact information of each Active Staff physician in the department who is required to fulfill on-call duties. On-call schedules will be prepared by PHPN and maintained by the PHE Executive Secretary. Copies of the on-call schedule will be provided to on-call physicians by the Executive Secretary and PHPN, and will be posted and available on-line via the Intranet. 2. The on-call schedule will include the following specialties: Hospitalist, Pediatrics, Obstetrics/Gynecology, General Surgery, Orthopedic Surgery, Ophthalmology, and Cardiology. On-call coverage for these specialties will be provided by a PHE physician, and dates, that are not covered by a PHE physician will be covered via a Community Call arrangement with PHD physicians. Specialties with a limited number of PHE physicians, consulting staff, and other specialties, may be included based on the availability of physicians and the nature of the service. ... Alternative On-Call support and Transfer Arrangements ... 7. Patients who must be cared for by the PHD on-call physician will be transferred to PHD if necessary, or to another appropriate facility if requested by the patient. Transfers to PHD will be completed in accordance with the Transfer Agreement between PHE and PHD. Regardless of an Emergency Department patient's final disposition and/or transfer, all patients who present to PHE will receive a Medical Screening Examination (MSE) and stabilizing treatment by appropriate PHE providers in accordance with PHE policy concerning EMTALA. 8. PHE patients who require emergency services by a specialist who is not available via call-coverage at PHE, such as specialties with limited numbers of PHE specialists, will be transferred to PHD or another appropriate facility in accordance with the process described in Section 7 above. ... ." 1. During review of the General Surgery Schedules it was noted that there is not a physician listed every day of call. There are days when the schedule only indicates a Group name, and not a physician. Review of the schedules also revealed no contact information is listed. A review of the General Surgery Call Schedule, dated October 2015, revealed there was no coverage indicated from October 1, 2015 to October 9, 2015. It was noted that on October 9, 2015, PHD (Penn Highlands DuBois) (physician group) beginning at 1:00 PM. October 10, 2015 to October 11, 2015, revealed forward arrows only. On October 12, 2015, the schedule stated EMP1 beginning coverage at 7:00AM. October 13 to October 18, 2015, revealed forward arrows only. On October 19, 2015, the schedule indicated that EMP25 coverage beginning at 7:00AM. October 20, and 21, 2015 schedule revealed forward arrows only. On October 22, 2015, the schedule indicated PHD (physician group) to begin coverage at 7:00AM. October 23-31, 2-15 revealed forward arrows only. A review of the General Surgery Call Schedule for November, 2015, revealed that on November 1, 2015, the schedule stated PHD (physician group) still covering. On November 2, 2015, the schedule stated EMP1 coverage starts at 7:00AM. On November 3-15, 2015, the schedule revealed forward arrows only. On November 16, 2015, the schedule indicated that EMP25 coverage starts at 7:00AM. On November 17-22, 2015, the schedule indicated forward arrows only. On November 23, 2015, the schedule indicated PHD (physician group) coverage starts at 7:00AM. On November 24-29, 2015, the schedule indicated forward arrows only. On November 30, 2015, the schedule indicated EMP1 coverage starts at 7:00AM. 2. A request was made to review the facility's Community Call Plan and no documentation was received. An interview was conducted with EMP8, on October 23, 2015, at approximately 2:00 PM. EMP8 revealed, "We are working on our Community Plan." 3. During a telephone interview with EMP8, on October 28, 2015, at 2:00 PM, EMP8, revealed that the above call schedules are utilized by the Emergency Department, and that they have formulated a the Community Call Plan with Penn Highlands DuBois, however, also stated that they are working on the Community Call Plan.

Based on a review of facility documents, closed medical records (MR), and staff interviews (EMP), it was determined that the facility failed to follow adopted policies related to Triage, and Patient Rounding in the Waiting Room, which delayed the medical screening examination for one of one patients (PT1), failed to document Charge and Triage Nurse designations for approximately 39 of 50 days, failed to follow adopted policies by failing to accurately document the sequence of events for one of one medical records reviewed (MR1), and by failing to document completion of yearly Triage Assessment Tests for three of eight educational records reviewed. (OTH7, OTH8, OTH11) Findings include: A review of the policy entitled, Penn Highlands Elk EMTALA Policy, undated, "... The purpose of the medical screening examination is to determine if an individual is experiencing an emergency medical condition. a. An "emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could be reasonably expected to result in: ... serious impairment of bodily functions, or serious dysfunction of any bodily organ or part ... All patients presenting will be afforded a Medical Screening Examination based upon their priority as determined by the Triage Nurse, other Registered Nurse in the absence of the Triage Nurse ... ." A review of a document provided by the facility entitled, Rounding in Emergency Department Waiting Room, revealed, "1. Rounding will be performed and documented every 30 minutes on the Emergency Department Waiting Room. 2. 30 minute rounding will focus on pain, making sure they are comfortable and informing patients of delays without saying any specific hours. 3. The Triage Nurse will explain rounding to the patient indicating the reason for its use is to re-evaluate and provide a visual assessment making sure we meet their needs and they are comfortable while waiting for a hospital bed. 4. The Triage RN will be responsible for assuring that the rounding has occurred as scheduled 5. Rounding Log Form is located in the Waiting Room on the wall in a holder by the sink 6. The Triage RN rounding will write the number of patients and sign in the space provided 7. Care delivered during rounds will be documented in the medical record 8. Completed Rounding Logs will be placed in the Directors mailbox for review 12/23/14 ... Director of Emergency Department." A review of the Emergency Department's Scope of Service, revealed, "... It is the philosophy of the Emergency Department to give the highest quality of care to all persons, regardless of age, race, religion, culture or ability to pay. We believe this is best accomplished through development of the Emergency Department personnel, utilization of physicians and specialist available on the hospital staff, use of referral specialist, and cooperation with the emergency facilities existing in the area ... The Emergency Department provides medical evaluation, treatment and disposition to presenting patients of various ages and varying levels of illness and injury from minor to critical. Objectives of the Department are to provide a clinical environment conducive to medical screening evaluation and identification of emergency medical conditions, prioritization (triage) for treatment, appropriate and prioritized medical interventions with continued monitoring provided consistent with the identified medical conditions and evaluation of the response to treatment. Also, to provide necessary definitive medical care to stabilize an emergency medical condition with the discretion of the physician providing the medical screening examination and within the capabilities and capacity of Elk Regional health Center. The Emergency Department also ensures to provide for appropriate continuity in patient care through discharge instructions, pertinent referrals, and mechanisms for inpatient admission or transfer to another facility for diagnosis or treatment as indicated. The Emergency Department is open 24 hours a day, seven days a week. It is located on the ground floor of the new building, and has easy access for ambulances, wheelchairs and ambulatory patients. It is well equipped to hand (sic) all emergencies ... All persons who present to the department shall be triaged by an appropriately trained registered nurse and medically screened by a qualified practitioner to determine if a medical emergency exists ... Staffing. The Emergency Department staff report to the Director of the emergency room . This Director oversees the overall operation of the emergency room in conjunction with the assistance of the emergency room Medical Director. Each shift will be staffed with a Charge Nurse, Triage Nurse, and Primary Nurses. There will be an Emergency Department Tech (EDT) scheduled 7 days during the busiest hours of the day 12 p-12 a. There will be a minimum of 2 nurses during the hours of 7AM to 9am, additional nursing staff are scheduled as the daily volumes increase to a maximum of 4 nurses within the Department and the EDT. Staff assignments are the responsibility of the Charge Nurse. Knowing the emergency room is often unpredictable, staffing is adjusted throughout the day depending on the patient's and department's needs. Additional staffing is available through utilizing department management, calling additional staff in from home and the ability to float personnel oriented to the Department. Each shift is also staffed with a Unit Secretary." A review of facility policy/procedure, Triage, reviewed and approved April 2015, revealed, "Purpose: The purpose of Triage is to screen all patients to ascertain the nature and severity of the patient's presenting symptoms. Triage will enable the Emergency Department to: ... 3. Provide assessment and reassessment of patients in the Waiting Room. ... Policy: The Triage Nurse, who is a Registered Nurse, will check all patients who present for treatment ... Procedure: 2. All patients must see the Triage Nurse prior to registering to comply with the EMTALA regulation that states that no insurance information can be obtained prior to determining that a medical emergency exists. ... Policy: The Emergency Department (ED) at Elk Regional Health Center maintains a triage function, staffed by an experienced Registered Nurse who has successfully completed the orientation process, a Triage Competency and a Triage educational program. ... Standards: 1. The Triage Nurse stationed near the ambulatory entrance will be the staff to interact with the ambulatory patient entering the Registration area. The Triage Nurse will be limited to activities in the Emergency Department, which permit continuous and consistent attention to the triage function; activities will include facilitating communication with family members/visitors and assisting with patient discharge instructions. ... 3. Patient data will be collected and entered into the computer by the Triage Nurse and a treatment category assigned. Treatment categories are: utilizing the 5 Level Emergency Severity Index. ... ESI Category II: This category used for any patient who's treatment is "time sensitive", a high risk patient, a patient who is in severe pain or distress, or any patient who has a new onset to confusion/lethargy or disorientation ... ESI Category IV: Only one resource is anticipated in this patient's care. ... Category III, IV and V: Patients are triaged to Categories III, IV, and V based on the anticipated resources they will use during their visit. ... Patient Categorization ... Category II (Urgent): Patients who are considered "high risk", in severe pain or distress, or a new onset of confusion, lethargy or disorientation. These patients should be seen within 15 minutes of being placed in a room ... Triage Standards of Care ... 8. Mild Headaches: Category: Level 3, Level 4, or Level 5 a. Do neuro exam b. Continue to monitor neuro's q 15 mins. C. Document assessment and interventions. ... . " A review of facility policy/procedure Emergency Medical Treatment and Active Labor Act, reviewed and approved April 2015, revealed, "Policy: Any persons who present to a hospital facility requesting assistance for a potential emergency medical condition/emergency services will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists ... 6. On Call List refers to the list that the hospital is required to maintain that defines those physicians who are "on-call" for duty after the initial medical screening examination, to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition ... 12. Triage is the sorting process to determine the order in which patients will be provided a medical screening examination by a physician or qualified medical person. Triage is not the equivalent of a medical screening examination and does not determine the presence or absence of an emergency medical condition ... All presenting patients will be afforded a medical screening examination based upon their priority as determined by the Triage Nurse, other Registered Nurse in the absence of the Triage Nurse ... On-Call Physicians: Each facility should have a documented system for providing on-call coverage, so that the Emergency Department is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide screening and treatment necessary to stabilize individuals with emergency medical conditions. If a facility offers a service to the public, the service should be available through on-call coverage of the Emergency Department. There is no requirement for a sole practitioner to be on-call at all times; hover (sic), the hospital must have policies and procedures to be followed when a particular specialty is not available or the on-call physician cannot respond because of situations beyond his/her control ... ." A review of facility policy/procedure Emergency Medical Record, reviewed and approved April 2015, revealed, "Policy: A medical record shall be kept for every patient receiving emergency service. ... 1. The record shall include: (a) Time of service, admission to the Emergency Department/Med-Express, seen by physician and discharge. ... (k) documentation of nursing care and an initial assessment for all patient and on-going assessment for those who are critically ill. ... 4. Accurate recording and time required is extremely important, as well as length of lacerations, location of injury, degree of burns and areas covered and location of foreign bodies. ... 5. The primary care nurse and any other nurse delivering care to a patient is responsible for documenting. (a) All critically ill patients will be reassessed every 5-15 minutes and their assessment findings will be documented ... ." 1. A review of MR1 revealed that PT1 was triaged on September 8, 2015, at 16:32. PT1 presented with complaints of a headache, with nausea and vomiting. Documentation also indicated that PT1 rated severity of pain as a 9, on a 0 to 10 pain scale. At the time of triage, a priority ESI 4 was assigned to PT1. Continued review of MR1 rvealed documentation that at 17:55, PT's husband was asking for PT1 to lay down, and that when attempting to transfer PT1 to a cart, PT1 was diaphoretic and semi-conscious. Documentation also stated, as a late entry, that the initial priority of ESI 4, was changed to an ESI 2, due to a change in the patient's condition. In addition, during review of MR1, it was noted that that there were no every 15 minute neuro checks documented between 16:32 and 17:48. There was also no documentation of pain reassessments. Upon further review of MR1, it was noted that that physician documentation stated that the time of intubation was 16:15 and the time seen by the provider was 16:45. Documentation in MR1 also stated that PT1 was not triaged until 16:32, and intubated at 17:59. 2. A telephone interview with EMP8, on October 28, 2015, at 2:00 PM, confirmed that there are no documented every 15 minute neuro checks present within MR1. EMP8 also confirmed inaccurate times noted in the patient's record related to time seen by provider and time of intubation. 3. A review of Emergency Department staff meeting minutes dated January 14, 2015, revealed, "... Waiting Room Triage Nurses must round in the Waiting Room everdry (sic) 30 minutes. a. Follow up wth (sic) patients regarding their concerns ... Triage rounding sheets must be completed ... ." 4. A review of the Rounding Log dated September 8, 2015, revealed no documentation of rounding in the Waiting Room from 3:00 PM to 7:00 PM. 5. A review of Rounding Logs dated September 1, 2015 through October 22, 2015, revealed gaps in documentation of Waiting Room rounding for approximately 29 of 52 days. 6. An interview with EMP9, on October 23, 2015, revealed that rounding is to be completed every 30 minutes by the Triage Nurse for patients in the Waiting Room, and that it is to be documented. 7. A telephone interview with EMP11, on October 28, 2015, at approximately 3:00 PM, revealed, "... We continue to educate on the Logs. They were leaving them blank because no one was out there. Maybe there was no one in the Waiting Room, or they didn't do it ... ." EMP11 also confirmed that rounding is to be documented every 30 minutes. 8. A review of the Emergency Department Staffing Assignment Sheet for September 8, 2015, revealed that assignments for the Charge Nurse and Triage Nurse were blank from 3:00 PM to 7:00 PM. 9. A review of Emergency Department Staffing Assignment Sheets for the period of September 6, 2015, through October 25, 2015, revealed gaps of who was the designated Charge and/or Triage Nurse for approximately 39 of 52 days. 10. An interview with EMP3 on October 23, 2015, at 9:40 AM, related to the events of September 8, 2015, revealed, "... We didn't have a Charge Nurse ... EMP1 wanted me or EMP6 to take charge. I said no, I'm not comfortable doing it ... ." 11. An interview with EMP5, on October 23, 2015, at 10:45 AM, related to the events of September 8, 2015, revealed, "... There was no Charge Nurse to direct the patient flow ... ." 12. An interview with EMP6, on October 23, 2015, ay 11:20 AM, related to the events of September 8, 2015, revealed, "... There wasn't a Charge nurse per se, I can't recall. I think it was assumed I would guide, but I'm not versed. I don't remember if I was asked ... ." 13. An interview with EMP11 on October 23, 2015, at 1:50PM, related to the events of September 8, 2015, revealed, "... EMP3 was the designated Charge Nurse from 3 PM to 7 PM. (They) didn't want to be. I did ask EMP6, (they) didn't want to ... ." 14. An interview with EMP18, on October 23, 2015, at 2:25 PM, related to the events of September 8, 2015, revealed, "... They haven't had a Charge Nurse for some time, six months to a year. Each nurse takes a section and one does Triage ... ." 15. A telephone interview with EMP9, on October 30, 2015, at 11:30AM, related to the Charge Nurse and Triage Nurse designations, revealed, "Part of it is that certain people who are here, are always in charge ... the Charge Nurse is also the Triage Nurse. The statement made that there hasn't been a Charge Nurse for six months is totally wrong ... ." 16. A review of three educational records (OTH7, OTH8, OTH11), revealed no documentation that the Triage Assessment Test was completed in 2014. 17. An interview with EMP9, on October 30, 2015, at approximately 11:30AM, revealed that Net Learning is done yearly, and that the expectation is that the Triage Assessment Test should be done yearly, and acknowledged that the deficits in the Triage Assessment tests are related to casual nurses.