QA Investigation Results

Pennsylvania Department of Health
UPMC BEDFORD
Health Inspection Results
UPMC BEDFORD
Health Inspection Results For:


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Initial Comments:

This report is the result of an unannounced special monitoring visit conducted on March 19-20, 2019, at UPMC Bedford Hospital. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 Pa Code, Part IV, Subparts A and B, November 1987, as amended June 1998.








Plan of Correction:




117.1 (b) LICENSURE
PROVISION OF SERVICES

Name - Component - 00
117.1
(b) Where there is an emergency service, it shall provide prompt examination or treatment, or both, to all persons who come or are brought into the hospital in need of such treatment, irrespective of ability to pay. Such treatment shall be of the highest type consistent with the facilities available and with the standards established in the medical community of which the hospital is a part.

Observations:

Based on a review of facility documents, audio recording, and staff interviews (EMP1), it was determined that UPMC Bedford Hospital failed to follow adopted policies by failing to ensure that an appropriate medical screening was provided for one of one patients who presented to the Emergency Department. (PT1)

Findings

Review of "Emergency Medical Treatment and Active Labor Act (EMTALA)", dated February 14, 2019, revealed " ... UPMC seeks to comply with all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act ... this policy sets forth the system hospitals requirements under EMTALA, including guidelines for providing the appropriate setting (department) for conducting medical screening ... Procedure. 1. If an individual seeking emergency medical care comes to the hospital's Dedicated Emergency Department a QMP (Qualified Medical Provider) shall offer a Medical Screening Exam. If an individual seeking emergency medical care comes to any other portion of the hospital campus, including on-campus clinics, sidewalks, driveways, and parking lots, and requests emergency medical care, a QMP will offer a Medical Screening Exam to that person ... 4. If the patient leaves before undergoing a medical screening exam, the QMP or staff shall note this in the Emergency Department record or log. If the patient or their representative refuses treatment, the QMP or other staff shall note the type of treatment refused in the Emergency Department record or log and take reasonable steps to secure a written informed refusal by the patient or their representative ... ."

Review of "Triage/Discharge to another facility ..." , dated September 2018, revealed " ...The hospital will provide treatment within its capability and when necessary services are not available, will make appropriate transfer arrangements. ... A Medical Screening Exam (MSE) must be performed and documented on those patients being considered for transfer. The MSE is an ongoing process and the record must reflect continued monitoring according to the patient's needs until the patient is stabilized and transferred. ... ."

"Medical Staff Bylaws, Policies, and Rules and Regulations of UPMC Bedford Medical Staff Rules and Regulations Adopted by the Medical Staff: December 14, 2017 ... Article X Emergency Services 10. A. General Emergency services and care will be provided to any person who comes to the emergency department, as that term is defined in the EMTALA regulations, whenever there are appropriate facilities and qualified personnel available to provide such services or care. ... 10. B. Medical Screening Examinations (1) Medical Screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified Medical Personnel ( " QMP " ) who can perform medical screening examinations within applicable Hospital policies and procedures are defined as: (a) a physician; (b) a certified registered nurse practitioner; (c) a physician assistant under the supervision of an Emergency Department physician; and (d) a certified nurse midwife. (2) The results of the medical screening examination must be documented within 12 hours of the conclusion of an Emergency Department visit. ..."

1. A review of Bedford Area Ambulance Service documentation, (MR 21), dated February 19, 2019,"... Patient is Cincinnati stroke scale positive upon evaluation. ... 19:18 Stroke alert sent ... via cellular. Hospital contacted and given ALS stroke advisory. ... ETA Given. 19:22 Bedford county contacted ... and advised that UPMC Bedford ED would like a call back. 19:23 ... consulted with (EMP 7) from UPMC Bedford via cellular. ... called back to UPMC Bedford ED. At same time of call, ... is pulling into UPMC Bedford ambulance bay. (EMP 8) answered and advised, Command was wondering if you guys can divert to UPMC Altoona. ... requested to speak to Medical Command. ... gave report to command and advised based on patient's condition, the decision was made for patient to be transported to closer hospital for stabilization. Medical command advised ... that based on patient's current BP and HR, patient should be diverted to UPMC Altoona. ... "
2. Review of audio medic command tape recording dated February 19, 2019 revealed The first call was received at 1908 and lasted 2 minutes at 8 seconds. EMS from Bedford Ambulance called. UPMC Bedford responded, "Do you need command?" Bedford EMS stated, "No I do not." The Bedford EMS stated ... developed acute stroke symptoms. Patient's heart rate was brady at 60 with blood pressure 166/112. EMS stated you are the closest hospital and I don't feel comfortable going to Altoona. EMS stated the heart rate decreased to 40 but was now 74. The patient was talking but with a left droop. ... EMS stated, "We are 8 minutes out. ... " UPMC Bedford stated, "See you then, bye." A second call was made to Bedford EMS by UPMC Bedford per request of EMP7. This call occurred at 1913 and lasted 1 min and 34 seconds. EMS stated, "We are pulling in now." EMP 8 from UPMC Bedford stated, "EMP7 wants to divert to Altoona. Do you want to talk to EMP7. EMP7 is comfortable with the heart rate and blood pressure, but thinks this patient needs to go to Altoona." EMS stated, "I am going to be pulling in right now." EMS stated, "Who is the doctor?" UPMC Bedford stated, "(EMP7)." EMS stated, "I can talk to EMP7." EMP7 stated, "BP is ok, not worried about heart rate." EMS stated, "Do you have TPA here?" EMP 7 stated, "Yes, ... . I would keep the patient here if the roads were bad or if pressure not good. Roads are good. Better to go to Altoona because of IR lab. Where are you now?' EMS stated, "We are here at hospital now." EMP7 stated, "I still think you should go there now."
3. An interview was conducted with EMP7, on March 19, 2019, at approximately 10:00AM. EMP7 worked at UPMC Bedford Memorial Hospital for two years. ... EMP7 stated that on February 19, 2019 an EMS call came in. ... the evening nurse told them that a patient with immediate onset of unilateral weakness would be here in 10-12 minutes. ... EMP7 stated they would benefit from going to Altoona. ... EMP7 stated EMS should take patient to Altoona and that the patient was within treatment window. EMP7 stated the patient should be taken to the IR lab. EMP7 stated that the EMS stated, "Don't you have TPA?". EMS stated they were not comfortable with the patient. EMP7 stated to them better to go to Altoona to specialists in Interventional Radiology to treat the issues. EMP7 stated that EMS stated they were here. ... EMP7 stated I told EMS, "I still think you need to go." EMP7 stated, "I understand EMTALA and I would never turn anyone away or put a patient at risk. ... I thought I made the best decision. I didn't believe they were outside, if I thought they were there I would have treated the patient. No one looked to see if they were there. I realize it was a mistake."













Plan of Correction:

UPMC Bedford has an EMTALA policy that requires a medical screening exam (MSE) be offered to any individual who present to any portion of the hospital campus seeking treatment. The policy is current and all employees are expected to understand and abide by the policy. All employees receive EMTALA training during orientation and are expected to abide by the EMTALA Policy.
Following the event of February 19, 2019, members of UPMC Bedford Administration met to address compliance with the UPMC Bedford EMTALA Policy. Administrative Members included the Interim Director of Nursing (DON), the Director of Clinical Ancillary Services/Regulatory/Compliance and the Director of Patient Experience/Patient Safety Officer. The group determined that staff education was required as the first step in addressing the problem.
On February 22, 2019 the Emergency Department Site Coordinator sent an EMTALA educational Powerpoint to all physicians working in the UPMC Bedford Emergency Department. On March 7, 2019 the Emergency Department Site Coordinator sent the EMTALA educational Powerpoint to the UPMC Bedford Hospitalists Providers, Residents, Students, and Volunteers. By March 28, 2019 there was 100% compliance with these individuals reviewing and acknowledging understanding of the materials.
On March 1, 2019, an educational program was pushed to all UPMC Bedford staff through the UPMC learning system known as ULearn. By March 28, 2019 there was 100% compliance with UPMC Bedford employees completing the EMTALA ULearn program. The Human Resources Manager will report the rate of the EMTALA Education Compliance to the Performance Improvement/Quality Committee at the April 18, 2019 meeting.
The Director of Emergency and Surgical Services began a daily monitoring of the command line to assure that no inappropriate diversions occur. The monitor includes reviewing 100% all the command tape. The monitor began on February 25, 2019 and will be completed daily until there is 100% compliance for six months. The results of the monitor will be reported by the Director of Emergency and Surgical Services at the April 18, 2019 Performance Improvement/Quality Meeting, and monthly thereafter until there is 100% compliance for six months.
Any incidence of non-compliance with the EMTALA Policy will be investigated immediately and involved staff will again be re-educated and/or counselled.



117.41 (b)(2) LICENSURE
EMERGENCY PATIENT CARE

Name - Component - 00
117.41 Emergency patient care
(b) Policies and procedures for
emergency patient care should, at a
minimum, do the following:
(2) Provide for the referral and
placement of patients whose needs
cannot be met by the hospital.

Observations:

Based on review of facility documents and staff interview it was determined that UPMC Bedford failed to follow established policies and procedures for transfer of patients whose needs cannot be met in one of one cases reviewed. (PT1)

Findings

A review of the "Medical Staff Bylaws, Policies, and Rules and Regulations of UPMC Bedford Medical Staff Rules and Regulations Adopted by the Medical Staff: December 14, 2017 ... Article XII Transfer To And From Other Facilities ... 12. B. EMTALA Transfers (1) The transfer of a patient with an emergency medical condition from the Emergency Department to another hospital will be made in accordance with the Hospital's applicable policy and in compliance with all applicable state and federal laws, such as EMTALA. (2) Before any such transfer occurs, the on-call physician and/or the Emergency Department physician must see the patient and enter a certification in the patient's medical record indicating that the medical benefits to be received at another medical facility outweigh the risk to the patient of being transferred (including, in the case of a woman in labor, the risk to the unborn child). 12. C. All Other Patient Transfers 12. .1. General: The process for providing appropriate care for a patient for all other transfers from the Hospital to another facility includes: (a) assessing the reason(s) for transfer; (b) establishing the conditions under which transfer can occur; (c) evaluating the mode of transfer/transport to assure the patient's safety; and (d) ensuring that the organization receiving the patient also receives necessary medical information and assumes responsibility for the patient's care after arrival at that facility. 12. 2. Procedures: Patients will be transferred to another hospital or facility based on the patient's needs and the Hospital's capabilities. The responsible practitioner will make the following steps as appropriate under the circumstances. (a) identify the patient's need for continuing care in order to meet the patient's physical and psychosocial needs; (b) inform patients and their families members (as appropriate), in a timely manner, of the need to plan for a transfer to another organization; (c) involve the patient and all appropriate practitioners, Hospital staff, and family members involved in the patient's care, treatment, and services in the planning for transfers, and (d) provide the following information to the patient whenever the patient is transferred: (1) the reason for the transfer; (2) the risk and benefits of the transfer; and (3) available alternatives to the transfer. 12. 3. Provision of Information When patients are transferred, the responsible practitioner will provide appropriate information to the accepting practitioner/facility, including: (a) reason for transfer; (b) significant findings; (c) a summary of the procedures performed and care. Treatment and services provided; (d) condition at discharge; (e) information provided to the patient and family, as appropriate; and (f) working diagnosis. ... A patient will not be transferred to another facility unless prior arrangements for admission have been made. ..."
Review of "Triage/Discharge to another facility ...", dated September 2018, revealed " ...The hospital will provide treatment within its capability and when necessary services are not available, will make appropriate transfer arrangements. A patient can be transferred when the hospital does not have the capability to provide services, or when requested by patient/family/payer. The physician in charge will exhaust the specialist on call list here at UPMC Bedford prior to transfer. If no specialist is on call or available for specialized patient care, the patient will be transferred according to the procedure stated below ... A Medical Screening Exam (MSE) must be performed and documented on those patients being considered for transfer. The MSE is an ongoing process and the record must reflect continued monitoring according to the patient's needs until the patient is stabilized and transferred. c. The provided is responsible for contacting the receiving the facility and physician for acceptance of the patient. The provider will determine the referral facility and verify receiving physician in conjunction with patient and/or family wishes, patient condition, and treatment required. This discussion must be documented in the medical record. d. Transportation mode, level of support personnel and transportation equipment needed will be determined by the physician/referral physician in charge at time of transfer. e. The physician will place an ED-Transfer order on the patient's chart and will complete the EMTALA for addressing all required elements. The required elements include: i. Diagnosis ii. Stable vs/unstable iii. Reason for transfer iv. Benefits versus risks v. Verbal consent obtained vi. Receiving provider and facility vii. Mode of transport and special equipment f. the provider will complete an Ambulance physician medical necessity for ... h. The RN will provide the receiving facility with a phone report (and document this in the medical record). i. Documentation of care should reflect transfers in responsibility of care as they occur. J. Nursing documentation should also include a reassessment prior to transfer and may include vital signs, pain and sedation assessment. K. The receiving facility will be provided with a paper or electronic copy of the patient's medical record ... ."
1. A review of Bedford Area Ambulance Service documentation, Trip Number: 19000396 (MR 21), dated February 19, 2019,"... Impression: Pain, Headache, Stroke/CVA ... 19:05 ... Patient is Cincinnati stroke scale positive upon evaluation. ... 19:18 Stroke alert sent ... via cellular. Hospital contacted and given ALS stroke advisory. ... ETA Given. 19:22 At same time of call ... is pulling into UPMC Bedford ambulance bay. EMP 8 answered and advised, Command was wondering if you guys can divert to UPMC Altoona. ... requested to speak to Medical Command. ... gave report to command and advised based on patient's condition, the decision was made for patient to be transported to closer hospital for stabilization. Medical command advised ... that based on patient's current BP and HR, patient should be diverted to UPMC Altoona. ... 19:33 ... consulted with Altoona Hospital Command from Altoona Hospital via cellular. Contacted (EMP1) and gave stroke and ALS advisory. ... "
2. An interview was conducted with EMP7, on March 19, 2019, at approximately 10:00AM. EMP7 stated that on February 19, 2019 an EMS call came in. ... EMP7 stated they would benefit from going to Altoona. ... EMP7 stated EMS should take patient to Altoona and that the patient was within treatment window. ... EMS stated they were not comfortable with the patient. EMP7 stated to them better to go to Altoona to specialists in Interventional Radiology to treat the issues. EMP7 stated that EMS stated they were here. ... EMP7 stated I told EMS, "I still think you need to go." EMP7 stated, "I understand EMTALA and I would never turn anyone away or put a patient at risk. ... I thought I made the best decision. I didn't believe they were outside, if I thought they were there I would have treated the patient. No one looked to see if they were there. I realize it was a mistake."











Plan of Correction:

The Medical Staff Bylaws of UPMC Bedford require transfers be made in accordance with all applicable state and federal laws, including EMTALA. UPMC Bedford also has an EMTALA policy that requires a medical screening exam (MSE) be offered to any individual who present to any portion of the hospital campus seeking treatment prior to any transfer. Physicians and staff are expected to understand and comply with the policies and procedures for transfer of patients.
Following the event of February 19, 2019, members of UPMC Bedford Administration met to address compliance with the UPMC Bedford EMTALA Policy. Administrative Members included the Interim Director of Nursing (DON), the Director of Clinical Ancillary Services/Regulatory/Compliance and the Director of Patient Experience/Patient Safety Officer. The group determined that staff education was required as the first step in addressing the problem.
On February 22, 2019 the Emergency Department Site Coordinator sent an EMTALA educational Powerpoint to all physicians working in the UPMC Bedford Emergency Department. On March 7, 2019 the Emergency Department Site Coordinator sent the EMTALA educational Powerpoint to the UPMC Bedford Hospitalists Providers, Residents, Students, and Volunteers. By March 28, 2019 there was 100% compliance with these individuals reviewing and acknowledging understanding of the materials.
On March 1, 2019, an educational program was pushed to all UPMC Bedford staff through the UPMC learning system known as ULearn. By March 28, 2019 there was 100% compliance with UPMC Bedford employees completing the EMTALA ULearn program. The Human Resources Manager will report the rate of the EMTALA Education Compliance to the Performance Improvement/Quality Committee at the April 18, 2019 meeting.
The UPMC Bedford Director of Emergency and Surgical Services and the UPMC Emergency Department Medical Director met on March 28, 2019 to review the UPMC Bedford EMTALA policy. The EMTALA policy was sent to all Emergency Department physicians on March 28, 2019 for their review of the transfer requirements; all ED physicians are required to acknowledge receipt and understanding of the policy by Sunday March 31, 2019.
The UPMC Bedford Director of Emergency and Surgical Services will monitor all transfers from the UPMC Bedford ED to assure that the EMTALA transfer requirements are met. The monitor will take place until there is 100% compliance for six months. The results of the monitor will be reported by the Director of Emergency and Surgical Services at the April 18, 2019 Performance Improvement/Quality Meeting, and monthly thereafter until there is 100% compliance for six months.
Any incidence of non-compliance with the EMTALA Policy and/or transfers will be investigated immediately and involved staff will again be re-educated and/or counselled.



117.42 LICENSURE
CONTROL REGISTER

Name - Component - 00
117.42 Control register

The emergency service shall maintain a control register for reference. The register shall contain, at a minimum the name, date, and time of arrival of each patient. The name of those dead on arrival shall be entered in the register. The control register shall indicate whether the patient has ever been a patient at the hospital, in order to facilitate coordination of patient medical records. Unless and until a permanent record number can be assigned to the records of a new patient, the control register shall contain, for each patient, a record number which shall also appear on all records pertinent to the care rendered that patient by the emergency service. These records shall be retained for at least three years.

Observations:

Based on a review of facility documents, video monitoring and staff interviews (EMP), it was determined the failed to ensure that an individual who came to the Emergency Department seeking assistance, was entered onto the Log, for one of one patients identified. (PT1)

Findings

1. A review of Bedford Area Ambulance Service, (MR 21), dated February 19, 2019,"... Chief Complaint ... 19:05 ... Patient is Cincinnati stroke scale positive upon evaluation. ... 19:18 Stroke alert sent ... via cellular. Hospital contacted and given ALS stroke advisory. ... ETA Given. 19:22 Bedford county contacted ... and advised that UPMC Bedford ED would like a call back. 19:23 ... consulted with (EMP 7) from UPMC Bedford via cellular. ... called back to UPMC Bedford ED. At same time of call, ... is pulling into UPMC Bedford ambulance bay. (EMP 8) answered and advised, Command was wandering if you guys can divert to UPMC Altoona. ... requested to speak to Medical Command. ... gave report to command and advised based on patient's condition, the decision was made for patient to be transported to closer hospital for stabilization. Medical command advised ... that based on patient's current BP and HR, patient should be diverted to UPMC Altoona. ... "
2. Video recording dated February 19, 2019, 19:25:13 revealed the Bedford Ambulance entering the parking lot and at 19:25:55 revealed the Bedford Ambulance arriving in the Emergency Department bay entrance, then exiting (without stopping) the hospital property.

3. A focused review of the Emergency Department Log dated February 19, 2019, in comparison with the Bedford Area Ambulance Service (MR21), the patient was not located on the UPMC Bedford Memorial Hospital Emergency Department log.
4. Interview with (EMP 3) was conducted on March 19, 2019. (EMP 3) confirmed that the patient in this complaint was never placed on the log.











Plan of Correction:

UPMC Bedford has an EMTALA policy that details the process whereby the facility will maintain a central log of each individual who comes to the Dedicated Emergency Department seeking assistance. The log outlines whether the individual refused treatment or was transferred, admitted and treated, stabilized and transferred, or discharged. The policy is current and all employees are expected to understand and abide by the policy.
Following the event of February 19, 2019, members of UPMC Bedford Administration met to address compliance with the UPMC Bedford EMTALA Policy. Administrative Members included the Interim Director of Nursing (DON), the Director of Clinical Ancillary Services/Regulatory/Compliance and the Director of Patient Experience/Patient Safety Officer. The group determined that staff education was required as the first step in addressing the problem.
On February 22, 2019 the Emergency Department Site Coordinator sent an EMTALA educational Powerpoint to all physicians working in the UPMC Bedford Emergency Department. On March 7, 2019 the Emergency Department Site Coordinator sent the EMTALA educational Powerpoint to the UPMC Bedford Hospitalists Providers, Residents, Students, and Volunteers. By March 28, 2019 there was 100% compliance with these individuals reviewing and acknowledging understanding of the materials.
On March 1, 2019, an educational program was pushed to all UPMC Bedford staff through the UPMC learning system known as ULearn. By March 28, 2019 there was 100% compliance with UPMC Bedford employees completing the EMTALA ULearn program. The Human Resources Manager will report the rate of the EMTALA Education Compliance to the Performance Improvement/Quality Committee at the April 18, 2019 meeting.
The Director of Emergency and Surgical Services will require the Health Unit Coordinators sign a daily attestation that all patients who presented during the shift were placed on the ED log. The UPMC Bedford Director of Emergency and Surgical Services will also monitor all transfers from the UPMC Bedford ED to assure that all transfers have been placed on the ED log. The monitor will take place until there is 100% compliance for six months. The results of the monitor will be reported by the Director of Emergency and Surgical Services at the April 18, 2019 Performance Improvement/Quality Meeting, and monthly thereafter until there is 100% compliance for six months.
Any incidence of non-compliance with the EMTALA Policy will be investigated immediately and involved staff will again be re-educated and/or counselled.