Abbeville General Hospital

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 44763 Based on observation and interview, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by non-functioning nurse call buttons located on the hand rails of patient beds for 6 of 6 beds located in the ICU (intensive care unit). This failure had the potential to delay or prevent assistance from the nursing staff if the patient pressed the nurse call button on the bed hand rail rather than the hand held call light. Findings: In an observation on 11/14/2024 at 4:20 p.m. - 4:44 p.m. of the ICU accompanied by S2CNO and S3CQO revealed the patient beds in rooms ‘a’ and ‘b’ had non-functioning nurse call buttons located on the hand rails. In an interview during the observation S2CNO and S3CQO verified all 6 patient beds in the ICU had non-functioning nurse call buttons on the hand rails.”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure an effective system was in place to ensure that each physician/practitioner providing services in the hospital was credentialed. This deficient practice was evidenced by failing to credential a physician for core procedures in emergency medicine. Findings: Review of the Medical Staff By-Laws revealed in part, “Determination of Clinical Privileges: Section 10.1- Practicing Within Scope of Privileges: Medical Staff members or others practicing at Abbeville General Hospital shall, in connection with such practice, be entitled to exercise only those privileges specifically granted by the Board of Commissioners, except as otherwise provided in these bylaws. The privileges shall only be within the scope of the licensure, certification or other legal limitations authorizing the practitioner’s practice. Delineated privilege list approved by the Board will be provided to the nursing staff for reference to ensure practitioners are practicing within their scope of practice. A list of the practitioner’s procedures and admissions will also be reviewed at the time of reappointment to ensure the practitioner is practicing within their scope of privileges. Section 10.2 - Delineation of Privileges in General: A. Requests: Each application for appointment and reappointment to the Medical Staff must contain a request for the specific clinical privileges desired by the applicant. A request by a Medical Staff member, pursuant to Article IX, Section 9.6, for a modification of privileges, must be supported by documentation of training and/or experience supportive of the request.” Review of S8MD’s credentialing file revealed a reappointment date of 11/16/2022. Review of the Application for Clinical Privileges revealed in part, Emergency Medicine Core privileges were approved for the reappointment period of 12/31/2022 - 12/30/2024. Further review revealed a list of core procedures under Emergency Medicine with a notation that indicated for these core procedures to check all procedures that the applicant wish to request. Review of this list failed to reveal any core procedures checked. Review of Patient #1’s emergency department record revealed Patient #1 presented to the emergency department on 04/09/2024. Further review revealed in part, Patient #1 was intubated by S8MD. In an interview on 11/20/2024 at 9:57 a.m. S9MSC verified S8MD did not check any of the core procedures under emergency medicine which included airway management and intubation. S9MSC verified S8MD was not credentialed in any of the core procedures under emergency medicine which included airway management and intubation. In an interview during record review on 11/20/2024 S2CNO verified S8MD was the physician that intubated Patient #1.”

“RESPIRATORY CARE SERVICES POLICIES CFR(s): 482.57(b) Services must be delivered in accordance with medical staff directives. This Standard is not met as evidenced by: 44763 Based on record review and interview, the hospital failed to ensure respiratory services were administered in accordance with hospital policy. This deficient practice was evidenced by failure to document patient ventilator system checks every 2 hours as per hospital policy for 1 (Pt #3) of 3 (Pt #1, Pt #2, Pt #3) medical records reviewed. Findings: Review of the hospital’s policy titled “Patient Ventilator System Checks” review date 06/19/2024, revealed in part, “I. Objective: A patient-ventilator system check is documented evaluation of a mechanical ventilator and of the patient’s response to mechanical ventilator support. This procedure is often referred simply as a ventilator check. II. Policy: a.) All data relevant to the patient-ventilator system check must be recorded on the appropriate hospital forms at the time of performance, must be included as an official part of the patient’s medical record, and include observations indicative of the ventilator’s operations at the time of the check q [every] 2 hours.” Review of Patient #3’s medical record revealed an admission date of 06/06/2024. Review of the ventilator management notes revealed there was documentation on 06/12/2024 at 5:10 p.m. Further review revealed the next ventilator management note was documented on 06/13/2024 at 6:51a.m. (approximately 13 hours) In an interview on 11/20/2024 at 3:50 p.m. S2CNO verified there was no documentation of a ventilator management note between 06/12/2024 at 5:10 p.m. and 06/13/2024 at 6:51 a.m. S2CNO verified there should have been a ventilator management note documented every 2 hours according to hospital policy.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by the hospital failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice is evidenced by failing to examine a patient who complained of sexual assault for 1 (#12) of 3 (#12, #18, #19) patients presenting with alleged assaults (see findings tag A-2406).”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital’s emergency department failed to provide an appropriate medical screening exam for 1 (#12) of 3 (#12, #18, #19) victims of sexual assault who presented to the emergency department from a total of 20 reviewed records. Findings: Review of the policy “Emergency Department EMTALA Guidelines,” reviewed 04/29/2021, revealed in part, “All patients shall receive a medical screening exam that includes providing all necessary testing an on-call services within the capability of the hospital to reach a diagnosis.” Review of the Emergency Department visit on 11/19/2023 for Patient #12 revealed the following timeline: 2:20 p.m. - Arrival 2:22p.m. - Initial assessment by S5MD 2:31 p.m. - Triage 2:49 pm. - antibiotics ceftriaxone and doxycycline ordered 2:50 p.m. - specimen for urinalysis, STI and pregnancy test collected 3:22 p.m. - advocate contacted and in route to hospital 3:33 p.m. - antibiotic metronidazole ordered 3:36 p.m. - discharge ordered placed by S5MD and S5MD completed his documentation 4:28 p.m. - Sexual assault advocate at bedside 4:47 p.m. - Antibiotics administered- nurse notes delay due to “NO ER ROOM AVAILABLE.” 5:30 p.m. - Discharge Instructions were signed Review of the nursing triage notes from 11/29/2023 at 2:31 p.m. revealed the chief complaint on presentation was “sexual assault Tuesday (11/28/2023) at 0130. Pt worried about STD exposure. Head slammed into concrete and choked during assault. LPD contacted via telephone but did not follow up with pt.” Vital signs documented at that time were temperature- 37 degrees Celsius, Pulse-97 beats per minute, respiratory rate- 18 breaths per minute, systolic blood pressure 158 mm hg, diastolic blood pressure- 104 mm Hg, mean arterial pressure- 122 mm HG, oxygen saturation- 100%. Review of the physician’s note from 11/29/2023 and signed at 3:36 p.m. revealed the following History of Present Illness: The patient presents following alleged sexual assault. The onset was 36 hours ago. The location where the incident occurred was in the street. Circumstance: 1 assailant(s) penetration: vaginal assailant ejaculation. Type of injury: none. Location: vagina. The character of symptoms is none. Risk factors consist of none. Prior episodes: none. Therapy today: see nurses’ notes. Associated symptoms: none. Drug facilitated Sexual Assault: alcohol consumed unknown. The last consensual intercourse was unknown. Post assault activities: urination, genital washing, showering or bathing, brushing teeth and changing clothes. Documentation: Police called and advocates called. Further review of the physician’s note from 11/29/2023 signed at 3:36 p.m. revealed the following physical examination: General: Alert, no acute distress Skin: warm, no rash Head: Normocephalic, atraumatic Neck: Supple, trachea midline, no tenderness, no JVD, no carotid bruit Eye: pupils are equal, round and reactive to light, extraocular movements intact Ears, nose, mouth, and throat: Tympanic membranes clear,oral mucosa moist, no pharyngeal erythema or exudate Cardiovascular: Regular rate and rhythm. No murmur, Normal peripheral perfusion, No edems, no Tachycardia, no Bradycardia. Respiratory: Lungs clear to auscultation, breath sounds are equal. Symmetrical chest wall expansion, respirations: Regular. Chest wall: No tenderness, No deformity Back: Nontender, Normal range of motion, Normal alignment Musculoskeletal: Normal ROM, normal strength, no tenderness, no swelling, no deformity Gastrointestinal: Soft, Nontender, Nondistended, Normal bowel sounds, No organomegaly. Genitourinary: No tenderness Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed. CN II- XII intact, normal sensory observed, normal motor observed, normal speech observed. Psychiatric: Cooperative, appropriate mood & affect Review of the physician’s impression and plan revealed, “Diagnosis: Sexual assault of adult; Trichomoniasis . . . Disposition: discharged: Time 11/29/2023 15:36:00, to home . . . Patient was given the following educational materials: Trichomoniasis . . . Follow up with: Follow up with primary care provider within 1 to 2 weeks. Counseled: Patient, Regarding diagnosis, Regarding diagnostic test results, Regarding treatment plan, Regarding prescription, Patient indicated understanding of instructions.” Review of the test results revealed the patient received a pregnancy test, a urinalysis and testing for chlamydia, gonorrhea and trichomonas. There was no testing for Hepatitis B, Hepatitis C, or HIV. Review of the physician’s notes and nursing notes failed to reveal documentation the staff inquired about possible depression, support systems, stress level, coping ability or the presence of traumatic sequelae ( panic attacks, changes in eating or sleeping patterns, or increased anxiety), other than the documented “Cooperative, appropriated mood & affect.” There was no documentation the patient was counseled on possible sequelae such as flashbacks, panic attacks or the window between exposure and the detection of some sexually transmitted diseases. Further review failed to reveal her elevated blood pressure was addressed or attributed to the stress of the event. Review of the discharge instructions revealed the patient was instructed to follow up with her primary care in 1 to 2 weeks and she was provided information about trichomonas and a list of medication. The reason for the follow up with the primary care physician was not given and the patient was not instructed that she would need to repeat the pregnancy test and have additional testing for hepatitis and HIV. The patient was not given a list of resources for mental health follow up. At 4:32 p.m. S6RN documented, “SANE Advocate at bedside.” In interview on 12/11/2023 between 2:30 p.m. and 2:45 p.m., S1RN and S3RN verified the physician finished his note and exam before the advocate arrived and made no addendums to his assessments. S3RN verified genitourinary exam which documented, “No tenderness,” did not specify what was not tender, did not identify what parts of the system were examined, and did not state if bruising or signs of trauma were or were not present. S3RN also verified there was no documentation the patient was given any information or resources for follow up after sexual assault such as the “Survivors Guide” for victims of sexual assault that was part the packet used when specimens were collected. S1RN and S3RN verified there were no instructions to follow up with the “City A” Police Department. On 12/11/2023 at 3:00 p.m. S5MD was interviewed. S5MD stated the patient came to the emergency department for evaluation for possible sexually transmitted infections and the patient was evaluated and prophylactically treated for all the common sexually transmitted infections. S5MD verified he had experience with treating patients of sexual assault. S5MD verified his documentation in the physical examination of “No tenderness,” was not adequate for an examination after a sexual assault, and his examination did not include documentation of the presence or absence of bruising, scratches, tears or swelling on the skin which would normally be evaluated after an assault. S5MD verified his examination did not reflect that an external genital examination was performed. S5MD stated he did perform an external examination of the genitalia, but did not document it. S5MD verified he did not do a speculum examination or a bimanual examination to assess for internal injuries because the patient changed her mind and refused the examination. S5MD verified he forgot to document the patient’s refusal after having signed the consents for the examination and collection of specimen. S5MD verified he did not counsel the patient on follow up for sexually transmitted infections or provide emotional or mental health resources because he thought that was the job of the advocate. On 12/12/2023 at 9:24 a.m., S6RN was interviewed via telephone. S6RN verified she was the charge nurse in the Emergency Department that afternoon. S6RN stated that Patient #12 was initially in the consult room, not an exam room, because the room for gynecological exams was not open. S6RN stated she did not move the patient out of the consult room and into the gynecological exam room until the sexual assault advocate arrived at 4:32 p.m. S6RN stated she did not stay in the room and does not know what happened when S5MD was in the room. S6RN verified her notes and the documented times were accurate and the physician had refused to perform the pelvic examination to collect specimen. S6RN said she was not aware of the physician later changing his mind and agreeing to perform the pelvic examination. In interview on 12/12/2023 at 9:45 a.m., S3RN verified again that the documentation of “No tenderness,” for the genitourinary exam did not identify what part of the body was not tender, what parts of the system were examined, and if there were signs of a sexual assault. . S3RN verified there was no documentation the patient refused collection of the evidence by the physician and no documentation the patient “self-collected.” S3RN verified there was no documentation the physician had changed his mind and agreed to perform the pelvic examination and collection of specimen from the vagina. In interview on 12/12/2023 at 9:50 a.m., S2RN verified that hospital administration had developed a plan for education about treating sexual assault victims for the medical staff and the nursing staff, but education had not yet been provided.”