HospitalInspections.org

Based on a review of facility documents, medical records (MR), and staff interviews (EMP) it was determined that Somerset Hospital failed to follow their adopted policies and Medical Staff Bylaws, by failing to follow adopted policies related to the formulation of the On Call schedule for Interventional Cardiology, and by failing to ensure that the Interventional Cardiologist On-Call responded to provide further evaluation and stabilizing treatment for one of one patient presenting with chest pain. (MR1)

Findings include:

Review of "Somerset Hospital Physician On-Call Scheduling Algorithm", dated August 2014, revealed, "Cath Lab Supervisor retrieves ALL on call requests from each physician. Cath Lab Supervisor creates On Call schedule on the 15th of every month for the next month. Supervisor then gives copy to EACH On Call physician for their approval. Physician is then to respond within 5 days to give their approval of schedule. If changes are made, process is repeated until ALL physicians approve schedule. Supervisor then posts 1 schedule in Cath Lab then distributes schedules to the ER, CCU, Telemetry and Switchboard Operator ... ."


Review of Somerset Hospital "Medical Staff Bylaws Rules & Regulations 2018, revealed, "... The responsibilities of the Staff are to render quality (effective, appropriate, compassionate, and accessible) health care to patients within the hospital ... E. To develop, administer, and require compliance with these Bylaws, the Rules and Regulations of the Staff and other medical care related Medical Staff policies and procedures ... Article 2 ... 2.3-Basic Responsibilities of Staff Membership ... B. Each staff member, consistent with his/her granted privileges, shall participate in the On Call coverage of the emergency service or in other hospital coverage programs as determined by the Medical Executive Committee (MEC), after receiving input from the appropriate clinical specialty (Department Chair) to assist in meeting the patient care needs of the Community ... H. Each staff member shall abide by the Medical Staff Bylaws and by all other non-conflicting applicable lawful standards, policies, and rules of the Hospital ... Somerset Hospital Medical Staff Rules and Regulations ... Rule 6. Procedures for Special Care Areas ... Emergency Department Services ... 2. On-Call Roster. a. All physicians and dentists on the Active Staff shall serve on applicable departmental Call Rosters. b. Any physician on the Medical Staff who, by nature of a call schedule, or because of an existing physician-patient relationship, is required to assume the care of patients presenting to the Emergency Department after initial examination by the emergency room physician. c. Patients needing urgent medical attention should receive and appropriate medical evaluation and stabilization of any emergency medical condition by a competent emergency room physician and consulting physician without consideration of ability to pay for these services. d. Medical staff members will provide consultative services by qualified on-call physicians who will respond in a reasonable period of time to requests for assistance by members of the (sic) Hospital Medical Staff. e. The on call physician/dentist shall be required to provide the appropriate medical care in the Emergency Department without regard to the patient's race, creed, color, sex, sexual preference, national origin, or source of payment. Specifically, a physician/dentist may not refuse to care for emergency patients on the sole basis that they are indigent, on Medicaid, or in other ways unable to pay for services provided. 3. Responsibility of Emergency Medicine Physicians in the Emergency Department. A mutual cooperative of emergency physician and attending or consulting physician relationship is critical to the provision of optimal patient care. a. Patients presenting to the Emergency Department of the hospital to be evaluated by their private physician should be offered an evaluation by emergency physician, if the private physician is not present to manage the patient. b. Patients with potentially life-threatening complaints should receive immediate emergency physician evaluation, if the private physician is not available to assume care of the patient. c. Transfer of responsibility for care should take place to ensure continuity of patient management. d. The attending or consulting physician will subsequently assume the ongoing care of the patient. e. The medical record and/or admission orders should clearly document this transfer of patient's care responsibility. 4. Follow-up Referrals. a. Somerset Hospital and the Medical Staff have an obligation to provide and/or assure access to outpatient follow-up services for Emergency Department patients on a timely basis if they are on-call, regardless of ability to pay. b. Written policy and procedures are in place to clearly delineate the follow-up responsibilities of on-call physicians ... e. If the emergency physician determines that a patient requires specialized care, he should refer the patient to the appropriate on-call specialist following consultation with the patient and, if appropriate, the primary care physician ... ."


Review of "Somerset Hospital Policy Stat ID: 4437218 ... Approved 01/2018 ... EMTALA Guidelines ... Purpose: To establish standards for a screening exam of all patients who seek emergency care at Somerset hospital. Philosophy: In cooperation with federal COBRA/EMTALA Law, supported by HCFA and the OIG, Somerset Hospital will comply with the legislative intent by putting into practice the process outlined as follows: A. Any individual who comes to Somerset Hospital or Somerset Hospital's Emergency Department and a request is made by an individual or on their behalf for examination or treatment of a medical condition, Somerset Hospital will provide an appropriate medical screening examination within the capability of the hospital. This examination may include ancillary services or specialty consultation routinely available to the Emergency Department, if needed, to determine whether or not an emergency medical condition exists. 1. "Any individual" includes non-Medicare patients, Medicare patients, noninsured-indigent, managed care patients, private patients and minors. B. Somerset Hospital will provide the medical screening examination without delay or preauthorization. Somerset Hospital will collect insurance and payment information as part of the routine registration process provided that: 1. No delay in providing an appropriate MSE or necessary stabilizing treatment occurs and: 2. All patients are treated equally regardless of their insurance or managed care status. C. In 2000, CMS issued new amendments to the rules under 42 CFR 489.24, expanding the responsibility of the emergency room to respond to any "presentation" on the hospital campus or at any provide-based off-campus facility of the hospital. In 2003, these rules were significantly revised. D. The 250-yard rule comes from the definition of "Campus" found at 42 CFR 413.65: "Campus means the physical area immediately adjacent to the to the provider's main buildings, other areas and structures are not strictly contiguous to the main buildings but are located within 250 yards of the main building, and any other areas determined on an individual case basis, by the HFCA regional office, to be part of the provider's campus. Associated Information A. Definitions: *HCFA - Health Care Financing Administration * HHS - Department of Health and Human Services. * ED - Emergency Department * EMTALA - Emergency Medical Treatment and Labor Act. * MSE - Medical Screening Examination. Standards: The Somerset Hospital Board of Directors is responsible for designating who is qualified to perform medical screening exams. Somerset Hospital will also comply with EMTALA requirements related to on-call physicians. On-call physicians, when requested by the ED physician, will not refuse to come in to see the patient, will come in within a reasonable time, and will not order the patient transferred without first evaluating the patient. The EMTALA legislation applies to all hospitals that agree to accept Medicare funds. The EMTALA legislation applies to all physicians in ahopsital(sic) that accepts Medicare funds. *This includes physicians who work in the ED as well as on-call admitting and consulting physicians. Compliance with this policy will be monitored on a quarterly basis by administration and Medical Executive Committee and the ED ... EMTALA - Common Questions ...*Which physicians must comply with EMTALA? *All physicians who practice in a hospital that accept Medicare are expected to comply with EMTALA's guidelines. This includes physicians who work in the ED, as well as on-call admitting and consulting physicians as outlined in the hospital's bylaws, who in this capacity are considered to be agents of the hospital ... Minimizing EMTALA Violations ... *Qualified medical personnel must perform the medical screening examination: * Should be performed by a physician or other qualified medical personnel as outlined by the hospital's governing bylaws and Rules and Regulations. Depending upon the individual's presenting symptoms, this screening examination may range from a relatively simple examination to a complex one which requires substantial use of ancillary services and on-call physicians available at the hospital ... Scope: Patients, physicians, Board of Directors and staff of Somerset Hospital ... ."

Review of "Somerset Hospital ... PolicyStat ID: 4437327 ... Approved: January 2018 ... Policy Area: Emergency Department ... MD Call Roster ... was reviewed and revealed, "... Policy Statement: Physician unassigned and on-call rosters are available in the Emergency Department to assist in the care and management of Emergency Department patients when necessary. Procedure: Physician On-Call Roster. A physician unassigned roster is established by the Director of the Department of Emergency Medicine and approved by the Administrator. The roster will include those physician specialists necessary to support the services of the Emergency Department Physicians. The physician specialists on the roster shall include, but not be limited to: General Medicine. General Surgery. Hospitalists. Neurosurgery. Cardiology. Orthopedics. Pediatrics. Oral and Maxillofacial Surgery. Neuropsychiatry. Obstetrics/Gynecology. Urology. Adult and Pediatric Dentistry. ... Physician Specialist's Responsibilities. The physician on the call roster must recognize that the Emergency Department must be on the highest priority when the physician is contacted for the purpose of providing care to the patients in the Emergency Department. The on-call/attending physician's response time must not exceed 30 minutes from the time the attending physician is contacted until the physician makes himself/herself present in the Emergency Department. If the time exceeds 30 minutes, the next physician in that specialty will be contacted. ... ."


Review of "Somerset Hospital ... PolicyStat ID: 3160562 ... Approved July 2017 ... Policy Area: Emergency Department ... General Organizational Guidelines ... was reviewed and revealed, "... Policy Statement: ... All patients coming to the emergency care area must be evaluated initially by the emergency care physician ... A second physician, on-call will be available against unexpected or unusual contingencies. There should be a mechanism whereby specialized medical services can be obtained as promptly as possible when needed. A roster of available specialist should be posted in the emergency care area. ... ."


1. An interview was conducted with EMP3 on March 27, 2018. "We never had a situation like this before in reference to On-Call. Usually [EMP16] tells me what [they] can cover. One week to ten days prior to the month, I take a picture of the On Call schedule and send it to all the docs (Interventional Cardiologists) in a group text. I tell them if there are any questions, to let me know. I assumed it was okay, until I got a call from the ER (Emergency Room) physician. No doc (Interventional Cardiologist) ever got back to me that the schedule was a problem. That March schedule was sent out Friday, February 23, 2018 at 11:15 AM ... I usually get a response, this time I did not ask for one ... ." EMP3 provided surveyors with view of the group text message which showed a picture of the on call schedule.


2. MR1 revealed, "... Physician Emergency Room Note, "... Creation Date: 03/18/2018 00:21 ... Chief Complaint: Chest discomfort and pressure worsening over the last couple days, including some this afternoon got significantly worse. States it is a 9 out of 10 pressure and pain today with radiation to left upper extremity does have an 81 mg Aspirin at one half hour prior to arrival ... Procedure/Treatment: Patient seen and examined. History and physical were completed cardiac labs and studies were completed, no ST segment elevations on the patient's EKG, but the patient did have positive enzymes. CPK-MB and positive troponin secondary to the patient's pain that was not relieved with Nitroglycerin ... I tried to get hold of ... (EMP16) ... but was not able to get hold [EMP16] for the 40+ minutes. I call the Cath Lab Director who got EMP17 to call me ... EMP17 was not On Call that night, was well over an hour away by travel ... Patient was still having chest pain ... Patient slumped back in gurney, lost consciousness and had a V. fib arrest ... Patient remained awake and oriented postarrest and was then airlifted to Shadyside Hospital for immediate emergent cardiac catheterization and further evaluation and treatment ... ."


3. MR2 (UPMC Shadyside) dated March 18, 2018, revealed, "Cardiology History and Physical ... Chief complaint: Chest Pain. History of Present Illness: ... presented to Somerset Hospital in early a.m. with severe chest pain and nausea ... Recommendations: The patient underwent emergency cardiac catheterization, which showed 95% in-stent stenosis of first diagonal branch and 80% ostial LAD stenosis and moderate other disease. The patient ended up with primary angioplasty/stenting of first diagonal branch, The patient will be treated as ST-segment elevation myocardial infarction ... ."


4. March 2018 I.C. (Interventional Cardiology) Call schedule revealed that on March 17 and March 18, 2018, (EMP16) was the On Call physician for that specialty.


5. An interview with EMP1 on March 27, 2018, revealed, "... They contacted EMP16 according to the On Call schedule. EMP16 didn't respond to initial call. The Bylaws say they have 30 minutes to respond. Door to balloon time is 90 minutes. At 40 minutes, the ER staff called the Director of the Cath Lab and said the doctor wasn't responding to call. They called EMP17 who was not On Call ... EMP16 denies they were On Call, but we have documentation that EMP16 wasn't ... ."


A telephone interview with EMP17 on March 28, 2018, at 12:05PM, in the presence of EMP1 revealed, "... When I got the phone call about 1:30 or 1:40 in the morning, I told them I'm about 70 miles away, about one hour and 20 minutes ... I drove to Somerset to take call for Sunday. I was told EMP16 didn't realize they were On Call."


6. A telephone interview with EMP20 on March 28, 2018, at 11:50AM, in the presence of EMP1 revealed. "... The physician covering, was not available ... We have a 30 minute response time. If a physician isn't available, I would go to the ... partner first. You should start the process for back up after ten minutes or call Management and say you can't get in touch with the doctor On Call ... ."