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Based on policy review, review of Medical Staff Rules and Regulations, record review, document review, and staff interview, the Critical Access Hospital (CAH) failed to enforce policies to ensure compliance with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases, and the related requirements at 42 CFR 489.20 for 1 of 1 ED patient (Patient #1) sampled for whom the practitioner on-call was not available.

Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements at §489.24. Failure of the CAH to enforce their Emergency Medical Treatment and Labor Act (EMTALA) policy limited the CAH's ability to ensure appropriate treatment for emergency department patients.

Findings include:

The CAH failed to ensure an on-call specialty provider presented to the ED in a reasonable time frame. (Refer to C2404).

Based on record review, review of Medical Staff Rules and Regulations, review of facility policy, document review, and staff interview, the critical access hospital (CAH) failed to ensure the availability of on-call physicians for patients who presented to the Emergency Department (ED) for care, for 1 of 1 ED patient (Patient #1) sampled for whom the practitioner on-call was not available. Failure to ensure the availability of on-call physician for patients who present to the ED for care may have placed patients at risk of prolonged illness, pain, and complications related to a lack of care.

Findings include:

Reviewed on 11/26/24, the facility policy titled "Examination, Treatment and Transfer of Individuals Who Come to the Emergency Department EMTALA", revised February 2024, stated, ". . . It is the policy of . . . (the Hospital) to comply with The Emergency Medical Treatment and Labor Act (EMTALA) as set out below: 1. The Hospital's EMTALA obligations are activated when there has been: a. A request for examination and/or treatment of a medical condition by an individual (or someone on that individual's behalf) made within a Dedicated Emergency Department (DED) . . . DEFINITIONS . . . C. Capabilities of the Hospital means . . . include the level of care that the Hospital's personnel can provide . . . including coverage available through the Hospital's On-Call List . . . W. On-Call List refers to the list that the Hospital is required to maintain listing those physicians who have been granted clinical privileges to practice medicine . . . X. On-Call Physicians means a physician who is listed on the On-Call List, who may be a specialist or subspecialist, who is scheduled to fulfill on-call responsibilities and is available to provide further medical screening and treatment necessary to stabilize individuals . . . B. Medical Screening Examination (MSE) . . . 6. If, after institution of the MSE, the physician . . . determines that the individual requires the services of an On-Call Physician, the On-Call Physician will be contacted and specifically requested to present to the DED to provide care and treatment. . . . E. Individual Determined to have an EMC [emergency medical condition] . . . d. The Hospital will have policies and procedures that define the responsibilities of the On-Call Physician to respond, examine and treat individuals with an EMC. . . . a. The On-Call Physician shall return telephone calls within 20 minutes. . . ."

Reviewed on 11/26/24, the undated Medical Staff Rules and Regulations stated, ". . . C. General Conduct of Care . . . 7. All providers who have patients in the hospital or are on call must be available for response and direct patient care within twenty (20) minutes or sooner if the clinical situation warrants. . . ."

Review of the October 2024 provider on-call schedule occurred on 11/26/24 and identified three providers on-call for the ED and one provider on-call for pediatrics on each day of the month. The on-call pediatrics schedule for 10/16/24 listed Provider #8 on-call starting at 4:00 a.m.

During interview on 11/26/24 at 7:14 a.m., Administrative Nurse #7 identified "occasional issues" contacting on-call specialty providers; on-call providers should arrive as specified in the Medical Staff Bylaws/Rules; and stated, "I believe it's 20 minutes."

Review of Patient #1's medical record occurred on 11/25/24 and identified the following:
* Patient #1 presented to the ED on 10/16/24 at 4:45 p.m. with his/her mother for complaints of shortness of breath.
* A triage assessment, dated 10/16/24 at 4:59 p.m., documented by Nurse #4, stated, ". . . presents with complaints of hypoxia [low levels of oxygen in the blood] when laying flat. . . . patient is vitally stable on arrival . . ."
* Vital signs, dated 10/16/24 at 4:59 p.m., identified a blood oxygen level of 100% [percent] on room air.
* A nurse's note, dated 10/16/24 at 7:26 p.m., stated, "pt [patient] had multiple brief incidents of decreased oxygen saturation [sat] to 80-82% on room air. RN [registered nurse] noted pt had grey [sic] appearance and apenic [sic] [breathing temporarily stops involuntarily] during episode, provider . . . was notified multiple times of the occurrence. . . ."
* An ED physician's note, dated 10/16/24 at 5:51 p.m., stated, ". . . Time Seen by Provider: 10/16/24 17:33 [5:33 p.m.] . . . Patient presents to the emergency department brought in by parent referred from peds [pediatric] clinic after seeing her pediatric nurse practitioner . . . with concern for episodes of hypoxia in the setting of congestion and cough . . . Patient was seen in the pediatric clinic and was noticed to be satting [maintaining oxygen level] quite well on room air when . . . held upright however when . . . placed in supine [laying] position, patient with desat [decrease in oxygen level] to 87 to 88% on room air. . . . Physical exam: . . . Lungs: . . . Normal work of breathing. Lung sounds clear bilaterally with good air movement . . . Medical Decision Making: . . . On exam currently patient is afebrile and nontoxic-appearing and appears well-perfused, [sic] and did not have any obvious respiratory distress or hypoxia when upright being held by mom to her chest. currently [sic] no retractions, lung sounds are clear with good air movement . . . There was however apparently at least one episode witnessed by RN [registered nurse] that patient had brief episode of hypoxia and cyanotic appearance that spontaneously resolves and I was not able to witness when I responded to patient. While patient is afebrile, I did recommend a work up including CXR [chest x-ray], resp [respiratory] viral panel, and screening lab work, as well as iv [intravenous] access. Advised to keep patient upright and continue to observe patient, and patient may benefit from inpatient observation admission or monitoring and treatment, and even potentially transfer to a higher level of care facility. Per my independent interpretation: Chest x-ray obtained shows some peribronchial cuffing [radiologic sign of fluid or mucus build-up in the small airways of the lungs] suggestive of a viral infection . . . Update: I was informed by RNs that Mom expressed frustration and is declining for additional attempts at iv insertion or lab draw. In addition, I was informed she is requesting a pediatrician to come and evaluate the patient. I think this is reasonable and did page the on call [sic] pediatrician [Provider #8], and is [sic] waiting for response. During that process, mom declined further intervention by me or others [sic] staff members. We continue to wait for response from on call [sic] pediatrician. I feel patient will benefit from hospital observation to ensure stability. . . ."
* Patient #1 discharged 10/16/24 at 8:00 p.m.
* A nurse's note, dated 10/17/24 at 12:57 a.m., documented by Nurse #5, stated, "Late entry nursing note. Patient's mother states she does not feel as though good care is being provided to her child and the pediatrician has not come to see her baby yet so she will take the patient to a different facility. Patient's mother is explained about the risks of leaving prior to diagnostic testing being performed. The patient's mother states she understands and signs AMA [against medical advice] form. 10/16/24 2000 [8:00 p.m.]."

During interview on 11/26/24 at 10:50 a.m., Provider #6 identified the ED staff receive a printed on-call list, he recalled the mother wanted a pediatrician to see Patient #1 and he had the registration staff contact the on-call pediatric provider (#8). He could not recall what time the staff contacted the provider (#8). He identified his shift ended at 7:00 p.m. and he handed off Patient #1's care to another ED provider.

During interview on 11/26/24 at 11:41 a.m., Administrative Staff Member #1 identified the facility had on-call administrative staff assigned daily and confirmed he was the administrative staff on-call 10/16/24. He stated he received a call from the house supervisor, Nurse #2, at 7:08 p.m. with concern the facility could not reach the on-call pediatric provider (#8) after multiple attempts. He stated he contacted his administrative assistant to find out where Provider #8 was staying and called back to the nurse (#2) at 7:11 p.m. with the information and instruction to contact him with further issues. He stated he did not get further calls from the facility on the matter.

During interview on 11/27/24 at 8:15 a.m., Nurse #2 stated he worked on 10/16/24 as the house supervisor. He stated if there are issues that he cannot handle he will contact the administrator on-call for assistance. He confirmed the facility had difficulty contacting the provider (#8) on 10/16/24, and he contacted an administrative staff member (#1) via phone. The nurse (#2) contacted the hotel for the provider (#8) and asked them to get a message to the provider to call the hospital as soon as possible. The nurse (#2) could not recall the times the provider (#8) was paged/called or what time the provider (#8) contacted the facility.

During interview on 11/27/24 at 8:21 a.m., Nurse #4 identified she triaged Patient #1 upon presentation to the ED on 10/16/24. The nurse (#4) identified Patient #1 had multiple apneic episodes, had to be roused several times, and had a gray color at times during her assessments and she notified Provider #6 of them. The nurse (#4) stated Patient #1's mother requested a pediatrician and the facility paged/called the on-call pediatric provider (#8). After a period of time and no response from the provider (#8), she asked the house supervisor to help contact the provider. The nurse (#4) was unsure what time the provider (#8) was paged/called. She believed she left her shift at 7:20 p.m. after she gave hand-off report to Nurse #5, and the provider (#8) had not responded by that time.

During interview on 11/27/24 at 8:32 a.m., Nurse #5 stated she took report for Patient #1 from Nurse #4, which included attempted contact with on-call pediatric Provider #8. The nurse (#5) asked the house supervisor, Nurse #2, if the provider (#8) contacted the facility. The nurse (#2) told her Provider #8 had not been contacted despite several attempts by facility staff. The nurse (#5) stated she explained this to Patient #1's mother and the mother decided to take Patient #1 to a different facility for treatment. The nurse (#5) explained the risks of leaving prior to completion of all diagnostic testing and Patient #1's mother expressed understanding and signed the AMA form. The nurse (#5) was unsure of the exact time Patient #1 discharged, but the provider (#8) had not contacted the ED before Patient #1 discharged.