HospitalInspections.org

Based on policy and procedure review, medical record review, on call schedule review and staff and physician interviews the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings include:

The hospital failed to ensure a physician who was on call for ophthalmology services was available to provide services upon the request of the dedicated emergency department (DED) physician for 1 of 36 sampled patients that presented with an emergency medical condition (Patient #22).

~ Cross refer to §489.20(r)(2) and §489.24(j)(1-2) On Call Physicians - Tag A2404.

Based on policy and procedure review, medical record review, on call schedule review and staff and physician interviews, the hospital failed to ensure a physician who was on call for ophthalmology services was available to provide services upon the request of the dedicated emergency department (DED) physician for 1 of 36 sampled patients that presented with an emergency medical condition (Patient #22).

The findings include:

Review of the "Medical Staff Policy on Consultant Physician Response to the Emergency Department" (not dated) revealed "... Policy for emergency situations: In response to a request from an attending physician seeing a patient in the ED (emergency department), the consultant physician on-call will come to the ED without delay."

Review of the hospital's "EMTALA Policy" revised 02/2014 and reviewed 02/2016 revealed "... On-Call Physician Responsibility under EMTALA ... Procedure 1. The Chief of Service of each department shall provide a list of on-call physicians from the respective department and their assigned coverage times. The list shall be submitted to the chairman of the emergency department. This will describe 24-hour per day coverage, each day of the month, and include contact information for all physicians on call. All specialties privileged in this hospital shall have a specific call list. All active members of the medical staff are required to serve pro-rata share of on-call duty for their specialty and to respond to call during scheduled on-call periods, and to physically report to the Emergency Department or other requesting department in a Timely Manner to assume care of any patient requiring their attendance. ...3. ... Where the on-call physician disagrees with the emergency physician on the need to respond, the on-call physician shall respond, and after rendering care, may address the disagreement to the director of the Emergency Department or to the chairperson of the on-call physician's department for evaluation and remedial actions, if indicated. ... Definitions ... Timely Manner: A timely response by an on-call physician who is not on Hospital Property is deemed to be 45 minutes to 60 minutes under normal conditions from initial call to appearance in the Emergency Department. For non-urgent consultations, the emergency physician and the consultant should agree on the response for the Emergency Department consultation, up to 4 hours. ..."

Closed medical record review of Patient #22 revealed a 54 year-old male that presented to the hospital's dedicated emergency department (DED) on 06/04/2015 at 2101 via private and was triaged at 2107. Review of the nursing triage note revealed the patient presented with a chief complaint of blindness with partial vision loss in the left eye, progressing over the last two day. Review revealed the patient was sent to the DED by VA (Veterans Administration) who were concerned for detached retina. Review revealed the patient complained of blindness in the right side of his left eye for one and one half days. Review revealed the patient had a history of diabetes and was on oral medication for this. Review of nursing notes revealed a visual assessment was recorded at 2321 with right eye acuity of 20/30, left eye acuity of 20/200 and both eyes visual acuity of 20/25. Review of the DED physician's medical screening examination revealed the patient was evaluated at 2321 with a presenting history of "vision loss in the left eye since this morning. Has one week h/o (history of) floaters and occasional poor vision. Patient denies pain in eye. Has worsening vision over last two days, acutely worsened this afternoon. States loss of vision felt like a curtain coming from below. ... This is a new problem. The current episode started 12 to 24 hours ago. The problem occurs constantly. The problem has not changed since onset. ..." Review of the physician's notes recorded "Medical Decision Making/Plans: ...presents with acute painless vision loss, suspicious for retinal detachment or vitreous hemorrhage. Discussed with (on-call) ophthalmology. Will see in AM. Place in obs (observation) until AM. ..." Review revealed the resident physician (MD #1) discussed the patient with the attending physician (MD #2). Review of DED physician notes recorded by MD #2 (attending physician) on 06/05/2015 at 0016 revealed the patient's wife had called an ophthalmologist in the location of residence and was told to come to Hospital A's DED to see an eye doctor tonight. Further review of the DED physician's note recorded "Patient and wife are upset that they will not be seen tonight. The resident called (ophthalmologist on-call - MD #3) and I spoke with her a second time. States the (sic) there is nothing to do tonight and they were given the wrong info. She did not want to come in and felt the patient could be seen in the office in the morning. I d/w (discussed with) the patient their options: 1 - call the optho (ophthalmologist) a 3rd time and have them come in. 2 - stay in the ED (I'll make an arrangement to keep them) and potentially have them seen in the morning before d/c (discharge). 3 - stay in the ED as above and go to their appointment in the a.m. 4 - go home and come back in the morning, not optimal given distance and time of day. Patient is willing to stay here and be d/c first thing in the morning to be seen by optho. ..." Review of MD #2 notes recorded at 0745 revealed "Patient was able to use connections to get in touch with (another ophthalmologist) office. He is awaiting call back. He wants to be d/c (discharged) so he can get over there to the office." Review revealed a physician order to discharge the patient at 0753. Review revealed discharge instructions were provided to go right over to the on-call ophthalmologist office to be seen and to see another ophthalmologist if possible. Review revealed the patient departed the DED on 06/05/2015 at 0822. Review of the record revealed MD #2 documented a return telephone call to the patient on 06/06/2015 at 1315 that revealed the physician "Called patient today and he had surgery on "both" eyes yesterday. He waited at (on-call ophthalmologist office) for 1.5 hours in the morning then went to see another specialist in Raleigh. He says that he is doing much better but that post op he will have slow restoration of vision. He was told that it would have been much worse if he waited longer."

Review of the on call schedule for 06/04/2015 revealed MD #3 was on-call for ophthalmology.

MD #1 (DED resident physician) and MD #2 (DED attending physician) were interviewed on 05/15/2016 at 0845. MD #1 stated Patient #22 came in with loss of vision and a questionable detached retina. MD #1 stated he called the ophthalmologist on-call (MD #3) and asked for the best plan. MD #1 stated MD #3 would see the patient the next morning. The physician stated he didn't remember the conversation but that "typically we would like them to come in (to see the patient)." MD #2 (attending physician) stated he placed a second telephone call to MD #3 (on-call ophthalmologist). MD #2 stated "They (patient and wife) wanted to see the ophthalmologist and I wanted them to see the ophthalmologist sooner than in the morning. She did not want to come in and felt the patient could be seen in the morning. She said there was nothing to do tonight." Interview revealed MD #2 provided the patient options of calling the on-call ophthalmologist back a third time to come in or having the patient stay in the ED overnight and the patient opted to stay overnight and see the on-call ophthalmologist in the morning. MD #2 stated "I didn't think it would change (patient's condition) drastically, but I also wouldn't have made a second call if I wasn't concerned. They understood that the ophthalmologist wasn't a retinal specialist and they knew about the previous calls. The mentioned a (another ophthalmologist). He is a retinal specialist. There was discussion surrounding him. I think they expected to see an ophthalmologist when they walked in. I called back to try to get her to come in. I wouldn't call someone at that time of night unless I needed them to come in." Further interview with MD #2 revealed "I made a follow up phone call to the patient because I was concerned and wanted to make sure he got care. He told me he got surgery on both eyes. He had gone to the (on-call ophthalmologist) office as requested. I don't remember how he ended up in Raleigh. They (patient and wife) knew she (on-call ophthalmologist) was not a retinal specialist. Yes, I wanted her to come in and I wouldn't have made a second call if I was not needing her to come in. I could have called the Chief Medical Officer and would have on the third call. The patient decided to stay overnight and go to the office in the morning."

Telephone interview on 05/04/2016 at 1620 with MD #3 revealed she was the ophthalmologist on call beginning at 0800 on 06/04/2015 through 0800 on 06/05/2015. MD #3 stated she remembered Patient #22. The physician stated the patient presented with a 4 day history of floaters and flashes of light and she was called sometime after 2200. Interview revealed she talked with the resident and recommended a plan for the patient to see a retinal specialist in her office the following morning. MD #3 stated she was not a retinal specialist and thought the patient had a possible retinal detachment and would need to see a retinal specialist. MD #3 stated the patient would need care within 24 hours if there was a detachment and that she felt the patient's condition wouldn't change. The physician stated "If I had come in, I wouldn't have changed the plan. I would still recommend he go to the office at 0800 the next day. We have specialized equipment available at the office that is not available at the hospital." MD #3 was asked about the second phone call from MD #2 (DED attending physician). MD #3 stated "I thought he wanted to verify the plan to come in the next day. He did not express any concerns." Interview with MD #3 revealed Patient #22 did not see the retinal specialist the next day because the retinal specialist was not available. Interview revealed the patient was seen by another ophthalmologist in the office and diagnosed with a retinal detachment and referred to a retinal specialist in Raleigh.