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Based on policy review, the hospital failed to follow their policies and ensure that the on-call Ear, Nose and Throat (ENT, a surgical subspecialty within medicine that deals with the surgical and medical management of conditions of the head and neck) physician responded to a request from the Emergency Department (ED) provider to evaluate one patient (#5) who presented to the ED with an emergency medical condition (EMC) of 22 ED records reviewed from 09/03/24 through 03/03/25. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC.

Findings included:

Review of the hospital's document titled, "Medical Staff Bylaws," dated 04/21/21, showed that the purposes and responsibilities of the medical staff are to:
- Provide patients with quality of care based on acceptable standards and available resources.
- Collaborate with the hospital to ensure uniform patient care processes throughout the hospital.
- Be accountable to the Board of Trustees concerning professional performance, provide quality and appropriate healthcare, and participate in initiatives to measure and improve hospital performance.

Review of the hospital's document titled, "Emergency Medical Treatment and Labor Act (EMTALA)-Medical Screening Examination and Stabilization Policy," dated 07/18/24, showed:
- An EMTALA obligation is triggered when an individual and/or their representative presents to the ED and requests an examination or treatment for a medical condition.
- The hospital must perform a medical screening examination (MSE) to determine if an EMC exits.
- An appropriate MSE and stabilizing treatment is to be provided within the ED's capability and capacity, including ancillary services.
- If an EMC exists, the hospital must provide stabilizing treatment or an appropriate transfer.

Review of the hospital's document titled, "EMTALA-Transfer Policy," dated 07/18/24, showed:
- An individual's transfer must be initiated by a written request for transfer from the individual or by a physician order.
- The transferring hospital must provide, within its capacity and capability, medical treatment to minimize the health risks to the individual.
- Evaluation, treatment and transfer shall be carried out as quickly as possible individuals with an EMC which has not been stabilized or when stabilization is not possible due to the lack of appropriate equipment or personnel to correct the underlying process.
- The transferring hospital must send the receiving hospital copies of all medical records related to the EMC that are available at the time of transfer. The name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment should also be included.

Review of the hospital's document titled, "EMTALA-Provision of On-Call Coverage Policy," dated 07/18/24, showed:
- The hospital must maintain a list of physicians who have privileges at the hospital.
- Physicians on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with EMC's who are receiving services in accordance with the resources available to the hospital.
- Medical staff members must cooperate with this policy in order for the hospital to be in compliance with the on-call provisions of ETMALA.
- Physicians should be aware of their legal obligations based on this policy and the Medical Staff Bylaws. All necessary steps should be taken to ensure that physicians perform their obligations.
- An on-call rotation schedule should include the name and direct telephone number or direct pager of each physician who is required to fulfill on-call duties.
- Only physicians that are available to physically come to the ED may be included on the on-call schedules.
- Any physician identified as being "on-call" to the ED for a specialty, has a duty and responsibility to ensure their immediate availability, at least by telephone, to the ED physician for their scheduled "on-call" period. It is their responsibility to secure a qualified alternate who has privileges at the hospital if necessary.
- The on-call physician must respond or ensure arrival to the ED within a reasonable time frame (generally, within 30 minutes).
- The ED physician, in consultation with the on-call physician, shall determine whether an individual's condition requires an immediate evaluation by the on-call physician. The determination of immediate evaluation is controlled by the ED physician who has personally examined and is currently treating the individual.
- The on-call physician has a responsibility to provide specialty care services as needed to any individual who comes the ED and to notify the Medical Staff Office of changes to the on-call schedule.
- If a physician on the on-call list is called by the hospital to provide emergency screening or treatment and either fails or refuses to appear within a reasonable timeframe, the hospital and that physician may be in violation of EMTALA.
- If, as a result of the on-call physician's failure to respond to an on-call request, the hospital must transfer the individual to another facility for care, the hospital must document on the transfer form the name and address of the physician who refused or failed to appear.

Please refer to 2404 for further details.

Based on interview, record review, and policy review, the hospital failed to follow their policies and ensure that the on-call Ear, Nose and Throat (ENT, a surgical subspecialty within medicine that deals with the surgical and medical management of conditions of the head and neck) physician responded to a request from the Emergency Department (ED) provider to evaluate one patient (#5) who presented to the ED with an emergency medical condition (EMC) of 22 ED records reviewed for patients that presented to the ED from 09/03/24 through 03/03/25. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC.

Findings included:

Review of the hospital's document titled, "Medical Staff Bylaws," dated 04/21/21, showed that the purposes and responsibilities of the medical staff are to:
- Provide patients with quality of care based on acceptable standards and available resources.
- Collaborate with the hospital to ensure uniform patient care processes throughout the hospital.
- Be accountable to the Board of Trustees concerning professional performance, provide quality and appropriate healthcare, and participate in initiatives to measure and improve hospital performance.

Review of the hospital's document titled, "Emergency Medical Treatment and Labor Act (EMTALA)-Medical Screening Examination and Stabilization Policy," dated 07/18/24, showed:
- An EMTALA obligation is triggered when an individual and/or their representative presents to the ED and requests an examination or treatment for a medical condition.
- The hospital must perform a medical screening examination (MSE) to determine if an EMC exits.
- An appropriate MSE and stabilizing treatment is to be provided within the ED's capability and capacity, including ancillary services.
- If an EMC exists, the hospital must provide stabilizing treatment or an appropriate transfer.

Review of the hospital's document titled, "EMTALA-Transfer Policy," dated 07/18/24, showed:
- An individual's transfer must be initiated by a written request for transfer from the individual or by a physician order.
- The transferring hospital must provide, within its capacity and capability, medical treatment to minimize the health risks to the individual.
- Evaluation, treatment and transfer shall be carried out as quickly as possible individuals with an EMC which has not been stabilized or when stabilization is not possible due to the lack of appropriate equipment or personnel to correct the underlying process.
- The transferring hospital must send the receiving hospital copies of all medical records related to the EMC that are available at the time of transfer. The name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment should also be included.

Review of the hospital's document titled, "EMTALA-Provision of On-Call Coverage Policy," dated 07/18/24, showed:
- The hospital must maintain a list of physicians who have privileges at the hospital.
- Physicians on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with EMC's who are receiving services in accordance with the resources available to the hospital.
- Medical staff members must cooperate with this policy in order for the hospital to be in compliance with the on-call provisions of ETMALA.
- Physicians should be aware of their legal obligations based on this policy and the Medical Staff Bylaws. All necessary steps should be taken to ensure that physicians perform their obligations.
- An on-call rotation schedule should include the name and direct telephone number or direct pager of each physician who is required to fulfill on-call duties.
- Only physicians that are available to physically come to the ED may be included on the on-call schedules.
- Any physician identified as being "on-call" to the ED for a specialty, has a duty and responsibility to ensure their immediate availability, at least by telephone, to the ED physician for their scheduled "on-call" period. It is their responsibility to secure a qualified alternate who has privileges at the hospital if necessary.
- The on-call physician must respond or ensure arrival to the ED within a reasonable time frame (generally, within 30 minutes).
- The ED physician, in consultation with the on-call physician, shall determine whether an individual's condition requires an immediate evaluation by the on-call physician. The determination of immediate evaluation is controlled by the ED physician who has personally examined and is currently treating the individual.
- The on-call physician has a responsibility to provide specialty care services as needed to any individual who comes the ED and to notify the Medical Staff Office of changes to the on-call schedule.
- If a physician on the on-call list is called by the hospital to provide emergency screening or treatment and either fails or refuses to appear within a reasonable timeframe, the hospital and that physician may be in violation of EMTALA.
- If, as a result of the on-call physician's failure to respond to an on-call request, the hospital must transfer the individual to another facility for care, the hospital must document on the transfer form the name and address of the physician who refused or failed to appear.

Review of the hospital's document titled, "ENT Call," dated 01/19/25 through 01/26/25, showed that Staff J, ENT Physician, was the ENT on-call for the date of 01/22/25.

Although requested, there was no contract for on-call specialists providing services to the ED on a non-emergent basis.

Review of Patient #5's medical record, dated 01/21/25, showed she was a 61-year-old female who presented to the ED at 1:51 PM, for intermittent nose bleeds for three days. She had no prior history of nose bleeds, a bleeding disorder or use of a blood thinning medication. She did not know what had caused her nose to begin bleeding and thought it could be due to cold, dry air. Initially Patient #5's nose was clamped; upon re-check her nose began to bleed again. She was given Afrin nasal spray (a topical medication used to relieve nasal congestion) and re-clamped. The bleeding improved and she was discharged with instructions for nosebleeds. Her instructions included the use of Vaseline in the nose twice a day, saline spray four to five times a day and, if her nose began to bleed again two Afrin sprays on both sides and clamp the nose for 20 to 30 minutes. For uncontrolled bleeding she was to return to the ED for further treatment. She was discharged from the ED at 3:10 PM.

Review of Patient #5's medical record, dated 01/22/25, showed:
- At 7:45 AM, Patient #5 presented to the ED for continued intermittent bleeding, passing blood clots and feeling lightheaded and dizzy.
- Her presenting blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) was 142/89 and her heart rate (HR, the number of times the heart beats within a certain time period, normal pulse/heartbeats for adults range from 60 to 100 beats per minute) was 98.
- She had a vasovagal (relating to, involving, or caused by the vagus nerve on blood vessel dilation and heart rate) reaction shortly after her arrival when her BP dropped to 70/48 with a HR of 51. Intravenous (IV, in the vein) fluids were started, and blood was drawn.
- Her hemoglobin (HGB, a protein in blood red blood cells that carries oxygen throughout the body, normal range was 11.5 to 15.3) was 10.9.
- She continued to have moderate bleeding and spit up blood clots after the insertion of bilateral nasal rockets (a sterile, single use nasal packing device specifically designed to control nosebleeds after trauma or surgery). She was given medications for pain and anxiety.
- At 10:25 AM, the bleeding was improved but she was very anxious and uncomfortable.
- At 10:53 AM, Staff I, Physician, spoke with Staff N, ENT Nurse Practitioner (NP), and reported the patients HGB dropped from 10.9 to 10.2 in two hours.
- At 11:10 AM, the patient was much improved after additional pain and anxiety medications. The bleeding had slowed and she was spitting up less blood.
- At 12:40 PM, Staff N was contacted and they recommended admitting the patient and starting tranexamic acid (TXA, a medication that blocks the breakdown of blood clots, preventing bleeding). An ENT would see the patient as an inpatient if necessary.
- At 1:45 PM, Staff I spoke with the hospitalist to report that Patient #5's HGB was 9.6. The hospitalist agreed to consult ENT.
- At 3:00 PM, Patient #5 was still in the ED and had started vomiting blood again. Her HR was elevated but her other VS were stable. She was anxious and had blood draining from her left ear canal. Staff I spoke with the hospitalist and the admission was cancelled. It was decided that Patient #5 would be transferred as there were no functioning ENT services at Hospital A.
- Patient #5's family requested that she be transferred to Hospital B (an Acute Care Hospital).
- At 3:20 PM, Hospital B accepted the transfer with an ENT consult.

Review of Patient #5's transfer form dated 01/22/25, showed Patient #5 was transferred for posterior epistaxis (bloody nose). She was stable for a medically indicated transfer to another hospital as ENT services were unavailable at Hospital A. The form was signed by Staff I, Physician, at 3:19 PM.

Review of Patient #5's Ambulance report, dated 01/22/25, showed:
- At 3:32 PM, Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) C was dispatched to transfer Patient #5 to Hospital B.
- Her chief complaint was nosebleeds with a secondary complaint of feeling lightheaded. She reported her nose had been bleeding for four days before she presented to the ED. The bleeding was stopped using Afrin and nasal clamps, so she was sent home. Her nose began bleeding again during the night, so she returned to the ED.
- Nursing staff reported that she had a syncopal (to faint) episode shortly after her arrival to the ED and her BP was low. She was given IV fluids and medications for pain and anxiety. Nasal rockets were inserted in both nostrils to slow the bleeding. Her tears became bloody, and she started bleeding from her ears. The bleeding continued so she was being transferred to Hospital B.

Review of Patient #5's Hospital B medical record, dated 01/22/25 through 01/23/25, showed:
- At 4:30 PM, she arrived via EMS for a bloody nose.
- At 4:37 PM, an ENT was consulted and responded.
- At 5:12 PM, her HGB was 9.7. IV fluids and medications for anxiety were administered. Her review of symptoms indicated a hemorrhage (excessive bleeding) of the left eye.
- Upon ENT evaluation, it was determined that the bleeding was coming from the left side of the nose. The right nasal rocket was removed.
- The ENT recommended an overnight admission for observation to monitor her VS, bleeding and HGB level.
- On 01/23/25 at 9:37 AM, she was discharged with instructions to use Afrin as needed for bleeding and to pinch over the soft part of the nose for 15 minutes without a break. She was to overinflate the cuff of the nasal rocket if bleeding did not stop and return to the ED. The nasal rocket was to remain in place for five days, until the ENT removed it.

During a telephone interview on 03/04/25 at 10:30 AM, Staff N, ENT NP, stated that she worked for Staff J, ENT Physician, in his private practice. They provided on-call services at Hospital A through their consultant group. They would receive a call from a physician and get a report on the patient. Based on the information provided during the phone call, they would either make recommendations or go in and evaluate the patient. She spoke with Staff I, Physician, about Patient #5 and he reported that he had placed bilateral nasal rockets and the bleeding had slowed, but her BP and anxiety had increased. Staff N recommended that he get her BP and anxiety under control. She did not think that the ED physician would remove the nasal packing while the patient's BP was elevated. After that initial conversation, she never spoke with Staff I again. She did discuss the case with Staff J, ENT, the next day. Staff J wasn't comfortable seeing the patient at Hospital A since they did not have interventional radiology (IR, a medical specialty that uses imaging techniques to guide minimally invasive procedures to diagnose and treat a wide range of conditions), which was a safety issue.

During a telephone interview on 03/04/25 at 11:20 AM, Staff J, ENT Physician, stated that he had a conversation with Staff N, ENT NP, about Patient #5. His contract obligation was to respond to ED calls within 30 minutes. 99% of the calls were for telephone triage, getting a verbal report and providing recommendations. Being on call had been rough on the ENT's. Two providers had opted out, choosing to not be on call. He didn't want to leave the hospital in the lurch so they had an agreement that he would be available, but not on an emergent basis. IR was not available at the hospital, which could have made it unsafe to treat Patient #5 there. If a patient had nasal packing on both sides, high anxiety and a low BP, he would need IR to take her to the operating room (OR). He did not know why Staff I, Physician, documented that ENT services were not available. He assumed that Patient #5 requested to be transferred to a bigger hospital.

During a telephone interview on 03/13/25 at 9:00 AM, Staff I, Physician, stated that Patient #5 was in the ED for eight hours while he tried multiple times to get a specialty consultation. He never even got the chance to speak with Staff J, ENT Physician. He only spoke with Staff N, ENT NP, who recommended admitting the patient and starting TXA. She was supposed to call him back to check on the patient but never did. He tried multiple times to get ENT to go in and evaluate the patient. They never said they would not go in and see her, but they never went either. Staff I spoke on the phone with the hospitalist who agreed to take the patient as an admission, begin TXA and insist that ENT evaluate her. He ended up keeping Patient #5 in the ED because he wanted to make sure, before he moved her to the floor, that an ENT would go in and see her, not just do a telephone consultation. ENT just kept putting the patient off. Staff I felt he did all he could do. ENT delayed Patient #5's care and she began getting worse. ENT never said they would not come in, but just kept telling him to call them if she got worse. She did get worse, and he called them several times to report it. It became clear that ENT was not going see the patient. As soon as the patient asked to be transferred to another hospital Staff I agreed. It was false advertisement to say that there were ENT services when ENT refused to respond to the hospital for assessments. He did not know why IR would be a concern for an ENT procedure, especially since Staff J hadn't even evaluated the patient to see if that would be needed. Staff N, ENT NP, never voiced any concerns about not having IR at the hospital to treat the patient. If she would have told him that, he would have transferred the patient much sooner. He did not believe that IR was available in the ENT's office. He wasn't sure why they agreed to see the patient the next day at the clinic where he would not have IR available if that was the reason he wouldn't evaluate her in the ED. It was well known that the ED was not going to get a specialist to respond to the ED to evaluate patients. He often had to transfer patients to other hospitals because the specialists refused to come in to see them and just wanted to do telephone consultations.

During a telephone interview on 03/13/25 at 9:30 and 10:55 AM, Staff H, ED Medical Director, stated that he spoke with Staff I, Physician, about Patient #5. He was told that the situation was frustrating for the family, and they requested to be transferred out. He expected that if an ED Physician requested a specialist to evaluate a patient, the specialist would see the patient. He did not know if ENT was a routine specialty or if there was a special contract with Staff J, ENT Physician.

During an interview on 03/13/25 at 11:45 AM, Staff A, Vice President of Quality, stated that for the hospital to advertise an ENT service they would have to be available to present to the hospital and evaluate patients. All specialists were expected to respond to the request of the ED Physician to present and evaluate patients. She was not aware of any type of "special contract" for on-call specialists to provide services to the ED on a non-emergent basis.