HospitalInspections.org

Based on interviews, medical records reviews, policies /procedures review, on-call list review, medical staff re-appointment application review, bed census review, ambulance report review, and review of medical staff bylaws, the facility failed to ensure that resources that were available to the hospital, including the availability of on-call physicians (Pulmonologist) provided further evaluation and treatment after the initial examination that was necessary when requested by the Emergency Department for 2 (#4 and #5) of 20 sampled patients that were intubated and placed on the ventilators. Refer to findings in Tag A- 2404.


Based on interview, medical record review, policies/procedures review, on- call schedules review, bed census report review, and review of the medical bylaws, the facility failed to provide within the capabilities of the staff, and facilities available at the hospital, for further examination and treatment as required to stabilize a medical condition for 2 (Patient #4 and #5) of 20 patients presenting to the facility. Refer to findings in Tag A-2407.


Based on review of medical records, on-call schedules, bed census reports, and policies and procedures, and interviews the facility failed to provide medical treatment that was within its capacity that minimizes the risk of the of the individuals health as evidenced by the refusal of the pulmonary on-call physician to consult on 2 (#4 & #5) of 20 sampled patients. This resulted in inappropriate transfer of patient #'s 4 and 5. Refer to findings in Tag A- 2409.

Based on interviews, medical records reviews, policies /procedures review, on-call list review, medical staff re-appointment application review, bed census review, ambulance report review, and review of medical staff bylaws, the facility failed to ensure that resources that were available to the hospital, including the availability of on-call physicians (pulmonologists) provided further evaluation and treatment after the initial examination that was necessary when requested by the Emergency Department for 2 (#4 and #5) of 20 sampled patients that were intubated and placed on the ventilators.

Findings:

Review of the EMS Ambulance Report for Patient #4 dated 9/26/2017, the narrative revealed in part, "Called for a reported Psychiatric problem/Suicide attempt ...on arrival a ...male patient ...Chief Complaint of Overdose ....Patients ... State #4 took 15 Augmentin and 20 Flexeril. At 20:20, the patient was found unresponsive on the floor ...Initial assessment revealed the patient had GCS of 3 (eye-1, Verval-1, Motor-1) with V/S 132/78, P-136, RR-15." The patient was intubated by EMS by EMS personnel prior to arrival to the ED.


Review of the medical record for Patient #4 showed that on 09/26/17 at 20:35, the patient was triaged as an ESI level 1- "Resuscitate." The ED nurse documented on 9/26/17 at 2150 that Patient #4 appeared agitated, 2202 Ventilator settings set Parameters were: Vent Mode: Assist control set, Tidal Volume 550cc Vent rate: 14 Set FiO2 40% and PEED -5cmH20. The ED Physician documented the following on 9/26/2017: at: 2141 the patient presents with decreased responsiveness; at 21:44 Respiratory: No distress on Ventilator; at 20:33 the patient was medically screened; 9/27/2017 at 00:11" PULMONOLOGY AT THIS FACILITY WOULD NOT CONSULT ON THIS PATIENT. THUS THE HOSPITALIST WOULD NOT ADMIT THIS PATIENT WITHOUT PULMONOLOGY CONSULT ON THIS PATIENT. PT. TO BE TX'D (TRANSFERRED)" TO ANOTHER ACUTE CARE FACILITY FOR HIGHER LEVEL OF CARE on 9/27/2017 at 1:23 AM intubated on ventilator. Patient #4 disposition Summary was documented, "9/27/2017 Diagnosis are Acute Respiratory failure, OVERDOSE" The patient's condition was listed as Critical.

Review of the on call list showed/verified that Staff A was the on call physician for pulmonary on 9/26/2017 and 9/27/2017.

Review of the bed census report dated 9/27/2017 revealed the ICU (Intensive Care Unit) had 15 open beds.

The Pulmonologist (Staff A) who was on call on 9/27/2017 refused to consult on Patient #4 when requested by the ED physician as Patient #4 required the emergency services of the Pulmonologist that was available at the hospital when the patient presented to the hospital on 9/26/2017.


Review of the medical record for Patient #5 showed that on 09/14/17, the patient presented to the ED after overdosing on pain pills and having suicidal thoughts. Patient #5 arrived from home with law enforcement.

The patient was triaged acuity was listed as an ESI Level 2, which is "Emergent." The ED physician documented the following on 9/1/4/2017: at 12:23 the patient presents to the emergency department with depression ...a history of substance abuse ...a history of suicide gesture ... took pill/medications ...STATES WANTED TO KILL HIMSELF. PT IS VERY DROWSY AND DRY HEAVING IN THE ED. DIFFICULT TO KEEP AWAKE ...EXAM 09/14 12:27 ...The patient appears in obvious distress, severely distressed obviously ill, uncomfortable ...12:27 Respiratory: mild respiratory is noted. Respirations shallow respirations that is mild, Breath sounds: are normal clear throughout. At 12:39, G-Tube placement: gastric lavage: Performed via NG tube with patient sedated tolerated well. Intubation ...ventilated and ventilator; 9/14/17 11:37 Patient medically screened ...9/14/2017 15:27 Physician Consultation: Staff A (Pulmonologist on-call) was called ...15:32 Physician consultation: was contacted regarding consult, and will see patient STAFF IS REFUSING THE CONSULTS SO [AT WILL BE TRANSFERRED OUT" Patient #5 was then transferred to higher care facility at 5:05 PM for overdose, respiratory failure (intubated on ventilator).

Review of the on call list showed/verified that Staff A was the on call physician for Pulmonary on 9/14/2017.

Review of the bed census report dated 9/14/2017 revealed the ICU had 11 open beds


The Pulmonologist (Staff A) was on call on 9/14/2017 refused to consult on Patient #4 when requested by the ED physician as Patient #5 required the emergency services of the Pulmonologist that was available at the hospital when the patient presented to the hospital on 9/14/2017.


Interviews:

During an interview on 10/04/17 at 10:50 AM, ICU (Intensive Care Unit) Manager stated that if there is a patient in the ED on a ventilator, they will need to have the ED get a Pulmonary Consult before sending the patient to ICU. The ICU Manager stated they have had to transfer patients to another facility within the system if the patient is on a ventilator and there is no Pulmonary Consult.

During an interview on 10/04/17 at 11:10 AM, Director of ED stated that any transfer is reviewed by the Medical Director of the ED. They have had 2 patients in month of September 2017 they have had to transfer to another facility due to the pulmonary On Call Physician not seeing the patients after being called.

During an interview on 10/04/17 at 11:41 AM, Unit Secretary/Monitor Technician stated he receives an on call list for each specialty monthly and does an update each day for any changes in the schedule. He stated when they need to call an on call specialist, they call the operator who will have the on call specialist call the ED. They will continue calling every 15 minutes until the on call specialist returns the call. If no contact with the on call Specialist after an hour, they will contact the House Supervisor or Administrator on call to find out who next can be called. When they are ready to transfer a Patient, the transfer call center is contacted with the information needed to transfer the patient.

During an interview on 10/04/17 at 3:50 PM, ED physician, when asked if there were problems getting a group of physicians to see a patient in the ED, stated, "Yes, usually Pulmonary." If they are unable to get a hold of pulmonary, they will talk with the Medical Director of ED. They usually can handle ventilators in the ED, but the patient is always transferred if there is no pulmonary consult.

During an interview on 10/05/17 at 12:20 PM, Chief Executive Officer stated that there have been problems with the pulmonary physicians, who have been refusing to see patients in the ED. The Pulmonary physicians felt there were too many uninsured patients from the ED and were not getting paid for the services provided.

During an interview on 10/05/17 at 12:45 PM, Medical Director of the ED stated that the Pulmonary group will not see patients in the ED if they do not have insurance. Even if the patient goes to the ICU (Intensive Care Unit), the patient is transferred if not seen by the on call Pulmonary Physician. He stated the patients in the ED on ventilators are not getting pulmonary management. The ED physicians can manage the ventilator, but then will transfer the patient. The pulmonary group states that the patient on the ventilator needs to be admitted to the ICU first, then the patient will be seen by the pulmonary physician in the ICU.

During an interview on 10/05/17 at 1:20 PM, Staff A (Pulmonary Physician, On call for Patients #4 and #5) stated that he did not come in to see Patients #4 and #5 because he was not asked by the ED physician to do so. If he is on call for the ED, the ED knows he could come in, but he has not been asked to do so. He stated, "The ED states that it is a consult and that means that I do not need to see the patient until after they are admitted to the ICU. I do not tell the ED physician what to do with their patients." He stated he has never asked if patients has insurance before seeing patients in the ED. He stated "The ED needs to tell me why they want me to see a patient in the ED. I have told the ED physicians and administration about this. When the ED calls, I need to know what they need, they can stabilize the patient on the ventilator in the ED." The facility failed to ensure that their policies and procedures were followed as evidenced by failing to ensure that the specialist (Pulmonologist) "on-call" for duty after the initial medical screening examination provided further evaluation and/or treatment as necessary to stabilize Patient #4 and Patient #5 emergency medical conditions.

Review of the facility's policy on EMTALA (Emergency Medical Treatment and Labor Act):

Record review of the facility's policy titled "EMTALA- Provisions for On-Call Coverage," dated 11/2003, showed that each hospital should have a documented system for providing on-call coverage, so that the ED is at all times aware of physicians, including specialists and sub specialists, who are available to provide screening and treatment necessary to stabilize individuals with EMC (Emergency Medical Conditions). If the hospital offers a service to the public, the service should be available through on-call coverage of the ED and should be reflected on the on-call list.

Record review of the facility's policy titled, "Emergency Medical Treatment and Patient Transfers," dated 09/2013,showed that Medical Screening Examination is in the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC. Such screening must be done within the hospital's capacity and available personnel, including on-call physicians. The Medical Screening is an ongoing process and the medical records must reflect it. On Call List refers to the list that the hospital is required to maintain that defines those physicians who are "On -Call" for duty after the initial MSE (Medical Screening Examination) to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC. The purpose of the On-Call list is to ensure that the ED is prospectively aware of each physician; including specialists, who are available to provide treatment necessary to stabilize individuals with EMC. Transfer will not be delayed in order to obtain insurance information. The insurance cannot be verified until an MSE and any other medical treatment that is required is provided.

Record review of the facility's policy titled "EMTALA-Reporting," dated 09/2013, stated an On-Call Physician who fails or refuses to come to the hospital within a reasonable period of time, as requested , to evaluate or stabilize the patient, must be reported.

Each hospital should have a documented system for providing on-call coverage, so that the ED is at all times aware of which physicians, including specialists, are available to provide screening and treatment necessary to stabilize individuals with EMC. If a hospital offers a service to the public, the service should be available through the on call coverage for the ED and should be reflected on the on-call list.

Review of Medical Staff Bylaws, Policies, and Rules and Regulations:

Record review of the Medical Staff Bylaws, Policies, and Rules and Regulations, revised 2017, showed under section three, Emergency Departments recognized ER (Emergency Room) call rosters are determined by the Medical Executive Committee (MEC) based on the need to provide emergency care or urgent follow up to patients seeking emergency services or who require admission. The recognized call rosters include Pulmonary. All unassigned patients are assigned to the service concerned with the treatment of the problem or diseases. Under consultations, it showed that any physician must be credentialed to manage a ventilator, or a pulmonologist consult must be generated upon intubation. Additionally, if any phase of the MSE discloses that it is clinically inappropriate to transport the patient to the other sites for services, then in any such case the on-call physician should immediately be required to attend to that patient where the patient is located.

Further review of Staff A medical staff Re-Appointment Application, dated 02/25/16, showed that duties are to care for unassigned patients and participation in the on-call coverage of the ED. This document also revealed that Staff A (Pulmonologist ) on call membership category was "Active", Primary Campus was "Bayfront Health Brookville and Spring Hill Hospitals" , Department "Medicine" and Privileges "Pulmonary". The appointment period time was "03/01/16 to 2/28/2018.

Based on interview, medical record review, policies/procedures review, on- call schedules review, bed census report review, and review of the medical bylaws, the facility failed to provide within the capabilities of the staff, and facilities available at the hospital, for further examination and treatment as required to stabilize a medical condition for 2 (Patient #4 and #5) of 20 patients presenting to the facility.

Findings:

Review of the medical record for Patient #4 showed that on 09/26/17, the patient presented to the Emergency Department (ED) by Emergency Medical Services (EMS) unconscious after an overdose. The patient was intubated by EMS prior to arrival.

At 12:11 AM, Staff A (Pulmonary Specialist) was called and would not consult on this patient.

Review of the On Call List showed that Staff A was the On Call Physician for Pulmonary on this date. Review of the bed census report dated 9/27/2017 revealed the facility had multiple ICU beds available.

Further review of the medical chart showed that Patient # 4 transferred on 09/26/17 at 1:23 AM to a higher care facility for respiratory failure/overdose (intubated on ventilator).

Review of the medical record for Patient #5 showed that on 09/14/17, the patient presented to the ED after overdosing on pain pills and having suicidal thoughts. Patient #5 arrived from home with Law Enforcement. At around 12:39 PM, Patient #5 was intubated. Staff A (Pulmonary Specialist) was contacted at 3:32 PM and refused consult.

Review of the on Call List showed that Staff A was the On Call Physician for Pulmonary on this date. Review of the bed census report dated 9/14/2017 revealed the facility had multiple ICU beds available.

Patient #5 was then transferred to higher care facility at 5:05 PM for overdose, respiratory failure (intubated on ventilator).


Interviews:


During an interview on 10/04/17 at 10:50 AM, ICU (Intensive Care Unit) Manager stated that if there is a patient in the ED on a ventilator, they will need to have the ED get a pulmonary consult before sending the patient to ICU. The ICU Manager stated they have had to transfer patients to another facility within the system if the patient is on a ventilator and there is no Pulmonary Consult.

During an interview on 10/04/17 at 11:10 AM, Director of ED stated that any transfer is reviewed by the Medical Director of the ED. They have had 2 patients in month of September 2017 they have had to transfer to another facility due to the Pulmonary on Call Physician not seeing the patients after being called.

During an interview on 10/04/17 at 11:41 AM, Unit Secretary/Monitor Technician stated he receives an on call list for each specialty monthly and does an update each day for any changes in the schedule. He stated when they need to call an On Call Specialist, they call the operator who will have the On Call Specialist call the ED. They will continue calling every 15 minutes until the On Call Specialist returns the call. If no contact with the On Call Specialist after an hour, they will contact the House Supervisor or Administrator on call to find out who next can be called. When they are ready to transfer a patient, the transfer call center is contacted with the information needed to transfer the patient.

During an interview on 10/04/17 at 3:50 PM, ED physician, when asked if there were problems getting a group of physicians to see a patient in the ED, stated, "Yes, usually pulmonary." If they are unable to get a hold of Pulmonary, they will talk with the Medical Director of ED. They usually can handle ventilators in the ED, but the patient is always transferred if there is no Pulmonary Consult.

During an interview on 10/05/17 at 12:20 PM, Chief Executive Officer stated that there have been problems with the Pulmonary Physicians, who have been refusing to see patients in the ED. The Pulmonary Physicians felt there were too many uninsured patients from the ED and were not getting paid for the services provided.

During an interview on 10/05/17 at 12:45 PM, Medical Director of the ED stated that the Pulmonary group will not see patients in the ED if they do not have insurance. Even if the patient goes to the ICU (Intensive Care Unit), the patient is transferred if not seen by the on call Pulmonary Physician. He stated the patients in the ED on ventilators are not getting Pulmonary management. The ED physicians can manage the ventilator, but then will transfer the patient. The Pulmonary group states that the patient on the ventilator needs to be admitted to the ICU first, then the patient will be seen by the Pulmonary Physician in the ICU.

During an interview on 10/05/17 at 1:20 PM, Staff A (Pulmonary Physician, On call for Patients #4 and #5) stated that he did not come in to see Patients #4 and #5 because he was not asked by the ED physician to do so. If he is on call for the ED, the ED knows he could come in, but he has not been asked to do so. He stated "The ED states that it is a consult and that means that I do not need to see the patient until after they are admitted to the ICU. I do not tell the ED physician what to do with their patients." He stated he has never asked if patients has insurance before seeing patients in the ED. He stated, "The ED needs to tell me why they want me to see a patient in the ED. I have told the ED physicians and administration about this. When the ED calls, I need to know what they need, they can stabilize the patient on the ventilator in the ED."

Review of the facility's policy on EMTALA (Emergency Medical Treatment and Labor Act):

Record review of the facility's policy titled "EMTALA- Provisions for On-Call Coverage," dated 11/2003, showed that each hospital should have a documented system for providing on-call coverage, so that the ED is at all times aware of physicians, including specialists and sub specialists, who are available to provide screening and treatment necessary to stabilize individuals with EMC (Emergency Medical Conditions). If the hospital offers a service to the public, the service should be available through on-call coverage of the ED and should be reflected on the on-call list.

Record review of the facility's policy titled, "Emergency Medical Treatment and Patient Transfers," dated 09/2013,showed that Medical Screening Examination is in the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC. Such screening must be done within the hospital's capacity and available personnel, including on-call physicians. The medical screening is an ongoing process and the medical records must reflect it. On call list refers to the list that the hospital is required to maintain that defines those physicians who are "On -Call" for duty after the initial MSE (Medical Screening Examination) to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC. The purpose of the On-Call list is to ensure that the ED is prospectively aware of each physician; including specialists, who are available to provide treatment necessary to stabilize individuals with EMC. Transfer will not be delayed in order to obtain insurance information. The insurance cannot be verified until an MSE and any other medical treatment that is required is provided.

Record review of the facility's policy titled "EMTALA-Reporting," dated 09/2013, stated an On-Call Physician who fails or refuses to come to the hospital within a reasonable period of time, as requested , to evaluate or stabilize the patient, must be reported.
Each hospital should have a documented system for providing on-call coverage, so that the ED is at all times aware of which physicians, including specialists, are available to provide screening and treatment necessary to stabilize individuals with EMC. If a hospital offers a service to the public, the service should be available through the on call coverage for the ED and should be reflected on the on-call list.

Review of Medical Staff Bylaws, Policies, and Rules and Regulations:

Record review of the Medical Staff Bylaws, Policies, and Rules and Regulations, revised 2017, showed under section three, Emergency Departments recognized ER (Emergency Room) call rosters are determined by the Medical Executive Committee (MEC) based on the need to provide emergency care or urgent follow up to patients seeking emergency services or who require admission. The recognized call rosters include Pulmonary. All unassigned patients are assigned to the service concerned with the treatment of the problem or diseases. Under consultations, it showed that any physician must be credentialed to manage a ventilator, or a pulmonologist consult must be generated upon intubation.

Based on review of medical records, on-call schedules, medical staff by-laws review, bed census reports, and policies and procedures, and interviews, the facility failed to provide medical treatment that was within its capacity that minimizes the risk of the of the individuals health as evidenced by the refusal of the pulmonary On-Call Physician to consult on 2 (#4 & #5) of 20 sampled patients. As this resulted in inappropriate transfer of Patient #'s 4 and 5.


Findings:


Review of the facility's transfer form for Patient #4 dated 9/26/2017 revealed in part, "Section C" Additional PHYSICIAN DOCUMENTATION TO BE COMPLETED FOR TRANSFERS FROM THE EMERGENCY ROOM ONLY. The patient presented to the Hospital requesting emergency medical treatment and the Hospital has provided a Medical Screening Examination and stabilization services to the extent possible, given the Hospital's current capacity and/or capabilities. Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated. Further review revealed the ED physician checked the box which indicated that patient (#4) is being transferred because of failure, refusal ...of an on-call. Staff A's name, address and phone number was listed.

Review of the On Call List showed/verified that Staff A was the on call Physician for pulmonary on 9/26/2017 and 9/27/2017.

Review of the bed census report dated 9/26/2017 revealed the ICU (Intensive Care Unit) had 14 open beds; and on 9/27/2017 the ICU had 15 open beds.

Review of the facility's transfer form for Patient #5 dated 9/14/2017 revealed in part, "Section C" Additional PHYSICIAN DOCUMENTATION TO BE COMPLETED FOR TRANSFERS FROM THE EMERGENCY ROOM ONLY. The patient presented to the Hospital requesting emergency medical treatment and the Hospital has provided a medical screening examination and stabilization services to the extent possible, given the Hospital's current capacity and/or capabilities. Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated. Further review revealed the ED physician checked the box which indicated that patient (#5) is being transferred because of failure, refusal ...of an on-call. Staff A's name, address and phone number was listed.

Review of the On Call List showed/verified that Staff A was the on call physician for pulmonary on 9/14/2017.

Review of the bed census report dated 9/14/2017 revealed the ICU had 11 open beds.


Interviews:

During an interview on 10/04/17 at 10:50 AM, ICU (Intensive Care Unit) Manager stated that if there is a patient in the ED on a ventilator, they will need to have the ED get a pulmonary consult before sending the patient to ICU. The ICU Manager stated they have had to transfer patients to another facility within the system if the patient is on a ventilator and there is no pulmonary consult.

During an interview on 10/04/17 at 11:10 AM, Director of ED stated that any transfer is reviewed by the Medical Director of the ED. They have had 2 patients in month of September 2017 they have had to transfer to another facility due to the pulmonary on call physician not seeing the patients after being called

Policy and Procedures:

The facilities policy titled "EMTALA-Emergency Transfer", CHS Compliance Policy and Procedure G2B, effective Date: Nov 2003, Date Revised: September 2013 was reviewed. The policy showed in part, "PROCEDURE ...If a patient comes to the Hospital and is determined to have an Emergency Medical Condition following a Medical Screening Examination, the hospital must provide further examination and treatment, including hospitalization if necessary, as required to stabilize the Emergency Medical Condition within the capabilities of the staff and facilities available at the hospital ...An emergency appropriate transfer to another Hospital will be appropriate only in those cases in which: ...The transferring Hospital provided medical treatment within its capabilities that minimizes the risks of the individual's health."


The hospital's Medical Staff Bylaws, Policies, and Rules and Regulations, revised 2017 were reviewed. The Medical Staff by-laws showed, in part "Additionally, if any phase of the MSE discloses that it is clinically inappropriate to transport the patient to the other sites for services, then in any such case the on-call physician should immediately be required to attend to that patient where the patient is located.


The facility failed to ensure that there policy and procedure were followed as evidenced by transferring Patients #4 (9/27/2017) and Patient #5 (9/14/2017) to other acute care hospitals, when pulmonary on- call services and Intensive Care Unit beds were available to Bayfront Health Brooksville. This resulted in inappropriate transfers for Patient #4 and #5.