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Based on interview, record review, hospital Medical Staff Bylaws, on-call physician schedule, and review of facility Emergency Medical Treatment and Labor Act (EMTALA) policy, the hospital failed to ensure the on-call physician provided stabilizing treatment for one (1) of 30 patients reviewed with an Emergency Medical Condition (EMC). (Patient #1).

The findings include:

Cross reference A2404: To ensure the on-call physician provided an evaluation and/or stabilizing treatment for one (1) of 30 patients reviewed with an Emergency Medical Condition (EMC), Patient #1.

Based on interview, record review, hospital Medical Staff Bylaws, on-call physician schedule, and review of facility Emergency Medical Treatment and Labor Act (EMTALA) policy, the hospital failed to ensure the on-call physician provided stabilizing treatment for one (1) of 30 patients reviewed with an Emergency Medical Condition (EMC), (Patient #1).

Findings include:

Review of Patient #1's medical record on 07/09/24 at 9:47 AM showed Patient #1 presented at Hospital A Emergency Department (ED) on 05/17/24 at 10:54 PM by car with spouse with a complaint of "vascular surgery last week on his/her carotid artery. Patient sts (states) that he/she noticed the swelling on the left side of his/her neck worsened tonight. Patient denies trouble swallowing or breathing at this time". Patient #1 presented with signs and symptoms of a large, pulsating and increasing in size hematoma of the left neck. Review of the chart revealed at 11:05 PM, triage vital signs of blood pressure 187/109, pulse 58, respirations 16, oxygen level of 100%, and pain intensity of 8 out of 10. On 05/17/24 at 11:06 PM, Patient #1 was triaged for Emergency Severity Index (ESI) of 2. (ESI is an acuity scale with five levels to base patient medical conditions in acute care settings. Level 2 is defined as High risk of deterioration, or signs of a time-critical problem.)

A Computer Tomography (CT) scan was ordered on 05/17/24 at 11:28 PM. Review of the CT scan report on 05/18/2024 at 1:27 AM revealed "Large perivascular hematoma along the left carotid artery, with foci of active bleeding, possibly arising from branches of the inferior thyroidal artery, additional edema/inflammatory changes within the left neck extending along the left pharyngeal wall/retropharynx, with mild narrowing of the oropharyngeal airway".

Review of ED Physician #1's "First Contact History of Present Illness" dated 05/18/24 at 12:34 AM showed "Neck: Left sided swelling which is significant, rock-hard and with a palpable pulse. Associated ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) that tracks into the anterior chest wall. No voice change. Bleeding around the suture of the superior aspect of the incision".

On 05/18/24 at 1:07 AM, ED Physician #1 intubated the patient due to airway protection and the ESI acuity level was changed to a level 1 (Level 1 is defined as Immediate, life-saving intervention required without delay.)

On 5/18/24 at 1:50 AM, Review of ACS (Acute Coronary Syndrome)/Trauma Consult Note by on-call Vascular Surgeon #1 stated, "Due to hemodynamic stability and secured airway, will plan for transfer back to Hospital B for left neck hematoma. Per Surgical Resident #1's note within the on-call Vascular Surgeon #1' s consult notes states "I was called by emergency attending around 1:00 AM for patient status post left Carotid Endarectomy by surgeon at Hospital B recently, presented to the hospital with neck swelling continued to worsen with some shortness of breath, at that time the patient was hypertensive when I got the phone call went from {spending} left neck swelling, patient underwent CAT scan...".

On 05/18/24 at 1:52 AM, ED Physician #1 documents "Discussed with on-call Vascular Surgeon #1. Evaluated by Surgical Resident #1 of surgery. On-call Vascular Surgeon #1 after evaluation by Surgical Resident #1 and reviewing imaging request patient be transferred to Hospital B". Medical Decision Making by ED Physician #1 states "Differential Diagnosis: Pseudoaneurysm formation, hematoma, respiratory failure, impending arterial rupture. Provider notes further state "Our Vascular Surgeon, on-call [Vascular Surgeon #1 name] declined operative management per general surgery intern [this person is Surgical Resident #1] after multiple phone discussions with him. Will transfer to [Hospital B]".

On 05/18/24 at 2:18 AM, ED Physician #1 documents "Discussed with [Hospital B's physician] agrees to accept". On 05/18/24 at 3:32 AM, patient was transferred to the stretcher with EMS (Emergency Medical Services) and "noted as stable for transfer to [Hospital B] with transport". On 05/18/24 at 3:34 AM, Patient #1 was discharged from the ED at Hospital A.

Review of Hospital Transfer form dated 05/18/24 at 2:49 AM states, "Patient condition: Patient stabilized, Reason for transfer: Qualified clinical personnel or service unavailable...".

Review of EMS run sheet dated 05/18/24 at 3:31 AM, EMS transported Patient #1 to Hospital B via stretcher while intubated with cardiac monitoring, a propofol drip, nicardipine drip and Fentanyl Intravenous infusions (IV). Run sheet denotes arrival at Hospital B at 4:04 AM.

Interviews

During an interview by telephone on 07/10/2024 between 8:34 AM to 8:44 AM, ED Physician #1 stated that Patient #1 came to Hospital A's ED on 05/17/2024 with his/her spouse and had massive, increasing swelling on the left side of his/her neck. Patient #1 had an endarterectomy performed at Hospital B on 05/09/2024. ED Physician #1 stated that the ED was "super busy " and when he/she went in to see Patient #1 and telephoned the on call Vascular Surgeon #1 to express his/her concerns. ED Physician #1 states "I had never seen (swelling) that massive, pulsating ...I 've worked ED in several hospitals". ED Physician #1 stated that on call Vascular Surgeon #1 called him/her back to tell him/her that he/she was sending down the in-house surgeon on call to assess Patient #1. I had spoken with him/her already 3 times and after we intubated, 1 more time and he/she (on call Vascular Surgeon #1) said the intern (this person is Surgical Resident #1) told him/her the patient was stable and I said "NO". ED Physician #1 states "10 minutes later, the intern (this person is Surgical Resident #1) said he/she (on call Vascular Surgeon #1) wanted the patient to be transferred to Hospital B. Lead Surveyor then asked ED Physician #1 why on call Vascular Surgeon #1 was asking for transfer and ED Physician #1 stated that on call Vascular Surgeon #1 felt his/her (Patient #1) surgery was done at Hospital B and he/she (Patient #1) was stable enough to go there. Lead Surveyor asked ED Physician #1 how he/she felt about the patient transfer and ED Physician #1 stated "I was uncomfortable with the transfer. I felt he/she was best served to go to OR (operating room) here ...was frustrating ...first time a physician on call did not come in".

During an in-person interview in the conference room on 07/10/2024 from 8:50 AM to 9:10 AM, Registered Nurse (RN) #1 stated that he/she was assigned to Patient #1 on 05/17/24 to 05/18/24. RN #1 reports that the swelling was continuing to grow and ED Physician #1 explained to the spouse and patient that they needed to put an airway in, patient nodded agreement and spouse verbalized agreement. Surgical Resident #1 was present and agreed with ED Physician #1 that the patient was "going to surgery". RN #1 states "then ED Physician #1 told me to get him/her ready, he/she is going to Hospital B". The Lead Surveyor asked who spoke with the spouse about the transfer consent and reports "me" ... and when asked why states "I' m not sure ...doctors made the decision ...then I got his/her meds (medications) ready to go with him/her". RN #1 states that he/she got Patient #1 ready for transport, spoke with the receiving hospital nurse for report and Patient #1's spouse signed all consents but seemed to be concerned why it was "taking so long". RN #1 states that ED Physician #1 had inferred earlier that the patient would be going to surgery, so RN #1 had been getting him/her ready to go to the Operating Room (OR) before the change to transfer. RN #1 states "it was crazy that day".

During an in-person interview in the conference room on 07/10/2024 from 9:47 AM to 10:07 AM, Chief Visionary Officer (CVO) states that he/she was aware of the event within one week and an internal investigation was done. He/she spoke with on call Vascular Surgeon #1 practice partners who felt that on call Vascular Surgeon #1 was not comfortable with "open cases... would not be able to meet the level expected". CVO reports on call Vascular Surgeon #1 had been with the practice and with the hospital less than 1 year. CVO states that he/she spoke with on call Vascular Surgeon #1 and told him/her "not fitting what we need ...mutual agreement for us to part". CVO states that specialty on-call physicians are to be immediately available to see, evaluate and treat patients and are under obligation to come in (to the hospital) and "take care of it (the situation)". Lead surveyor asked if CVO felt there was any reason why on call Vascular Surgeon #1 wanted the patient transferred and states "I spoke with the Medical Director and partners ...something he/she was uncomfortable doing ...open procedures ... on call Vascular Surgeon #1 had transferred or not accepted another 3 patients within the past month". This surveyor asked if an internal audit/investigation was done and CVO stated that no meetings were done, just an internal investigation, all done within 1 week of the incident.

Surgical Resident #1 was interviewed in person on 07/10/24 from 3:03 PM to 3:16 PM. Surgical Resident #1 states on the night Patient #1 was in the ED there was "a lot of trauma going on" and the "Operating Rooms (OR) were already up and running." Surgical Resident #1 states on call Vascular Surgeon #1 was at home and called him/her and asked him/her to see Patient #1. Surgical Resident #1 saw Patient #1 and ED Physician #1 had "already administered medication to intubate." Surgical Resident #1 states Patient #1 had a "pulsatile expanding hematoma" and he/she agreed with the intubation" to secure an open airway and he/she "agreed with ED Physician #1's concerns." Surgical Resident #1 states he/she thought Patient #1 should go to the OR and he/she alerted the OR of the patient. Surgical Resident #1 states he/she called on call Vascular Surgeon #1 and on call Vascular Surgeon #1 "wanted to see the CTA (Computed Tomography)" which he/she states they could normally view remotely but on call Vascular Surgeon #1 "couldn't open it or the Hospital B record". On call Vascular Surgeon #1 asked Surgical Resident #1 about Patient #1's vital signs which were stable. Surgical Resident #1 states, "So, technically hemodynamically stable." Surgical Resident #1 states on call Vascular Surgeon #1 called back again and said Patient #1 "...needs to go back to Hospital B." Surgical Resident #1 states he/she talked with the patient's family member and explained the reason for the transfer stating, "...because we don't know exactly what Hospital B had done...they did his/her surgery and are the most familiar with what they did." Surgical Resident #1 states the family member said, 'Ok." When asked by the Lead Surveyor if there are other considerations in a case that is progressing in determining if a patient is stable for transport besides being hemodynamically stable, Surgical Resident #1 states, "l do agree it was a progressive process and needed to be dealt with immediately."

Medical Staff Bylaws

Review of Acute Care Medical Staff Bylaws on 07/08/24 shows that "2.B. ACTIVE STAFF ...2.B.3. Responsibilities: (b) providing on-call coverage for the Emergency Department for unassigned patients and accepting referrals from the Emergency Department for follow-up care of patients without regard to financial status for the initial visit, arranging for ambulatory office follow-up, as appropriate, for any emergency center patient they consult on either via phone or in person".

EMTALA Policy

Review of EMTALA Policy on 07/08/24 shows that "PROCEDURE, 5, 5.5, "Where, in the opinion of a Qualified Medical person or physician, the patient ' s condition requires Stabilizing Treatment or further evaluation by another physician available through the on-call list, the patient will be seen by an on-call physician who will assume responsibility for the further care and treatment of the patient".

On-call schedule

A review of the Vascular Surgery on-call schedule for May 17 - 18, 2024, revealed the hospital had a Vascular Surgeon available to provide evaluations and stabilizing treatment. The hospital on-call schedule revealed Vascular Surgeon #1 was listed as the available physician.