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Based on interview and record review, Hospital A (Medical Center of Arlington) failed to enforce its policy to ensure compliance with 489.24 (j) (1) and 489.24 (d) (1) (i)stabilizing treatment. The ED (emergency department) physician on-call schedule did not accurately reflect the urologist who was on call for 4 of 4 schedules on 01/17/16, 01/18/16, 01/19/16 and 01/21/16. Patient #1 was seen in the ED on 1/18/16 for right testicular pain and Patient #1 wasn't stabilized before being transferred to Hospital B. He was not seen by a urologist on-call.

Cross refer to A2404 and A2407

Based on interviews and record reviews the hospital failed to ensure the hospital's ED on-call schedule accurately indicated which physician was on call for urology on 4 of 4 on-call schedules that were reviewed (01/17/16, 01/18/16, 01/19/16, and 01/21/16). Patient #1 was seen in the ED (Emergency Department) on 01/18/16 for right testicular pain.

Findings included:

Patient #1's medical record face sheet at Hospital A indicated that he was 12 years old and seen in the ED on 1/18/16 for right testicular pain. The ED Physician's notes dated 1/18/16 at 4:45 PM included that he had improved with mild relief and was transferred to Hospital B in stable condition for pediatric care.

A review of the ED physician on-call schedule for the dates of 01/17/16, 01/18/16, 01/19/16, and 01/21/16 revealed the name of the physician for urology coverage was documented with only the physician's last name and first name initial along with his office telephone number.

During an interview on 01/21/16 at 12:30 PM with Personnel #8 she said there were 2 urologists (father and son) who were partners that took call for the ED department. They had the same first and last name but their middle names were different. The surveyor asked which urologist was on call on 01/18/16. She said she thought it was Physician #15 because his name was documented in Patient #1's medical record. The surveyor asked how staff knew which physician to call for urology because the on-call sheet dated 01/18/16 listed only the last name with a first initial. She said a call would be placed to the physician's office. The urologists decided between themselves which one would be on call. The physician taking call would respond to the ED's phone call. Personnel #8 confirmed the ED physician on-call schedules for the dates of 01/17/16, 01/19/16, and 01/21/16 reflected the same information.

During a telephone interview on 01/21/16 at 3:00 PM with Physician #11 he was asked by the surveyor who was the consulting urologist for Patient #1 on 01/18/16. Physician #11 thought he was speaking to Physician #15. When he was informed it was Physician #12 he said they both sound a lot alike on the phone.

During a telephone interview on 01/21/16 at 3:30 PM with Physician #12 he indicated that he was the consulting physician for Patient #1 on 01/18/16.

The hospital's "EMTALA- Texas Provision of ON-CALL COVERAGE POLICY" with a revision date of 7/2013 indicated on page 2, "...The facility's governing board must assure that the medical staff is responsible for developing an on-call rotation schedule that includes the name and direct pager or telephone number of each physician who is required to fulfill on-call duties. Physician group names are not acceptable for identifying the on-call physician. Individual physician names with accurate contact information, including a telephone number where the physician can be reached are to be put on the on-call list..."

Based on interview and record review Hospital A failed to provide stabilizing treatment to: 1 of 1 (Patient #1) patient. Patient #1 presented to the hospital's ED on 01/18/16 for right testicular discomfort. Patient #1 was diagnosed with right testicular torsion. Patient #1 was not seen by the urologist on-call before he was transferred and his medical condition was not stabilized. The patient was transferred to Hospital B where he was treated and discharged.

Findings included:

A review of Patient #1's Hospital A medical record revealed:
On 01/18/16 at 3:23 PM Patient #1 arrived at the hospital's ED via a car accompanied by his mother for right testicular discomfort per the patient's face sheet.

ED Nurse's Notes dated 01/18/16:
At 3:23 PM Patient #1 arrived in the ED, was registered, and then had a nursing Rapid Initial Assessment at 3:30 PM. Patient #1 indicated he had right testicular pain and swelling that began on 01/16/16 at 8:00 AM. Patient #1's right testicle did not appear to be reddened. Patient #1 was 5 ft. 8 inches tall and weighed 226 lbs. His temperature was 99.8 F. (normal 97.8-99.0 F.), blood pressure was 132/69 (normal 120/80), pulse was 110 (normal 60-100) and his respirations were 17 (normal 12-20).

At 4:42 PM Patient #1 received a detailed nursing assessment. Patient #1 indicated his right testicular pain began 2 days ago and it had been a constant aching pain. On a pain scale of 0-10 with 0 being no pain and 10 being extreme pain Patient #1 indicated his pain level was at a 3.

At 5:17 PM EMS (Emergency Medical Service) arrived to transfer Patient #1 to Hospital B's ED.

ED Physician Notes dated 01/18/16. Physician #11:
At 3:23 PM: Patient #1 complained of right moderate scrotal pain. The onset of scrotal pain and swelling was spontaneous and began 2 days ago. Patient #1's pain was exacerbated by movement and unrelieved by Tylenol. He denied dysuria. Patient #1 generally appeared well and was smiling. Patient #1's right testicle was tender, red, with no cremasteric reflex noted. An attempt was made to detorse the right scrotum using the open book technique. The attempt was unsuccessful due to the hardening of the right testicle.

At 3:30 PM: A portable ultrasound of the right testicle was conducted and indicated a right testicular torsion

At 3:58 PM: Physician #15 (as indicated in the medical record) was consulted by phone. Physician #15 indicated he would come and see the patient. He agreed with Physician #11's evaluation and plan. Physician #15 would take patient to the operating room the next day.

At 4:45 PM: Patient #1 had improved with mild relief. Patient #1 was stable for transfer. " ...Pt was diagnosed with torsion during my initial clinical examination. I immediately called the US [ultrasound] tech to come into the room to confirm diagnosis. No blood flow was noted on US. I attempted to detorse the testicle using the open-book method. The scrotum appears to be hardened. There is significant thickening of the scrotum wall on US. I suspected that the right testicle may no longer be viable. [Physician #15], the oncall urologist was called. After discussing case, he instructed me to admit pt to hospitalist service for orchiectomy. He is not able to perform this procedure immediately since he is in the OR with other cases. I contacted our hospitalist service, they informed me that pediatric pts can not be admitted to our hospital even though pt was > 100 kg. Discussed case with [Physician #15] again, he instructed me to transfer pt to [Hospital B]. Discussed case with [Hospital B's] Urology service. They did not feel that it was in the best interest of pt to be transferred to [Hospital B] given that we have a urology service here in our hospital. I gave contact information for both urologist [Hospital A's Physician #12 and #15] so they can discuss case and figure out the best way to take pt to OR as soon as possible. [Hospital B's] urologist called me back and was willing to accept pt. Discussed case with mom and transferred pt to [Hospital B] ..."

Transfer request call: 1645
Call returned at: 1645. Spoke with attending physician and transfer was accepted.
Transfer reason: pediatric care. Patient was stable for transfer.
ED Disposition: Patient #1 was transferred to [Hospital B].

Patient #1's blood chemistry results dated 01/18/16 were normal (at Hospital A).

Patient #1's right scrotal ultrasound findings (at Hospital A) dated 01/18/16 indicated the patient's right testis had a diffusely abnormal echotexture and parenchymal hypo-echogenicity. There was no blood flow detected and there was marked scrotal wall thickening. The left testis was normal. Impression: Rt. Testicular torsion.

Review of the ED medical record for Patient #1 at Hospital B dated 01/18/16 reflected:
History of Present Illness: Patient #1 presented to the ED on 01/18/16. Patient #1's vital signs were taken at 6:02 PM. A history and physical was done at 6:16 PM. Patient #1 was a 12-year-old male with a history of autism who presented with onset of right testicular pain on 01/16/16. Patient #1 tried taking some pain medicine at home without resolution of pain. The patient reportedly noticed some swelling on 01/17/16 but didn't inform his mother. The patient's mother noticed Patient #1 was "walking funny today and looked and noticed significant swelling." Patient #1 continued to have significant pain. The patient was taken to Hospital A where he was evaluated and was transferred for a concern of testicular torsion to Hospital B.

The outside hospital (Hospital A) evaluation, laboratory evaluation and ultrasound of Patient #1's testicles were reviewed by Hospital B. Physician #18 with urology at Hospital B was consulted immediately and evaluated Patient #1 in the ED. The plan was to take Patient #1 to the operating room for exploration of the right testicle.

Hospital B Discharge: 01/18/16 at 6:24 PM.
Diagnosis: Torsion of the right testicle.
Disposition: Patient #1 was discharged from the ED to surgery for exploration of his right testicle.

During a telephone interview with Physician #18 at Hospital B on 01/21/16 at 9:27 AM he said no one knows the time of salvageability of a testicle from the time of the testicular torsion until the time of the incision of the scrotum. Studies that have been completed indicate salvageability can range from 4-12 hours after the onset of the testicular torsion. Considerations have to be made on whether the testicular torsion had been constant or intermittent and the degree of the torsion. Nobody really had the answer. That's why it's an emergency. After the patient's arrival to Hospital B's ED, Patient #1 was immediately taken to surgery. The patient's right testicle was torsed and Physician #18 was unable to salvage the testicle.

During an interview on 01/21/16 at 12:30 PM with Personnel #8 at Hospital A she said Physician #15 offered to come and see Patient #1 when he was finished with his procedure and indicated he would take Patient #1 to surgery. She thought Physician #15 was doing a procedure in surgery but wasn't certain.

There were 2 urologists that were available for ED consults. They were father and son partners, Physician #15 and Physician #12. Their first and last names were the same, but their middle name was different.

When the surveyor asked which urologist was on call at Hospital A on 01/18/16 ED Personnel #8 said she thought it was Physician #15 because his name was documented in Patient #1's medical record.

No patients were admitted to Hospital A who were younger than 18. The ED accepted all ages. If a pediatric patient needed an admission to a hospital they were transferred to a hospital that provided pediatric services.

During an interview on 01/21/16 at 1:00 PM with Personnel #2 at Hospital A, she said the hospital did not accept the admissions of patients who were under the age of 18. Nurses were not prepared with competencies to take care of pediatric patients. The physician hospitalist's malpractice insurance didn't cover treatment of pediatric patients.

During an interview with Personnel #4 of Hospital A on 01/21/16 at 2:30 PM he said the hospital did not admit pediatric patients. The malpractice insurance didn't cover any patient under the age of 18. Patient #1 was not admitted because he was 12-years-old. The hospital did not have the capability to provide treatment and care for pediatric patients except in the ED. The pediatricians who were on staff, were for the women's center only.

During a telephone interview on 01/21/16 at 3:00 PM with Physician #11 (Hospital A) he was asked by the surveyor who was the consulting urologist for Patient #1. He said he thought it was Physician #15. When he was informed it was Physician #12 he said they sound a lot alike on the phone.

He said Patient #1 was diagnosed with testicular torsion soon after his admission to the ED. Patient #1 indicated his pain had been constant for 2 days. Two sonograms of the patient's testicles indicated there was a right testicular torsion and there was no blood flow to Patient #1's right testicle. Physician #11 said he attempted to detorse the testicle but was unable to in that the testicle was hardened. He called Physician #12 who told him he was doing a procedure and couldn't come right away but would come and see the patient when he was finished. Physician #12 said to admit Patient #1 and he would do his surgery in the morning.

Physician #11 spoke to Physician #14 regarding Patient #1's admission and Physician #14 said the hospital could not admit patients under the age of 18. Physician #11 then called Physician #12 and informed him the patient could not be admitted due to his age. Physician #12 instructed Physician #11 to transfer Patient #1 to Hospital B. The situation was discussed with Patient #1's mother and she requested that Patient #1 be transferred to Hospital B.

A call was placed to the transfer center to have Patient #1 transferred to Hospital B. Physician #11 received a phone call from Hospital B's urologist Physician #18. He told Physician #11 that the transfer was inappropriate because Hospital A provided urology services. Physician #11 informed Physician #18 about "all avenues." Physician #18 was given both of Hospital A's urologist's phone numbers and was told they could discuss the case and decide what was best for the patient. Physician #18 said if the patient was transferred to him and there was no blood flow to the testicle he was going to report Physician #11.

Physician #18 called Physician #11 after speaking with Physician #12 and said he would accept Patient #1's transfer.

During an interview with Physician #13 at Hospital A on 01/21/16 at 3:15 PM he said Physician #18 from Hospital B called him on the afternoon of 01/18/16 to discuss Patient #1's case. Physician #13 said at first he thought he was a physician on staff at Hospital A. Physician #13 was asked if he was comfortable with providing anesthesia for Patient #1 after he was given some facts about the case. Physician #13 said he had not seen the patient but he probably would be comfortable with providing anesthesia to Patient #1. He couldn't speak for any of the staff who would be caring for Patient #1 in that they don't provide pediatric services at the hospital. Personnel #4 was called and he confirmed Hospital A did not admit pediatric patients.

During a telephone interview on 01/21/16 at 3:30 PM with Physician #12 at Hospital A he said he was on call for the ED on 01/18/16, and not Physician #15. When he received a call from the ED on 01/18/16 regarding Patient #1 he was in the hospital's ICU (intensive care unit) inserting a suprapubic catheter and irrigating it. Physician
#11 explained the details of Patient #1's case. Physician 12's intentions were to finish up with the procedure and see Patient #1. Physician #12 said he intended to admit the patient and perform surgery on him that evening. Physician #12 said the patient had experienced constant testicular pain for almost 3 days and the testicle was way beyond saving at that point. He planned to take him to surgery to explore the right testicle and to save the left testicle in that many times the other testicle will also torse. Physician #12 was at the hospital and would have done the surgery "right then and there." The surveyor asked how many hours had to pass from the onset of a testicular torsion to the point that the testicle was no longer salvageable. Physician #12 said it varied from 6-10 hours. Two of Patient #1's right testicle sonograms indicated there was no blood flow.

Physician #12 said he instructed Physician #11 to admit the patient to Hospital A for surgery. He received another call from Physician #11 informing him that Patient #1 couldn't be admitted to Hospital A in that he was 12-years-old and the hospitalist said their malpractice insurance wouldn't cover the care of anyone under 18-years-old. Physician #12 instructed him to transfer the patient.

Physician #12 received a phone call from Hospital B's urologist Physician #18 who informed him that he should take Patient #1 to surgery instead of transferring the patient. Physician #12 informed Physician #18 that he wouldn't put the hospital at risk for a non-acute emergency. He explained to Physician #18 the situation "several times." Physician #12 said he didn't perform procedures on pediatric patients at Hospital A. He always had to perform those surgeries elsewhere.

During a phone interview with Physician #14 at Hospital A on 01/25/16 at 10:15 AM he confirmed he told Physician #11 that Patient #1 couldn't be admitted to Hospital A in that the hospitalists didn't have privileges to treat patients under 18-years-old. Physician #14 along with the other physician hospitalists belonged to a group that provided hospitalist coverage to the hospital. Their malpractice insurance didn't allow them to admit anyone under 18-years-old or cross-cover anyone under 18-years-old.

During a phone interview with Hospital B's ED Physician #19 on 02/01/16 at 11:15 AM he said Patient #1 presented to the ED on 01/18/16 with right testicular pain. Physician #19 examined Patient #1 and reviewed his medical record from the Hospital A. Physician #18 was notified of the patient's arrival to the ED. Physician #18 quickly arrived to the ED and Patient #1 was taken to surgery. Physician #19 said the transfer "seemed appropriate."