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Based on review of specialty physician on call documentation, policies/procedures, patient medical records, and staff interviews, the hospital failed to ensure that Practitioner #A followed hospital EMTALA policies and procedures to provide stabilizing treatment for a patient in an emergency medical condition within the hospital's capabilities. (Patient #1) The hospital identified an average of 1534 emergency room visits per month.

Failure to provide stabilizing treatment for a patient in an emergency medical condition within the hospital's capability could potentially delay the appropriate treatment for the patient.

Findings include:

1. Review of hospital policy titled "Transfer and Emergency Examination - EMTALA", dated reviewed/revised 6-26-07, revealed "Purpose: To establish a procedure for the examination, stabilization, and transfer of individuals coming to a Trinity Regional Health System (TRHS) emergency department (ED) where a request has been made for examination and treatment for a medical condition."

2. Patient #1 arrived at the hospital by ambulance at 10:40 PM on 2/12/10 with the chief complaint of syncopal episode - patient vomited and passed out in bathroom prior to arrival. Review of Patient #1's medical record revealed upon arrival to the emergency room, the patient's blood pressure documented as 94/66, pulse 87, 1000 cc Normal Saline IV (Intravenous) infusing wide open in right antecubital via 16 gauge catheter, skin cool and pale, lower abdomen tender to touch. The physician examined the patient, ordered and obtained x-rays, laboratory studies and CT scan which revealed blood in the patient's abdomen possibly from the spleen. The patient's blood pressures remained low in the 60s and 70s. The patient continued to complain of abdominal pain and the physician ordered Dopamine [medication given to increase a person's blood pressure]. The hospital paged Practitioner #A, on-call surgeon, at the request of Practitioner #B at 12:15 AM. After numerous pages, Practitioner #A responded by telephone at 1:05 AM. The patient received a total of 4 units of blood and a six pack of platelets upon an order from Practitioner #B. The patient's blood pressure remained in the 60s. Practitioner #A arrived at the hospital at 1:50 AM and failed to examine Patient #1 upon arrival at the hospital.

3. Review of Practitioner #A's privileges revealed privileges granted for 3/1/09 - 2/18/11 for general surgery including approved for "operation on spleen".

4. During an interview on 2/18/10 at 9:00 AM, Practitioner #B stated Patient #1 arrived to the emergency room and described the patient as diaphoretic, shivering, pale and complained of severe abdominal/low chest/high abdominal pain, with blood pressure in the 70s. The patient received intravenous fluids, blood and Dopamine as ordered. Practitioner #B ordered and obtained a CT scan of the patient's abdomen and the scan revealed blood in the patient's abdomen. Practitioner #B stated the hospital paged Practitioner #A, a surgeon, at 12:15 AM, 12:30 AM, 12:50 AM, and 1:00 AM to assist with managing the patient's condition. Practitioner #B stated Practitioner #A, responded by telephone at 1:05 AM. Practitioner #A, Surgeon, upon arrival to the hospital at 1:50 AM failed to examine Patient #1.

5. During an interview on 2/17/10 at 11:50 AM, Staff A stated Patient #1 presented to the emergency room via ambulance after passing out twice at home. Staff A stated shortly after arriving in the emergency room, the patient became more anxious, blood pressure dropped and was cold/clammy. Staff A stated Practitioner #A failed to examine Patient #1.

6. During an interview on 2/18/10 at 1:20 PM, Practitioner #A, Surgeon, acknowledged the lack of an examination of Patient #1 by Practitioner #A upon arrival at the hospital.

7. Review of documentation provided by the hospital revealed services provided by the hospital included a 10 bed critical care unit that provides comprehensive monitoring to critically ill adult patients including some surgical cases. Review of the Intensive Care Unit census on 2/12/10 at 10:00 PM revealed the patient census to be 8 patients.

8. Review of Patient #1's medical record revealed the patient, at time of transfer to another facility, required ambulance transport for hypotension and acute medical condition and receiving Dopamine drip and Blood products. The Transfer Record specified the patient required "Emergent Surgical Care". Patient #1 transferred from Hospital A on 2/13/10 at 3:20 AM to go to Hospital B.

9. Review of Hospital B's medical record for Patient #1, the patient arrived at Hospital B on 2/13/10 at 3:51 AM and taken to surgery emergently.

Based on review of specialty physician on call documentation, physician privileges, patient medical records, and staff interviews, the hospital failed to provide stabilizing treatment for a patient in an emergency medical condition within the hospital's capabilities. (Patient #1) The hospital identified an average of 1534 emergency room visits per month.

Failure to provide stabilizing treatment for a patient in an emergency medical condition within the hospital's capability could potentially delay the appropriate treatment for the patient.

Findings include:

1. Review of the list of on-call physicians for Trinity at Terrace Park revealed the hospital provided Surgery Services on call and identified Practitioner #A as the physician on call for Surgery on February 12 - 13, 2010.

2. Review of Practitioner #A's privileges revealed privileges granted for 3/1/09 - 2/18/11 for general surgery including approved for "operation on spleen".

3. Patient #1 arrived at the hospital by ambulance at 10:40 PM on 2/12/10 with the chief complaint of syncopal episode - patient vomited and passed out in bathroom prior to arrival. Review of Patient #1's medical record revealed upon arrival to the emergency room, the patient's blood pressure documented as 94/66, pulse 87, 1000 cc Normal Saline IV (Intravenous) infusing wide open in right antecubital via 16 gauge catheter, skin cool and pale, lower abdomen tender to touch.

4. Practitioner #B examined Patient #1 at 10:48 PM and documented on arrival to the emergency room, the patient's systolic blood pressure was in the 70's. X-rays, laboratory studies, CT scan ordered and obtained. At 00:10 radiology called Practitioner #B with results from the CT scan that the patient appeared to have hemoperitoneum and possibly a splenic source. The patient's blood pressures were in the 70s. Practitioner #B ordered blood immediately. The patient's systolic blood pressure continued in the 70s. The patient continued to complain of abdominal pain and Dopamine [medication given to increase a person's blood pressure] ordered and started. At this point, the patient had had about 3 liters of fluids. At 00:30 we increased the patient's dopamine to 15. Practitioner #A, Surgeon had been paged at 00:15, at 00:30 we were still waiting on Practitioner #A. At 00:45 Practitioner #B ordered uncrossed matched blood as the blood bank stated that it would be a while yet before they had cross matched blood. At 01:05 I discussed with Practitioner #A, who stated that he would come in and asked that we give platelets. The patient was on Plavix [medication to thin a person's blood]. At this point, 2 units of uncrossed blood were going. Blood pressure was in the 60s. We placed the patient's bed in a head down position and we increased the dopamine to 20, the 2 units were put on blood pumpers and his systolic blood pressure increased to the 100s.

5. Review of Patient #1's medical record revealed Practitioner #A paged at 12:10 AM and failed to respond until 1:05 AM. Review of documentation lacked evidence Practitioner #A examined Patient #1 upon Practitioner #A's arrival at the hospital.

6. During an interview on 2/18/10 at 9:00 AM, Practitioner #B stated Patient #1 arrived to the emergency room and described the patient as diaphoretic, shivering, pale and complained of severe abdominal/low chest/high abdominal pain, with blood pressure in the 70s. The patient received intravenous fluids, blood and Dopamine as ordered. Practitioner #B ordered and obtained a CT scan of the patient's abdomen and the scan revealed blood in the patient's abdomen. Practitioner #B stated we paged Practitioner #A, a surgeon, at 12:15 AM, 12:30 AM, 12:50 AM, and 1:00 AM to assist with managing the patient's condition. Practitioner #B stated Practitioner #A, responded by telephone at 1:05 AM. Practitioner #A, Surgeon, upon arrival to the hospital at 1:50 AM failed to examine Patient #1.

7. During an interview on 2/17/10 at 11:50 AM, Staff A stated Patient #1 presented to the emergency room via ambulance after passing out twice at home. Staff A stated shortly after arriving in the emergency room, the patient became more anxious, blood pressure dropped and was cold/clammy. Staff A stated Practitioner #A failed to examine Patient #1.

8. During an interview on 2/18/10 at 1:20 PM, Practitioner #A, Surgeon, acknowledged the lack of an examination of Patient #1 by Practitioner #A upon arrival at the hospital.

9. Review of documentation provided by the hospital revealed services provided by the hospital included a 10 bed critical care unit that provides comprehensive monitoring to critically ill adult patients including some surgical cases. Review of the Intensive Care Unit census on 2/12/10 at 10:00 PM revealed the patient census to be 8 patients.

10. Review of Patient #1's medical record revealed the patient, at time of transfer to another facility, required ambulance transport for hypotension and acute medical condition and receiving Dopamine drip and Blood products. The Transfer Record specified the patient required "Emergent Surgical Care". Patient #1 transferred from Hospital A on 2/13/10 at 3:20 AM to go to Hospital B.

11. Review of Hospital B's medical record for Patient #1, the patient arrived at Hospital B on 2/13/10 at 3:51 AM and taken to surgery emergently.