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On the days of the EMTALA (Emergency Medical Treatment And Labor Act) investigation based on interviews, reviews of hospital policy and procedures, Medical Staff Bylaws, Rules and Regulations of the Medical Staff, Hospital physician on - call schedules, bed census reports, and Medical Staff roster, the hospital failed to secure the response of the hospital's designated on call Urologist when requested by the emergency department physician which delayed the patient's medical treatment, and resulted in an inappropriate transfer of the patient who presented in the hospital's emergency department for urological services which the hospital had the capability and capacity to treat for 1 of 21 patient records reviewed for care and services. (Patient 1)

The findings are:

Cross Reference to A 2404: On the days of the Emergency Medical Treatment and Labor Act (EMTALA) complaint investigation, based on reviews of emergency department patient records, emergency department policy and procedures, Medical Staff Bylaws, physician on call schedules, and medical staff rosters and interviews, the hospital failed to ensure the designated physician on call for urology responded and was available for stabilizing treatment for a patient who presented to the hospital's emergency department with an identified urological emergency medical urological condition (EMC) for stabilizing treatment for 1 of 21 patient records reviewed for care and services. (Patient 1)

Cross Reference to A 2409: On the days of the Emergency Medical Treatment and Labor Act (EMTALA) complaint investigation based on reviews of emergency department patient records, physician on call schedules, Rules and Regulations of the Medical Staff, bed census reports, emergency department policy and procedures and interviews, the hospital failed to provide medical treatment that was within its capacity that minimize the risks to the individual's health as evidenced by inappropriately transferring an individual, since presenting to the hospital (Coastal Carolina Hospital) offered Urology services and had the capability and capacity to provide required services for 1 (Patient #1) of 21 sampled patients; The hospital also failed to document the name and address of the on-call physician who failed to appear within reasonable time provide necessary stabilizing treatment for 1 (Patient #1) of 21 sampled patients.

On the days of the Emergency Medical Treatment and Labor Act (EMTALA) complaint investigation, based on review of emergency department patient records, review of emergency department patient records, emergency department policy and procedures, physician on - call schedules, Medical Staff Bylaws, Medical Staff rosters, and interviews, the hospital failed to ensure the designated physician on call for urology responded and was available for stabilizing treatment for a patient who presented to the hospital's emergency department with an identified urological emergency medical condition (EMC) for stabilizing treatment for 1 of 21 patient records reviewed for care and services. (Patient 1)


The findings include:


Hospital policy, titled, EMTALA Policy ADM 14, 8/2004 and revised 1/2009, pg 8, reads, " E. Individuals Who Have An Emergency Medical Condition, 1. If, after, a medical screening examination, it is determined that an individual has an emergency medical condition, the Hospital shall: a. Within the capability and capacity of the staff and facilities available at the Hospital (including coverage available through the Hospital's on - call roster), provide treatment necessary to stabilize the individual, at which time the individual may be discharged; or b. admit the individual to the Hospital in order to stabilize the individual; ....".

Hospital policy, titled, EMTALA Policy ADM 14, 8/2004 and revised 1/2009, pg 9, reads, G. Physicians On - Call, 1. The Hospital shall maintain a list of physicians who are on - call for duty after the initial medical screening examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. 3. A determination as to whether an on - call physician must physically assess the individual in the emergency department is the decision of the treating emergency physician. 4. If a physician on the on- call list is called by the emergency department physician to provide emergency screening or treatment, the physician must respond within a reasonable time in accordance with the time established in the facility by - laws."

Hospital policy, titled, Medical Staff, Medicine & (and) Surgery, and all sub-specialties thereof, ER On-Call Guidelines, reads, "ER on-call physicians are: 1. Responsible for emergency room call pursuant to the hospital's policy on Screening, Stabilization, and Transfer of Individuals with Emergency Medical Conditions. 2. On - call for 24 hours: 7:00 a.m. - 7:00 a.m., unless otherwise noted. 4. Geographically located within one (1) hour of the hospital when scheduled to take call. 5. Responsible to respond by phone within thirty (30) minutes to a call from the Emergency Department Physician...If during that response call to the ED, the on-call physician is requested to come to the ED, he shall do so as soon as possible consistent with the request from the ED physician.... 6. Responsible for finding a suitable replacement if they cannot be available for duty and for notifying Medical Staff services at least 24 hours prior to the day of scheduled call coverage (excluding emergencies)."

On 1/27/2014 at 2:00 p.m., review of the hospital's Coastal Carolina Hospital Medical Staff Roster dated 1/27/2014 verified three (3) Active Urologists( Physicians who have specialized knowledge and skill regarding problems of the male and female urinary tract) are credentialed and privileged at the hospital. The hospital's Medical Staff Bylaws (revised 12/15/11) were reviewed. A review of Article 4. Categories of the Medical Staff specified in part "...(C) Members of the active Staff assume, the functions and responsibilities of (i) emergency room coverage as assigned by the appropriate Department Chair."

On 1/27/2014 at 2:15 p.m., review of Patient 1's emergency department record showed Patient 1 presented to the hospital's emergency department (ED) on 12/21/2013 at 9:10 p.m. with chief complaint of Hematuria(Blood in urine) since the a.m. and Urinary Retention(Inability to completely or partially empty the bladder), was triaged at 9:21 p.m. with a triage acuity level of 3. Review of emergency department nurse notes revealed the Emergency Department Physician 1 visited Patient #1 on 12/21/2013 at 9:27 p.m. and ordered a urinalysis, a complete blood count, Prothrombin, Partial Prothrombin, and a Foley catheter( flexible tube that is passed through the urethra and into the bladder). Medications included Pyridium(pain medication reliever that affects the lower part of the urinary - bladder), Dilaudid (pain medication), Zofran (medication used to prevent nausea and vomiting), and Clonidine(medication used to treat high blood pressure). On 12/21/2013 at 11:11 p. m., the nurse documented, "Attempted to place Foley catheter by 3 RNs (Registered Nurses) and MD (Medical Doctor). Unable to place catheter. Dr..... (Urologist 1 and on call on 12/21/2013) called for consult." On 12/22/2013 at 00:38 a.m., the nurse documented, "Dr....., ((Urologist 2) called at this time message left for return phone call)." There was no documentation in the patient's emergency department chart regarding the designated on call physician(Urologist 1) and/or the other Urologist 2's response (not on call) but notified according to the interview with Emergency Room Physician 1.

Review of Emergency Department Physician 1's notes dated 12/21/2013 at 9:21 p.m. showed, "Patient medically screened". Patient 1's vital signs were recorded and remarkable as:
9:22 p.m.: Blood Pressure (BP) 205/91, (Normal blood pressure values range from more than 90/60 and less than 120/80).
23:29 p.m.: BP 185/94,
12/22/13 at 00:05 a.m.: BP 208/101,
00:11 a.m.: BP 161/85, and
00:05 a.m.: BP 202/103

Review of nurse notes dated 12/22/2013 at 00:40 a.m., read, "transfer ordered by MD(Medical Doctor)" and at 01:03 a.m., reads ,"Transferred by EMS (Emergency Medical Services) ground."

Further review of Patient #1's emergency department record on 1/29/2014 at 12:00 p.m., revealed that there was no documentation of the on -call physician's response when the on - call physician failed to respond per the hospital's policy and procedure nor any documentation that the emergency department staff followed the hospital's policy to notify hospital administration when the on - call physician did not respond or refused to respond when contacted by emergency department staff.

Review of the hospital's on - call schedule dated 12/21/2013 at 07:00 a.m. - 12/22/2013 at 07:00 a.m., showed the hospital had a designated urologist scheduled for on-call for the hospital's emergency department on 12/21/2013. The Urologist on - call (Urologist 1) failed to respond to the emergency department's physician's request/notification for further evaluation for patient screening and/or stabilizing treatment for Patient #1 on 12/21/2013.

On 1/29/2014 at 11:00 a.m., a telephone interview was conducted with on -call Urologist 1 who verified that he/she was on - call for urology for the hospital's emergency department on 12/21/2013 at 07:00 a.m. to 12/22/13 at 07:00 a.m., but he/she had not responded to the emergency room's physician request for his/her services for a patient on this date 12/21/2013 - 12/22/2013 (Patient #1) because he/she was unaware that the emergency department physician had made a referral, and he/she had not responded on that date because he/she received a text message that was not seen until 5 hours later. Urologist 1 stated that he/she did not know there had been a call from the emergency department until then. Urologist 1 stated that no one from the hospital had ever addressed any issues related to call with him/her. The hospital failed to ensure that their policy and procedure was followed as evidenced by failing to ensure the Urologist responded to the ED physician's request to provide further emergency screening or treatment within a reasonable time in accordance with the time established in the facility by-laws for Patient #1 on 12/21/2013.

On 1/30/2014 at 12:25 p.m., an interview was conducted with Emergency Department Physician 1 who verified that he/she was on duty in the hospital's emergency department on 12/21/2013 to 12/22/2013 when he/she notified the Urologist (1) on-call for a patient who presented with hematuria and an inability to urinate. Emergency Department Physician 1 stated that he/she tried to get the Urologist (1) on-call and when the Urologist(1) on-call failed to respond, he/she(Emergency Department Physician 1) transferred the patient to another hospital. Emergency Department Physician 1 stated that he/she believed that was the only option after 4 unsuccessful attempts to catheterize the patient. Emergency Physician 1 stated that he/she did try to get another Urologist who was not on - call, but he/she was unsuccessful.

On 1/30/2014 at 11:05 a.m., the Chief Executive Officer(CEO) stated that an on - call physician's failure to respond to a request by an emergency department physician to see a patient was unacceptable and is a Medical Staff issue. The CEO reported that he/she was not aware of any issues with this physician (Urologist 1) in the past.

On the days of the Emergency Medical Treatment and Labor Act (EMTALA) complaint investigation based on review of emergency department patient records, physician on - call schedules, bed census reports, and emergency department policy and procedures, and interviews, the hospital failed to provide medical treatment that was within its capacity that minimizes the risks to the individual's health as evidenced by inappropriately transferring an individual, since the presenting hospital (Coastal Carolina Hospital) offered Urology services and had the capability and capacity to provide required services for 1 (Patient #1) of 21 sampled patients; The hospital also failed to document the name and address of the on-call physician who failed to appear within reasonable time to provide necessary stabilizing treatment for 1 (Patient #1) of 21 sampled patients.

The findings include:


Cross reference to 2404: The hospital failed to ensure that the designated on - call physician responded to a request to examine a patient who presented to hospital's emergency department with hematuria and urinary retention which necessitated a transfer to another hospital.

Review of hospital policy, titled, "EMTALA Policy ADM 14" (last reviewed 5/11) page 1, reads," ... Capacity encompasses such things as numbers and availability of qualified staff beds and equipment, as well as the Hospital's past practices of accommodating patients in excess of its occupancy limits ." ...page 8, reads, "... E...Individuals Who have An Emergency Medical Condition .... 1. If after a medical screening examination, it is determined that individual has an emergency medical condition, the hospital shall: a. Within the capability and capacity of the staff and facilities available at the Hospital (including coverage available through the Hospital on call roster) provide treatment necessary to stabilize the individual." ..pg 11, reads, "a. The Hospital shall, within its capability, provide medical treatment that minimizes the risk of the individual's health."
The Rules and Regulations of the Medical Staff (Revised 3/21/2013) were reviewed. The section, titled, "section 8. Transfer of patient from Hospital to other Facilities: ... (b) Patients shall be admitted for treatment of any and all conditions and diseases for which the hospital has facilities and personnel."

Hospital policy, titled, EMTALA Policy ADM 14, 8/2004 and revised 1/2009, pg 9, G. Physicians On - Call, reads, "If a physician refuses or fails to arrive within the required response time the chain of command should be initiated in an effort to obtain treatment for the emergency patient. If the individual is required to be transferred as a result of the on-call physician's failure to appear, the Hospital is required by EMTALA to document in the medical record the name and address of the physician who failed to appear....." .

Review of the hospital's on - call schedule dated 12/21/2013 at 07:00 a.m. - 12/22/2013 at 07:00 a.m., showed the hospital had a designated urologist scheduled for on-call for the hospital's emergency department on 12/21/2013.

The hospital's bed census report dated 12/21/2013 was reviewed. The bed census report revealed that 8 beds were vacant and available. On 12/21/2013, Coastal Carolina Hospital had capability and capacity to provide further evaluation and medical treatment for Patient #1. This resulted in an inappropriate transfer of Patient #1 on 12/21/2013.

On 1/29/2014 at 12:30 p.m., review of Patient #1's chart revealed the patient presented to the hospital with a chief complaint of Hematuria and urinary retention on 12/21/2013 at 21:05 p.m. and was transferred to another hospital for a higher level of care. Review of the hospital transfer form on the patient's chart revealed the inter facility transport drug report section was not authenticated by the emergency department physician, the patient's signature on the patient request to transfer section was blank, the explanation of risk section was blank, the transfer requirements section was blank, and the updated patient condition status section had no date and time with the signature. Review of the hospital's transfer form for Patient 1 dated 12/22/2013 at 00:11 a.m. revealed the benefits of transfer were listed as (A) Diagnostic tests/procedures/treatments indicated are not available and (B) Physician specialties needed are not available. (Specialty not available (is written in as Urology). Patient 1's transfer form had no explanation of risks section completed and many other sections of the form were not completed or incomplete. The hospital failed to ensure that their policy and procedure was followed as evidenced by Patient #1's medical record lacked documentation of the name and address of the on-call physician that failed to appear.

On 1/30/2014 at 11:05 a.m., the Chief Executive Officer(CEO) stated that an on - call physician's failure to respond to a request by an emergency department physician to see a patient was unacceptable and is a Medical Staff issue. The CEO reported that this was bad for the patient and we (hospital) don't transfer patients unless we have too. The hospital failed to ensure that the Rules and Regulations of the Medical Staff were followed as evidenced by failing to ensure that on 12/21/2013 that the patient was admitted and treated for his urological emergency medical condition which the hospital had capacity and personnel.