HospitalInspections.org

1. Based on medical records reviews, On Call logs, Hospital License list of services, Policies and Procedures, and Medical Staff Rules and Regulations and Physician interviews, the facility failed to maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/ or treatment necessary to stabilize individuals with an emergency medical condition; and failed to implement procedures to respond to situations in which the Obstetrics Trauma specialty is not available or when the on-call physician cannot respond for 3 out of 20 sampled patients (SP #10, #12, #18). (Refer to findings in Tag A-2404).

2. Based on medical records reviews, Hospital License list of services, medical staff privileges, Active Medical Staff (Gynecology) GYN Roster, On-Call logs, policies and procedures, and physician's interviews, the facility failed to ensure that the on-call physician provided further medical examination and treatment as required to stabilize the medical condition for 3 of 20 sampled patients (SP #10, #12, #18) within the capabilities of the staff and facilities available at the hospital. (Refer to finding in Tag A-2407)

Based on medical records reviews, On Call logs, Hospital License list of services, Policies and Procedures, and Medical Staff Rules and Regulations and Physician interviews, the facility failed to maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/ or treatment necessary to stabilize individuals with an emergency medical condition; and failed to implement procedures to respond to situations in which the Obstetrics Trauma specialty is not available or when the on-call physician cannot respond for 3 out of 20 sampled patients (SP #10, #12, #18).

Findings include:

1. The facility self- reported uninsured sample patient (SP) #10.

Review of sample patient (SP) #10 Emergency Provider Report dated 4/24/18 revealed that she presented to Emergency Department (ED) via ambulance with sudden lower abdominal pain. The ED physician listed the patient's Chief complaint as abdominal pain, Nausea and pelvic pain. Documentation by the ED physician revealed the patient reported that earlier today she felt pressure in her left lower abdominal quadrant, and then just prior to arrival she awoke with sudden severe intense abdominal pain with nausea and weakness. The patient arrived in the ED in moderate distress in moderate pain and hypotensive. She was noted to be hypotensive with blood pressure of 90/60. SP #10 was evaluated by the Emergency Department Physician and showed on physical examination of the abdomen revealed diffuse tenderness on palpation to the abdomen, no rebound or guarding. The patient had no bleeding or discharge noted. The patient was provided with intravenous fluids, oxygen, monitoring, medications for pain, and intravenous broad spectrum, antibiotics were administered. Diagnostics tests were performed and resulted. Results of the transvaginal and pelvic ultrasound showed differential diagnosis of ruptured hemorrhagic cysts versus torsion. (Twisting of the ovary due to the influence of another condition or disease. This results in extreme lower abdominal pain. Ovarian torso is a medical emergency. If not treated quickly, it can result in loss of ovary.) The Computed Tomography (CT) scan of the abdomen showed in the pelvis characteristic of blood products or infection. Differential finding include ruptured hemorrhagic ovarian cyst. Physician D (Trauma Obstetrics on-call) OB Trauma surgeon was called by the ED Physician , and he responded right away and reported that he is on call for trauma obstetrics only. Another physician was called Physician E (OB/GYN not on-call) and responded to the call right away however was unavailable to assist with the care of the patient. A receiving facility was contacted and the accepting physician at the receiving the facility agreed to accept the transfer.

Reviewed SP#10 vital signs on the Emergency Patient Record showed that the vital signs was monitored and the blood pressure improved 99/57, 112/68, and 107/63. Pt pain intensity is 0 at the time of the transfer.

Record review of the Emergency Provider Report for sample patient (SP) #10 revealed on 04/24/2018 the OB/GYN (OB Trauma on-call physician D) was called at 4:21 AM on 04/25/2018 stated he is currently in a procedure, and unavailable to assist.

Review of the hospital's April 2018 Trauma OB log revealed that Physician D was on call for Trauma OB on 4/24/2018 when SP#10 presented to the ED. The facility failed to ensure that it met the needs of the hospital patients who are receiving services available, to include the OB on-call for Trauma services for SP #10 when she presented to the ED on 4/24/2018.

Record review of SP #10 " Memorandum of Transfer (MOT)" - on 04/24/2018 reads: Emergency Medical Condition (EMC) identified: I. Medical condition: Diagnosis Ovarian torsion. b. Unstable Patient Request for Transfer: The patient has been examined and an EMC has been identified and the patient is not stable. The hospital has the capability and capacity to provide the care needed but the patient has specifically requested to be transferred to another facility after being notified that the hospital can and is willing to provide the care needed to stabilize and treat the EMC. The RISKS AND BENEFITS FOR TRANSFER: Obtain level of care/ service unavailable at this facility. Service: Gynecology. Reason for transfer: Specialist not available, Service not offered. Services required for transfer: Gynecology. The portion of the form for consent for request for transfer was not completed by the patient.

Review of the ED provider notes from the receiving hospital showed on 04/24/2018 at 7:30 AM the OB/GYN physician saw the patient (SP#10) at bedside, will admit and take the patient to surgery. At 7:40 am the physician noted that SP #10 present with acute onset abdominal pain at 11:00 PM last night. Was initially evaluated at Aventura Hospital and Medical Center (transferring hospital) and noted to have a hemoperitoneum consistent with a possible ruptured hemorrhagic cyst. She was transferred to the receiving hospital as there is no GYN available to care for the patient at transferring hospital. The Op (operative) notes showed SP #10 had a pre-op diagnosis acute abdomen. Hemoperitoneum (is the presence of blood in the peritoneal cavity. The blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs.) Right ruptured ovarian cyst. Post-Op diagnosis same. Bilateral cysts. Sample patient #10 had evacuation of 650 cc hemoperitoneum.


2. SP#12 Medical Record Review

Review of SP#12 medical record Emergency Provider Report dated 06/05/2018 revealed that the patient who is uninsured presented to the ED with abdominal pain, nausea and mild vomiting. Pt. was seen and evaluated by an Advanced Registered Nurse Practitioner, and documentation showed a right lower quadrant severe tenderness for the past days 2 with involuntary guarding. Documentation also revealed the patient reported that the pain had worsened overnight, had chills but no fever, and pain was a 10/10 (worst pain on a scale of 1-10), non- radiating, and pain was aggravated by palpating the areas and nothing relieved the pain. SP#12's initial VS were: Blood Pressure: 138/76, Pulse -93, Respirations-20, Oxygen saturation -100% on room air. Diagnostic tests were performed which showed on pelvic ultrasound and CT scan of the abdomen and pelvis a complex structure in the right hemipelvis consistent with cysts. Pt was medicated for pain (Morphine Sulfate IV x2), vital signs were stable and disposition to transfer to another facility for surgical intervention. Pt. Primary Clinical Impression is Dermoid cyst of right ovary, Secondary Impression: Intractable pelvic pain. Pt disposition for transfer to possible OR intervention to a sister facility of the hospital for GYN services. There was no evidence that pt. was evaluated by a gynecologist at the ED prior to transfer.

Review of the hospital's April 2018 Trauma OB log revealed that Physician D was on call for Trauma OB on 6/05/2018 when SP#12 presented to the ED. The facility failed to ensure that it met the needs of the hospital patients who are receiving services available, to include the OB on-call for Trauma services for SP #12 when she presented to the ED on 6/05/2018.


Review of SP#12 MOT form revealed that physician certification for pt. to transfer to a receiving facility with the name of an accepting physician noted. Pt is stable for transfer and the medical benefit of the transfer is for pt. to obtain Gynecology service that is not available at the facility. Risk and benefits reviewed, appropriate transportation and documents were provided on transfer.


3. SP #18 Medical Record

Review of SP#18 medical record Emergency Provider Report revealed that she is uninsured patient who presented to the ED on 7.7.2018 at 3:41 with a chief complaint of left lower quadrant abdominal pain, which stated today. Pt was seen and evaluated by a Physician's Assistant (PA) and noted that there is left lower quadrant and suprapubic tenderness. The pelvic examination revealed "Right Adnexal Tenderness". Other body systems exam are unremarkable. The patient's initial VS in the ED were B/P 186/106, Pulse- 79; Respirations- 16 oxygen saturation 98% on room air. SP #12 was provided Medications for pain and nausea, and intravenous fluids while in the ED. Diagnostic laboratory tests were performed and it is noted on the pelvic ultrasound and transvaginal ultrasound reports completed on 7/7/2018, revealed in part, "Impression: 1. Lack of color Doppler flow with the right Ovary which was concerning for right ovarian torsion; ...2. Complex right ovarian cysts ...3. Mild pelvic fluid. The case was then discussed telephonically with the diagnostic Radiologist, who is a part of the patient care team and his her impression of the findings were consistent with right ovarian torsion; and that there was no arterial or venous blood flow was demonstrated." Further review of the record revealed in part, "The medical screening examination was incomplete. Further evaluation and/or treatment is required." Physician D (on-call OB Trauma Physician) was called on 7/7/2018 at 6:55 p.m., by the PA and he (Ob Trauma on-call Physician) promptly returned the call at 6:55 p.m. Physician D recommended to transfer SP#18 to a facility with GYN service, and that he was not available since he is heading to deliver at another facility at this time. Documentation by the PA revealed that SP#18 disposition is to transfer to another facility with the Impression is Right Ovarian Torsion. There was no evidence in the medical record to indicate that SP#18 was evaluated by a gynecologist at the ED prior to transfer.

Review of SP#18 the Memorandum of Transfer (MOT) form showed a physician certification for transfer to a receiving facility with the accepting physician. The medical benefits of the transfer is for pt. to obtain GYN service which is not available at the facility. Pt was stable for transfer for transfer and appropriate transportation and documents were provided on transfer.



Review of the facility's license effective date 11/5/2017 revealed list of services that the facility provide which include but not limited to: Dedicated Emergency Department Level 2 trauma Center Emergency Services, Emergency Medicine, and Gynecology.


On- Call Logs

Review of the On Call log titled "CentralLogic" for July 2018 revealed that there is an On Call for every service line listed on the facility license list of services except for Gynecology. There is no On Call log for Gynecology. It is noted that there is an On Call log for Trauma OB. It is also noted during review of the On-Call log that on 7/7/2018 Physician D was the assigned physician on-call for Trauma OB. The facility failed to ensure that it met the needs of the hospital patients who are receiving services available, to include the OB on-call for Trauma services for SP #18 when she presented to the ED on 7/7/2018.


Interviews

Interview on 11/14/18 at 12:36 pm of the Emergency Department (ED) Medical Director who stated that all patients. that presents to ED are seen and evaluated by a qualified medical practitioner and treated. On a gynecology (GYN) case on presentation at ED, there is no specific GYN On - Call but only a Trauma Obstetrics (OB) On Call.

Interview on 11/14/18 at 1:14 PM with the Chief of Surgery who stated that he oversees the GYN department. He said that there are gynecologic surgeons mostly doing gynecologic oncology, and no (Obstetrics) OB service line. There is no On Call gynecologist.

Interview on 11/14/18 at 1:34 pm with the Chief Medical Officer (CMO) who stated that there is no currently On Call for GYN. In situation that a gynecologic patient presents to the ED with immediate threat for loss of life, the team here will be called to evaluate and intervene if it is emergent.

Policy and Procedure

Record review of Policy Description: EMTALA- Definitions and General Requirements, Effective Date February 1, 2016, Reference number LL.EM.001, page 14 of 18, reads On-Call Obligations 1. Each hospital that has a Medicare provider participation agreement (including both the transferring and receiving hospitals and specialty hospitals) is required to maintain a list of physician specialists who are available for additional evaluation and stabilizing treatment of individuals with EMCs (Emergency Medical Conditions). The facility did not follow their own guidelines as evidenced by failing to ensure that the OB trauma on call specialty provided further evaluation and treatment as required for SP #10, SP#12 and SP#18.

Medical Staff Rules and Regulations

Review of the Medical Staff Rules and Regulations approved Oct. 19, 2017, page 11 of 12 Section I. Hospital On-Call Service which showed that 1. Hospital administration will organize on-call services to meet hospital coverage needs for Emergency Services. The facility failed to follow their own Medical Staff Rules and Regulations by as evidenced by failure to provide on-call services to meet the gynecologic service needs at Emergency Services for SP #10, SP#12 and SP#18 when the presented to the ED seeking gynecological services.

Based on medical records reviews, Hospital License list of services, medical staff privileges, Active Medical Staff (Gynecology) GYN Roster, On-Call logs, policies and procedures, and physician's interviews, the facility failed to ensure that the on-call physician provided further medical examination and treatment as required to stabilize the medical condition for 3 of 20 sampled patients (SP #10, SP#12, SP#18) that was within the capabilities of the staff and facilities available at the hospital.


Based on medical records reviews, License list of services, medical staff privileges, Active Medical Staff (Gynecology) GYN Roster, On-Call logs, policies and procedures, and physician's interviews, the facility failed to ensure that an individual is provided further medical examination and treatment to stabilize the medical condition for 3 of 20 sampled patients (SP #10, SP #12, SP #18) within the capabilities of the staff and facilities.


Findings Include:

1. This the self -reported patient (SP #10).

Review sample patient (SP) #10 Emergency Provider Report dated 4/24/18 revealed that she presented to Emergency Department (ED) via ambulance with sudden lower abdominal pain. She was noted to be hypotensive with blood pressure of 90/60. SP #10 was evaluated by the qualified medical professional and showed on physical exam diffuse tenderness on palpation to the abdomen, no rebound or guarding. The patient had no bleeding or discharge noted. The patient was provided with intravenous fluids, oxygen, monitoring, medications for pain, intravenous fluid, antibiotics were administered. Diagnostics tests were performed and resulted. Results of the transvaginal and pelvic ultrasound showed differential diagnosis of ruptured hemorrhagic cysts versus torsion. The CT scan of the abdomen showed in the pelvis characteristic of blood products or infection. Differential finding include ruptured hemorrhagic ovarian cyst. Physician D (Obstetrics) OB Trauma surgeon was called and responded right away and reports that he is on call for trauma obstetrics only. Another physician was called Physician E and responded to the call right away however was unavailable to assist with the care of the patient. A receiving facility was contacted and the accepting physician agreed to accept the transfer.

Reviewed SP#10 vital signs on the Emergency Patient Record and showed that the vital signs was monitored and the blood pressure improved 99/57, 112/68, and 107/63. Pt pain intensity is 0 at the time of the transfer.

Record review of the Emergency Provider Report for sample patient (SP) #10 revealed on 04/24/2018 the OB/GYN (OB Trauma on-call physician D) was called at 4:21 AM on 04/25/2018 stated he is currently in a procedure - and unavailable to assist.

Review of the ED provider notes from the receiving hospital showed on 04/24/2018 at 7:30 AM the OB/GYN physician saw the patient (SP#10) at bedside, will admit and take the patient to surgery. At 7:40 am the physician noted that SP #10 present with acute onset abdominal pain at 11:00 PM last night. Was initially evaluated at (transferring hospital) and noted to have a hemoperitoneum consistent with a possible ruptured hemorrhagic cyst. She was transferred to the receiving hospital as there is no GYN available to care for the patient at transferring hospital. The Op (operative) notes showed SP #10 had a pre-op diagnosis acute abdomen. Hemoperitoneum (is the presence of blood in the peritoneal cavity. The blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs.) Right ruptured ovarian cyst. Post-Op diagnosis same. Bilateral cysts. Sample patient #10 had evacuation of 650 cc hemoperitoneum.

2. Review of SP#12 medical record Emergency Provider Report dated 06/05/2018 revealed that the patient who is uninsured presented to the ED with abdominal pain, nausea and mild vomiting. Pt. was seen and evaluated and showed a right lower quadrant severe tenderness with involuntary guarding. Diagnostic tests were performed which showed on pelvic ultrasound and CT scan of the abdomen and pelvis a complex structure in the right hemipelvis consistent with cysts. Pt was medicated for pain, vital signs were stable and disposition to transfer to another facility for surgical intervention. Pt. Primary Clinical Impression is Dermoid cyst of right ovary, Secondary Impression: Intractable pelvic pain. Pt disposition for transfer to possible OR intervention to a sister facility of the hospital for GYN services.



3. Review of SP#18 medical record Emergency Provider Report revealed that she is uninsured patient who presented to the ED with left lower quadrant abdominal pain. Pt was seen and evaluated and noted that there is left lower quadrant and suprapubic tenderness. Other body systems exam are unremarkable. Diagnostic tests were performed and it is noted on the pelvic ultrasound and transvaginal ultrasound a concern for right ovarian torsion. Medications for pain, intravenous fluid, and for nausea was provided at ED. Physician D was called and he recommends to transfer to facility with GYN service and he was not available since he is heading to deliver at another facility at this time. Disposition is to transfer to another facility with the Impression is Right Ovarian Torsion.



Review of the facility's license effective date 11/5/2017 revealed list of services that the facility provide which include but not limited to: Dedicated Emergency Department Level 2 trauma Center Emergency Services, Emergency Medicine, and Gynecology.

Review of the On Call log titled "CentralLogic" from April 2018 revealed that there is an on call for every service line listed on the facility license list of services except for Gynecology. There is no On Call log for Gynecology. It is noted that there is an On Call log for Trauma OB. It is noted on the review of the On-Call log that on April 23 to 24, 2018, Physician D is the assigned physician on-call for Trauma OB.

Interview on 11/14/18 at 12:36 pm of the ED Medical Director who stated that all patients (pt.) that presents to ED are seen and evaluated by a qualified medical practitioner and treated. On a GYN (Gynecology) case on presentation at ED, there is no specific GYN on call but only a trauma OB on call. GYN pt. presenting to ED, a complete MSE (Medical Screening Evaluation) is done, stabilize and treated, and if meets criteria for discharge, pt. can be discharged for outpatient follow up. If the pt. requires inpatient surgical, the Trauma OBGYN On Call are called and if available can take care of the pt. Otherwise if not available the pt. have to be transferred to a facility with the capability to take care of the pt. There is no GYN (gynecology) on call for ED only for trauma OB. The OB trauma On Call takes cases for blunt trauma or qualifies for trauma who is at the same time pregnant. The OB trauma On Call calls back and comes in if asked within 30 minutes. If there was a GYN case at ED that the ED doctor would require the expertise of a gynecologist, there is no On Call but would seek the assistance and expertise by calling the OB Trauma On Call and see if he is available. Most of the time he gets himself available however if he is not, then the pt. when stable has to be transferred to a receiving facility with the services for GYN.

Interview on 11/14/18 at 1:14 PM with the Chief of Surgery what stated that he oversees the GYN department. He said that there are gynecologic surgeons mostly doing gynecologic oncology, and no OB service line. There is no On Call gynecologist. He does not take part of developing the On Call list. On patients that presents with an acute abdomen with a question of sepsis or shock, diagnostics will be run and there are options to be taken by the ED practitioner. Call gynecologist on staff if available or trauma team can take care of it. Acute abdomen is condition that requires immediate intervention.
Abdominal pain presentation and once you identify a gynecologic problem, however if not immediate life threatening, the patient is not septic or in shock, an ED doctor can reach out to the gynecologist staff if available otherwise we can arrange for transfer to the sister facility or any facility which can provide the service

Medical Staff Roster
Review of the Active Medical Staff GYN Roster provided by the Quality Department Manager on 11/13/18 at 9:53 am revealed that there are 24 active medical staff with Obstetrics and Gynecology Specialty.


Gynecology Core Privileges

Review of the Privilege Application: Gynecology Core Privileges showed there were 15 active medical staff approved for GYNECOLOGY with privilege to perform the following: Admit, perform history and Physical Examination, evaluate, diagnose, consult, and pre, intra-and post-operative care necessary to correct or treat female patients of all ages presenting with illnesses, injuries and disorders of the gynecological or genitourinary system and non-surgically treat disorders and injuries of the mammary glands and operative laparoscopy; including treatment of endometriosis, ectopic pregnancy and benign ovarian neoplasm. The facility showed the service capability to examine, diagnose, evaluate, and treat the gynecologic conditions.

Policies and Procedures

Review of the Policy Titled: "EMTALA Medical Screening Examination and Stabilization", effective 10/2001, last revision 04/01/2018, revealed that EMTALA obligation is triggered when an individual or representative on the individual's behalf, including EMS or a transferring hospital requests emergency services and care. Further if a prudent layperson observer would believe that the individual experience an emergency medical condition (EMC), then an appropriate medical screening exam (MSE), within the capabilities of the hospital's DED (including ancillary services routinely available and the availability of on-call physicians), shall be performed. The facility failed to follow their own policy as evidenced by failing to ensure that further medical examination and treatment stabilizing treatment was provided as required to stabilize the emergency medical conditions or SP#10, SP#12, and SP#18, with identified emergency medical conditions. The hospital was equipped with such staff services and equipment necessary to stabilize SP#10, SP#12 and SP#18's emergency condition to include the services of the OB on-call trauma physician.


Record review of Policy Description: EMTALA- Definitions and General Requirements, Effective Date February 1, 2016, Reference number LL.EM.001, page 14 of 18, reads On-Call Obligations 1. Each hospital that has a Medicare provider participation agreement (including both the transferring and receiving hospitals and specialty hospitals) is required to maintain a list of physician specialists who are available for additional evaluation and stabilizing treatment of individuals with EMCs (Emergency Medical Conditions). The facility did not follow their own guidelines.