HospitalInspections.org

Based on review of the transferring and recipient hospital's medical record (#1), Medical Staff Bylaws / Rules and Regulations, Medical Staff policies and procedures, Emergency Department Service Agreement, credential files, Emergency Department policies and procedures, Emergency Department physician's schedule, on-call schedules, staff interviews, and physician's statement it was determined that the facility lacked an effective system to ensure that individuals from a referring hospital were accepted as an appropriate transfer who required the specialized capabilities or facilities if the receiving hospital had the capacity to treat the individual. This affected 1 of 23 sampled patients (#1). Refer to findings in tag A-2411.

Based on review of the transferring and recipient hospital's medical record (#1), Medical Staff Bylaws / Rules and Regulations, Medical Staff policies and procedures, Emergency Department (ED)Service Agreement, credential files, Emergency Department policies and procedures, Emergency Department physician's schedule, on-call schedules, staff interviews, and physician's statement, it was determined that the facility lacked an effective system to ensure that individuals from a referring hospital were accepted as an appropriate transfer who required the specialized capabilities or facilities if the receiving hospital had the capacity to treat the individual. This affected 1 of 23 sampled patients (#1). Refer to findings in tag A-2411.

Findings were:

Review of the patient's medical record (#1) from the transferring facility revealed the following information. The nurses' notes indicated that the patient arrived at the transferring facility on 03/28/11 at 2:35 a.m. The physician noted that the patient's left eye lid was swollen shut and that fluid consistent with bloody tears was leaking from the eye, and that "Tissue appears to be protruding". The physician ordered a computerized tomography (specialized x-ray) of the left eye which revealed the bones on the floor of the eyeball were broken. The physician noted that the patient had a left eye globe rupture (occurs when the integrity of the outer membranes of the eye has been disrupted by blunt or penetrating trauma). The physician also noted that his/her facility did not have an ophthalmologist (physician who specializes in the treatment of eyes) on-call. The physician noted that phone calls and pages were made to the physician on-call for ophthalmology (physician's statement #1) at Northside Hospital. The physician noted that after making multiple attempts to locate the ophthalmologist on-call, he/she contacted the ED physician (interviewee #7) at Northside Hospital, discussed the patient's case with the ED physician, explained that he/she had been unable to reach the on-call physician, and wanted to arrange an ED to ED transfer. The physician noted that the ED physician at Northside Hospital was concerned that he/she might not be able to reach Northside Hospital's on-call ophthalmologist either and "declined the transfer to Northside Hospital". The physician noted that the ophthalmologist he/she had tried to contact did call back some time later and explained that he/she was not the on-call ophthalmologist for Northside Hospital and was actually out of town at the time. The physician noted that he/she informed the ophthalmologist that he/she had actually checked the original on-call schedule for Northside Hospital and had contacted Northside Hospital's house coordinator who had also checked the master schedule at Northside Hospital.

The physician noted that Northside Hospital's house coordinator contacted the Chief of Services for ophthalmology (interviewee #8) and that he/she had spoken with the Chief of Services for ophthalmology several times but that the Chief of Services for ophthalmology also declined to accept the patient in transfer for himself /herself. The physician noted that he/she spoke with several ophthalmologist that worked at Northside Hospital and that there seemed to be some confusion as to who was on-call for that service. The physician noted that several ophthalmologist who he/she had spoken with by phone had informed him/her that the patient needed to be transferred immediately and would need surgery that day. The physician noted that the patient was accepted and transferred to another acute care facility (recipient hospital) . The transferring nurse noted that the patient left the facility on 03/28/11 at 8:15 a.m. The recipient hospital medical record for patient #1 was reviewed. Review of "Physician's Pre-Operative History and Physical" dated 3/28/11 revealed in part,"History of Present Illness: Pt (patient) fell early this am and on left orbit (eye) suffering instant loss of vision, (+) (positive of ) pain." Review of the recipient hospital's Operative Report, dated 3/28/11 indicated that patient #1 was taken to surgery for an Exploratory orbitotomy (a surgical incision made into the orbit) and repair of open globe(eye) involving uveal contents posterior rectus muscle and repair of left upper lid laceration.

Review of Northside Hospital's Medical Staff Bylaws, approved by the Medical Staff 04/20/11, approved by the Board of Directors 05/02/11, effective 06/20/11, revealed each staff member "shall" abide by the Medical Staff Bylaws and by all other lawful standards, policies and rules of the hospital or the staff, and participate in emergency service coverage. In addition, consulting Medical Staff were to serve on-call for emergency department coverage.

Review of Northside Hospital's Medical Staff policy and procedure, entitled "Coverage Arrangements", policy number MS - 008, effective 08/06/07, revealed all Medical Staff members were required to inform the Medial Staff Office if there was a change in the on-call coverage. The notification was to be made at least 48 hours in advance of the assigned on-call coverage responsibility. In addition, physicians were required to respond promptly when paged and "should be on-site within one (1) hour of an emergency call". This policy required on-call physicians to assist in identifying a back-up physician if they were unable to respond to call because the physician was tied up with another emergency or there were circumstances beyond the physician's control.
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Review of Northside Hospital's Emergency Department Service Agreement, effective 05/02/11, revealed that the ED physicians and mid-level providers were to comply with all applicable laws and regulations governing their respective licensing and conduct with the ethical standards of their profession, and with the applicable policies, procedures, rules and regulations of the hospital and hospitals' Medical staff, including but not limited to those policies, procedures, rules and regulations applicable to the provision of ED services and to those policies, procedures, rules and regulations equally applicable to all medical staff members.

Review of four (4) of four (4) credential files revealed all four (4) physicians had signed the above agreement. The Chief Nursing Officer (CNO) provided a copy of the EMTALA training packet that was sent out to physicians in 2010, but there was no documented evidence that the physicians had received and/or read the information.

Review of Northside Hospital's ED policies and procedures revealed all required EMTALA policies were present. These policies included facility policy entitled "Access to Emergency Medical Treatment", policy #F-013, effective 02/08/11, this policy indicated the facility would accept all requested transfers, unless the facility did not have the capacity to treat the patient at the time of the request. The policy required any request to transfer patients from other facilities to be referred to the House Coordinator, who would be responsible for determining, in consultation with the ED physician, on-call physician and/or Internal Medicine Service physician as appropriate, and Room Control, whether the facility had sufficient capacity to treat the patient at the time of the transfer request.

Review of the ED physicians' schedule revealed interviewee #1 was working in the ED on 03/27/11 from 7:00 p.m. until 03/28/11 at 7:00 a.m.

Review of the original on-call schedule for ophthalmology revealed interviewee #5 had originally been scheduled to be on-call for ophthalmology services on 03/28/11. However, review of a fax sent on 02/25/11 from the ophthalmology group's office revealed the physician (statement #1) was actually on-call on 03/27/11 from 8:00 a.m. until 03/28/11 8:00 a.m.

During a telephone interview on 09/22/11 at 12:05 p.m. in the conference room, interviewee #5 stated that the original ophthalmology on-call schedule did list him/her as the on-call physician but the office had changed the schedule and faxed a copy to the hospital. The physician added that on 03/27/11 he/she had been out of town.

During a telephone interview on 09/22/11 at 12:15 p.m. in the conference room, interviewee #6 stated that he/she had been the Overhouse Supervisor (OHS) /House Coordinator on 03/27/11 from 7:00 p.m. until 03/28/11 at 7:00 a.m. The OHS stated that he/she had received a call from the transferring facility wanting to confirm who was on-call for ophthalmology. The OHS stated there had been some confusion as to who had been on-call and that he/she had contacted the Chief of Services for ophthalmology and multiple calls to clarify who was on-call. The OHS stated he/she called the transferring facility later to accept the patient but had been told that the transferring facility was transferring the patient elsewhere.

During a telephone interview on 09/22/11 at 1:05 p.m. in the conference room, interviewee #7 stated that he/she had been the ED physician working on 03/27/11 from 7:00 p.m. until 03/28/11 at 7:00 a.m. The physician stated he/she received a call from the transferring physician who had told him/her that the on-call ophthalmologist (interviewee #5) had not responded when called. The physician explained that he/she had told the transferring physician that it was not a good idea to transfer the patient until they knew exactly who was on-call for ophthalmology. The physician stated that he/she contacted the OHS who would contact the Chief of Service for ophthalmology and confirm who was on-call for that specialty. The facility lacked an effective system to ensure that on 3/28/2011 when a request was made for patient #1 from a referring hospital was accepted as an appropriate transfer who required the specialized capability and capacity to treat the patient.

During a telephone interview on 09/22/11 at 1:20 p.m. in the conference room, interviewee #8 (Chief of Services for ophthalmology) stated that the original on-call schedule for ophthalmology had listed physician/interviewee #5 as being on-call but that the schedule had been changed and physician (statement #1) had actually been on-call at the time. The COS stated he/she had been contacted by the OHS because they could not find interviewee #5 and that he/she had called the physician and confirmed that the physician was not on-call. The COS stated that he/she then spoke with the physician (statement #1) about taking the patient, but that the physician was scheduled for surgery. The COS stated he/she and the physician (statement #1) both tried to arrange to see the patient. The COS stated he/she agreed to accept the patient but the transferring facility had already made arrangements to transfer the patient to another facility.

Review of physician's statement #1 revealed the physician was on-call during the early morning hours of 03/28/11. The physician's statement revealed the physician was contacted by the COS. The physician explained that he/she contacted his/her partner at the transferring facility, the next ophthalmologist on-call, and several other ophthalmologists. The physician stated he/she called the OHS to accept the patient and was told that the transferring facility had made arrangements to transfer the patient somewhere else. The physician stated that the COS had also agreed to accept the patient.