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Based on review of medical records, Policies and Procedures, Medical Staff Bylaws, and Physician on-call schedules and staff interview, it was determined the facility failed to ensure that physicians listed on the Physician on-call list and on-call for duty, failed to come to the emergency department after the emergency department physician request for consultation, after the initial examination to provide further evaluation and or treatment necessary to stabilize 1 of 20 sampled patients. (Patient 11) Refer to findings in Tag A-2404

Based on review of medical records, Policies and Procedures, Medical Staff Bylaws, and Physician on-call schedules, and staff interview, it was determined the facility failed to ensure that physicians listed on the Physician on-call list and on-call for duty, failed to come to the emergency department after the emergency department physician request for consultation, after the initial examination to provide further evaluation and or treatment necessary to stabilize 1 of 20 sampled patients. (Patient 11)

The findings were:


1. Policy and Procedure Review
The facility's Policy and Procedure, titled, "EMTALA On and Off Campus Outpatient Departments", Policy #: IM800.119, Procedure Date: 10/05/2018 was reviewed. The policy and procedure revealed in part, "3. Scope of Responsibilities and Privileges ...3.3. The designated screening professional will determine, within the limits of his or his privileges and these procedures, whether the patient has an emergency medical condition as defined in these policies and procedures, and those patients deemed to have an emergency medical condition or be unstable will be examined by a physician ...4.4. Where vital signs or test results indicate the patient may be unstable, the patient will be seen by and evaluated further by the department physician, who will assume responsibility for further care and treatment...4.5. Where, in the opinion of the designated screening professional, the patient condition requires stabilizing treatment or further evaluation by a physician, who will assume responsibility for the further care and treatment of the patient."

2. Medical Staff Bylaws

Review of Hospital A's(transferring hospital) Medical Staff Bylaws, revealed, "Article 10, Emergency Services, 10 C. On - Call Responsibilities", that reads, "The Medical Staff shall adopt a method of providing coverage in the emergency center. .....Physicians on - call shall be available to provide consultation and treatment to their own patients as well as to accept unassigned patients on a timely basis. Physicians, who are on unassigned call and are requested to see a patient, shall respond promptly. ....It is the responsibility of the scheduled on - call physician to respond to calls from the Emergency Department in accordance with policies and procedures"

3. Patient #11

On 10/24/2018 at 11:15 a.m., review of Patient 11's chart revealed the patient presented to Hospital A's ED with a chief complaint of "cut top of thumb off" on 5/16/2018 at 14:24 p.m.. On 5/16/2018 at 14:26 p.m., the triage nurse documented the patient's pain score was a 10 with 10 represented as worst pain ever. Patient 11's pulse was recorded as 97. Triage level was assessed as an acuity 3. On 05/16/ 2018 at 16:29 p.m., the physician documented "Patient's x-ray of the left hand reviewed by me showed fracture of the distal phalanx. Through and through 100%(percent) displacement." On 8/16/2018 at 16:37 p.m., the ED physician documented, "I discussed patient with Dr. .... who is on call for hand surgery. Discussed patient's physical exam x-ray results. He is requesting the patient's transfer to Hospital B to be taken to the OR. He'll(Patient 11) be transferred to the emergency department. Dr. ....will be accepting. .....I discussed this with the patient he'll be transferred via personal vehicle.....". Patient 11 was transferred to Hospital B to receive the same level of service offered by Hospital A at the request of the designated on - call physician for Hospital A,

4. On Call Log/Schedules

On 10/22/18 at 02:00 a.m., the hospital's physician on - call logs for the emergency department, dated from 04/01/2018 through 10/31/2018, were reviewed. The on-call log revealed that an On-call Plastic surgeon was on call on 5/16/2018 from 8:00 A.M. to 5/17/2018 8:00 A.M. There was no documented evidence in the medical record to indicate the Plastic surgeon - on call came to the emergency department to consult on Patient #11 when he/she was notified by the ED physician. Patient #11 was not stabilized as he/she needed required hand services for further evaluation/care and treatment as stated in the facility's Policy and procedure.

5. Interview
In an interview with the hospital's Compliance Officer, the Compliance Officer reported that the hand physician wants to operate at Hospital A and not Hospital B. The Compliance Officer stated, "He asks us to do all these things, and then to send the patient to Hospital B's emergency department". The facility failed to ensure that their Medical Staff Bylaws were followed as evidenced by failing to ensure that the on-call plastic surgeon came to the emergency room to consult on Patient #11 on 5/16/2018.