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Based on review of the medical record for patient #1 (P1), staff interviews, and review of facility documents, it was determined the facility failed to ensure compliance with EMTALA regulation 42 CFR 489.24, that ensures patients presenting to the Emergency Department (ED) receive an appropriate medical screening examination (MSE) to determine whether or not an emergency medical condition (EMC) exists.

Findings include:

The facility failed to ensure that P1 received an appropriate MSE during two consecutive ED visits. (Cross refer to Tag A-2406).

Based on observation, staff interviews, and review of facility documents, it was determined the facility failed to ensure that: 1) individual physician names are identified on the Emergency Department (ED) physician on-call list for all disciplines; 2) policies and procedures addressing physician on-call at multiple facilities simultaneously, are developed and implemented.

Findings include:

1) Review of the physician on-call lists for the "Hand Surgery" specialty from January 1, 2023 to July 31, 2023, revealed that the physician on-call was listed as "RO - Reconstructive Ortho" on the following dates: 1/1/23, 1/4/23, 1/6/23 - 1/8/23, 1/18/23, 1/30/23, 2/1/23, 2/3/23 - 2/6/23, 2/8/23, 2/10/23 - 2/13/23, 2/15/23, 2/17/23 - 2/19/23, 2/21/23, 2/27/23, 3/1/23, 3/6/23, 3/8/23, 3/14/23, 3/22/23, 3/24/23 - 3/27/23, 3/29/23, 3/31/23, 4/1/23, 4/2/23, 4/11/23, 4/13/23, 4/17/23, 4/19/23, 4/21/23 - 4/23/23, 4/26/23, 4/28/23 - 4/30/23, 5/1/23, 5/3/23, 5/5/23 - 5/7/23, 5/9/23, 5/15/23, 5/17/23, 5/22/23, 5/24/23, 5/26/23 - 5/28/23, 6/5/23, 6/7/23, 6/9/23 - 6/11/23, 6/13/23, 6/19/23, 6/21/23, 6/23/23 - 6/26/23, 6/30/23, 7/1/23, 7/2/23, 7/4/23, 7/10/23, 7/12/23, 7/14/23 - 7/17/23, 7/19/23, 7/21/23 - 7/23/23. There was no individual physician identified as the physician on-call for the above referenced dates.

Review of the physician on-call lists for the "Psychiatry" specialty from January 1, 2023 to July 31, 2023, revealed that the physician on-call was listed as "Access Center" on the following dates: 1/2/23, 1/3/23, 1/5/23, 1/12/23, 1/17/23, 1/19/23, 1/20/23, 1/26/23, 1/27/23, 1/30/23, 1/31/23, 2/1/23 - 2/3/23, 2/6/23 - 2/10/23, 2/13/23 - 2/17/23, 2/20/23 - 2/24/23, 2/27/23, 2/28/23, 3/1/23 - 3/4/23, 3/6/23 - 3/18/23, 3/20/23 - 3/24/23, 3/27/23 - 3/31/23, 4/1/23, 4/3/23 - 4/8/23, 4/10/23 - 4/15/23, 4/17/23 - 4/22/23, 4/24/23 - 4/29/23, 5/1/23 - 5/6/23, 5/8/23 - 5/13/23, 5/15/23 - 5/19/23, 5/22/23 - 5/26/23, 5/29/23 - 6/3/23, 6/5/23 - 6/9/23, 6/12/23 - 6/16/23, 6/19/23 - 6/23/23, 6/26/23 - 6/30/23, 7/3/23 - 7/8/23, 7/10/23 - 7/14/23, 7/17/23 - 7/21/23, 7/24/23 - 7/28/23, 7/30/23 and 7/31/23. There was no individual physician identified as the physician on-call for the above referenced dates.

Review of the physician on-call lists for the "Colorectal Surgery" specialty from January 1, 2023 to July 31, 2023, revealed that the physician on-call was listed as "QLIQ/Contact Office" on the following dates: 1/2/23 - 1/6/23, 1/9/23 - 1/13/23, 1/16/23 - 1/20/23, 1/23/23 - 1/27/23, 1/30/23, 1/31/23, 2/1/23 - 2/3/23, 2/6/23 - 2/10/23, 2/13/23 - 2/17/23, 2/20/23 - 2/24/23, 2/27/23 - 3/3/23, 3/6/23 - 3/10/23, 3/13/23 - 3/17/23, 3/20/23 - 3/24/23, 3/27/23 - 3/31/23, 4/3/23 - 4/7/23, 4/10/23 - 4/14/23, 4/17/23 - 4/21/23, 4/24/23 - 4/28/23, 5/1/23 - 5/5/23, 5/8/23 - 5/12/23, 5/15/23 - 5/19/23, 5/22/23 - 5/26/23, 5/30/23 - 6/2/23, 6/5/23 - 6/9/23, 6/12/23 - 6/16/23, 6/19/23 - 6/23/23, 6/26/23 - 6/30/23, 7/3/23 - 7/7/23, 7/10/23 - 7/14/23, 7/17/23 - 7/21/23, 7/24/23 - 7/28/23, and 7/31/23. There was no individual physician identified as the physician on-call for the above referenced dates.

On 7/13/23 at 3:48 PM, Staff #1 (Quality Director) and Staff #2 (Risk Safety Manager) confirmed that the specialities referenced above lacked evidence that individual physicians were identified as the on-call physician.

2) Reference: Facility document titled "Medical Staff and Advanced Practice Credentials Policy" (dated 5/10/2022) states, " ... 2.A.1 ... (3) be available on a continuous basis, either by personally or by arranging appropriate coverage ... ('Appropriate Coverage' means coverage by another credentialed practitioner with appropriate specialty-specific privileges as determined by the Credentials Committee) ... ."

Review of the physician on-call lists titled "Infectious Disease On Call Schedule" for dates January 1, 2023 to July 31, 2023, revealed that the physician on-call was listed as being on-call in multiple locations simultaneously.

Review of the physician on-call lists titled "West Jersey Orthopedics Call Schedule" for dates January 1, 2023 to July 31, 2023, revealed that the physician on-call was listed as being on-call in multiple locations simultaneously.

Review of the physician on-call lists titled "Gastroenterology" for the dates January 1, 2023 to July 31, 2023 revealed that on the following dates, the on-call physician was listed as being on-call in multiple locations simultaneously: 1/1/23, 1/2/23, 1/6/23 - 1/8/23, 1/13/23 - 1/15/23, 1/17/23, 1/20/23 - 1/22/23, 1/27/23 - 1/29/23, 2/3/23 - 2/5/23, 2/10/23 -2/12/23, 2/17/23 - 2/19/23, 2/24/23 - 2/26/23, 2/28/23, 3/3/23 - 3/5/23, 3/10/23 - 3/12/23, 3/17/23 - 3/19/23, 3/24/23 - 3/26/23, 3/31/23 - 4/2/23, 4/7/23 - 4/11/23, 4/13/23 - 4/16/23, 4/21/23 - 4/23/23, 4/28/23 - 4/30/23, 5/5/23 - 5/7/23, 5/12/23 - 5/14/23, 5/19/23 - 5/21/23, 5/26/23 - 5/30/23, 6/2/23 - 6/4/23, 6/8/23 - 6/11/23, 6/16/23 - 6/18/23, 6/24/23, 6/25/23, 6/27/23, 7/1/23 - 7/4/23, 7/7/23 - 7/9/23, 7/14/23 - 7/16/23, 7/21/23 - 7/23/23, 7/25/23, and 7/28/23 - 7/30/23.

Review of the physician on-call lists titled "Bariatric ER On Call Schedule" for dates January 1, 2023 to July 31, 2023, revealed that the physician on-call was listed as being on-call in multiple locations simultaneously.

Review of the physician on-call lists titled "Department of Cardiology Call Schedule" for dates January 1, 2023 to July 31, 2023, revealed that the physician on-call was listed as being on-call in multiple locations simultaneously.

Review of the physician on-call lists titled "West Jersey Urology Call Schedule" for dates January 1, 2023 to July 31, 2023, revealed that the physician on-call was listed as being on-call in multiple locations simultaneously.

Review of the physician on-call lists titled "Virtua Endocrine Voorhees On-Call Schedule" for dates January 1, 2023 to July 31, 2023, revealed that the physician on-call was listed as being on-call in multiple locations simultaneously.

Review of the physician on-call lists titled "West Jersey Otolaryngology On-Call Schedule" for dates December 26, 2022 to July 31, 2023, revealed that the physician on-call was listed as being on-call in multiple locations simultaneously.

Review of the physician on-call lists titled "West Jersey Internal Medicine On-Call Schedule" for dates January 1, 2023 to July 31, 2023 revealed that on the following dates, the on-call physician was listed as being on-call in multiple locations simultaneously: 2/1/23 - 2/14/23, 5/1/23, 5/25/23, 5/26/23, and 5/29/23.

Review of the facility's "Medical Staff Rules and Regulations" (dated 11/10/2020) lacked evidence of policies or procedures addressing physician simultaneous call.

Upon request on 7/13/23 at 1:59 PM, the facility was unable to provide a policy addressing the ED physician on-call list as it relates to simultaneous call. Staff #1 confirmed the facility did not have a policy related to physician's on-call at multiple locations simultaneously.

Based on medical record review, review of Obstetric (OB) triage logs, staff interviews, and review of facility policy and procedure, it was determined the facility failed to ensure that all persons presenting to the OB triage walk-in for emergency medical treatment, are entered in the OB triage log.

Findings include:

Reference #1: Facility policy titled, "Emergency Medical treatment and Active Labor Act (EMTALA) Compliance" (last reviewed 6/7/21) states, " ... Requirements: ... 5. All patients presenting for emergency medical treatment will be entered into the ED (emergency department) EMR (electronic medical record) or L&D (labor and delivery) Log Book."

Reference #2: Facility policy titled, "OB Triage at [name of facility]" (effective 2/21) states, " ... Patient is registered per hospital protocol and information entered into required logs and EMR."

During the entrance conference on 7/10/23 at 10:10 AM, Staff #1 (Assistant Vice President, Quality) stated that the facility has an OB triage walk-in entrance that is separate from the Main entrance of the ED. Staff #1 stated that OB patients can present directly to the OB triage walk-in entrance to request an emergency medical screening exam (MSE). A request was made to Staff #1 and Staff #2 (Risk Safety Manager) for the ED Central logs and the OB Triage Logs for February 2023 to July 2023.

Upon review of the medical record of patient #1 (P1) on 7/11/23, it was revealed that the patient arrived to the OB triage walk-in entrance of the facility on 4/7/23 at 2:33 AM. The patient's chief complaint was "Bladder Pain." The patient received an MSE, was diagnosed with "Pelvic Cramping," and discharged to home on 4/7/23 at 4:49 AM.

There was no evidence of the patient's 4/7/23 emergency visit documented on the OB triage logs for April 2023. There was no evidence of the patient's 4/7/23 emergency visit documented on the ED central logs for April 2023.

At 11:05 AM, Staff #2 confirmed that the OB triage log for April 2023 does not include evidence of P1's arrival to OB triage on 4/7/23.

Based on review of the medical record for patient #1 (P1), staff interviews, and review of facility documents, it was determined the facility failed to ensure that patients presenting to the Emergency Department (ED) receive an appropriate medical screening examination (MSE) to determine whether or not an emergency medical condition (EMC) exists.

Findings include:

Reference #1: Facility policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) compliance" (last reviewed 6/7/21) states, " ... 4. Medical Screening Examination (MSE) ... An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency exists. ... Depending on the patient's presenting symptoms, the medical screening examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures ... It is not an isolated event, it is an ongoing process. ... ."

Reference #2: Facility document titled, "Medical Staff Rules and Regulations" state, " ... 10.4 Supervising Physician's Documentation ... 10.4.5.2 All orders, discharge summaries, histories and physicals, and operative and delivery notes that are documented by a resident must be countersigned within 24 hours and must be dated and timed."

Review of the medical record of P1 on 7/11/23 revealed the following:

P1 arrived to the Main ED on 4/6/23 at 9:40 AM with complaints of pelvic cramping and urinary symptoms. P1 was 35 weeks pregnant. Vital signs were taken at 9:42 AM and the patient was transferred to OB (Obstetrics) Triage at 9:49 AM. Documentation in the medical record revealed P1 had a past medical history of sickle cell anemia (An inherited red blood cell disorder. During a sickle cell crisis, red blood cells may burst or stick to vessel walls causing sudden severe pain, fatigue, a fast heart rate, and yellowing of the skin and eyes), accessory placenta in the second trimester of a previous pregnancy (condition in which there is an extra placenta that is separate from the main placenta, increasing the chances of postpartum hemorrhage), footling breech presentation in previous pregnancy (baby enters the birth canal feet first), obesity, pre-eclampsia (high blood pressure in pregnancy), hyperbilirubinemia in pregnancy [condition in which there is a build up of bilirubin in the blood, causing yellow discoloration of the eyes and skin (jaundice), dark or brown colored urine and itching], previous c-section, and polyhydramnios (too much amniotic fluid during pregnancy). Per the National Institutes of Health document, titled Evidence Based Management of Sickle Cell Disease, dated 2014, read in pertinent part "Pregnancy in women with SCD is considered high risk, and there is an increased risk of adverse pregnancy outcomes including ... preterm delivery, and stillbirth ... There are increased risks to a woman ' s health during pregnancy. These risks include an increased frequency of pain crises and an increased risk of thrombosis [blood clots], infections, preeclampsia ... ." (retrieved from https://www.nhlbi.nih.gov/sites/default/files/media/docs/sickle-cell-disease-report%20020816_0.pdf).

P1 received an MSE by Staff #44 (Resident) at 10:54 AM. The examination revealed P1's initial blood pressure was high, urine specimen was dark brown, and fluids were ordered for potential dehydration. Staff #44 further documented, " ... At this time, admission is not indicated. Recommend continued fluid hydration, and will follow up urinalysis results. ... Discussed w/(with) attending [Staff #48]." P1 was discharged home on 4/6/23 at 11:54 AM. There was no evidence in the medical record P1's blood pressure was re-checked prior to his/her discharge, considering his/her past medical history of pre-eclampsia.

An attestation note entered by Staff #48 on 4/11/23 at 5:31 PM states, "The patient was evaluated and managed by the Resident. I reviewed the note above and agree with the findings and plan of care." Staff #48 (Attending physician) failed to countersign Staff #44's orders and history and physical within 24 hours.

An interview was conducted on 7/13/23 at 10:06 AM with Staff #37 (Vice President, Clinical Operations for Women's Health). Upon interview, Staff #37 stated, "Residents can rule-out medical conditions depending on their level. The Attending sees the patient prior to discharge. Third and fourth year residents have more independence. They have more experience so they may not need to come down to see the patient." Review of the credentialing file of Staff #44 on 7/13/23 confirmed that he/she was a second year resident, requiring the Attending OB physician to see his/her patients prior to discharge. Staff #4 and Staff #37 confirmed that the attestation note entered by Staff #48 did not indicate that he/she saw and evaluated P1. Staff #37 stated, "If the Attending sees the patient, they should document it."

Review of the nursing flowsheet revealed that P1 had a pain assessment at 10:11 AM where he/she indicated his/her pain was a "4 - moderate pain." There was no evidence in the medical record that pain interventions, pharmacologic or non-pharmacologic, were implemented for P1. There was no evidence in the medical record that P1's pain was reassessed. P1 was discharged home on 4/6/23 at 11:54 AM. Facility policy titled "Pain Assessment and Management of the Adult" (last reviewed 3/23) states, " ... C. Pain reassessment should occur: ... 3. Reassessment intervals after non-pharmacological interventions vary, depending on the intervention. The RN will determine the reassessment interval, based on individual patient needs, nature of the intervention, and response to the intervention. ... Documentation ... F. Non-pharmacologic interventions, including patient response."

Review of the medical record revealed P1 returned to the ED on 4/7/23 at 2:33 AM, approximately 15 hours after he/she was previously discharged. P1 presented directly to OB Triage with complaints of "lower abd (abdominal) discomfort with shooting and stabbing pain in her vagina ... reports that the pain is similar to what she experienced earlier today when she was evaluated in triage but she was unsure how to get relief so she came in for re-evaluation."

P1 arrived to the OB Triage on 4/7/23 at 2:33 AM and was triaged at 3:23 AM, 50 minutes after his/her arrival. Facility policy titled, "OB Triage at [name of facility]" states, "... C. Initial maternal and fetal assessment by the RN or LIP (licensed independent practitioner), with decision about the priority level for evaluation, should take place within 30 minutes of arrival. ... D. This assessment should include: maternal and fetal vital signs (including fetal movement), chief complaint, labor status and identification of any high-risk medical or obstetric conditions through review of records and competing [sic] a history."

A pain assessment was conducted at 3:23 AM where P1 indicated his/her pain score was a "9 - severe pain." At 4:02 AM, 975 mg (milligrams) of Tylenol was given to P1 for pain relief. There was no evidence P1 received a pain re-assessment after the Tylenol was administered, or at any point after the initial pain assessment was conducted.

P1 had an MSE performed by Staff #45 (Resident) on 4/7/23 at 4:01 AM. The MSE revealed scleral icterus (yellowing of the whites of the eyes), tachycardia, and abdominal tenderness. There was no documentation the exam included further investigation for the new findings of acute onset of severe pain, scleral icterus and tachycardia in a patient with sickle cell disease and a previous history of hyperbilirubinemia. There was no evidence Staff #45 reassessed the patient's response to pain interventions prior to discharge. P1 was discharged on 4/7/23 at 4:49 AM.

An attestation note entered by Staff #42 on 4/7/23 at 5:09 AM indicated Staff #42 examined the patient. However, there was no documentation indicating Staff #42 addressed the new findings of acute onset of severe pain, scleral icterus, and tachycardia in a patient with sickle cell disease and a previous history of hyperbilirubinemia, with the resident.

Upon interview on 7/12/23 at 11:36 AM, Staff #42 was asked why there was no additional follow-up regarding the patient's scleral icterus. Staff #42 stated, "I don't remember if I saw the patient or not. I don't think [Staff #45] told me about the patient having scleral icterus and I don't remember seeing scleral icterus when I examined [P1]." Staff #42 was asked about P1's indication of severe pain 9 out of 10 on the pain scale. Staff #42 stated, "I remember [Staff #45] discussing [P1]'s pain. [Staff #45] stated the patient said her pain was a 9, but the physical exam didn't suggest extreme pain. It was not what we would consider pain 9 out of 10." Staff #42 was asked why the patient's hematologist was not consulted, considering the patient's history of sickle cell anemia and this being the patient's second admission in less than 24 hours. Staff #42 stated, "Based on the patient's examination, we felt that the patient's complaints were normal for that stage of pregnancy. We focused on the physical exam." P1 was discharged on 4/7/23 at 4:49 AM. There was no evidence indicating further investigation for the new findings of acute onset of severe pain, scleral icterus and tachycardia in a patient with sickle cell disease and a previous history of hyperbilirubinemia.

Review of P1's medical record revealed there was no documented evidence the facility provided a complete MSE to evaluate P1's presentation on 4/6/23 with high blood pressure, dark brown urine and P1's presentation on 4/7/23 with acute onset of severe pain, scleral icterus and tachycardia in a patient with sickle cell disease and a previous history of hyperbilirubinemia.