HospitalInspections.org

1. Based on medical record reviews, policy and procedure review, Medical Staff Rules and Regulations review, facility hospital license review, Medical Staff By Laws review, Physician Credentialing files review, and on-call staff rosters, and interviews the facility failed to ensure that on-call Pulmonologists listed on the On-Call Roster and who are on the hospital's medical staff and available to provide necessary treatment after the initial examination to stabilize individuals with emergency medical conditions for five (5) #2, #3 ,#4 , 5, & #6 of twenty (20) sampled patients. Refer to findings in Tag A-2404.


2. Based on review of medical records, on-call rosters, policies and procedures, Physician Credentialing Files/Delineation of privileges, and interviews, the facility failed to ensure that medical treatment was provided that was within the capacity that minimizes the risk of the individual's health, as evidenced by the refusal of the on-call Pulmonologist physician to consult on 5 (#2, #3, #4, #5, & #6) of 20 sampled patients who were intubated and on the ventilator. As this resulted in inappropriate transfers for Patient #2, Patient #3, Patient #4, patient #5 and Patient #6. Refer to findings in Tag 2409.

Based on medical record reviews, policy and procedure review, Medical Staff Rules, Policies, and Rules and Regulations review, facility hospital license review, Policy and Procedure review, Physician Credentialing files review, on-call staff rosters, and interviews, the facility failed to ensure that on-call Pulmonologists listed on the On-Call Roster and who are on the hospital's medical staff and available to provide necessary treatment after the initial examination to stabilize individuals with Emergency Medical Conditions for five (5) #2, #3,#4, #5, & #6 of twenty (20) sampled patients.


Findings:


I. A review of documentation which the facility had filed with the State of Florida regarding the services it provides under its license revealed that Pulmonary Medicine was "provided on site 24 hours per day, 7 days per week."

II. A review of the document, "Medical Staff Bylaws, Policies, and Rules & Regulations" revealed the following: "Appointees to the Consulting category must: Care for unassigned patients and participate in the on-call coverage in the event of a coverage crisis as specified in the rules and regulations of each campus." Therefore, participation in the on-call process as defined by the hospital is expected. This expectation also means that if there was a lack of coverage available for a specialty that was sought by the Emergency Department physician for consultation, a non-scheduled physician would be expected to fill in. This understanding was confirmed during an interview with the Chief Executive Officer (CEO) on 10/4/17 at 10:04 AM.

III. A review of the document, "Rules & Regulations" for the Emergency Department revealed the following: "Each member of the Active and Provisional Active staff agree that, when he/she is the designated practitioner on call, he will accept responsibility during the time specified by the published schedule and provide care to any patient requested by the Emergency Department physician. ... If there is a desire to change the published on call schedule, it is the scheduled medical staff member's responsibility to notify the Medical Staff Office by letter or memorandum at least twenty-four (24) hours prior to the scheduled rotation as to whom they have arranged to cover their ER call. The Medical Staff Office will verify coverage with both the scheduled physician and the covering physician." Thus, per facility expectations, if an Emergency Room Physician requests inpatient care be accepted by an On-Call Physician to a patient planned for admission, and the admission is completely dependent on the on-call physician's acceptance, the On-Call physician must comply. This requirement does not specify that the desired care be provided solely in the Emergency Room. Furthermore, acceptance of an in-patient assignment would be necessary to finalize treatment in the emergency room. During an interview of the C.E.O. on 10/4/17 at approximately 10:04 AM, he confirmed this understanding. Regarding the published schedule, this entry in the "Rules & Regulations" requires that it be followed and that any changes follow certain steps.

A review of the "Rules & Regulations" revealed the following: "A physician must be credentialed to manage a ventilator patient or a Pulmonologist consult must be generated upon intubation." Thus, if a ventilator patient were to be admitted from the Emergency Room while on a ventilator, unless an Admitting Physician had ventilator management credentials, a Pulmonologist would need to be consulted immediately. This was confirmed during an interview with the Risk Manager on 10/6/17 at 12:53 PM.

IV. The "Medical Staff Bylaws, Policies, and Rules & Regulations" read: "All unassigned patients are assigned to the service concerned with the treatment of the problems or disease which necessitated admission. In order to expedite the emergency care of a patient, the Emergency Department Physician on duty may, at his/her discretion, assign the appropriate specialist on call." This requirement further supports the right of the Emergency Department physician to call upon the services of an on-call physician.

V. The facility's Policy titled, "EMTALA Emergency Transfers Policy" Approval date 6/8/2018, Review Date 6/12/2017 was reviewed. The policy stated in part, "PROCEDURE ...2. If a patient comes to the Hospital and is determined to have an Emergency Medical Condition following a Medical Screening Examination, the Hospital must provide further medical examination and treatment, including hospitalization if necessary, as required to stabilize the Emergency medical condition within the capabilities of the staff and facilities available at the hospital."

VI. A review of the medical record of Patient #2 revealed the following. The patient arrived in the Emergency Department on 9/17/17 at 10:23 PM. A nurse's note on 9/17/17 at 10:23 PM read: "Presenting complaint: EMS (Emergency Medical Services) states: Pt c/o (complains of) SOB (shortness of breath) since 2:00 PM today." A nurse's note at 10:29 PM on 9/17/17 read: "(I, MD) is Attending Physician." An Emergency Department physician note of 10:29 PM on 9/17/17 by I, MD read: "This ... presents to ER (Emergency Room) via EMS (Emergency Medical Services) ground with complaints of shortness of breath." An Emergency Department Physician note of 9/17/17 at 10:32 AM by I, MD read: "He c/o (complains of) sob (shortness of breath), vomiting that began this afternoon. States he was weak and unable to get out of bed. Was able to make it to his mother's bedroom later and fell in her room. ..."

The Discharge Summary, authored by I, MD indicated the following diagnoses: "Acute Respiratory Failure with hypoxia, acute respiratory distress syndrome, pneumonia, unspecified organism." An Emergency Room physician note of 9/18/17 at 12:10 AM by I, MD read: "ED course: Case was discussed with the on-call (H, MD) of pulmonology. The pulmonology group here currently is not seeing patients without insurance. This patient has Medicaid and the group will see the patient in consultation." At this point the on-call pulmonologist (H, MD) had agreed to consult with the patient because he had an understanding that Patient #2 had insurance.

The record continued. An Emergency Department physician note at 12:20 AM on 9/18/17 by I, MD read: "ED (Emergency Department) course: Registration informed me that this patient does not have Medicaid or any other form of insurance. I informed the on-call Pulmonologist (H, MD) of this fact and he asks that the patient be transferred to another facility." Per, medical record documentation, the On-Call Physician (H, MD) had originally agreed to consult regarding the patient, but this changed when the On-Call Physician (H, MD) learned that Patient #2 did not have the previously mentioned Medicaid or any other type of insurance. During an interview of I, MD on 10/4/17 at 1:17 PM, he stated that his plan was to admit the patient and that he had been preparing an admission order and was waiting for an Admitting Physician to call back, but before he could send the order, registration had called back with their news of Patient #2 not having insurance coverage. He stated that he felt compelled to tell H, MD of such, due to problems the facility had with prior admissions in which Pulmonology would not cover and provide treatment to an eventual admitted patient upon learning that an admitted patient had a lack of insurance. He stated that during the conversations he had not asked H, MD for any Emergency Room guidance regarding their management of the patient.

A review of the facility's On-Call Roster dated 9/18/2017 verified that the on-call Pulmonologist (H, MD) was on call, while Patient #2 was in the ED. A review of the Physician call log for Patient #2 revealed that the on -Call Pulmonologist was called on 9/18/2018 at 0010 and returned call at 0010; called at 0015 and returned call at 0015; and called at 0025 and returned call at 0025.

A review of the facility's credentialing file titled "Request for Clinical Privileges and Record of Privileges Granted" dated 10/15/01 for the on-call pulmonologist (H, MD) was reviewed. The clinical privileges revealed the "Areas of Practice" checked off were, "Internal Medicine and Pulmonary and Critical Medicine."

The refusal of the On-Call Pulmonologist (H, MD) to consult regarding Patient #2 was a violation of Medical Staff expectations. This understanding was confirmed during an interview of the C.E.O. on 10/4/17 at approximately 1:45 PM.

The Pulmonologist (H, MD) who was On-Call and consulted refused to come and see Patient #2 on 9/18/2017 to provide treatment necessary after the initial examination to stabilize the patient's identified emergency medical condition, when requested by the ED physician.


VII. A review of the medical record of Patient #3 was performed. The patient was admitted to the Emergency Department on 9/9/17 at 4:54 AM. A nursing note on 9/9/17 at 4:58 AM read: "Presenting complaint: Patient states: difficulty breathing starting at 12:00 AM. A nurse's note on 9/9/17 at 4:58 AM read: "(I, MD) is Attending Physician." A nurse's note on 9/9/17 at 5:04 AM read: "Complains of pain in chest. ... Respiratory: Reports shortness of breath. Onset: The symptoms/episode began/occurred today, the patient has moderate difficulty breathing and speaking full sentences." A nurse's note on 9/9/17 at 6:30 AM read: "Assist provider with intubation via oral route. Intubated by (I, D)." A nurse's note on 9/9/17 at 6:39 AM addressed ventilator settings. A nurse's note on 9/9/17 at 8:02 AM read: "Attending physician role handed off by (I, MD)." An Emergency Department Physician note of 9/9/17 at 8:22 AM by L, MD read: "Physician consultation: "(J, MD) was called at 8:22 AM, was contacted at 8:24 AM, regarding admission, to the ICU (intensive care unit), patient's condition, would like consultation with the on-call pulmonologist (E, MD) discussed with (M, MD) ... who agreed but wanted pulmonary called and confirm that they will consult and follow pt (patient) #3 prior to accepting pt. (#3) for admission." A nurse's note on 9/9/17 at 8:02 AM read: (L, MD) is attending physician." An Emergency Room Physician note of 9/9/17 at 8:23 AM by L, MD read: Physician consultation: Pulmonologist on-call (E, MD) was called at 8:24 AM, was contacted at 8:28 AM, regarding consult, patient's condition, (E, MD) refused the pt consult." An Emergency Department physician note of 9/9/17 at 8:50 AM by I, MD read: "... Spring Hill Regional Hospital does not immediately have the required specialist, the on-call Pulmonologist (E, MD) refused to consult on patient"


A review of the hospital's On-call Roster dated 9/9/2017 verified that the On- Call Pulmonologist (E, MD) was on call for Pulmonology services when Patient #3 presented to the ED.

A review of the hospital's credentials file "delineation of Privileges for the On-Call Pulmonologist (E, MD) was reviewed. The Delineation of Privileges for (E, MD) was "Pulmonology" and the effective dates were 3/1/2016 to 2/28/2018, and Board approval on 2/21/2016. The requested and approved privileges revealed in part, "Endotracheal Intubation, Ventilation Management, acute and chronic."

The Pulmonologist (E, MD) who was on-call and consulted, refused to come and see Patient #3 on 9/9/2017 to provide treatment necessary after the initial examination to stabilize the patient's identified emergency medical condition, when requested by the ED physician.


VIII. A review of the medical record of Patient #4 was performed. The Patient was admitted to the Emergency Department on 9/28/17 at 5:49 AM. A nurse's note at 5:50 AM on 9/28/17 read: "Presenting complaint: EMS states: Called to a residence for altered mental status." Another nurse's note at this same time read: "Respiratory: hyperventilation, RR (respiratory rate) 40." Another nurse's note at this time read: "Triage completed." A nurse's note on 9/28/17 at 6:19 AM read: "Assist provider with intubation." A nurse's note of 9/28/17 at 6:30 AM read: "(I, MD) is attending physician." An Emergency Department Physician note of 9/28/17 at 7:22 AM read: "This ... presents to ER via EMS ground with complaints of altered mental status. An Emergency Department physician note of 9/28/17 at 7:23 AM read: "Respiratory: severe respiratory distress is noted. Respirations: tachypnea, Kussmaul respirations." An Emergency Department Physician note by I, MD on 9/28/17 at 7:46 AM read: "Pt had a severe metabolic acidosis despite breathing over 50 times a minute, so patient was intubated. Call placed to the on-call (E, MD) of pulmonary for ventilator management. Because this patient does not have insurance, he is refusing to consult and the patient will have to be transferred." An Emergency Department Physician note at 8:00 AM on 9/28/17 by I, MD read: "Transfer ordered to Bayfront Medical Center, Diagnosis are Type 1 Diabetes Mellitus with Ketoacidosis, Hyperkalemia, Acute Kidney Failure, IV drug abuse. Reason for transfer: Pulmonology - higher level of care. ... Condition is serious. ... Symptoms have improved."

A review of the hospital's credentials file "delineation of Privileges for the on-call Pulmonologist (E, MD) was reviewed. The Delineation of Privileges for (E, MD) was "Pulmonology" and the effective dates were 3/1/2016 to 2/28/2018, and board approval on 2/21/2016. The requested and approved privileges revealed in part, "Endotracheal Intubation, Ventilation Management, acute and chronic."


A review of the hospital's Emergency On-call Roster dated 9/28/2017 verified that the on-call Pulmonologist (E.MD) was on-call for Pulmonology services when Patient #4 presented to the ED.

The On-Call Pulmonologist (E, MD) refused to come and see Patient #4 in response to a call from the ED physician (I, MD). The facility failed to ensure that (E, MD) who was on-call for Pulmonology services and consulted come to the hospital's emergency department and see Patient #4 on 9/28/2017 to provide treatment necessary after the initial examination to stabilize the patient's identified emergency medical condition ,when requested by the ED physician.


IX. A review of the medical record of Patient #5 was performed. A nurse's note of 9/6/17 at 11:20 PM read: "Presenting complaint: Patient states: Patient in ED (Emergency Department) from after taking 40 pills of Clonazepam 0.5 MG (milligrams) and 20 pills of zolpidem as a suicide attempt. Patient is sleepy, patient also appears to have fallen, hematoma noted to back of head." A nurse's note of 9/6/17 at 11:21 PM read: "(B, DO) is attending physician." A nurse's note of 9/6/17 at 11:40 PM read: "Assist provider with intubation ..." As prior text indicates, the patient was now intubated. An Emergency Department physician note on 9/6/17 at 11:46 PM by B, DO read: "No Pulmonologist and Hospitalist. NP (Nurse Practitioner) O, ARNP (Advanced Registered Nurse Practitioner) declined ICU (Intensive Care Unit) without the On-Call Pulmonologist (E, MD) who decline consult." An Emergency Department physician note of 9/6/17 at 11:49 PM by B, DO read: "Transfer ordered to Bayfront Medical Center. Diagnosis is overdose, ETOH (Ethyl Alcohol), head contusion. Reason for transfer: Pulmonology - Higher level of Care. ... Condition is critical. ... Symptoms have improved." A nurse's note on 9/6/17 at 11:49 PM read: "ED care complete, transfer ordered by MD (Medical Doctor)." An Emergency Department physician note by B, DO on 9/7/17 at 12:14 AM described the intubation process.


A review of the hospital's Emergency On-Call Roster dated 9/06/2017 verified that the On-Call Pulmonologist (E.MD) was On-Call for Pulmonology services when Patient #5 presented to the ED.

A review of the credentials file for the On-Call Pulmonologist (E, MD) did not reveal any evidence of a lack of skills or abilities applicable to #5.

The on-call Pulmonologist refused to come and see Patient #5 after being called by Physician B, DO (Doctor of Osteopathy). The facility failed to ensure that (E, MD) who was on-call for Pulmonology services and consulted come to the hospital's emergency department and see Patient #5 on 9/6/2017 to provide treatment necessary after the initial examination to stabilize the patient's identified emergency medical condition.

As for E, MD's (on-call Pulmonologist) position on the Emergency Department requests regarding Patient #3, #4 and #5, during an interview with him on 10/6/17 at 11:51 AM, he stated that in each of the calls from the Emergency Department physicians for these patients he was aware that his response would affect whether or not the patients would be admitted to the hospital, when requested by the ED physician.


X. A review of the medical record of Patient #6 was performed. The patient was admitted to the Emergency Room on 9/16/17 at 1:24 AM. A nurse's note on 9/16/17 at 1:25 AM read: "Pt found by EMS tripoding on side of road. ... Pt had swollen tongue upon arrival and was intubated en route. ... Care prior to arrival: See EMS report. Assisted ventilation ..." A nurse's note on 9/16/17 at 1:27 AM read: "Behavior is patient sedated and intubated. ... Respiratory: Airway via oral intubation." An Emergency Department physician note of 9/16/17 at 1:55 AM by P, MD read: "The patient has shortness of breath at rest. Onset: The symptoms/episode began/occurred at an unknown time. Duration: The symptoms are continuous. ... At their worst, the symptoms were incapacitating in the emergency department the symptoms have improved mildly. ... PT was intubated ... by EMS." An Emergency Department physician note on 9/16/17 at 1:44 AM by P, MD, documenting an event at 2:03 AM read: "Response to treatment: the patient's symptoms have mildly improved after treatment. Physician consultation: (H, MD) was contacted at 2:03 AM, regarding consult. Pulmonary on call (G, MD) being covered by (H, MD) who is refusing consultation, recommends transfer of patient to Bayfront St. Pete." A nurse's note of 9/16/17 at 3:11 am documented an event on 9/16/17 at 2:07 AM. It read: "Initial call made to transfer center @ 2:07 AM." An Emergency Department physician note by P, MD on 9/16/17 at 2:12 AM read: "Respiratory: Respirations: poor air movement. Breath sounds: wheezing, that is severe, decreased breath sounds that are moderate."


An Emergency Department Physician note of 9/16/17 at 3:26 AM by P, MD read: "Transfer ordered to Bayfront Medical Center. Diagnosis are unspecified asthma with status asthmaticus, acidosis, respiratory with hypercarbia, other psychoactive substance abuse, hypokalemia. Reason for transfer: Pulmonology - Higher level of Care. ... Condition is critical. ... Symptoms are unchanged."

A review of the hospital's Emergency On-call Roster dated 9/16/2017 verified that the On-Call Pulmonologist (E.MD) was On-Call for Pulmonology services when Patient #6 presented to the ED.


A review of the facility's credentialing file titled "Request for Clinical Privileges and Record of Privileges Granted" dated 10/15/01 for Pulmonologist H, MD was reviewed. The clinical privileges revealed the "Areas of Practice" checked off were, "Internal Medicine and Pulmonary and Critical Medicine."

The On-Call Pulmonologist refused to come and see Patient #6 after being called by Physician (P, MD). The facility failed to ensure that (H, MD) who was on-call for Pulmonology services and consulted come to the hospital's emergency department and see Patient #6 on 9/16/2017 to provide treatment necessary after the initial examination to stabilize the patient's identified emergency medical condition when, requested by the ED physician..

Based on review of medical records, on-call rosters, policies and procedures, Physician Credentialing Files/Delineation of privileges, and interviews, the facility failed to ensure that medical treatment was provided that was within the capacity that minimizes the risk of the individual's health, as evidenced by the refusal of the on-call Pulmonologist Physician to consult on 5 (#2, #3, #4, #5, & #6) of 20 sampled patients who were intubated and on the ventilator. As this resulted in inappropriate transfers for Patient #2, Patient #3, Patient #4, Patient #5 and Patient #6.


The findings include:

A review of facility policy, "Transfers Policy" revealed the following: "When the patient's emergent need for service is not available in the organization, the patient is transferred to the facility which is most appropriate and capable of providing the service. No patient is arbitrarily transferred on the basis of financial status or the ability to pay."

A review of the facility's policy titled, "EMTALA Emergency Transfers Policy" Approval date 6/8/2018, Review Date 6/12/2017 revealed in part, ` An Emergency Appropriate Transfer to another hospital will be appropriate only in those cases in which...The transferring Hospital provided medical treatment within it's Capabilities that minimizes the risks to the individual's health."

Patient #2

A review of the medical record of Patient #2 was performed. The document, "Patient Transfer Form," for Patient #2, signed by the patient on 9/18/17 at 12:44 AM read: "The patient is being transferred because of failure, refusal or inability of an on-call physician to respond. On-Call physician name: (H, MD)." The document "Patient Transfer Form," also read: "Additional physician documentation to be completed for transfers from the emergency room only. The patient presented to the hospital requesting emergency medical treatment and the hospital provided a Medical Screening Examination and stabilization services to the extent possible ... Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated, or has been requested by the patient's legal guardian. ... The patient is being transferred because of failure, refusal or inability of an on-call physician to respond. On-Call physician name: (H, MD)." A physician note of 9/18/17 at 1:16 AM by I, MD, MD read: "Transfer ordered to Bayfront Medical Center. Diagnosis are Acute Respiratory Failure with hypoxia, acute respiratory distress syndrome, pneumonia, unspecified organism. Reason for transfer: other. ... Condition is serious. ... Symptoms have improved." A nurse's note on 9/18/17 at 1:16 AM read: "ER care complete, transfer ordered by MD. A nurse's note at 1:52 AM on 9/18/17 read: "Patient left the ED (Emergency Department)."

A review of the facility's credentialing file titled "Request for Clinical Privileges and Record of Privileges Granted" dated 10/15/01 for Pulmonologist H, MD was reviewed. The clinical privileges revealed the "Areas of Practice" checked off were, "Internal Medicine and Pulmonary and Critical Medicine."

A review of the facility's On-Call Roster dated 9/18/2017 verified that the On-Call Pulmonologist (H, MD) was on call, while Patient #2 was in the ED. A review of the Physician call log for Patient #2 revealed that the on -Call Pulmonologist was called on 9/18/2018 at 0010 and returned call at 0010; called at 0015 and returned call at 0015; and called at 0025 and returned call at 0025.

During an interview of the CEO on 10/4/17 at approximately 1:45 PM, he confirmed that Bayfront Health Spring Hill would have to be capable to provide services to Patient #2 if the on call Pulmonologist had accepted him and that there was a violation of the expectations of the "Transfer Policy" as quoted above regarding the care of Patient #2.


Patient #3

A review of the medical record of Patient #3 was performed. An Emergency Room Physician note of 9/9/17 at 8:23 AM by L, MD read: Physician consultation: (E, MD) was called at 8:24 AM, was contacted at 8:28 AM, regarding consult, patient's condition, (E, MD) refused the pt consult." An Emergency Department Physician note on 9/9/17 at 8:28 AM by L, MD read: "Other consultation: Bayfront Medical Center, was alerted at 8:29 AM, discussed with ER attending (N, MD) who accepted patient for transport to ER (Emergency Room) at 8:49 AM." An Emergency Department physician note of 9/9/17 at 8:50 AM by I, MD read: " ... Spring Hill Regional Hospital does not immediately have the required specialist, pulmonologist refused to consult on pt." An Emergency Department physician note by L, MD on 9/9/17 at 8:53 AM read: "Transfer ordered to Bayfront Medical Center, Diagnosis are respiratory failure, pneumonia, sepsis, jaundice, pancreatic pseudo cyst, coagulopathy secondary to Coumadin, anemia, alcohol abuse. ... Reason for transfer: Pulmonology - Higher level of care. ... Condition is critical. ... Symptoms have improved." A nurse's note on 9/9/17 at 8:53 AM read: "ER (Emergency Room) care complete, transfer ordered by MD."

The document "Patient Transfer Form," signed by the patient on 9/9/17 at 8:55 AM read: "Additional physician documentation to be completed for transfers from the emergency room only. The patient presented to the hospital requesting emergency medical treatment and the hospital provided a Medical Screening Examination and stabilization services to the extent possible ... Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated, or has been requested by the patient's legal guardian. ... The patient is being transferred because of failure, refusal or inability of an on-call physician to respond. On-Call physician name: (E, MD)." A nurse's note on 9/9/17 at 10:49 AM read: "Patient left the ED (Emergency Department)."


A review of the hospital's credentials file "delineation of Privileges for the on-call Pulmonologist (E, MD) was reviewed. The Delineation of Privileges for (E, MD) was "Pulmonology" and the effective dates were 3/1/2016 to 2/28/2018, and board approval on 2/21/2016. The requested and approved privileges revealed in part, "Endotracheal Intubation, Ventilation Management, acute and chronic." A review of the facility's on-call roster dated 9/18/2017 verified that the on-call Pulmonologist (H, MD) was on call, while patient #3 was in the ED.

Patient #4

A review of the medical record of Patient #4 was performed. An Emergency Department Physician note at 8:00 AM on 9/28/17 by I, MD read: "Transfer ordered to Bayfront Medical Center, Diagnosis are Type 1 Diabetes Mellitus with Ketoacidosis, Hyperkalemia, Acute Kidney Failure, IV drug abuse. Reason for transfer: Pulmonology - higher level of care. ... Condition is serious. ... Symptoms have improved." The document "Patient Transfer Form," signed by the patient on 9/28/17 at 8:00 AM read: "Additional physician documentation to be completed for transfers from the emergency room only. The patient presented to the hospital requesting emergency medical treatment and the hospital provided a Medical Screening Examination and Stabilization services to the extent possible ... Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated, or has been requested by the patient's legal guardian. ... The patient is being transferred because of failure, refusal or inability of an on-call physician to respond. On-Call physician name: (E, MD)." A nurse's note on 9/28/17 at 9:29 AM read: "Transferred by EMS ground to Bayfront Medical Center." A nurse's note on 9/28/17 at 9:32 AM read: "Patient left the ED."

A review of the facility's On-Call Roster dated 9/18/2017 verified that the on-call Pulmonologist (H, MD) was On Call, while Patient #4 presented to the ED. A review of the credentials file for E, MD did not reveal any evidence of a lack of skills or abilities applicable to #4.


Patient #5

A review of the medical record of Patient #4 was performed The document "Patient Transfer Form," signed by Patient #5 on 9//7/17 at 12:25 AM (patient had written "9/7/10") read: "Additional physician documentation to be completed for transfers from the emergency room only. The patient presented to the hospital requesting emergency medical treatment and the hospital provided a Medical Screening Examination and stabilization services to the extent possible ... Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated, or has been requested by the patient's legal guardian. ... The patient is being transferred because of failure, refusal or inability of an on-call physician to respond. On-Call physician name: (E, MD)." The handwritten time indicated on this document conflicts with nursing documentation, below, which indicates a departure at 12:14 AM. A nurse's note of 9/7/17 at 12:14 AM read: "RN (Registered Nurse) escorted patient out of department to Bayfront St. Pete with EMS." A nurse's note of 9/7/17 at 1:51 AM read: "Patient left the ED."

A review of the credentials file for E, MD did not reveal any evidence of a lack of skills or abilities applicable to #5. A review of the facility's on-call roster dated 9/18/2017 verified that the on-call Pulmonologist (H, MD) was on call, while Patient #5 presented to the ED.

Patient #6

A review of the medical record of Patient #6 was performed .The document "Patient Transfer Form," signed by the patient (Patient #6) on 9/16/17 at 3:20 AM read: "Additional physician documentation to be completed for transfers from the emergency room only. The patient presented to the hospital requesting emergency medical treatment and the hospital provided a Medical Screening Examination and stabilization services to the extent possible ... Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated, or has been requested by the patient's legal guardian. ... The patient is being transferred because of failure, refusal or inability of an on-call physician to respond. On-Call physician name: (H, MD)."

An Emergency Department Physician note of 9/16/17 at 3:26 AM by P, MD read: "Transfer ordered to Bayfront Medical Center. Diagnosis are unspecified asthma with status asthmaticus, acidosis, respiratory with hypercarbia, other psychoactive substance abuse, hypokalemia. Reason for transfer: Pulmonology - Higher level of Care. ... Condition is critical. ... Symptoms are unchanged." A nurse's note on 9/16/17 at 4:15 AM read: "O2 (oxygen) via ventilation terminated at this time. Patient transported out via EMS."

A review of the facility's on-call roster dated 9/18/2017 verified that the On-Call Pulmonologist (H, MD) was on call, while Patient #6 presented to the ED. A review of the credentials file for H, MD did not reveal any evidence of a lack of skills or abilities applicable to #6.

The hospital had the capacity to provide treatment within the medical capability of the on-call pulmonologists, to minimize the risks of Patient #2, #3, #4, #5, and #6 these individuals health but were instead transferred out to other acute care hospitals when pulmonary services were available at Bayfront Health Springhill. During an interview of the Chief Executive Officer on 10/6/17 at approximately 3:45 PM, he confirmed the preceding.