HospitalInspections.org

Based on interviews, record reviews, review of the Medical Staff Rules and Regulations, unattached speciality on call physicians' schedules, Physician Education EMTALA Regulations Regarding On Call Physicians and review of ED (Emergency Department) and EMTALA policies and procedures, Hospital A failed to:

A. Ensure that unattached speciality on call physicians admit patients who needed further evaluation and treatment to stabilize the patient(s)' emergency medical condition (EMC) as determined by the emergency department (ED) Physician for two ED patients. Patient identifier number one (PI #1) on 8-11-2012 and PI #2 on 8-12-12.

B. Prevent the inappropriate transfer of patients requiring further evaluation and treatment to stabilize their EMC as determined by the ED Physician to another facility (Hospital B) while Hospital A had the capacity and capability to provide the necessary services for PI #1 (08-11-12) and PI#2 (08-12-12).

This deficient practice effected PI #1 and PI #2, two of twenty-six (26) ED sampled patients and had the potential of effecting other patients who presented to Hospital A's emergency department.


Findings Include:

On 8-11-12 at 13:45, PI #1 presented to Hospital A's ED with complaints of severe abdominal pain. The ED Nurse Practitioner (NP), Employee Identifier #1 (EI #1) (with the ED Physician), determined that PI #1 needed to be admitted to Hospital A for further evaluation and treatment to stabilize PI #1's EMC of gallstone pancreatitis. EI #1 (ED NP) presented PI #1 to EI #2 (On Call Hospitalist) for admission to Hospital A. EI #2 (On Call Hospitalist) stated he would not admit PI #1 as PI #1 was a surgical patient but would consult if needed. EI #2 (On Call Hospitalist) suggested that EI #1 (ED NP) call EI #3 (On Call General Surgeon). EI #1 (ED NP) then presented PI #1 to EI #3 (On Call General Surgeon) for admission to Hospital A. EI #3 (On Call General Surgeon) stated she would not admit PI #1 but would consult as PI #1 was more of a medical patient. PI #1 was then transferred on 08-11-12 to Hospital B to receive further evaluation and treatment necessary for stabilizing of the patient's EMC.

On 8-11-12 at 23:45, PI #2 presented to Hospital A's ED with complaints of severe abdominal pain, nausea, vomiting and diarrhea with breath having the odor of feces. The ED Physician (MD), EI #4, determined that PI #2 needed to be admitted to Hospital A for further evaluation and treatment to stabilize PI #2's EMC of small bowel obstruction. EI #4 (ED MD) presented PI #2 to EI #5 (On Call Hospitalist) for admission to Hospital A. EI #2 (On Call Hospitalist) stated he would not admit PI #2 as PI #2 was a surgical patient but would consult if needed. EI #5 (On Call Hospitalist) suggested that EI #4 (ED MD) call EI #3 (On Call General Surgeon). EI #4 (ED MD) then presented PI #2 to EI #3 (On Call General Surgeon) for admission to Hospital A. EI #3 (On Call General Surgeon) stated she would not admit PI #2 but would consult as PI #2 was more of a medical patient. PI #2 was then transferred on 08-12-12 to Hospital B to receive further evaluation and treatment necessary for stabilizing of the patient's EMC.

On 8-13-2012, Hospital B notified Hospital A's Administrator of PI #1's and PI #2's possible inappropriate transfers to Hospital B for further stabilizing evaluation and treatment of the patients' EMC related to on call physicians not admitting PI #1 and PI #2 as requested by the ED physician(s). Hospital A began an investigation on 08-13-12 but did not provide all documented evidence of their investigation and no documentation of immediate corrective actions to prevent reoccurrence of the reported incident.

Refer to findings under A 2404 / 489.20(r)(2) and 489.24(j)(1-2) On Call Physicians and A 2409 / 489.24(e)(1-2) Appropriate Transfer.

Based on interviews, record reviews, review of the Medical Staff Rules and Regulations, unattached speciality on call physicians' schedules, and Physician Education EMTALA Regulations Regarding On Call Physicians, it was determined Hospital A failed to ensure that speciality on call physicians admitted unattached patients who needed further evaluation and treatment to stabilize the patient(s)' emergency medical condition (EMC) as determined by the emergency department (ED) Physician for two ED patients. Patient Identifier number one (PI #1) on 8-11-2012 and PI #2 on 8-12-12.

On 8-11-12 at 13:45, PI #1 presented to Hospital A's ED with complaints of severe abdominal pain. The ED Nurse Practitioner (NP), Employee Identifier #1 (EI #1) (with the ED Physician), determined that PI #1 needed to be admitted to Hospital A for further evaluation and treatment to stabilize PI #1's EMC of gallstone pancreatitis. EI #1 (ED NP) presented PI #1 to EI #2 (On Call Hospitalist) for admission to Hospital A. EI #2 (On Call Hospitalist) stated he would not admit PI #1 as PI #1 was a surgical patient but would consult if needed. EI #2 (On Call Hospitalist) suggested that EI #1 (ED NP) call EI #3 (On Call General Surgeon). EI #1 (ED NP) then presented PI #1 to EI #3 (On Call General Surgeon) for admission to Hospital A. EI #3 (On Call General Surgeon) stated she would not admit PI #1 but would consult as PI #1 was more of a medical patient. PI #1 was then transferred on 08-11-12 to Hospital B to receive further evaluation and treatment necessary for stabilizing of the patient's EMC.

On 8-11-12 at 23:45, PI #2 presented to Hospital A's ED with complaints of severe abdominal pain, nausea, vomiting and diarrhea with breath having the odor of feces. The ED Physician (MD), EI #4, determined that PI #2 needed to be admitted to Hospital A for further evaluation and treatment to stabilize PI #2's EMC of small bowel obstruction. EI #4 (ED MD) presented PI #2 to EI #5 (On Call Hospitalist) for admission to Hospital A. EI #2 (On Call Hospitalist) stated he would not admit PI #2 as PI #2 was a surgical patient but would consult if needed. EI #5 (On Call Hospitalist) suggested that EI #4 (ED MD) call EI #3 (On Call General Surgeon). EI #4 (ED MD) then presented PI #2 to EI #3 (On Call General Surgeon) for admission to Hospital A. EI #3 (On Call General Surgeon) stated she would not admit PI #2 but would consult as PI #2 was more of a medical patient. PI #2 was then transferred on 08-12-12 to Hospital B to receive further evaluation and treatment necessary for stabilizing of the patient's EMC.

This deficient practice effected PI #1 and PI #2, two of twenty-six (26) ED sampled patients and had the potential of effecting other patients who presented to Hospital A's emergency department prior to 8-13-2012.


Findings Include:

1. MEDICAL STAFF RULES & REGULATIONS
(Hospital A) Medical Staff Rules and Regulations 2012 includes the following information.

A. Admission and Discharge of Patients
2. A patient may be admitted to the Hospital only by a member of the Medical Staff with Approved privileges...
4. Any physician who accepts a patient from another facility or otherwise for admission to the Hospital, regardless of specialty will serve as the attending / admitting physician and any subsequent referrals to any other physician will be made as a consult...

E. Emergency Department Services
1. Responsibility for on call coverage for unattached patients seen in the Hospital Emergency Department and admitted to the Hospital will be assigned to Active Staff physicians on a rotating basis with the exception of physicians over 60 years of age... Members of the Active Staff will be responsible for on call coverage for each service in which they have privileges...

2. PHYSICIAN EDUCATION
EMTALA Regulations Regarding On Call Physicians

The following information was taken from the "Physician Education EMTALA Regulations Regarding On Call Physicians which was distributed to all Medical Staff (according to the Director of Physicians) as "physician updates " on Monday, 6-18-12.

Responsibilities of Medicare Participating Hospitals in Emergency Cases
EMTALA, Section 1867 of the Social Security Act.
Section 1867 of the Act provides for the Office of the Inspector General (OIG) to levy civil monetary penalties or take other actions against hospitals or physicians for EMTALA violations. CMS (Centers Medicare and Medicaid Services) refers cases it has investigated to the OIG when CMS finds violations that appear to fall within the OIG's EMTALA jurisdiction. Section 1867(d)(1)(C) of the Act specifically provides for penalties against both a hospital and the physician when a physician who is on call either fails to appear or refuses to appear within a reasonable period of time.

If a physician is listed as on call and requested to make an in person appearance to evaluate and treat an individual, that physician must respond in person in a reasonable amount of time.

If a physician who is on call, either directly or indirectly refuses or fails to appear at the hospital where he/she is directly on call in a reasonable period of time, then that physician as well as the hospital have violated EMTALA and are subject to civil monetary penalties and withdrawal of Medicare participation.

If a physician who is on call typically directs the individual to be transferred to another hospital or to come to his office instead of making an appearance as requested, then that physician as well as the hospital may be found to be in violation of EMTALA...

3. SPECIALTY PHYSICIAN ON CALL SCHEDULE

The Specialty On Call Physicians schedule was reviewed for the months of June through August 2012. The following on call physicians were verified for the Hospitalist and General Surgery on 8-11-12 and 8-12-12 (Saturday and Sunday).

Hospitalist 8-11-12 8-12-12
6 am - 6 pm Admitting EI #1 no EI #
6 am - 6 pm no EI # EI #1
6 pm - 6 am EI #5 EI #5

General Surgery 8-11-12 8-12-12
7 am - 7 am EI #3 EI #3

The following Memorandum is posted in the front of the Specialty On Call Physician schedule book addressed to surgical service, ED Medical Director, Administrator, Chief Nursing Officer (CNO) and Director of Physicians from the Director Hospitalist Program dated 1-25-12.

After much consideration, I would like to suggest the follow process to handle general surgery admissions going forward...

Surgical cases which present to the ED will be screened by the ED physician. Those cases with acute medical on going problems, which would have required a medical admission, will be admitted to the Hospitalist service.

Surgical cases with medical problems which do not merit medical admission will be admitted to surgery. The hospitalist service will be available for medical consults and will see the patient the same day if requested...

4. REVIEW OF PI #1's ED RECORD & INTERVIEWS

PI #1's ED record was reviewed for the ED visit of 08-11-12 and included the following information.

"EMERGENCY ENCOUNTER RECORD
ED Arrival Information: 08-11-2012 13:45.
Acuity: Urgent...
Chief Complaint: Abdominal pain severe, low back pain.
Pain score: 10 worst pain ever, acute, throbbing...
Diagnostics
Labs: Amylase - 234 (28-100 u/l - units/liter). Lipase - 686 (11-57 u/l)...
Commuted Tomography (CT) abdomen pelvis with Intravenous (IV) contrast:
Impression:
1. No acute or significant abnormality in the abdomen or pelvis.
2. There are questionable gallstones. Consider GB (gall bladder) ultrasound for complete evaluation.
Plan of Care and Medical Decision Making:
Comment: Reexamined and pt (patient) with only minimal pain after IV Morphine 14:47 (EI #1 - EDNP).
Comment: Spoke with (EI #2 - Hospitalist) about pt, request to call Surgery on call (EI #3 -General Surgeon) for admit and they (Hospitalist) would be glad to consult 16:15 (EI #1 - EDNP).
Comment: Spoke with (EI #3 - General Surgeon) who refuses to admit pt. States pt needs to be admitted to medicine service 16:16 (EI #1 - EDNP).
Comment: Spoke with (Surgical Service) at (Hospital B) who accepts pt in transfer 17:06 (EI #1 - EDNP).
Clinical Impression:
Gallstone pancreatitis...
Disposition...
Transfer to Acute Care facility, (PI #1) should be transferred out to (Hospital B, Surgical Service).

DISCHARGE SUMMARY - Hospital B
Admitted: 08-11-12. Discharged: 08-14-12.
Procedure: Robotic single site cholecystectomy.
History: (PI #1) presented with abdominal pain that began suddenly. It was in her epigastric abdominal area. Her amylase was 234, and she was determined to have gallstone pancreatitis. She was admitted and treated over the weekend with IV fluid resuscitation. On Monday, she was taken to operating room and robotic cholecystectomy was performed after the patient's amylase and lipase returned to normal..."

*EI #1 (ED NP) (worked ED on 08-11-12, 9 AM -7 PM), was interviewed on 08-28-12 at 13:00 stating "I did talk to (ED physician) about this patient (PI #1). We did this jointly, decision making, to admit this patient... This was a patient with acute abdominal epigastric pain, elevated amylase and CT scan showed uncomplicated gallstones... The patient was determined to be unattached. I called (EI #2 - Hospitalist), presented the patient (with gallstone pancreatitis) to him, that this patient needed to be admitted. (EI #2 - Hospitalist) said he could not admit this patient because he recently had four to five admissions that he was working up. (EI #2 - Hospitalist) said that he would be glad to consult on the patient but could not admit and for me to call the surgeon on call. I called (EI #3 - General Surgeon), presented this patient... I said that I talked to (EI #2 - Hospitalist on call) and he said to call you, (EI #3 - General Surgeon). (EI #3 - General Surgeon) said that she could not admit because the patient may need an ERCP (endoscopic retrograde cholangiopancreatography) but that she would consult. I explained to (EI #3 - General Surgeon) how she (PI #1) presented, what the CT scan showed, her lab work, gallstone pancreatitis... I work with general surgeons all the time. I know what the criteria is... I informed (ED Physician) of this, that (EI #3 - General Surgeon) said she wouldn't admit the patient but would consult... I called (Surgical Service) at Hospital B, presented the patient's case to him and he accepted the patient..."

*EI #2 (Hospitalist on call for 08-11-12) was interviewed on 08-28-12 at 15:15 and stated "Basically this was a surgery patient with gallstone pancreatitis, healthy with no other medical problems. Our role (hospitalist) is to admit patients, also surgical and orthopedic patients, with medical problems. There are surgical patients that are healthy with no other medical problems that we (hospitalist) don't need to admit because we'd just be doing the paper work. This is taken on a case by case basis and capacity as well. This patient had a diagnosis of gallstone pancreatitis with no other medical problems. I had seven admissions that day. I said (when EI #1 -EDNP called presenting this patient) 'Why don't you call the surgeon on call.' She (EI #1 - EDNP) said 'I already did and she (EI #3 - General Surgeon) won't do it (admit the patient).' I said I'd call (EI #6 - Director Hospitalists) and I did. (EI #6 - Director Hospitalists) said not to admit this patient, to consult if needed, this is a healthy patient with no medical problems with the chief complaint of abdominal pain and CT shows gallstone pancreatitis. This was a surgical patient with no medical problems and the surgeon should be the admitting physician. All we're (hospitalist) doing is paperwork for them (surgeon). The surgeon can admit patients without medical problems and consult us, (Hospitalist), if a medical problem arises."

*EI #6 (Director Hospitalist Program) was interviewed on 08-28-12 at 15:15 stated "At (Hospital B) internal medicine physicians won't take surgical patients. (EI #2 - Hospitalist) called me that weekend (Saturday, 08-11-12). I told him (EI #2 - Hospitalist) not to admit this patient. The patient was a surgical patient with no medical problems and we would consult if there was a medical problem..."

*EI #3 Dr (General Surgeon on call 08-11-12 and 08-12-12) was interviewed on 08-28-12 at 15:43 and stated "We're taught EMTALA in residency so I know EMTALA... It's very rare that I get called for pancreatitis gallstone (PI #1 08-11-12). We don't have GI (gastrointestinal physician) on call on weekends to do the ERCP. Pancreatitis is a medical issue and refer the patient to GI for the ERCP for the gallstones... It has been the practice in the past for medicine to admit them (patients) and consult us, surgery. This has never been question in the past. This is the first time I've been asked to admit a patient with gallstone pancreatitis..."

5. REVIEW OF PI #2's ED RECORD & INTERVIEWS

PI #2's ED record was reviewed for the ED visit of 08-11-12 to 08-12-12 and included the following information.

"EMERGENCY ENCOUNTER RECORD
ED Arrival Information: 08-11-2012 23:42.
Acuity: Urgent...
History of Present Illness: Pt c/o (complaint of) abdominal pain. Pt states s/s (signs / symptoms) for approx (approximately) 3 days. Pt states when she burps it smells like feces... The history is provided by the patient...
Past Medical History Reviewed
Diagnosis:
IBS (irritable bowel syndrome).
Diverticulitis.
Gastritis.
Plan of Care and Medical Decision Making:
(EI#4 - EDMD) 08-12-12 06:49 to 07:50 ED provider notes filed.
CT scan preliminary report, stated that " findings concerning for partial to early high grade SBO " (small bowel obstruction). WBC (white blood count) is 22,900 with a left shift. I spoke with (EI #5 - Hospitalist) concerning admission of this patient. (EI #5 - Hospitalist) stated that this was a surgical patient and should be admitted to the General Surgeon on call. I spoke with (EI #5 - Hospitalist) again who stated this was a surgical patient and still would not admit the patient, that the surgeon should admit the patient. She (EI #5 - Hospitalist) informed me that since (EI #3 - General Surgeon) would not admit the patient that I should transfer the patient to the on call general surgeon at (Hospital B). I then spoke with the House Supervisor. I then spoke with (physician) in the ER at (Hospital B). who explained that I would have to get general surgery to accept the patient at (Hospital B) rather than attempt an ER to ER transfer. I again spoke with the House Supervisor, who stated that she would contact administration, here (Hospital A).
(EI #3 - General Surgeon) called me back and informed me that she would not accept the patient for admission, that she did not feel that this patient had a surgical problem. I once again explained to (EI #3 - General Surgeon) that the patient's abdomen was tender, the patient had a very high WBC, and the preliminary radiology report suggested a small bowel obstruction. (EI #3 - General Surgeon) stated she would see the patient if someone else admitted the patient and consulted her. (EI #3 - General Surgeon) suggested that I try to transfer this patient to the Hospitalist on call at (Hospital B).
I then spoke with (EI #6 - Director Hospitalists). (EI #6 - Director Hospitalists) stated that this patient would not be admitted by the Hospitalist Service because this was a surgical patient. I again spoke with the Nursing Supervisor and informed her that I had exhausted all options to get this patient admitted here.
I spoke with (General Surgeon) @ 07:30, the general surgeon on call at (Hospital B). (General Surgeon) accepted this patient for transfer as a direct admission to his service at (Hospital B). (PI #2) is to be transferred via ALS (advanced life support) Ground (ambulance) (on 8-12-12 at 08:22),
Clinical Impression:
Acute abdominal pain.
Leukocytosis.
Possible small bowel obstruction...

DISCHARGE SUMMARY (Hospital B)
Admitted: 08-12-12. Discharged: 08-16-12.
Discharge diagnosis: Partial small bowel obstruction..
Hospital course: Patient was placed on NG (nasogastric) tube to low wall suction and kept NPO (nothing by mouth). Patient had good relief of her nausea and pain with NG tube. Patient continued NG tube until hospital day four. NG tube was pulled and bowel function resumed. Patient was passing flatus, having bowel movements, and was not reporting any abdominal pain or nausea or vomiting. Patient was hep (heparin) locked and placed on a clear liquid diet, which she tolerated well. Patient remained afebrile without any increase in white blood cell count during her hospitalization. Patient made a full recovery from her partial small bowel obstruction without any need for surgical intervention...

*EI #4 (ED MD on 08-11-12 and 08-12-12) was interviewed on 08-29-12 at 15:35 stating "(PI #2), a 26 year old female with complaints of severe abdominal pain, nausea, vomiting and diarrhea for days presented to this ED between 11 PM to 12 AM. Her abdomen felt pretty tender and looked highly suspicious for a small bowel obstruction (per CT scan). I talked to (EI #5 - Hospitalist on call) about admitting (PI #2). (EI #5 - Hospitalist) said this sounded like a surgical patient and said that I needed to talk to the surgeon on call. Then I talked to the surgeon on call (EI #3), who said she wouldn't admit the patient but would consult if the patient was admitted by the Hospitalist. I went over the patient again, that I was very concerned, that this was highly suspicious for a small bowel obstruction. Then (EI #3 -General Surgeon) looked at the patient's CT scan via her laptop and said the radiologist didn't read the CT correctly, this was not a bowel obstruction and the patient did not have a surgical problem. (EI #3 - General Surgeon) said 'I will not admit this patient' and argued with me that the patient did not have a small bowel obstruction. Now I did not demand (EI #3 - General Surgeon) to come to (ED) to evaluate the patient. I then called (Hospitalist) at (Hospital B) (to accept this patient as a transfer) and he (Hospitalist) said that I would have to call the on call surgeon to accept this patient. Then I got the surgeon on call at (Hospital B) and he accepted the patient... The House Supervisor was notified several times about this situation, the on call physicians refusing to admit this patient who then had to be transferred to another hospital. The House Supervisor said she would call the Administrator on call..."

*EI #5 (Hospitalist 6 PM - 6 AM on call for 08-11-12 / 08-12-12) was interviewed on 08-28-12 at 17:30 stating "That night (08-11-12 Saturday night / 08-12-12 Sunday morning) was a bad night. I had to intubate a patient in the ED... That ED physician (EI #4) was concerned whether or not this might be an EMTALA violation... (EI #4 - ED MD) said he had a 26 year old that had a possible small bowel obstruction, possible free air, very tender abdomen... I asked if he (EI #4)) had called the surgeon on call. (EI #4 - ED MD) said 'Yes, I called.' I said 'We cannot admit a bowel obstruction and the surgeon won't come in to see the patient.' In the past I have had two to three patients who needed surgery emergently and (EI #3 - General Surgeon) would not come in until the following morning... I then asked (EI #4 - ED MD) if she (PI #2) had any medical problems such as diabetes, hypertension, etc. He (EI #4 - ED MD) said 'No. No medical problems.' He (EI #4 - ED MD) never mentioned diverticulitis or IBS. I suggested he call (EI #3 - General Surgeon) back. (EI #4 - ED MD) also called (EI #6 - Director Hospitalists) that night about this patient. (EI #6 - Director Hospitalists) said he also felt this was a surgical patient... In essence we did not have surgical service and had to transfer the patient to (Hospital B) for treatment... It's usually a partial bowel obstruction with other medical problems which we will admit. This patient (PI #2) (EI #4 - ED MD) said he felt was a bowel obstruction, not a partial bowel obstruction. (EI #4 - ED MD) was very concerned about this patient..."

* EI #3 (General Surgeon on call 08-11-12 and 08-12-12) was interviewed on 08-28-12 at 15:43 stating "I have my lap top so I can bring up the patient's CT scan, etc., to view while the ED physician is talking about the patient... This patient (PI #1) CT with contrast possible bowel obstruction... It was high in the small bowel, jejunum, not a lot of dilatation, no hernia, no Crohn's disease... She (PI #2) had dirty urine and high WBC 22,000. I said (EI #4 ED MD) 'Let the medical guy put her (PI #2) in (admit).' Diverticulitis is a medical problem and (Hospitalist) admits those patients, then consults surgery... 80% of small bowel obstructions are not surgical but patience and perseverance is the best thing for the patient. I read my own CT scans (trained at Hospital B) so when an ED physician calls me about a patient I will pull up the CT scan, labs, etc., from the portal on my lap top while speaking to the ED physician... They (Hospitalists) have always admitted the patient(s) then consult us (surgeon). Why this change?"

*EI #7 RN (Registered Nurse) House Supervisor on 08-11-12 / 08-12-12, 7 PM -7 AM, was interviewed on 09-07-12 at 10:15 and stated the following.

"I started getting calls around 04:30 to 05:00 about the on call Hospitalist and on call Surgeon refusing to admit (PI #2). I talked to (EI #5 - Hospitalist) who said the patient was out of her scope of practice, can't admit patients with surgical diagnosis and not being comfortable with admitting (PI #2). I talked to (EI #4 - ED MD) who said that they have this ED patient who needed to be admitted, that he talked to (EI #3 - General Surgeon) who said (PI #2) was not a surgical patient and would not admit (PI #2). I also talked to the Hospitalist that was coming on at 06:00 (EI #2 - Hospitalist) about admitting this patient and he said the exact same thing as (EI #5 - Hospitalist) that they can't admit a surgical patient. I did inform the Administrator on call about this situation. I had also passed this information on to the on coming House Supervisor (EI #8). I can find out why the physician(s) won't admit the patient but I can't make the physicians take the patient..."

*EI #8 (House Supervisor on 08-11-12 / 08-12-12, 7 AM -7 PM) was interviewed on 08-28-12 at 15:15 stating "I talked to (EI #2 - Hospitalist) who said he was going to talk to (EI #6 - Director Hospitalists) and then they made the decision not to admit the patient. (EI #3 - General Surgeon) was aware of this... I called Administrator on Sunday morning (08-12-12)... I (Administrator) about the two patients who were transferred (Hospital B) and neither physicians (EI #2 - Hospitalist for PI #1, EI #5 -Hospital for PI #2 and EI #3 - General Surgeon for both PI #1 and PI #2) would admit the patients. This type of thing usually does not take place. The patient is usually admitted."

*EI #9 Director Physicians was interviewed on 08-29-12 at 18:30 stating
"On 06-18-12 we had sent out (e-mail and fax to all medical staff and posted in the two physicians' lounges) EMTALA Regulations Regarding On Call Physicians (Physician Education) as a reminder of the On Call Physicians' responsibilities... All physicians, as part of their orientation to the hospital, are educated regarding the EMTALA regulations by (EI #10 Risk and Compliance Officer)... We have a Medical Executive Committee scheduled for 09-20-12 for the purpose of developing a follow up plan to the problem of the On Call Physicians not accepting patients for admission when requested by the ED physician (on 08-11-12 and 08-12-12). We want to keep patients from our community in our hospital when we have the ability to care for them."

*EI #10 Risk and Compliance Officer was interviewed on 08-29-12 at 17:20 stating "I got a call from (Risk Officer) at (Hospital B) on 08-13-12 saying that they had received two transfers (patients) from our ED... and may have to report us (Hospital A) to CMS for inappropriate transfer... Both patients' ED records were reviewed... The Administrator (EI #11) had been called on Sunday, 08-12-12, by the House Supervisor (EI #8) and informed (EI #11 - Administrator) of these two transfers to (Hospital B) because the on call physicians here would not admit these patients... (EI #11 - Administrator) talked to the involved physicians. I also talked to the physicians... Back in June 2012 a one page education sheet was sent out to the Medical Staff about On Call Physicians' obligations... There is a Medical Executive Meeting on 09-20-12 to discuss and resolve these issues..."

*EI #1 Administrator was interviewed on 09-05-12 at 09:35 stating "I was not the Administrator on call but I did receive a call on Sunday morning (08-12-12) and spoke with the House Supervisor (EI #8) who made me aware of the patients (two) that were transferred to (Hospital B)... On Monday 08-13-12 I received a call from Administration at (Hospital B) saying that they had received two admissions from our ED over the weekend and that I needed to research this... We have done some education with Medical Staff and will do more. A Medical Executive Committee Meeting is scheduled for 09-20-12 with the main agenda of addressing the above issues with Medical Staff... I did speak one on one to (EI #3 - General Surgeon)."


These citations were written as the result of the investigation of complaint/report AL00027321.

Based on interviews, record reviews, review of the Medical Staff Rules and Regulations, Physician Education EMTALA Regulations Regarding On Call Physicians and review of ED (Emergency Department) and EMTALA policies and procedures, Hospital A failed to prevent the inappropriate transfer of patients requiring further evaluation and treatment to stabilize their EMC (emergency medical condition) as determined by the ED Physician to another facility (Hospital B) while Hospital A had the capacity and capability to provide the necessary services for Patient Identifier (PI) #1 (08-11-12) and PI#2 (08-12-12).

On 8-11-12 at 13:45, PI #1 presented to Hospital A's ED with complaints of severe abdominal pain. The ED Nurse Practitioner (NP), Employee Identifier #1 (EI #1) (with the ED Physician), determined that PI #1 needed to be admitted to Hospital A for further evaluation and treatment to stabilize PI #1's EMC of gallstone pancreatitis. EI #1 (ED NP) presented PI #1 to EI #2 (On Call Hospitalist) for admission to Hospital A. EI #2 (On Call Hospitalist) stated he would not admit PI #1 as PI #1 was a surgical patient but would consult if needed. EI #2 (On Call Hospitalist) suggested that EI #1 (ED NP) call EI #3 (On Call General Surgeon). EI #1 (ED NP) then presented PI #1 to EI #3 (On Call General Surgeon) for admission to Hospital A. EI #3 (On Call General Surgeon) stated she would not admit PI #1 but would consult as PI #1 was more of a medical patient. PI #1 was then transferred on 08-11-12 to Hospital B to receive further evaluation and treatment necessary for stabilizing of the patient's EMC.

On 8-11-12 at 23:45, PI #2 presented to Hospital A's ED with complaints of severe abdominal pain, nausea, vomiting and diarrhea with breath having the odor of feces. The ED Physician (MD), EI #4, determined that PI #2 needed to be admitted to Hospital A for further evaluation and treatment to stabilize PI #2's EMC of small bowel obstruction. EI #4 (ED MD) presented PI #2 to EI #5 (On Call Hospitalist) for admission to Hospital A. EI #2 (On Call Hospitalist) stated he would not admit PI #2 as PI #2 was a surgical patient but would consult if needed. EI #5 (On Call Hospitalist) suggested that EI #4 (ED MD) call EI #3 (On Call General Surgeon). EI #4 (ED MD) then presented PI #2 to EI #3 (On Call General Surgeon) for admission to Hospital A. EI #3 (On Call General Surgeon) stated she would not admit PI #2 but would consult as PI #2 was more of a medical patient. PI #2 was then transferred on 08-12-12 to Hospital B to receive further evaluation and treatment necessary for stabilizing of the patient's EMC.

This deficient practice effected PI #1 and PI #2, two of twenty-six (26) ED sampled patients and had the potential of effecting other patients who presented to Hospital A's emergency department prior to 8-13-2012.


Findings Include:

1. MEDICAL STAFF RULES & REGULATIONS
(Hospital A) Medical Staff Rules and Regulations 2012 includes the following information.

E. Emergency Department Services
1. Responsibility for on call coverage for unattached patients seen in the Hospital Emergency Department and admitted to the Hospital will be assigned to Active Staff physicians on a rotating basis with the exception of physicians over 60 years of age... Members of the Active Staff will be responsible for on call coverage for each service in which they have privileges...

2. PHYSICIAN EDUCATION
EMTALA Regulations Regarding On Call Physicians

The following information was taken from the "Physician Education EMTALA Regulations Regarding On Call Physicians which was distributed to all Medical Staff (according to the Director of Physicians) as "physician updates " on Monday, 6-18-12.

Responsibilities of Medicare Participating Hospitals in Emergency Cases
EMTALA, Section 1867 of the Social Security Act.
Section 1867 of the Act provides for the Office of the Inspector General (OIG) to levy civil monetary penalties or take other actions against hospitals or physicians for EMTALA violations. CMS (Centers Medicare and Medicaid Services) refers cases it has investigated to the OIG when CMS finds violations that appear to fall within the OIG's EMTALA jurisdiction. Section 1867(d)(1)(C) of the Act specifically provides for penalties against both a hospital and the physician when a physician who is on call either fails to appear or refuses to appear within a reasonable period of time.

If a physician is listed as on call and requested to make an in person appearance to evaluate and treat an individual, that physician must respond in person in a reasonable amount of time.

If a physician who is on call, either directly or indirectly refuses or fails to appear at the hospital where he/she is directly on call in a reasonable period of time, then that physician as well as the hospital have violated EMTALA and are subject to civil monetary penalties and withdrawal of Medicare participation.

If a physician who is on call typically directs the individual to be transferred to another hospital or to come to his office instead of making an appearance as requested, then that physician as well as the hospital may be found to be in violation of EMTALA...

3. ED AND EMTALA POLICIES AND PROCEDURES

Policies and procedures for the ED were present. The "Transfer of Patient Policy number: WLK NRS070" states the following.

1. Transferring from (Hospital A) to another facility:
If a patient presents with an emergency medical condition that cannot be stabilized or definitive care cannot be given due to the resources of the facility, the transfer process is implemented...

Policies and procedures addressing EMTALA were requested throughout the survey, 08-27-12 through 08-28-12, and none were produced.

EI #12 - Chief Nursing Officer (CNO) was interviewed on 08-28-12 at 16:00 regarding the presence of policies and procedures addressing EMTALA. EI #12 (CNO) stated that this facility did not have any policies and procedures addressing EMTALA at this time.

4. REVIEW OF PI #1's ED RECORD & INTERVIEWS

PI #1's ED record was reviewed for the ED visit of 08-11-12 and included the following information.

"EMERGENCY ENCOUNTER RECORD
ED Arrival Information: 08-11-2012 13:45.
Acuity: Urgent...
Chief Complaint: Abdominal pain severe, low back pain.
Pain score: 10 worst pain ever, acute, throbbing...
Diagnostics
Labs: Amylase - 234 (28-100 u/l - units/liter). Lipase - 686 (11-57 u/l)...
Commuter Tomography (CT) abdomen pelvis with Intravenous (IV) contrast:
Impression:
1. No acute or significant abnormality in the abdomen or pelvis.
2. There are questionable gallstones. Consider GB (gall bladder) ultrasound for complete evaluation.
Plan of Care and Medical Decision Making:
Comment: Reexamined and pt (patient) with only minimal pain after IV Morphine 14:47 (EI #1 - ED NP).
Comment: Spoke with (EI #2 - Hospitalist) about pt, request to call Surgery on call (EI #3 -General Surgeon) for admit and they (Hospitalist) would be glad to consult 16:15 (EI #1 - ED NP).
Comment: Spoke with (EI #3 - General Surgeon) who refuses to admit pt. States pt needs to be admitted to medicine service 16:16 (EI #1 - EDNP).
Comment: Spoke with (Surgical Service) at (Hospital B) who accepts pt in transfer 17:06 (EI #1 - ED NP).
Clinical Impression:
Gallstone pancreatitis...
Disposition...
Transfer to Acute Care facility, (PI #1) should be transferred out to (Hospital B, Surgical Service).

DISCHARGE SUMMARY - Hospital B
Admitted: 08-11-12. Discharged: 08-14-12.
Procedure: Robotic single site cholecystectomy.
History: (PI #1) presented with abdominal pain that began suddenly. It was in her epigastric abdominal area. Her amylase was 234, and she was determined to have gallstone pancreatitis. She was admitted and treated over the weekend with IV fluid resuscitation. On Monday, she was taken to operating room and robotic cholecystectomy was performed after the patient's amylase and lipase returned to normal..."

*EI #1 (ED NP) (worked ED on 08-11-12, 9 AM -7 PM), was interviewed on 08-28-12 at 13:00 stating "I did talk to (ED physician) about this patient (PI #1). We did this jointly, decision making, to admit this patient... This was a patient with acute abdominal epigastric pain, elevated amylase and CT scan showed uncomplicated gallstones... The patient was determined to be unattached. I called (EI #2 - Hospitalist), presented the patient (with gallstone pancreatitis) to him, that this patient needed to be admitted. (EI #2 - Hospitalist) said he could not admit this patient because he recently had four to five admissions that he was working up. (EI #2 - Hospitalist) said that he would be glad to consult on the patient but could not admit and for me to call the surgeon on call. I called (EI #3 - General Surgeon), presented this patient... I said that I talked to (EI #2 - Hospitalist on call) and he said to call you, (EI #3 - General Surgeon). (EI #3 - General Surgeon) said that she could not admit because the patient may need an ERCP (endoscopic retrograde cholangiopancreatography) but that she would consult. I explained to (EI #3 - General Surgeon) how she (PI #1) presented, what the CT scan showed, her lab work, gallstone pancreatitis... I work with general surgeons all the time. I know what the criteria is... I informed (ED Physician) of this, that (EI #3 - General Surgeon) said she wouldn't admit the patient but would consult... I called (Surgical Service) at Hospital B, presented the patient's case to him and he accepted the patient..."

*EI #2 (Hospitalist on call for 08-11-12) was interviewed on 08-28-12 at 15:15 and stated "Basically this was a surgery patient with gallstone pancreatitis, healthy with no other medical problems. Our role (hospitalist) is to admit patients, also surgical and orthopedic patients, with medical problems. There are surgical patients that are healthy with no other medical problems that we (hospitalist) don't need to admit because we'd just be doing the paper work. This is taken on a case by case basis and capacity as well. This patient had a diagnosis of gallstone pancreatitis with no other medical problems. I had seven admissions that day. I said (when EI #1 -EDNP called presenting this patient) 'Why don't you call the surgeon on call.' She (EI #1 - EDNP) said 'I already did and she (EI #3 - General Surgeon) won't do it (admit the patient).' I said I'd call (EI #6 - Director Hospitalists) and I did. (EI #6 - Director Hospitalists) said not to admit this patient, to consult if needed, this is a healthy patient with no medical problems with the chief complaint of abdominal pain and CT shows gallstone pancreatitis. This was a surgical patient with no medical problems and the surgeon should be the admitting physician. All we're (hospitalist) doing is paperwork for them (surgeon). The surgeon can admit patients without medical problems and consult us, (Hospitalist), if a medical problem arises."

*EI #6 (Director Hospitalist Program) was interviewed on 08-28-12 at 15:15 stated "At (Hospital B) internal medicine physicians won't take surgical patients. (EI #2 - Hospitalist) called me that weekend (Saturday, 08-11-12). I told him (EI #2 - Hospitalist) not to admit this patient. The patient was a surgical patient with no medical problems and we would consult if there was a medical problem..."

*EI #3 Dr (General Surgeon on call 08-11-12 and 08-12-12) was interviewed on 08-28-12 at 15:43 and stated "We're taught EMTALA in residency so I know EMTALA... It's very rare that I get called for pancreatitis gallstone (PI #1 08-11-12). We don't have GI (gastrointestinal physician) on call on weekends to do the ERCP. Pancreatitis is a medical issue and refer the patient to GI for the ERCP for the gallstones... It has been the practice in the past for medicine to admit them (patients) and consult us, surgery. This has never been question in the past. This is the first time I've been asked to admit a patient with gallstone pancreatitis..."

4. REVIEW OF PI #2's ED RECORD & INTERVIEWS

PI #2's ED record was reviewed for the ED visit of 08-11-12 to 08-12-12 and included the following information.

"EMERGENCY ENCOUNTER RECORD
ED Arrival Information: 08-11-2012 23:42.
Acuity: Urgent...
History of Present Illness: Pt c/o (complaints of) abdominal pain. Pt states s/s (signs / symptoms) for approx (approximately) 3 days. Pt states when she burps it smells like feces... The history is provided by the patient...
Past Medical History Reviewed
Diagnosis:
IBS (irritable bowel syndrome).
Diverticulitis.
Gastritis.
Plan of Care and Medical Decision Making:
(EI#4 - EDMD) 08-12-12 06:49 to 07:50 ED provider notes filed.
CT scan preliminary report, stated that " findings concerning for partial to early high grade SBO " (small bowel obstruction). WBC (white blood count) is 22,900 with a left shift. I spoke with (EI #5 - Hospitalist) concerning admission of this patient. (EI #5 - Hospitalist) stated that this was a surgical patient and should be admitted to the General Surgeon on call. I spoke with (EI #5 - Hospitalist) again who stated this was a surgical patient and still would not admit the patient, that the surgeon should admit the patient. She (EI #5 - Hospitalist) informed me that since (EI #3 - General Surgeon) would not admit the patient that I should transfer the patient to the on call general surgeon at (Hospital B). I then spoke with the House Supervisor. I then spoke with (physician) in the ER at (Hospital B). who explained that I would have to get general surgery to accept the patient at (Hospital B) rather than attempt an ER to ER transfer. I again spoke with the House Supervisor, who stated that she would contact administration, here (Hospital A).
(EI #3 - General Surgeon) called me back and informed me that she would not accept the patient for admission, that she did not feel that this patient had a surgical problem. I once again explained to (EI #3 - General Surgeon) that the patient's abdomen was tender, the patient had a very high WBC, and the preliminary radiology report suggested a small bowel obstruction. (EI #3 - General Surgeon) stated she would see the patient if someone else admitted the patient and consulted her. (EI #3 - General Surgeon) suggested that I try to transfer this patient to the Hospitalist on call at (Hospital B).
I then spoke with (EI #6 - Director Hospitalists). (EI #6 - Director Hospitalists) stated that this patient would not be admitted by the Hospitalist Service because this was a surgical patient. I again spoke with the Nursing Supervisor and informed her that I had exhausted all options to get this patient admitted here.
I spoke with (General Surgeon) @ 07:30, the general surgeon on call at (Hospital B). (General Surgeon) accepted this patient for transfer as a direct admission to his service at (Hospital B). (PI #2) is to be transferred via ALS (advanced life support) Ground (ambulance) (on 8-12-12 at 08:22),
Clinical Impression:
Acute abdominal pain.
Leukocytosis.
Possible small bowel obstruction...

DISCHARGE SUMMARY (Hospital B)
Admitted: 08-12-12. Discharged: 08-16-12.
Discharge diagnosis: Partial small bowel obstruction..
Hospital course: Patient was placed on NG (nasogastric) tube to low wall suction and kept NPO (nothing by mouth). Patient had good relief of her nausea and pain with NG tube. Patient continued NG tube until hospital day four. NG tube was pulled and bowel function resumed. Patient was passing flatus, having bowel movements, and was not reporting any abdominal pain or nausea or vomiting. Patient was hep (heparin) locked and placed on a clear liquid diet, which she tolerated well. Patient remained afebrile without any increase in white blood cell count during her hospitalization. Patient made a full recovery from her partial small bowel obstruction without any need for surgical intervention...

*EI #4 (ED MD on 08-11-12 and 08-12-12) was interviewed on 08-29-12 at 15:35 stating "(PI #2), a 26 year old female with complaints of severe abdominal pain, nausea, vomiting and diarrhea for days presented to this ED between 11 PM to 12 AM. Her abdomen felt pretty tender and looked highly suspicious for a small bowel obstruction (per CT scan). I talked to (EI #5 - Hospitalist on call) about admitting (PI #2). (EI #5 - Hospitalist) said this sounded like a surgical patient and said that I needed to talk to the surgeon on call. Then I talked to the surgeon on call (EI #3), who said she wouldn't admit the patient but would consult if the patient was admitted by the Hospitalist. I went over the patient again, that I was very concerned, that this was highly suspicious for a small bowel obstruction. Then (EI #3 -General Surgeon) looked at the patient's CT scan via her laptop and said the radiologist didn't read the CT correctly, this was not a bowel obstruction and the patient did not have a surgical problem. (EI #3 - General Surgeon) said 'I will not admit this patient' and argued with me that the patient did not have a small bowel obstruction. Now I did not demand (EI #3 - General Surgeon) to come to (ED) to evaluate the patient. I then called (Hospitalist) at (Hospital B) (to accept this patient as a transfer) and he (Hospitalist) said that I would have to call the on call surgeon to accept this patient. Then I got the surgeon on call at (Hospital B) and he accepted the patient... The House Supervisor was notified several times about this situation, the on call physicians refusing to admit this patient who then had to be transferred to another hospital. The House Supervisor said she would call the Administrator on call..."

*EI #5 (Hospitalist 6 PM - 6 AM on call for 08-11-12 / 08-12-12) was interviewed on 08-28-12 at 17:30 stating "That night (08-11-12 Saturday night / 08-12-12 Sunday morning) was a bad night. I had to intubate a patient in the ED... That ED physician (EI #4) was concerned whether or not this might be an EMTALA violation... (EI #4 - ED MD) said he had a 26 year old that had a possible small bowel obstruction, possible free air, very tender abdomen... I asked if he (EI #4)) had called the surgeon on call. (EI #4 - ED MD) said 'Yes, I called.' I said 'We cannot admit a bowel obstruction and the surgeon won't come in to see the patient.' In the past I have had two to three patients who needed surgery emergently and (EI #3 - General Surgeon) would not come in until the following morning... I then asked (EI #4 - ED MD) if she (PI #2) had any medical problems such as diabetes, hypertension, etc. He (EI #4 - ED MD) said 'No. No medical problems.' He (EI #4 - ED MD) never mentioned diverticulitis or IBS. I suggested he call (EI #3 - General Surgeon) back. (EI #4 - ED MD) also called (EI #6 - Director Hospitalists) that night about this patient. (EI #6 - Director Hospitalists) said he also felt this was a surgical patient... In essence we did not have surgical service and had to transfer the patient to (Hospital B) for treatment... It's usually a partial bowel obstruction with other medical problems which we will admit. This patient (PI #2) (EI #4 - ED MD) said he felt was a bowel obstruction, not a partial bowel obstruction. (EI #4 - ED MD) was very concerned about this patient..."

* EI #3 (General Surgeon on call 08-11-12 and 08-12-12) was interviewed on 08-28-12 at 15:43 stating "I have my lap top so I can bring up the patient's CT scan, etc., to view while the ED physician is talking about the patient... This patient (PI #1) CT with contrast possible bowel obstruction... It was high in the small bowel, jejunum, not a lot of dilatation, no hernia, no Crohn's disease... She (PI #2) had dirty urine and high WBC 22,000. I said (EI #4 ED MD) 'Let the medical guy put her (PI #2) in (admit).' Diverticulitis is a medical problem and (Hospitalist) admits those patients, then consults surgery... 80% of small bowel obstructions are not surgical but patience and perseverance is the best thing for the patient. I read my own CT scans (trained at Hospital B) so when an ED physician calls me about a patient I will pull up the CT scan, labs, etc., from the portal on my lap top while speaking to the ED physician... They (Hospitalists) have always admitted the patient(s) then consult us (surgeon). Why this change?"

*EI #7 Registered Nurse (RN) House Supervisor on 08-11-12 / 08-12-12, 7 PM -7 AM, was interviewed on 09-07-12 at 10:15 and stated the following.

"I started getting calls around 04:30 to 05:00 about the on call Hospitalist and on call Surgeon refusing to admit (PI #2). I talked to (EI #5 - Hospitalist) who said the patient was out of her scope of practice, can't admit patients with surgical diagnosis and not being comfortable with admitting (PI #2). I talked to (EI #4 - ED MD) who said that they have this ED patient who needed to be admitted, that he talked to (EI #3 - General Surgeon) who said (PI #2) was not a surgical patient and would not admit (PI #2). I also talked to the Hospitalist that was coming on at 06:00 (EI #2 - Hospitalist) about admitting this patient and he said the exact same thing as (EI #5 - Hospitalist) that they can't admit a surgical patient. I did inform the Administrator on call about this situation. I had also passed this information on to the on coming House Supervisor (EI #8). I can find out why the physician(s) won't admit the patient but I can't make the physicians take the patient..."

*EI #8 (House Supervisor on 08-11-12 / 08-12-12, 7 AM -7 PM) was interviewed on 08-28-12 at 15:15 stating "I talked to (EI #2 - Hospitalist) who said he was going to talk to (EI #6 - Director Hospitalists) and then they made the decision not to admit the patient. (EI #3 - General Surgeon) was aware of this... I called Administrator on Sunday morning (08-12-12)... I (Administrator) about the two patients who were transferred (Hospital B) and neither physicians (EI #2 - Hospitalist for PI #1, EI #5 -Hospital for PI #2 and EI #3 - General Surgeon for both PI #1 and PI #2) would admit the patients. This type of thing usually does not take place. The patient is usually admitted."

*EI #9 Director Physicians was interviewed on 08-29-12 at 18:30 stating
"On 06-18-12 we had sent out (e-mail and fax to all medical staff and posted in the two physicians' lounges) EMTALA Regulations Regarding On Call Physicians (Physician Education) as a reminder of the On Call Physicians' responsibilities... All physicians, as part of their orientation to the hospital, are educated regarding the EMTALA regulations by (EI #10 Risk and Compliance Officer)... We have a Medical Executive Committee scheduled for 09-20-12 for the purpose of developing a follow up plan to the problem of the On Call Physicians not accepting patients for admission when requested by the ED physician (on 08-11-12 and 08-12-12). We want to keep patients from our community in our hospital when we have the ability to care for them."

*EI #10 Risk and Compliance Officer was interviewed on 08-29-12 at 17:20 stating "I got a call from (Risk Officer) at (Hospital B) on 08-13-12 saying that they had received two transfers (patients) from our ED... and may have to report us (Hospital A) to CMS for inappropriate transfer... Both patients' ED records were reviewed... The Administrator (EI #11) had been called on Sunday, 08-12-12, by the House Supervisor (EI #8) and informed (EI #11 - Administrator) of these two transfers to (Hospital B) because the on call physicians here would not admit these patients... (EI #11 - Administrator) talked to the involved physicians. I also talked to the physicians... Back in June 2012 a one page education sheet was sent out to the Medical Staff about On Call Physicians' obligations... There is a Medical Executive Meeting on 09-20-12 to discuss and resolve these issues..."

*EI #1 Administrator was interviewed on 09-05-12 at 09:35 stating "I was not the Administrator on call but I did receive a call on Sunday morning (08-12-12) and spoke with the House Supervisor (EI #8) who made me aware of the patients (two) that were transferred to (Hospital B)... On Monday 08-13-12 I received a call from Administration at (Hospital B) saying that they had received two admissions from our ED over the weekend and that I needed to research this... We have done some education with Medical Staff and will do more. A Medical Executive Committee Meeting is scheduled for 09-20-12 with the main agenda of addressing the above issues with Medical Staff... I did speak one on one to (EI #3 - General Surgeon)."



These citations were written as the result of the investigation of complaint/report AL00027321.