HospitalInspections.org

Based on record review, policy review, and interview, the facility failed to comply with the conditions of participation outlined in §489.24: The facility Medical Bylaws failed to describe the expectations of having a specific on-call physician named for each shift and failed to keep a comprehensive schedule of on-call physicians. The facility failed to consult an on-call physician for 2 of 10 transferred patients (#'s 2 and 8) who were determined to be emergent in their medical condition. The on-call physician responsible for evaluating the risks and benefits of such transfers was not contacted. The facility failed to provide a timely medical screening exam and treatment for one patient (#2). These failures could cause unintended adverse medical consequences for all emergency department patients being transferred to other facilities. Finding include:

1. In a review of the physician on-call list from November 2020 through April 2021, mid-level providers were scheduled on all days. Physicians were listed during the week days (but not all weekdays), weekends and holidays only listed the on-call mid-level providers. In an interview on 4/29/21 at 9:00 a.m., staff member A said the facility did not have an on-call physician list and utilized an on-call telemedicine group. The schedule did not specifically identify on-call physicians from the on-call telemedicine group. Refer to C-2404.

2. An Immediate Jeopardy was called for the delay in the provision of a medical screening exam and treatment for patient #2. Interviews with patient #2 on 4/27/21 and family members #1 and #2 on 4/27/21 showed the facility had discouraged patient #2 from coming to the emergency department on two occasions, and from receiving an MSE for 50-minutes after arrival at the emergency department. The facility developed a plan for the removal of the immediacy and the immediacy was removed on 4/29/21 at 11:15 a.m. Patient #2 was assessed to be at imminent risk for deterioration and in critical condition before transfer. Refer to C-2406

3. Review of the medical records for patients #2 and #8 lacked evidence that an on-call physician for the facility was consulted regarding the patient's condition prior to transfer to another facility. The Physician had not been held responsible for assessing the risks and benefits of transfer prior to the implementation of the transfer. Refer to C-2409

4. Review of the Medical Bylaws showed the expectations for an on-call physician and a backup plan for when the on-call physician would not be available were not developed in the facility's Medical Bylaws and subsequently no related policies and procedures were developed in support of the Bylaws. Refer to C-2404 and C-2409.

Based on record review and interview, the facility failed to have posted and have available a list of on-call physicians for each shift at the hospital. This failure could cause the patients to have a decreased availability of an on-call physician to assist with needed assessment and care. This failure could affect all patients receiving services through the emergency department (ED), with a monthly average census of 70. Findings include:

Review of the Provider Schedule for the months of November 2020 through April 2021, provided by the facility as their on-call physician list, showed during the week days and weekends, mid-level providers are listed. During the week days (but not all week days) some physicians are named. On the weekends there was no named physician on-call. Further, during the week days and on holidays, the schedule did not address which physicians are on-call for which shifts and no contact information was listed on the schedule. The schedule did not list the names of the telemedicine company for physicians who provided services to the facility and did not list a specific physician who would be on-call for the telemedicine company.

During an interview on 4/29/21 at 9:00 a.m., staff member A stated the facility's on-call schedule listed the providers (mid-level). Staff member A stated they used a company called [telemedicine company] who provide telemedicine if the mid-level provider needed a physician. Staff member A did not think having a consultation with a physician prior to transferring an unstable patient was a requirement and said they [the mid-level providers] always consult with the physician from the receiving hospital.

During an interview on 04/29/21 at 10:30 a.m., staff member E stated the facility did not have an on-call physician list. Staff member E stated the facility only had an on-call provider list (mid-level). Staff member E stated the facility had a doctor begin working in March of 2021 and this physician was now listed on the facility on-call provider list.

A request was made for policies to cover the on-call physician schedule and expectations of the on-call physician. The facility was unable to provide an on-call physician list or policies prior to the end of the survey.

Based on interview and record review, the facility delayed examination and treatment for a patient when the patient called the facility ahead of time, prior to admission, and again when the patient arrived at the facility for 1(#2) of 20 sampled patients; and, the facility diverted 2 community members from coming to the ED when the community members called the ED to inform them they would be arriving at the ED for medical assistance. This failure caused harm to patient #2, who was found to be in imminent deteriorating condition once provided an emergency medical stabilization examination, and transferred to another facility for a higher level of care; and delayed access to emergency medical treatment for patient #20, who was experiencing complications from heart disease.

IMMEDIATE JEOPARDY

On 4/28/21 at 10:45 a.m., the facility Chief Executive Officer and the HIM Manager were notified that an Immediate Jeopardy existed in the area of C-2406 (§489.24(a); §489.24(c)) Appropriate Medical Screening Examination.

Patient #2 experienced shortness of breath and difficulty breathing on 11/13/20. Per the FNP, the patient was in imminent danger. Review of patient #2's medical record showed the patient was diagnosed with pneumonia related to COVID and possible sepsis. The facility delayed examination and treatment for the patient when the patient called the facility ahead of time prior to admission, and again when the patient arrived at the facility.

The facility submitted an acceptable plan to remove the immediacy on 4/28/2021 at 6:57 p.m.

The removal of the immediacy was verified on 4/29/21 at 11:15 a.m.

PLAN TO REMOVE IMMEDIACY

A summary of the facility's plan to remove the immediacy was as follows:

SMHA Removal of Immediacy Plan
April 28, 2021

A. Patient number two filed a grievance in December of 2020, Sheridan Memorial Hospital Association is currently working through resolution of this grievance and it has been introduced into our QAPI beginning in January of 2021.
B. Purpose: The purpose of the improvement plan is to provide Sheridan Memorial Hospital Association (SMHA) Staff guidance on how to properly screen patients who call the hospital on the phone and when the patient presents to the Emergency Department in order to reduce the risk of a delay in care.
Procedure:

1. Patients Calling into SMHA:
a. SMHA Staff will follow the procedures set forth in the "CAH Telephone Calls" policy (which was implemented April 28, 2021) policy when a patient calls into the CAH.
i. Refer To: CAH Telephone Calls PolicyStat ID: 9711986
b. Documentation will be completed for patients who call in, the following documentation will be completed on the call log:
i. Patient Name and Date of Birth
ii. Reason for Calling
iii. Staff Response
iv. Patient's Response
v. Staff Name and Position
vi. Date and Time of Phone Call
vii. Staff Signature

2. Patients Arrive at the Emergency Room Entrance:
a. CAH Nurses, CNAs, APPs, Physicians, and Ward Clerks will be retrained to complete patients MSE inside the facility.
b. Patients who present at the Emergency Room will be immediately triaged and provided an MSE timely based on need.

3. Patient Dignity
a. For the morning shift on April 29, 2021 training will begin for all staff currently on shift.
b. Staff who are not currently working will receive a copy of this document and will be educated on the updated procedures when they arrive for their next scheduled shift.
c. Staff will be required to sign off that they have been educated and understand the procedures set forth in this improvement plan.
d. A copy of the patient dignity policy will be emailed to all staff by 11:59PM on April 28, 2021

4. Patient Rights
a. For the morning shift on April 29, 2021 training will begin for all staff currently on shift.
b. Staff who are not currently working will receive a copy of this document and will be educated on the updated procedures when they arrive for their next scheduled shift.
c. Staff will be required to sign off that they have been educated and understand the procedures set forth in this improvement plan.
d. A copy of the patient rights policy will be emailed to all staff by 11:59PM on April 28, 2021

5. CEO is going to review facility policies for video surveillance and security by 11:59PM on April 28, 2021 and will suggest improvements at the next Quality Committee Meeting.

6. Immediate Education for Nurses, CNAs, APPs, Physicians, and Ward Clerks who receive calls and provide patient care in the ER will be retrained according to the following:
a. Education on the updated procedures will be completed by Employee Health Registered Nurse, Director of Nursing, CNO, or Registered Nurse as soon as possible but no later than their next scheduled shift.
b. For the morning shift on April 29, 2021 training will begin for all staff currently on shift.
c. Staff who are not currently working will receive a copy of this document and will be educated on the updated procedures when they arrive for their next scheduled shift.
d. A copy of this document will be emailed to all CAH Staff by 11:59PM on April 28, 2021.
e. Staff will be required to sign off that they have been educated and understand the procedures set forth in this improvement plan.
f. The Improvement Plan will be reinforced daily in facility safety huddle and CAH huddle for the next month.

Findings include:

1. During a phone interview on 4/27/21 at 8:48 a.m., patient #2 stated she was diagnosed with COVID-19 on 10/31/2020. She stated she saw her primary care provider (PCP) on 11/02/2020, and she was instructed to go to the emergency room in the event she had any further complications. Patient #2 stated she began experiencing shortness of breath on 11/13/20. She stated her oxygen saturations on her home pulse oximeter read in the 70's and 80's. Patient #2 stated her (family member #1) called the hospital at 3:17 a.m. to inform staff that he was bringing patient #2 to the emergency department. Patient #2 stated the nurse who triaged the call told her family member there was nothing the hospital could do for patient #2 because of her size. Patient #2 stated the nurse instructed the patient's family member #1 not to bring patient #2 to the emergency room, and told family member #1 to take the patient to another hospital, which was 82 miles away. Patient #2 stated she began having trouble breathing at 6:30 a.m., and she called family member #2 to explain her symptoms and share the information about the earlier call to the hospital. She stated family member #2 contacted the emergency room and explained that patient #2 was in crisis and needed to be seen. Patient #2 stated family member #2 was informed by the triage nurse that the emergency room did not have the staff to handle patient #2 or her disability and she needed to go to Sidney or Williston. Patient #2 stated family member #2 told the hospital that she was bringing patient #2 to the emergency room as she would not make it to Sidney, and she would die. Patient #2 stated she arrived at the emergency room at 7:00 a.m. and was accompanied by two family members (family members #1 and #2). Patient #2 stated the hospital staff instructed (them) to move their vehicle because of an ambulance that was expected to arrive soon. Patient #2 stated the ambulance departed the facility at 7:24 a.m., and the party pulled up in front of the emergency room doors. Patient #2 stated another call was made to the hospital and the parties were told that they weren't going to let patient #2 in, and she needed to be transported to Sidney, which was 82 miles away. Patient #2 stated family member #2 began calling hospital staff including (staff member B) and (staff member A). Patient #2 stated [staff member D] and [staff member I] arrived at the emergency room doors at 7:59 a.m. Patient #2 stated she had been sitting in the car for over fifty minutes by the time they arrived. Patient #2 stated [staff member D] approached her and stated, "I expected you to look worse. You are flying out; I already made the arrangements. You can agree to fly, or you can go home and die." Patient #2 stated since 11/13/20 she was, "Having severe depression and started counseling," and, "I sleep for days."

During an interview on 4/27/21 at 11:08 a.m., family member #2 stated they received a call from patient #2 around 6:30 a.m. on 11/13/20. Family member #2 stated patient #2 had told her that their health had begun declining in the middle of the night and they could not breath and they thought they were going to die. Family member #2 stated patient #2 told them that family member #1 had called the ER and was told that they could not care for [patient #2] and it was about [patient #2's] weight because [patient #2] was too large, and that [patient #2] should go to Sidney or Williston. Family member #2 stated they hung up the phone with patient #2 and called the hospital desk and asked to speak with the night nurse who had spoken with the patient's [family member #1]. Family member #2 stated they spoke to the nurse who had spoken to family member #1. Family member #2 said that patient #2 was in a crisis, she could not breathe, and she needed to be seen by a doctor. Family member #2 stated the nurse told her, "We don't have the staff to handle [patient #2], [patient #2] needs to go to Sidney or Williston. We don't have the staff to handle [patient #2's] disability." Family member #2 stated they told the nurse that they were bringing the patient to the hospital. Family member #2 stated the patient cannot make it to Sidney, and [patient #2] was going to die. Family member #2 stated they accompanied patient #2 to the hospital. Family member #2 stated when they arrived at the hospital, they rang the bell, and no one came to the door. Family member #2 stated the hospital had a sign on the door with instructions posted to call a number. Family member #2 stated they called the number and was told by the facility staff they could not talk to the nurse at the hospital desk about patient #2 due to confidentiality and was told that patient #2 would have to call. Family member #2 stated they told the person on the phone the patient could not breathe, and the person stated they were sorry, but the patient would have to call. Family member #2 stated the patient called and was told they needed to move their vehicle for an incoming ambulance and the hospital staff would not be able to see [patient #2] until the ambulance left the facility. Family member #2 stated family member #1 backed the vehicle out of the way and both family members and the patient waited. Family member #2 stated the ambulance arrived and later departed the facility, and still no one came out to assess the patient. Family member #2 stated the patient told them, "I'm not going to make it, I'm going to die." Family member #2 stated they decided to begin calling hospital staff. Family member #2 stated they called [staff member B], the quality assurance / performance improvement (QAPI) nurse, and [staff member A]. Family member #2 stated she called [staff member A] at home and told them, "I'm at the ER with [patient #2], [patient #2] had COVID-19, [patient #2] is gravely ill, and is going to die at the ER door if somebody doesn't help us." Staff member A told [family member #2] they would call the hospital desk and talk to the nurse and would call [family member #2] back. Family member #2 stated the patient had to wait almost an hour before anyone came out to address the patient. Family member #2 stated [staff member D] approached patient #2 and said, "You cannot refuse transfer, you can go home and die, or you can fly to Billings, but you cannot stay in this hospital." Family member #2 stated they asked [staff member D] why, and staff member D stated they did not have the staff to take care of patient #2 and then proceeded to explain how many staff would be needed to transfer patient #2 if they were to stay. Family member #2 stated the event has been very devastating for patient #2. Family member #2 stated patient #2, "Is still emotionally unstable and cries, [patient #2] talks about ending [their] life. Patient #2 stopped having the grandkids come over. Patient #2 is afraid to come back to the hospital."

During a phone interview on 4/27/21 at 12:12 p.m., family member #1 stated they called the hospital on 11/13/20 at 3:17 a.m. and stated patient #2 was having trouble breathing. They stated they were told there was nothing the hospital could do for patient #2, and they could not even give patient #2 an X-ray. Family member #1 stated they were not sure who they had talked to, but the person discouraged them from bringing patient #2 to the hospital. Family member #1 stated patient #2 woke up at 6:30 a.m. and told them that they really needed to go to the hospital. Family member #1 stated patient #2 called family member #2, and family member #2 called the hospital to notify them that they were bringing patient #2 to the Emergency Room. Family member #1 stated they called the number posted on the emergency room doors when they arrived at the facility. Family member #1 stated they were asked to move their vehicle for an incoming ambulance. Family member #1 stated patient #2 had to wait almost an hour before anyone came out to assist [patient #2]. Family member #1 stated the doctor from the emergency room came out and told patient #2 that [patient #2] could not stay at the hospital and [patient #2] could go home and die or fly out. Family member #1 stated they and patient #2 had received permission from both the hospital [staff member #A] and [staff member B] to assist staff with providing care for the patient in the event of an emergency. Family member #2 stated they were denied this opportunity on the morning of 11/13/20. Family member #1 said the staff who assisted patient #2 into the hospital had a difficult time. Family member #1 stated one of the nurse's made a comment about patient #2 being so large and she didn't know if she could push [patient #2]. Family member #1 stated patient #2 was, "Very, very weak, [patient #2] could hardly get a breath in and was in bad shape. [Patient #2] needed help."

Review of Patient #2's cell phone records showed, patient #2 had called family member #2 at 6:24 a.m. on 11/13/20.

Review of family member #1's cell phone records showed, family member #1 had called the hospital at 3:17 a.m., 7:02 a.m., and again at 7:26 a.m. on 11/13/20.

Review of family member #2's cell phone records showed, they called the hospital at 6:29 a.m. on 11/13/20. They called the facility QAPI nurse at 6:39 a.m. and 6:50 a.m., staff member A at 7:34 a.m., and staff member B at 6:51 a.m. and 7:15 a.m., on 11/13/20.

During an interview on 4/27/21 at 3:43 p.m., staff member B stated the hospital kept a call log for all patients who called the hospital for phone triage. Staff member B said they were unable to find the call logs for the month of November 2020. Staff member B stated, "I've looked everywhere and I can't find them."

During an interview on 4/27/20 at 5:18 p.m., staff member Q stated the hospital had video surveillance at their emergency room doors. Staff member Q stated the cameras only record when they detect motion. Staff member Q stated he was asked to look at the video footage from the morning of 11/13/20 previously. During the interview, staff member Q showed the surveyors video footage of patient #2 arriving in front of the ED in their vehicle. Staff member Q stated no footage was available for viewing of patient #2 entering the ED (patient #2 entered the ED on the morning of 11/13/20).

Review of video surveillance footage for the morning of 11/13/21 was requested, but the facility did not provide the requested information.

Review of patient #2's medical chart showed patient #2 had a diagnosis of chronic renal insufficiency, diabetes, diastolic heart failure, hypertension, morbid obesity, super ventricular tachycardia, and others.

Review of patient #2's discharge summary, dated 11/13/20, showed, "Upon my evaluation this pt has a high probability of imminent or life-threatening deterioration due to her Covid pneumonia, obesity, DM, and CHF. This required my direct attention, intervention, and personal bedside mgmnt [sic]." The final note was signed electronically by staff member D.

During an interview on 4/28/20 at 9:47 a.m., staff member D stated the ED was capable of handling more than one ED patient at a time. Staff member D stated they recalled the incident on 11/13/20 when patient #2 arrived at the ED. Staff member D stated they wrote a letter to the hospital following the incident. Staff member D stated they did not feel comfortable answering questions about the incident, and would return a call to the surveyors at a later time. Staff member D has not returned a call.

Record review of a letter staff member D wrote to the hospital, dated 2/2/21 showed, "... When I started my shift at [hospital], I was informed by the staff that there was a patient in the community that was Covid positive, having complications and may be coming into the ER. The staff was knowledgeable for her past HX, multiple comorbidities and concerns that [patient #2] was decompensating. There were concerns that their facility was not able to accommodate a patient of [patient #2's] size due to limited bariatric equipment."

Record review of facility policies on 4/28/21 showed the facility did not have a practice of directing patients to an alternate site for MSE's during a public health emergency, as allowed under an 1135 waiver.

2. During a phone interview on 4/27/21 at 1:19 p.m., community member #3 stated they called the ER on 11/11/20 regarding their daughter having difficulty breathing due to COVID-19. They stated they were monitoring their daughter's oxygen levels at home with a pulse oximeter. Community member #3 stated she talked to a nurse at the facility and explained that her daughter had a fever and her oxygen levels were in the 80's, with 79 being the lowest. Community member #3 stated the nurse at the ER asked her if anyone in their home had COVID-19. Community member #3 stated she told the nurse that the adults in the immediate household had recently tested positive for COVID-19, and the children were showing symptoms. Community member #3 stated the nurse at the facility told her, "I rather you not bring her in, so everyone here doesn't get COVID." She stated the nurse also said that home oxygen monitoring devices often read lower than those devices used in the ER. Community member #3 stated the nurse did not tell her to bring her daughter into the ER if her symptoms got worse. She stated she panicked after hanging up the phone with the nurse at the ER, and began using rescue inhalers for her daughter. Community member #3 stated she never took her daughter to the ER, and she was afraid that if she did so she would be denied services.

During an interview on 4/27/21 at 3:43 p.m., staff member B stated the hospital keeps a call log for all patients who call the hospital for phone triage. Staff member B said they were unable to find the call logs for the month of November 2020. Staff member B stated, "I've looked everywhere, and I can't find them."

3. During a phone interview on 4/28/21 at 12:25 p.m., community member #4 stated patient #20 was seen in the ER for an ear infection on the morning of 08/19/20. She stated patient #20 began feeling worse throughout the day, he had not ate or drank anything, and he spent the day sleeping. Community member #4 stated she called the ER in the afternoon and spoke to a nurse and told her the concerns she had for patient #20, and told her that she was, "Really scared." Community member #4 stated the nurse at the ER told her, "You really need to give the medications time to work. We can't do anything here that you can't do at home." Community member #4 stated she called her boss and shared her concerns with him. She stated she works with the Assistant Coroner, who is a nurse, and she asked her boss if he would call her and ask her if she would assess patient #20. Community member #4 stated the Assistant Coroner called her right away and stated, "Take [patient #20] to the ER right away. The hospital cannot turn you away." Community member #4 stated she took patient #20 to the ER and within a half hour of their arrival, patient #20 was flown to Minot to have a pacemaker placed. Community member #4 stated, "The doctor in Minot told me that if I wouldn't have gotten [patient #20] medical care he would have died."

During an interview on 4/27/21 at 3:43 p.m., staff member B stated the hospital keeps a call log for all patients who call the hospital for phone triage.

Record review of the facility ER call logs for 8/19/20 showed, the facility lacked documentation of the call for patient #20.

Record review of patient #20's EHR dated 8/19/20, under Emergency Room Report, showed, "Upon arrival to the emergency department the patient was evaluated in the CCU and heart monitoring demonstrated third-degree heart block ... EKG was faxed to [physician in Minot] and [physician] accepted transfer given [patient #20's] third-degree heart block and need for a pacemaker placement."

Based on record review and interview, the facility failed to consult the facility on-call physician prior to the transfer of patients in an emergency status, including review of the risk and benefits of transfer for 3 (#s 2, 8, 14); the provider or physician failed to accurately date and time the Physician Certificate of Transfer orders for 5 (#s 4, 8, 12, 14, 17) of 20 sampled patients. These failures placed the patients at a higher possible risk for deterioration during transfer and contributed to incomplete documentation of the transfers. Findings include:

1. Review of patient #2's electronic medical record (EHR), provided in hard copy by the facility, showed patient #2 was seen in the emergency department (ED) on 11/13/20 at 7:50 a.m. by staff member D. Patient #2 was assigned an emergency severity index (ESI) level of three, or minor. At 8:57 a.m. she was assigned an ESI level of one, or immediate lifesaving intervention is required without delay. Review of patient #2's Physician Certificate of Transfer, dated 11/13/20 at 9:18 a.m., showed staff member D had signed and dated the transfer indicating it was an emergency transfer. Staff member C later reviewed and signed the form but did not date or time the form. Review of the EHR dated 11/13/20 showed no on-call physician was contacted for consultation and the on-call physician did not have an opportunity to weigh the risks and benefits of the transfer prior to the transfer being implemented.

2. Review of patient #4's EHR, provided in hard copy by the facility, showed patient #4 was seen in the ED on 10/18/20 at 1:22 p.m. by staff member N. Patient #4 was transferred to another facility. Review of the transfer sheet showed the transfer sheet was signed and dated by staff member N and later signed by staff member C. Staff member C did not include the time and date of their signature.

3. Review of patient #8's EHR, provided in hard copy by the facility, showed patient #8 was seen in the ED on 1/5/21 at 8:54 a.m. by staff member O. Patient #8 was later transferred to another facility at 12:00 p.m. Review of the Physician Certificate of Transfer sheet showed patient #8 was transferred in an emergent condition and the transfer order was signed by staff member N. The transfer order was dated by staff member N, but no time was included with the signature. The Physician Certificate of Transfer was later signed by staff member C, but no date or time of signature was included. Review of the EHR showed no evidence a facility on-call physician was contacted to review the risks or benefits of transfer prior to the transfer of patient #8 being implemented.

4. Review of patient #12's EHR, provided in hard copy by the facility, showed patient #12 was seen in the ED on 11/19/20 at 5:27 p.m. Review of the Physician Certificate of Transfer sheet showed patient #12 was transferred to another facility in stable condition on 11/19/20 at 10:20 p.m. The Physician Certificate of Transfer sheet was signed by staff members P and C, and dated, but no time was included with the signatures.

5. Review of patient #14's EHR, provided in a hard copy by the facility, showed patient #14 was seen in the ED on 11/6/20 at 3:56 p.m. with a chief complaint of COVID positive, respiratory distress. Patient #14 was given an ESI score of two, or emergent with high risk of deterioration or signs of time-critical problem. Patient #14 EHR showed orders, "Patient is [sic] significant distress currently ... likely pulmonary emboli ... Flight team contacted and patient agreeable with transfer given complicate [sic] of situation." The EHR failed to show a facility on-call physician had been contacted regarding patient #14's transfer and an on-call physician was not given an opportunity to consider the risks and benefits to the patient prior to transfer. Review of the Physician Certificate of Transfer showed staff member O had selected emergency transfer for patient #14, had signed and dated the form, but had not included the time of signature. Staff member C had later signed the form but had not included a date or time of the signature.

6. Review of patient #17's EHR, provided in hard copy by the facility, showed patient #17 was seen in the ED on 10/10/20 at 12:46 p.m., with a chief complaint of abdominal pain and profound fatigue. Review of patient #17's Physician Certificate of Transfer showed staff member P signed the transfer order, but did not date or time the transfer order, and showed staff member C later signed the order, but did not date or time the order.

In a phone interview on 4/28/21 at 1:54 p.m., staff member N said she did not reach out to the hospital on-call physician prior to transferring a patient, this would be a delay in care. She stated she does reach out to the receiving hospitals to let them know she is sending the patients. Staff member N stated, "The supervising doctor is not always on-call and there is no on-call physician if he is not." Staff member N stated after signing the transfer notices, they are sent to the doctor electronically for signature at a later time.

In an interview on 4/29/21 at 10:30 a.m., staff member E stated, "There is no on-call physician list, just an on-call provider list. We had a doctor start in March of 2021, and I have highlighted where he is on-call. Other than that, it's just a provider on-call list that is posted."

In a phone interview on 04/28/21 9:47 a.m., staff member D stated, regarding contacting an on-call physician prior to transfer of unstable patients, "No, not necessarily, no. No, absolutely not we do not need the physician to sign off. Transfers occur in conjunction with the receiving physician. I've never worked in a facility where I have had to have approval for transfer. I have worked in multiple facilities."

In a phone interview on 4/29/21 at 10:00 a.m., staff member C stated mid-level providers never contact him when transferring patients. He said if the provider needed a physician, they could call the telemedicine physician [telemedicine outreach company]. He said he received a copy of transfer orders and signed them later, after the transfer. Staff member C said the provider would consult with the physician at the receiving hospital.

Review of the Physician on-call schedule for the months of November 2020 through April 2021, failed to show specific named physicians on-call for each shift at the facility.

Review of the Medical Staff Bylaws, last updated February 14, 2012, showed a physician was defined as a, "Doctor of medicine or doctor of osteopathy...." The Bylaws failed to address and detail the expectations of an on-call physician.

Review of the policy Examination and Treatment for Emergency Medical Conditions and Women in Labor, last updated 9/7/19, showed under appropriate transfer, " ... the patient needs treatment at the receiving facility, and the medical risks of transferring him/her are outweighed by the medical benefits of the transfer ... the weighing process as described above is certified in writing by a physician."

In an interview on 4/28/21 at 12:08 p.m., staff member E said the facility did not have policies for physician signatures on certificates of transfer and did not have a policy for consultation with the on-call physician for transfers of unstable patients.

Review of the policy Examination and Treatment for Emergency Medical Conditions and Women in Labor, last updated 9/7/19, showed, under Procedure III Patient Transfer "... 3. A physician has signed a certification that based upon the information available a the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual, and in the case of labor, to the unborn child from effecting the transfer, or 4. If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person has signed a certification after a physician, in consultation with the person, has made the determination described in such clause, and subsequently countersigns the certification; ..."