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Based on interview and record review the facility failed to have an on-call (physicians scheduled to provide treatment and services including consultations to patients when needed) gastroenterology (GI) physician at the Emergency Department (ED) for several days over several months.

This failure resulted in an on-call GI physician to not be available for consult and services at the ED for several months and for patients (Patients 3, 10, 25, 26, and 27), who were needing consultation with a GI physician, to be transferred to other facilities.

Findings:

On May 3, 2023, at 9 a.m., an unannounced visit was conducted at the facility to conduct an Emergency Medical Treatment and Labor Act (EMTALA) survey.

On May 3, 2023, at 9:32 a.m., an interview with Multi-Skilled Clerk II (MSCII) 1 was conducted. She stated if a patient comes into the ED and there is no GI physician on call, the patient would be stabilized then would be transferred to another hospital. She further stated the ED has had a shortage of GI consultants for several days a month for the past few months.

On May 3, 2023, at 9:50 a.m., an interview with the ED CNC (Clinical Nurse Coordinator) was conducted. He stated the GI on-call coverage has been an issue at the ED since the GI on-call physician passed away in March 2023. He further stated if there is no on-call physician, the ED will begin the process to transfer the patient who needed the consult to another local hospital for care.

On May 3, 2023, at 9:57 a.m., an interview with the MSCII (2) was conducted. She stated when a GI on-call physician was not available, the ED could not accept an incoming transfer from another hospital. She further stated if an emergent patient came in and needed a GI physician when one was not available, the patient would be transferred out to another facility.

On May 4, 2023, at 10 a.m., Patient 3's record was reviewed. The facility document titled, "HPI (History of Present Illness)-General Illness," dated January 1, 2023, at 5:39 p.m., indicated Patient 3 was initially brought to the hospital via ambulance for right upper quadrant abdominal pain associated with nausea and vomiting since December 25, 2022. The document indicated Patient 3's past medical history included a previous cholecystectomy (surgical removal of gallbladder) in 2011. The document indicated, "...Unfortunately, RCH does not have GI lab/ERCP (endoscopic retrograde cholangiopancreatography, procedure to visualize the upper portion of the digestive tract by xray and camera) capability until 8 January 2023 (January 8, 2023)...Will call for transfer to local surrounding hospitals with GI capability." The document indicated Patient 3 was transferred to Hospital A on January 1, 2023, at 7:36 p.m.

On May 4, 2023, at 10:30 a.m., Patient 10's record was reviewed. The facility document titled, "HPI-General Illness," dated February 3, 2023, at 10:12 p.m., indicated Patient 10 was initially brought to the hospital for chest pain after eating steak and feeling it was stuck at the bottom of his chest. The document indicated, "...We do not have gastroenterology here. Plan to transfer him. Transfer process initiated at 10:30 p.m...As GI services are not available at this time, transfer to outside facility for continuation of care will be arranged for higher level services..." The document titled, "Emergency Patient Record," indicated, "...Disposition: (Name of Hospital A)...Departure Date/Time: 02/04/23 (February 4, 2023)- 0104 (1:04 a.m.)..."

On May 4, 2023, at 10:45 a.m., Patient 25's record was reviewed. The facility document titled, "HPI-General Illness," dated March 15, 2023, at 1:57 p.m., indicated Patient 25 was initially brought to the hospital with right upper quadrant pain on and off for the last three weeks which worsened with eating. The document indicated Patient's 25's past medical history includes peptic ulcer disease (PUD, an open sore or raw area in the lining of the stomach or upper part of the small intestine), hypertension (a condition in which the blood vessels have persistently raised pressure), and type 2 diabetes (abnormal blood sugar). The document titled, "Critical Care Event," indicated, "...patient will need GI eval for GIB (gastrointestinal bleed). however (sic) our hospital does not have emergent GI coverage until 0/20 (March 20, 2023)..." The facility document titled, Clinical Note," dated March 15, 2023, at 9:30 p.m., indicated, "...I was contacted by the ED for admission d/t (due to) concern of GIB (GI bleed)...possible PUD. Unfortunately, there is no oncall GI at this time and it will be medically unsafe to admit this patient without GI available given concern of GIB...At this time, I declined to admit this patient given lack of GI availability in the setting of acute GIB..." The facility document titled, "Emergency Provider Report," dated March 16, 2023, indicated, "...0315 (3:15 a.m.): Spoke to (name of physician) at (Name of Hospital A) who accepted the patient for GI bleed..." The facility document titled, "Emergency Patient Record," indicated, "...Disposition: (Name of Hospital A)...Departure Date/Time: 03/16/23 (March 16, 2023) - 0600 (6 a.m.)..."

On May 4, 2023, at 10:45 a.m., an interview and record review were conducted with the Regulatory Compliance Manager (RCM). Review of the facility documents titled, "Gastroenterology," dated January 2023, February 2023, March 2023, April 2023, and May 2023, was conducted. The documents indicated:

-In January 2023, there was no GI physician coverage at the ED for 17 days;
-In February 2023, there was no GI physician coverage at the ED for nine days;
-In March 2023, there was no GI physician coverage at the ED for nine days;
-In April 2023, there was no GI physician coverage at the ED for nine days; and
-For May 2023, there was no GI physician coverage listed for the ED for 20 days.

The RCM stated, there were nine days for both March 2023 and April 2023, there was no GI physician on call at the ED, and there were 20 days in May 2023 when there was no GI physician coverage at the ED listed. The RCM referred to the GI physician on call coverage at the ED and stated, "We were short."

On May 4, 2023, at 11 a.m., Patient 26's record was reviewed. The facility document titled, "HPI-General Illness," dated April 21, 2023, at 2:18 p.m., indicated Patient 26 presented with three episodes of hematemesis (vomiting of blood) of bright red blood with clots and black stool for one day. The document indicated the medics observed approximately 300 ccs of blood on scene when they responded to check on the patient prior to bringing the patient to the facility. The document indicated Patient 26's past medical history included hematemesis and melena (dark tarry stool). The document indicated, "...(Name of Hospital A) unable to accept transfer at 1700 (5 p.m.)...(Name of Hospital B) accepted patient. 1726 (5:26 p.m.)...Patient will be transferred via critical care transport..." The facility document titled, "Emergency Patient Record," indicated, "...Disposition...(name of Hospital B)...Departure Date/Time: 04/21/23 (April 21, 2023)- 1831 (6:31 p.m.)...

On May 4, 2023, at 11:30 a.m., Patient 27's record was reviewed. The facility document titled, "Emergency Provider Report," dated April 26, 2023, at 11:32 a.m., indicated Patient 27 was seen in the emergency department due to vomiting blood since the day before. The document indicated Patient's 27's past medical history included atrial fibrillation (abnormal heart rhythm), congestive health failure (heart does not pump blood efficiently), hypertension (a condition in which the blood vessels have persistently raised pressure). The document indicated, "...Overall presentation is consistent with massive GI bleed...No GI on-call at this hospital today. Initiated transfer center at 12pm (sic), accepted by (name of Hospital A)...Disposition...Transfer...Time 1223 (12:23 p.m.)...Date 402623 (April 26, 2023)..."

On May 4, 2023, at 1 p.m., a concurrent interview and review of the facility policy and procedure titled, "Provision of On Call Coverage," dated April 22, 2020, were conducted with the Vice President ED (VPED). The VPED stated GI "is a service we offer." The VPED stated the GI on call should be listed in the document. The VPED stated the document "does say, not limited to, and that covers everything."

On May 4, 2023, at 1:20 p.m., an interview was conducted with the Chief Medical Officer (CMO). He stated the GI on-call physician was unavailable in January because he fell ill and was hospitalized and passed away on March 22, 2023. He stated there has been a shortage of GI on-call coverage for the ED since January of 2023.

A review of the facility policy and procedure (P&P) titled, "Provision of On Call Coverage," date April 22, 2020, was conducted. The P&P indicated, "...The types of on-call panels will be representative of the services offered and include, but not limited to: Trauma, Medicine, Cardiology, Cardiovascular Surgery, Cardiothoracic, Ophthalmology, Urology, Vascular, General Surgery, Plastic, Anesthesiology, ENT, Orthopedics, Neurosurgery, Pediatrics, Radiology/Angio/Interventional and Obstetrics/Gynecology, Neurology, Bariatric..."

A review of the facilityP&P titled, "EMTALA Provision of On-Call Coverage," dated March 2023, was conducted. The P&P indicated, "...The hospital must maintain a list of physicians on its medical staff who have privileges at the hospital...The facility's governing board must require that the medical staff be responsible for developing an on-all rotation schedule...The on-call schedule may be by specialty or sub-specialty...The Medical Executive Committee (MEC, a hospital committee comprised of physicians) shall review the on-call schedule and make recommendations to the CEO when formal changes are to be made or when legal and /or operational issues arise...The hospital shall keep local Emergency Medical Services advised of the times during which certain specialties are unavailable...The hospital is expected to provide adequate specialty on-call coverage consistent with the services provided at the hospital...The on-call physician has a responsibility to provide specialty care services as needed to any individual who comes to the Emergency Department..."