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Based on review of medical records and other documents and interviews with staff, it was determined the medical staff failed to ensure established rules and regulations relative to on-call responsibilities were enforced for at least one (1) of ten (10) cases reviewed (patient #1). This has the potential to create a situation in which the needs of patients are not met.

Findings include:

Review of the medical staff rules and regulations, dated 3/4/12, revealed the requirements include "Patients requiring admission who have no attending physician/dentist shall be assigned to the member of the active medical staff on emergency call. The specific department to which the patient is to be assigned will be determined by the Emergency Department (ED) physician ...Physicians who are on call for the ED and in-house consultations as set forth in Section D of the Hospital's Emergency Medical Screening, Treatment, Transfer and On-Call Roster Policy are unable or unwilling to see a patient in consultation are personally responsible for designating an alternate ...Failure of an attending physician/dentist to meet this requirement shall result in loss of clinical privileges."

The policy "Hospital's Emergency Medical Screening, Treatment, Transfer and On-Call Roster" policy, effective 8/11/09, states under section D "A refusal or failure on an on-call physician to timely respond shall be reported immediately to the President of the Medical Staff and the Chief Executive Officer, who shall review the matter and determine how to address the situation. If the refusal or failure to respond is found to be deliberate, or if it is a repeated occurrence, the matter shall be referred to the Medical Executive Committee for further investigation and appropriate disciplinary action. "

Review of the medical record for patient #1 revealed the 65 year old male patient presented to the ED at 13:42 on 5/21/2012. The patient complained of abdominal pain related to a hernia. The patient was assessed by the Nurse Practitioner (NP). During the course of the patient's treatment, two (2) CT scans were obtained. The first CT scan showed the patient's bowel was incarcerated in the hernia. It was documented the hernia was manually reduced. A post-reduction CT scan showed the incarceration of the bowel was resolved. It was documented that a Physician Assistant (PA) went in to discharge the patient to home. The PA noted that when he went in to discharge the patient, he discovered the patient's hernia had re-occurred. Further attempts to manually reduce the hernia were unsuccessful. It was documented that the on-call surgeon was called to accept the patient for admission and surgical treatment. It was documented the surgeon refused to accept the patient. The patient was ultimately transferred to another acute care facility on 5/22/2012 at 06:10 hours.

The NP was interviewed on 8/15/2012 at about 09:00 hours. She stated that when it was determined the patient needed surgical intervention; she called the surgeon on call. She stated the surgeon stated he would perform surgery, but he would not admit the patient to his services and he requested that she call the hospitalist and request he admit the patient. The NP stated she called the hospitalist and he also refused to admit, saying the patient needed surgical intervention. She stated she called the surgeon again, and he stated to her on the phone that she should just transfer the patient, as he was continuing to refuse to admit the patient to his services. She stated she then called the nursing supervisor, who in turn called the administrator on call. She stated the administrator called and spoke with her two (2) times, and on the second call she was instructed to transfer the patient to another facility.

The Vice President (VP) of Human Resources was interviewed on 8/15/2012 at 11:50. He stated the situation which occurred on 5/22/2012 has not been discussed with the surgeon or resolved as of 8/15/2012. He reviewed a list of dates of Medical Staff committee meetings and other information provided by the Medical Staff Office Manager, and concurred that the surgeon was sent a letter on 8/13/2012 relative to the situation and a response is expected back from the surgeon by 8/22/2012. The VP stated during the interview that after the surgeon responds, the situation will be resolved through appropriate channels.

The on-call surgeon was not available for interview during the investigation.

Based on review of medical records and other documents and interviews with staff, it was determined Emergency Services were not appropriately integrated with the Surgical Department of the hospital for at least one (1) of ten (ten) emergency cases reviewed (patient #1). This has the potential to create a situation in which the needs of patients are not met.

Findings include:

Review of the medical staff rules and regulations, dated 3/4/12, revealed the requirements include "Patients requiring admission who have no attending physician/dentist shall be assigned to the member of the active medical staff on emergency call. The specific department to which the patient is to be assigned will be determined by the Emergency Department (ED) physician."

Review of the medical record for patient #1 revealed the 65 year old male patient presented to the ED at 13:42 on 5/21/2012. The patient complained of abdominal pain related to a hernia. The patient was assessed by the Nurse Practitioner (NP). During the course of the patient's treatment, two (2) CT scans were obtained. The first CT scan showed the patient's bowel was incarcerated in the hernia. It was documented the hernia was manually reduced. A post-reduction CT scan showed the incarceration of the bowel was resolved. It was documented that a Physician Assistant (PA) went in to discharge the patient to home. The PA noted that when he went in to discharge the patient, he discovered the patient's hernia had re-occurred. Further attempts to manually reduce the hernia were unsuccessful. It was documented that the on-call surgeon was called to accept the patient for admission and surgical treatment. It was documented the surgeon refused to accept the patient. The patient was ultimately transferred to another acute care facility on 5/22/2012 at 06:10 hours.