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Based on Medical Staff Rules and Regulations, policy and procedure review, medical record review, on call schedule review, emergency medical services (EMS) report and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

The hospital failed to ensure a physician who was on call for Obstetrical/Gynecology services presented to the Emergency Department to provide services upon the request of the dedicated emergency department (DED) physician for 1 of 20 sampled patients that presented with an emergency medical condition (Patient #20).

Cross Refer to A-2404.

Based on Medical Staff Rules and Regulations, policy and procedure review, medical record review, physician on call schedule review, emergency medical services (EMS) report and staff and physician interviews, the hospital failed to ensure a physician who was on call for Obstetrical/Gynecology services presented to the Emergency Department (ED) to provide services upon the request of the dedicated emergency department (DED) physician for 1 of 20 sampled patients that presented with an emergency medical condition (Patient #20).

The findings included:

Review on 02/11/2025 of the hospital's Medical Staff Rules and Regulations last reviewed July 26, 2023, revealed "... an individual, including a minor who presents without a parent, comes to the dedicated emergency department or is present elsewhere on hospital property and requests a medical examination or treatment (or requests is made on the individual's behalf, EMTALA requires the hospital to provide that individual with an appropriate medical screening exam (MSE) within the capability and capacity of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition (EMC) exits. ... E. Unassigned Patient Call for the Emergency Department ... 2. Response times a. Call back On-call physicians must respond to calls from the emergency department within 30 minutes. ... b. Physical presence in the emergency department If the emergency medicine physician believes he/she needs on-site assistance from an on-call physician in order to determine whether a patient has an EMC or to provide stabilizing treatment, the on-call physician must present to the hospital within 60 minutes of the request being made unless the attending physician provides an alternate timeframe. ..."

Review on 02/11/2025 of the hospital policy titled "EMTALA -- Emergency Medical Treatment and Labor Act last revised May 2023 revealed "... E. Availability of on-call physicians ... Physician Responsibilities ... b) Each facility shall establish a process to ensure that when a physician is identified as being "On-Call" to the ED for a given specialty, is shall be the duty and the responsibility of that physician to assure the following: 1) Immediate availability, at least by telephone, to the ED physician for his or her scheduled "on-call" period, or to secure a qualified alternate in the event he or she is temporarily unavailable; and 2) Arrival and responds to the ED within a reasonable timeframe as specified in the facility's Medical Staff Bylaws.

Closed medical record review on 02/12/2025 for Patient #20 revealed a 29-year-old female that presented to the DED on 07/16/2024 at 1954 with a chief complaint of MVC (motor vehicle crash). Review of the medical record revealed the patient did not arrive via EMS. Triage note documented at 2018 revealed "Chief Complaints Updated; Motor Vehicle Crash (Pt [patient] reports that she was in a car accident. Gave birth 5 [five] days ago via C section. Restrained driver, closed eyes, and went into another lane, hit a fire hydrant. Denies LOC [loss of consciousness]. C/O [complain of] neck pain, back pain, lower abdominal pain. Air bags deployed. Speed 35 mph [miles per hour]. Ambulatory at scene.) Review of the Patient Care Timeline revealed at 2020 Patient #20 was assigned an acuity score of "3" (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). The "CBC (complete blood count) And Differential" resulted at 2132 revealed an "Abnormal Result" with decreased RBC (red blood cell), HGB (hemoglobin) and HCT (hematocrit). The Comprehensive Metabolic Panel resulted at 2156 revealed an "Abnormal Result" with elevated Glucose, ALT (alanine transaminase), AST (aspartate aminotransferase) and decreased Creatinine. Review of the CT Abdomen Pelvis W (with) IV (intravenous) Contrast resulted at 2317 revealed "IMPRESSION: Hematoma (localized collection of blood outside of blood vessel) along the cesarean section incision scar in the anterior lower uterine segment, tracking into the space of Retzius (retropubic space - space anteriorly [toward the front of the body] by the pubic symphysis [front of the pelvis where two pubic bones meet] and posteriorly [toward the back] by the urinary bladder). Possible associated uterine dehiscence (condition where the layers of the uterus separate)." Patient #20 was given a bolus of Normal Saline and an injection of Morphine (pain medication) 4 mg (milligrams) intravenously at 2348. Review of the Patient Care Timeline on 07/17/2024 at 0015 revealed "Ready for Transfer Status Set". Review of the EMTALA Transfer Form at 0052 revealed ... "Reason for transfer: Specialized capabilities required - Benefits: patient will be able to receive necessary medical care that is not available at this facility. ..."

Medical record review of the Hemoglobin and Hematocrit resulted at 1216 revealed an "Abnormal Result" with a low hemoglobin and low hematocrit level. Review of the Provider Orders at 1400 revealed an order for "Inpatient consult to Obstetrics/Gynecology". Patient #20 received at 1403, Morphine 4 mg intravenously for abdominal pain rated at 10 out of 10 on the pain scale. Report was called to Hospital B at 1609. Review of the MAR revealed at 1719 Morphine 4 mg was administered intravenously for abdominal pain of 8 out 10. Patient #20 was transferred to Hospital B at 1726.

Review on 02/13/2025 of the OB Call Schedule for 07/17/2024 revealed Provider #7 was scheduled to be on-call from 0730 am to 0730 am on 07/18/2024.

Review of the Novant Critical Care Transport Report dated 07/17/2024 revealed " ...Primary Impression: Obstetric trauma ... Secondary Impression: Abdominal Pain ... Chief Complaint: ABDOMINAL PAIN AFTER MVA (motor vehicle accident) ... PT HAD A C-SECTION DELIVERY FIVE DAYS AGO AND WAS IN AN MVA YESTERDAY AS A RESTRAINED DRIVER. SHE CAME INTO THE ED (emergency department) LAST NIGHT WITH ABDOMINAL PAIN AND WAS FOUND TO HAVE A POSSIBLE HEMATOMA ON HER UTERUS WITH POSSIBLE UTERINE DEHISCIENCE. SHE IS BEING TRANFERRED BACK TO (Hospital B) BECAUSE THAT'S WHERE SHE HAD HER C-SECTION. ... 1726 PT WAS LOADED INTO OUR TRUCK WITHOUT INCIDENT AND WE DEPARTED ... 1800 ARRIVED AT (Hospital B), ESCORTED PT TO ROOM ...1828 BEDSIDE REPORT GIVEN TO RECEIVING NURSE. ....1837 Call closed.


Patient #20 Hospital B Visit 07/17/2024

Review on 02/18/2025 of the closed medical record for Patient #20 revealed a 29 year-old female presented via emergency medical services (EMS) to Hospital B as a direct admit on 07/17/2024 at 1835 with a chief complaint of "pelvic hematoma after MVC (motor vehicle crash)."

Review of the Nurse Note on 07/17/2024 at 1841 revealed "Due to bed issues, patient was not able to be transferred for around 20 hours. I called the ED doctor at (Hospital A) immediately prior to transfer, as I wanted to see if she still required transfer with stable hemoglobin and vital signs. He preferred that patient be transferred as he wanted her to be cleared by surgeon, and stated that the OB/GYNs at his facility refused to see the patient as they did not perform the initial surgical procedure. Per prior ED notes, OB was consulted and agreed to see patient, but there is no consult note, and patient did not remember seeing an Ob/Gyn while she was there...Despite the long delay in transfer, she was not seen by the OB/GYNs at the prior facility despite the ED's concern for hematoma vs dehiscence."

Review of the Discharge Summary Note at 2141 revealed " ... Hospital Course: ... transferred from (Hospital A) after MVC and concern for pelvic hematoma. Patient was restrained driver when she hit a fire hydrant at around 25-30 mph. Pelvic CT showed pelvic hematoma and possible uterine dehiscence. Due to bed issues, patient was not able to be transferred for over 20 hours. She was not seen by OB at Rowan as, per ED physician report, they refused to see her."

Interview on 02/12/2025 at 1526 with Nurse Manager (NM) #3 revealed Patient #20 came into the ED after a MVC and had given delivery five days prior. The interview revealed typically patients go back to the provider that performed their surgery. Surgeons like for their patient to return with them if they have any complications. Interview revealed NM #3 was not aware of anytime an on-call provider refused to come see a patient in the ED.

Interview on 02/12/2025 at 1642 with Provider #4 revealed he had reviewed the care Patient #20 had received in the ED on 07/16/2024. Patient #20 had received previous care at Hospital B and Provider #5 "rightfully wanted to get her back to the providers" at Hospital B that had performed her cesarean surgery. Interview revealed Provider #4 spoke with Provider #7, the on-call provider for OB/GYN service while Patient #20 was in the ED, and Provider #7 said he would come see and evaluate Patient #20. Interview revealed, "If there was an extended time (Patient #20) would be in the emergency department awaiting transfer, it would be appropriate for the in-house to see and evaluate the patient."

Interview on 02/13/2025 at 0901 with Provider #5 who cared for Patient #20 during her visit on 07/16/2024. Patient #20 had recent surgery, and the injury could be from the surgery. The interview revealed the decision was made by Patient #20 to go back to the physician that performed her surgery. The dehiscence at the surgical site, Provider #5 would not be able to determine if the injury was from the surgery or from the MVC. Interview revealed the "accident on that day, was most likely the cause however (Provider #5) could not say for sure." Provider #5 would not get OB/GYN at Hospital A involved without asking Patient #20 who she would want to see. When signing the EMTALA form it says that it is filled out correctly and that the patient needs to be transferred. There is a place that is filled out if the patient requested the transfer. It was not filled out in this case.

Notified on 02/13/2025 Provider #7 was not available for interview.

Follow up interview on 02/13/2025 at 1303 with NM #3 revealed the specialty on-call cannot refuse to come see a patient if requested.