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A. Based on document review, record review and staff interview it was revealed the facility failed to provide community call coverage as stated in the 'Community Call Coverage Agreement' for one (1) of twenty-three (23) patients (patient #1) requiring orthopedic surgery. This failure has the potential to affect all patients requiring consultations for specialty care as described in the 'Community Call Coverage Agreement'. This failure could possibly result in loss of limb, hemorrhage, infection or death (See A 2404).

B. Based on document review and record review it was determined the hospital failed to ensure a proper Medical Screening Exam (MSE) was performed prior to asking the patient to sign the hospital's document entitled 'Consent for Testing, Treatment and/or Admission/Observation' in four (4) out of twenty-three (23) records reviewed (patients #15, 16, 17 and 19). This failure has the potential to discourage patients from possibly seeking life-saving services if the patient was having a medical emergency. This failure could possibly lead to the incapacitation or death of the patient (See A 2408).

Based on document review, record review and staff interview it was determined the facility failed to provide community call coverage as stated in the 'Community Call Coverage Agreement' for one (1) of twenty-three (23) patients (patient #1) requiring orthopedic surgery. This failure has the potential to affect all patients requiring consultations for specialty care as described in the 'Community Call Coverage Agreement'. This failure could possibly result in loss of limb, hemorrhage, infection or death of a patient.

Findings include:

1. A review of the facility document entitled 'Community Call Coverage Agreement' dated 4/23/20 states in part: "WHEREAS PCH and BRMC are affiliated in that PCH is the sole Member of BRMC...WHEREAS PCH has employed, or otherwise engaged, physicians (individually referred to herein as a "Physician" and collectively as the "Physicians") with the training and qualifications to provide services in the specialties of obstetrics and gynecology, pediatrics, orthopedic surgery and general surgery (the "Specialties") and desires to provide call coverage services in the Specialties (the "Services") to the residents and communities served by PCH and BRMC, including Mercer County, West Virginia, and the surrounding communities (the "Service Area") on the terms and conditions set forth herein ...SERVICES-In order to help meet the need for coverage in the Specialties, as set forth above, PCH agrees to provide community call coverage to the Service Area in accordance with this Agreement. Services shall include, but are not limited to: 1) consultations on emergency patients as requested by members of BRMC's medical staff in one or more of the Specialties ... 3) acceptance of transfer of patients from BRMC requiring care in one or more of the Specialties...BRMC and PCH shall each maintain a list of on-call physicians, including Physicians who have privileges at PCH participating in this Agreement, that are available to provide treatment necessary after the initial examination to stabilize individuals with emergency medical conditions who are receiving services at BRMC."

2. A review of the hospital document entitled 'Meeting: Department of Emergency Medicine' dated 5/11/20 stated in part: "Accepting Transfers: Members discussed the issue related to accepting transferred patients. Some of our physicians are adamant about having transferred patients seen in our ER before they accept them. There has been discussion about issues with transfers and creating a transfer center."

3. A review of the hospital document entitled 'Meeting: Medical Executive Committee' dated 5/11/20 stated in part: " ...discussed issues related to the ED at BRMC calling surgeons directly for admissions rather than sending them through our ER...reported that there was discussion at the ED meeting this morning, and there had some examples of patients being transferred to the ED here but not being approved for admission by the physician on call. This is a problem when a patient has been in two ED's and still has to be transferred. The ED providers discussed several related issues and are asking again that a transfer center be considered."

4. A review of the facility policy document entitled 'Emergency Treatment and Labor Act (EMTALA) last review date 6/18 stated in part: "On Call List: a list of physicians who are on call after the initial MSE to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC...The designated on-call physician is ultimately responsible for providing the necessary services to the individual."

5. A review of the Emergency Department (ED) on call calendar for May 2020 entitled 'May 2020' revealed Physician #3 was the on-call orthopedic physician on 5/20/20.

6. A review of the medical record for Patient #1 revealed he had presented to the ED at Bluefield Regional Medical Center (BRMC) on 5/20/20 at 12:32 p.m. with a partially amputated and fractured finger on the right hand from a band saw injury. The medical record revealed the patient was treated and stabilized at BRMC but required orthopedic services which were not available at BRMC. A call was made to the on call orthopedic physician who said he did not take consults for BRMC.

7. A telephone interview was conducted with Physician #1 on 6/9/20 at approximately 12:45 p.m. and he stated he called Charleston Area Medical Center (CAMC) to inquire about reattachment of the finger. CAMC told him they could not reattach it and referred him to facilities in Louisville, Kentucky and Pittsburgh, Pennsylvania. Both hospitals told him reattachment would not be possible and to provide local orthopedic treatment. The patient requested treatment at Princeton Community Hospital. The unit secretary called the office of the orthopedic surgeon (Physician #3) on call to notify him of the consult and was told Physician #3 does not accept consults from BRMC. Physician #3 did not speak to Physician #1. Physician #1 tried to call an orthopedic surgeon who was not on call to see if he could speak to Physician #3 but could not reach him. CAMC agreed to take the patient for further treatment but the patient stated his insurance would not pay for an ambulance to take him to CAMC and he wanted to go by private vehicle. The patient signed out against medical advice (AMA).

8. A telephone interview was conducted with Physician #2 on 6/9/20 at approximately 1:40 p.m. and he stated it is his understanding after the patient left BRMC, Physician #3 took Patient #1 to surgery at Princeton Community Hospital (PCH). He thought the patient's daughter worked for Physician #3.

9. An interview was conducted with Physician #3 on 6/10/20 at approximately 8:15 a.m. and he stated he does not recall taking any calls from BRMC. He did remember a finger amputation a couple of weeks ago and stated the patient was related to someone in the Operating Room (OR). He also stated he "has an agreement to cover Princeton Emergency Room (ER)." He does "not have an agreement to cover BRMC ER" and "Administration has not talked to us about the on-call process." He said he and his partners have talked about the liability issues of covering call at BRMC with administration but has not heard anything from them.

10. An interview was conducted with Physician #4 on 6/10/20 at approximately 9:00 a.m. and he stated, "if they can do the service, he does not think they can refuse a call from BRMC."

11. An interview was conducted with Physician #5 on 6/10/20 at approximately 9:20 a.m. who stated the "most recent process" for on call "was everything comes through the ER." The "specialist does not get the call; it should go to the ER doctor. He also stated previously the process was they were supposed to call the specialist on call and then come through the ER. The latest memo came out a couple of weeks ago. Prior to the memo the call was to go to the specialist. The expectation is if someone calls the specialist, they should tell them to call the ER doctor."

12. An interview was conducted with the Nursing Director of ED, Critical Care and Employee Health on 6/10/20 at approximately 9:40 a.m. and she stated the PCH ED faxes a copy of the on-call schedule (written on a card) to the BRMC ED daily. She said this has been a recent change which has occurred since services have been shut down at BRMC.

13. A telephone interview was conducted with the Emergency Room Technician/Unit Secretary on 6/10/20 at approximately 10:00 a.m. She stated she called Princeton hospital and 'talked to the operator.' "I was told previously because we were part of Princeton instead of doing two (2) ER visits to call the specialist on call or the hospitalist. The Princeton operator said to call [Physician #3] so I called [Physician #3's] office. I talked with one (1) of the staff at the office and the staff member checked with [Physician #3] and came back and said we do not consult with Bluefield." She stated this occurred on May 20, 2020. When asked what the process is now, she stated they "have to call and ask for a bed assignment and then call the specialist."

Based on document review and record review it was determined the hospital failed to ensure a proper Medical Screening Exam (MSE) was performed prior to asking the patient to sign the hospital's document entitled 'Consent for Testing, Treatment and/or Admission/Observation' in four (4) out of twenty-three (23) records reviewed (Patients #15, 16, 17 and 19). This failure has the potential to discourage patients from possibly seeking life-saving services if the patient was having a medical emergency. This failure could possibly lead to the incapacitation or death of the patient.

Findings include:

1. A review of the hospital document entitled, 'Consent for Testing, Treatment and/or Admission/Observation' last revised 9/17/15, states under the paragraph entitled 'Assignment of Insurance Benefits or Payments': "I hereby irrevocably assign payment of all hospitalization and medical benefits applicable and otherwise payable to me to the hospital and all clinical providers providing care to me at the hospital." The document further states, "I agree I am 100% responsible to PCH for payment not made by my insurance." The document also states under the paragraph entitled, 'Medicare Non-Covered Services': "I understand that there are certain outpatient services or medications that may not be covered by Medicare if they consider it as 'self-administered' or 'take home medications' (if you have Medicaid secondary to Medicare, Medicaid will not cover these items either), OBSERVATION CARE beyond 48 hours, or 24 hours if 'Non-covered Services'. I understand I will be responsible for payment of these items." The document also states, under the heading entitled 'Financial Assistance': "I am aware of PCH's Financial Assistance Program."

2. A review of the hospital document entitled, 'Emergency Treatment and Labor Act (EMTALA)' last revised on 1/3/2013, states in part: "PCH will not delay in providing a MSE (Medical Screening Exam) or necessary stabilizing treatment in order to inquire about an individual's method of payment or insurance status. Requests for payment or payor authorization are not to be made prior to MSE and initiation of stabilizing treatment."

3. A review of the medical record for patient #15 reveals the document entitled, 'Consent for Testing, Treatment and/or Admission/Observation' states the patient gave verbal consent on 5/11/20 at 12:56 p.m. and his MSE was not conducted until 1:50 p.m. .

4. A review of the medical record for patient #16 reveals the document entitled, 'Consent for Testing, Treatment and/or Admission/Observation' states the patient was "unable to sign because: patient too ill." The document was signed on 6/1/20 at 6:08 p.m. The patient was triaged at 6:11 p.m. and her Glasgow Coma Score was fifteen (15) which means the patient was able to open eyes spontaneously, obey commands and oriented to surroundings. The MSE was not conducted until 6:25 p.m.

5. A review of the medical record for patient #17 reveals the document entitled, 'Consent for Testing, Treatment and/or Admission/Observation' states the patient gave verbal consent on 3/24/20 at 6:34 p.m. and the MSE was not performed until 7:10 p.m.

6. A review of the medical record of patient #19 reveals the document entitled, 'Consent for Testing, Treatment and/or Admission/Observation' was signed by the patient on 3/1/20 at 7:34 p.m. The patient presented to the Emergency Room with complaints of chest pain and was triaged at 7:32 p.m. The MSE never occurred because the patient left without being seen by the provider. The disposition time was 3/2/20 at 12:24 a.m.