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A. Based on review of the Bylaws of the Medical Staff, Medical Staff General Rules and Regulations, Medical Staff policies and procedures, Emergency Department physician's contract, EMTALA policies and procedures, staff interviews, it was determined that the facility lacked effective policies and procedures related to how long on-call physicians had to respond once requested by the Emergency Department physician to see a patient. Refer to findings in tag A-2404.

B. Based on review of the Bylaws of the Medical Staff, Medical Staff General Rules and Regulations, Medical Staff policies and procedures, Emergency Department physician's contract EMTALA policies and procedures, staff interviews, it was determined that the facility lacked effective policies and procedures related to who had been approved to perform a medical screening. Refer to findings in tag A-2406.

C. Based on review of the Bylaws of the Medical Staff, Medical Staff General Rules and Regulations, Medical Staff policies and procedures, Emergency Department physician's contract, EMTALA policies and procedures, staff interviews, it was determined that the facility staff failed to accept a patient from a referring hospital. Refer to findings in tag A-2411.

A. Based on review of the Bylaws of the Medical Staff, Medical Staff General Rules and Regulations, Medical Staff policies and procedures, Emergency Department physicians' contract EMTALA policies and procedures, staff interviews, it was determined that the on call physician failed to respond when requested to respond when requested by the Emergency Department physician to see a patient.

Findings were:

Review of the facility's Medical Staff General Rules and Regulations, revised 10/ 07 page #6 under 2.3 PARTICIPATION IN THE ON-CALL ROSTER states that "Unless specifically exempted by the medical executive committee and the professional affairs committee for good cause shown, each member of the active and associate staffs agrees that, when he is the esignated practitioner on call, he will except responsibility and respond in a timely fashion during the time specified by the published schedule for providing care for any appropriate patient to which he is assigned, referred to the service for which he is providing on call coverage".

Review of the Bylaws of the Medical and Dental Staff, revised 06/06, Article 4.2-3 (c) revealed that active medical staff members were to participate in the emergency department (ED) on-call requirements. The Medical Staff General Rules and Regulations, revised 06/06, Part 2.3 revealed that each member of the active and associate staffs were to participate in on-call coverage for the ED but had not revealed the response times in minutes. Part 4.2-1 revealed that patient transfers to another facility required a physician's order, arrangements for acceptance of the patient, stabilization of the patient, and pertinent medical information to accompany the patient. Part 4.2-2 required the transferring physician to explain the seriousness of the patient's condition and the risks associated with the transfer to the patient, family, and/or significant other.

In addition, review of the Medical Staff policies and procedures revealed the EMTALA and Emergency Call Coverage policy, had no policy number, however, the effective date was 08/01/02. This policy required a MSE to be performed on any individual who presented to the ED requesting or having a request made in his or her behalf for an examination of a medical condition. Furthermore, this policy required stabilizing treatment to be provided for patients with an emergency medical condition within the capabilities of the facility or an appropriate transfer of the individual to another medical facility. An appropriate transfer was to include a transfer certificate that had been signed by the transferring physician which was to include the medical benefits of the transfer and also the risks associated with the transfer. In addition, this policy required the on-call physician to be physically present in the ED "within a reasonable period of time after being requested", but had no time documented in minutes.

During interview #7 on 2/24/10 at 2:35 p.m. in the administrative conference room, the Senor Vice President of Medical Affairs(SVPMA) explained that the facility's medical staff response time for the emergency room (ER) was indicated as "reasonable". The SVPMA explained that the facility did not want to restrict the physicians to a specific time in minutes because he/she did not want to box them into a specific time frame. He/she stated that the timeliness response by the physicians required the facility was absolutely dependent upon the urgency which was determined by the emergency room physician, and conveyed to the "on-call" physician" and that he/she had no intentions to set or change to a specific time span in minutes because he/she felt that created a potential safety issue. The SVPMA also stated that the patients that presented to the ER were treated by the ER physicians that were present 24 hours a day. The SVPMA verbalized that the consultation of another physician on the medical staff was requested by the emergency ER physician.

During interview #9 on 3/2/10 at 9:15 a.m. via phone, the unit secretary for Hospital A that requested the consult, stated that the Emergency Department (ED) needed to get in touch with the neurosurgeon on - call for Phoebe Putney Memorial Hospital for a consult requested by the ED physician on duty. The secretary stated that he/she called Hospital A and had spoken to the charge nurse and asked who was on call for neurosurgery. The charge nurse at Phoebe Putney Memorial Hospital told him/her who was on call. The secretary stated that he/she explained that he/she had a patient that had a head bleed and that the ED physician was requesting a consult and wanted to speak to the neurosurgeon on-call for their hospital. The secretary stated that he/she already had the number to the neurosurgeon's office, so he/she called that number. According to the secretary, when he/she called the number he/she was transferred to the physician's answering service. The secretary stated that he/she spoke to a male employee at the answering service and he/she relayed the patient's information and the severity of the patient's condition and requested a consult for the neurosurgeon. The secretary also stated that the male employee at the answering service returned the call about five (5) minutes later and stated that the neurosurgeon had refused the patient and refused to speak with the physician because the neurosurgeon did not admit to Hospital A who requesting the consult. The secretary explained to the answering service person that he/she knew that the neurosurgeon did not admit patients to their hospital but that he/she wanted to speak to the neurosurgeon. The secretary stated that the answering service employee told him/her that he/she was not going to call the neurosurgeon again. The secretary also stated that he/she had no previous problems and that he/she had called the neurosurgeon before. The secretary further stated that Phoebe Putney Memorial Hospital had a bed board (system used by Hospital A that would transfer patients after the physicians had agreed to accept the transfer) but he/she said that the neurosurgeon and ER physician would have communicated first. The secretary was unaware that there was a number that he/she could have called at the Phoebe Putney Memorial Hospital that connected him/her to the hospital's Central Intake and Assessment area. She stated that he/she had called the physician's number directly when wanting to consult a physician before.

During interview #5 on 2/23/10 at 4:40 p.m. via conference call in the administrative conference room, the answering service employee stated that he/she had received a call from Hospital A's (hospital requesting the transfer) administrative person. The employee explained that the administrative person was not a physician but requested to speak with a neurosurgeon from Phoebe Putney Memorial Hospital. The employee also stated that he/she had taken the message from the caller that included the caller's name and phone number, the patient's name, date of birth and nature of the call. The employee explained that he/she contacted the neurosurgeon on call for duty and relayed the information that he/she had a consult from Hospital A (hospital requesting the transfer). The employee stated that the physician stated that he/she would not contact the hospital that made the request because he/she was not on call for consults for Hospital A. The employee explained that nothing else was communicated by the physician concerning the patient. The employee stated that he/she took it upon him/herself and called the requesting hospital (Hospital A) to tell them what the physician said. The employee also stated that eventually the requesting hospital (Hospital A) would have called him/her back but that he/she wanted to save them some time.

During interview #6 on 2/23/10 at 4:40 p.m. via phone in the conference room, the supervisor of the answering service for the contracted physicians services stated that the answering service took calls for the physicians's group that was from the hospital. The employees of the answering machines only take messages for the group and if they was a communication problem between hospitals they service does not get into that but only relays the information. The supervisor stated that the call of the alleged complaint came into the answering service. The supervisor explained that the employee received the the information and and put it into the system that he/she had spoken with the receiving hospital personnel. He/she said that the hospital requested to speak with a neurosurgeon for a consult from another facility(transferring hospital) and that the patient had a fall. The supervisor indicated that there was no guideline in place that would follow up or let the hospital know that the physician had denied the consult. The supervisor indicated that it was up to the on-call physician to relay that information to the hospital that he/she had denied the patient because the answering service was not required to do that. The supervisor explained that when a consult was requested and there was a question or concern about the consult that the on-call physician was responsible to further investigate and not the answering service.

During interview #1 on 2/23/10 at 2"00 p.m. in the administrative conference room, the neurosurgeon that was on call for the facility explained that the answering service employee had spoken to him/her and told him/her that he/she had a consult from another hospital(hospital requesting the transfer). The neurosurgeon stated that the normal process was the Central Intake and Assessment staff member took the call for requests for transfers and that they would call him/her. The neurosurgeon stated that he/she explained to the answering machine employee that he/she was not on call for that hospital(hospital requesting the transfer) who requested to speak to him/her and that he/she did not have privileges there. The neurosurgeon stated that he/she had not made an attempt to notify the requesting hospital or the facility's emergency room that he/she had denied the request for a consult. The neurosurgeon stated that he/she had received calls for referrals all the time but had not received a consult. The neurosurgeon said that he/she felt the request was strange because he/she had never been requested to consult a patient from that hospital and stated that he/she had not saw a need to further involve him/herself in the matter.

During an interview #2 on 2/23/10 at 3:40 p.m. in an ED classroom, a Registration Clerk stated that he/she had received EMTALA training upon hire and once a year. The clerk was able to verbalize the EMTALA regulations and stated that only physicians and mid-level providers could perform a medical screening examination. The clerk also stated that there had been no problems associated with the on-call response time and that normally physicians responded less than ten (10) minutes.

B. Based on review of the Bylaws of the Medical and Dental Staff , Medical Staff General Rules and Regulations, Medical Staff policies and procedures, Emergency Department physician's contract EMTALA policies and procedures, staff interviews, it was determined that the facility lacked effective policies and procedures related to who had been approved to perform a medical screening.

Findings were:

Review of the Bylaws of the Medical and Dental Staff, revised 06/06, Article 4.2-3 (c) revealed that active medical staff members were to participate in the emergency department (ED) on-call requirements. The Medical Staff General Rules and Regulations, revised 06/06, Part 2.3 revealed that each member of the active and associate staffs were to participate in on-call coverage for the ED. but had not revealed the response times in minutes. Part 4.2-1 revealed that patient transfers to another facility required a physician's order, arrangements for acceptance of the patient, stabilization of the patient, and pertinent medical information to accompany the patient. Part 4.2-2 required the transferring physician to explain the seriousness of the patient's condition and the risks associated with the transfer to the patient, family, and/or significant other. The Bylaws of the Medical and Dental Staff and the Medical Staff General Rules and Regulations lacked evidence of who was approved to perform a medical screening examination (MSE) in the ED. However, the facility did have a contract which provided Medical Staff coverage for the ED.

In addition, review of the Medical Staff policies and procedures revealed the EMTALA and Emergency Call Coverage policy, had no policy number, however, the effective date was 08/01/02. This policy required a MSE to be performed on any individual who presented to the ED requesting or having a request made in his or her behalf for an examination of a medical condition. Furthermore, this policy required stabilizing treatment to be provided for patients with an emergency medical condition within the capabilities of the facility or an appropriate transfer of the individual to another medical facility. An appropriate transfer was to include a transfer certificate that had been signed by the transferring physician which was to include the medical benefits of the transfer and also the risks associated with the transfer.

Review of the ED physician's contract, effective 05/30/08, revealed that a sufficient number of physicians and mid-level providers were to be on duty at all times as necessary to provide examinations and treatment to patients presenting to the ED for services. In addition, this contract required the physicians to comply with the facility's Medical Staff Bylaws, policies, and rules and regulations, federal, state, and local laws and regulations, including the EMTALA laws.

Review of three (3) credential files revealed that physician file #1 had completed his/her EMTALA training during 04/08. Physician #2 had no evidence of EMTALA training and physician #3 was not required to attend EMTALA training.

During interview #7 on 2/24/10 at 2:35 p.m. in the administrative conference room, the Senor Vice President of Medical Affairs(SVPMA) stated that the patients that presented to the ER were treated by the ER physicians that were present 24 hours a day. The SVPMA verbalized that the consultation of another physician on the medical staff was requested by the emergency ER physician. The SVPMA stated that the Medical Staff Bylaws did not say specifically who was approved to do a medical screening examination but that the job description of the Nurse Practitioner indicated that the he/she would be supervised and reviewed by a credentialed medical staff physician.

During an interview #2 on 2/23/10 at 3:40 p.m. in an ED classroom, a Registration Clerk stated that he/she had received EMTALA training upon hire and once a year. The clerk was able to verbalize the EMTALA regulations and stated that only physicians and mid-level providers could perform a medical screening examination. The clerk also stated that there had been no problems associated with the on-call response time and that normally physicians responded less than ten (10) minutes.

During interview #8 on 2/24/10 at 1:10 pm. in the administrative conference room the Director of Quality Risk indicated that the facility's were revising some of there policies.

C. Based on review of the Bylaws of the Medical Staff, Medical Staff General Rules and Regulations, Medical Staff policies and procedures, Emergency Department physician's contract, EMTALA policies and procedures, staff interviews, it was determined that the facility staff failed to accept a patient from a referring hospital.

Findings were:


During an interview #3 on 2/23/10 at 3:50 p.m. in the conference room, the Emergency Department (ED) Director stated that the patient or patient's information received by the facility's physician's answering service never presented to the facility on the day in question. The director also stated that the ER had not made a record for the patient. The director explained that all calls for requested transfers that come through the ED are rerouted to the Central Intake and Assessment area. The director stated that a number and area was provided to the callers. The director indicated that the staff receive yearly EMTALA(Emergency Medical Treatment and Labor Act) training.

Review of the facility's policy# AD.PCS.0016 entitled "Transfer Policy - Internal /External EMTALA" dated 4/2004 stated on page #5 that under ACCEPTING TRANSFERS FROM OTHER FACILITIES that:
1. Request for transfers from other health care facilities will be routed to Central Intake and Assessment.
2. The Central Intake and Assessment staff member shall determine the following before accepting the patient for transfer: a. Attending physician acceptance; b. Appropriate diagnosis/needs warranting transfer: and c. Availability of appropriate bed assignment.
3. Once the patient is accepted, the staff member will assign a bed and notify the unit.
4. If no bed is available, the patient will be placed on a waiting list, and the transferring institution notified as soon as possible when a bed becomes available.
5. If the patient for whom transfer is being requested is currently receiving the appropriate level of care in the transferring institution, and the transfer is for convenience only, the patient and family will be informed of the potential liability for the cost of the hospitalization. Care management and financial counseling will follow up with the patient regarding financial concerns as soon as possible following transfer.

Review of the the facility's contracted physician's group answering service, revealed that the a call came into the answering service on 2/7/10 at 6:15 p.m. and that the answering service personal documented that the caller from Hospital A (hospital requesting the transfer) identified him/herself and gave his/her phone number. The documentation of the call revealed that a patient's name, date of birth and nature of call was noted. The nature of the call indicated that a doctor requested a consult for a patient that had fallen.

During interview #9 on 3/2/10 at 9:15 a.m. via phone, the unit secretary for Hospital A that requested the consult, stated that the Emergency Department (ED) needed to get in touch with the neurosurgeon on - call for Phoebe Putney Memorial Hospital for a consult requested by the ED physician on duty. The secretary stated that he/she called Hospital A and had spoken to the charge nurse and asked who was on call for neurosurgery. The charge nurse at Phoebe Putney Memorial Hospital told him/her who was on call. The secretary stated that he/she explained that he/she had a patient that had a head bleed and that the ED physician was requesting a consult and wanted to speak to the neurosurgeon on-call for their hospital. The secretary stated that he/she already had the number to the neurosurgeon's office, so he/she called that number. According to the secretary, when he/she called the number he/she was transferred to the physician's answering service. The secretary stated that he/she spoke to a male employee at the answering service and he/she relayed the patient's information and the severity of the patient's condition and requested a consult for the neurosurgeon. The secretary also stated that the male employee at the answering service returned the call about five (5) minutes later and stated that the neurosurgeon had refused the patient and refused to speak with the physician because the neurosurgeon did not admit to Hospital A who requesting the consult. The secretary explained to the answering service person that he/she knew that the neurosurgeon did not admit patients to their hospital but that he/she wanted to speak to the neurosurgeon. The secretary stated that the answering service employee told him/her that he/she was not going to call the neurosurgeon again. The secretary also stated that he/she had no previous problems and that he/she had called the neurosurgeon before. The secretary further stated that Phoebe Putney Memorial Hospital had a bed board (system used by Hospital A that would transfer patients after the physicians had agreed to accept the transfer) but he/she said that the neurosurgeon and ER physician would have communicated first. The secretary was unaware that there was a number that he/she could have called at the Phoebe Putney Memorial Hospital that connected him/her to the hospital's Central Intake and Assessment area. She stated that he/she had called the physician's number directly when wanting to consult a physician before.

During interview #5 on 2/23/10 at 4:40 p.m. via conference call in the administrative conference room, the answering service employee stated that he/she had received a call from Hospital A's (hospital requesting the transfer) administrative person. The employee explained that the administrative person was not a physician but requested to speak with a neurosurgeon from Phoebe Putney Memorial Hospital. The employee also stated that he/she had taken the message from the caller that included the caller's name and phone number, the patient's name, date of birth and nature of the call. The employee explained that he/she contacted the neurosurgeon on call for duty and relayed the information that he/she had a consult from Hospital A (hospital requesting the transfer). The employee stated that the physician stated that he/she would not contact the hospital that made the request because he/she was not on call for consults for Hospital A. The employee explained that nothing else was communicated by the physician concerning the patient. The employee stated that he/she took it upon him/herself and called the requesting hospital (Hospital A) to tell them what the physician said. The employee also stated that eventually the requesting hospital (Hospital A) would have called him/her back but that he/she wanted to save them some time.

During interview #6 on 2/23/10 at 4:40 p.m. via phone in the conference room, the supervisor of the answering machine service for the contracted physicians services stated that the answering service took calls for the physicians's group that was from the hospital. The employees of the answering machines only take messages for the group and if they was a communication problem between hospitals they service does not get into that but only relays the information. The supervisor stated that the call of the alleged complaint came into the answering service. The supervisor explained that the employee received the the information and and put it into the system that he/she had spoken with the receiving hospital personnel. He/she said that the hospital requested to speak with a neurosurgeon for a consult from another facility(transferring hospital) and that the patient had a fall. The supervisor indicated that there was no guideline in place that would follow up or let the hospital know that the physician had denied the consult. The supervisor indicated that it was up to the on-call physician to relay that information to the hospital that he/she had denied the patient because the answering service was not required to do that. The supervisor explained that when a consult was requested and there was a question or concern about the consult that the on-call physician was responsible to further investigate and not the answering service.

During interview #1 on 2/23/10 at 2"00 p.m. in the administrative conference room, the neurosurgeon that was on call for the facility explained that the answering service employee had spoken to him/her and told him/her that he/she had a consult from another hospital(hospital requesting the transfer). The neurosurgeon stated that the normal process was the Central Intake and Assessment staff member took the call for requests for transfers and that they would call him/her. The neurosurgeon stated that he/she explained to the answering machine employee that he/she was not on call for that hospital(hospital requesting the transfer) who requested to speak to him/her and that he/she did not have privileges there. The neurosurgeon stated that he/she had not made an attempt to notify the requesting hospital or the facility's emergency room that he/she had denied the request for a consult. The neurosurgeon stated that he/she had received calls for referrals all the time but had not received a consult. The neurosurgeon said that he/she felt the request was strange because he/she had never been requested to consult a patient from that hospital and stated that he/she had not saw a need to further involve him/herself in the matter.

Review of the facility' policy and procedures lacked a process to follow up on calls from the contracted answering services. The hospital was unaware of any miscommunication of the request for the neurosurgeon to consult the patient for a potential transfer from another facility.