HospitalInspections.org

Based upon record review and interview, the facility failed to ensure the availability of an on-call physician for specialized treatment. The facility also failed to have written policies and procedures in place to ensure the availability of on-call physicians for specialized treatment.

Review of patient #1's chart revealed the patient came into the facility via EMS on 4/11/18 at 9:51AM. Review of the ED physician notes at 10:03AM stated, ""abdominal cramping and pain since 0500 this morning with nausea. Abdomen tender to touch. Pale and diaphoretic upon arrival. States bowel movements are regular at this time. History of stomach cancer" The physician also stated, "all GI removed and small intestine connected to throat."
Review of the chart revealed the physician ordered IV of ringer's lactate, stat lab that included blood cultures. IV antibiotics were ordered. Chest x-ray was ordered. At 11:23 AM The Radiologist recommended obtaining a CT.
1:37 PM written CT report indicated a "Large defect at the level of the esophageal hiatus with multiple loops of intestine, mostly small intestine, herniated into the lower hemithorax."

1:58 PM ED RN documented, "Pt back in bed, ask ERP (Emergency Room Provider) for a diagnosis to attempt transfer. States, he wants to talk with _____(Staff#8) first to see if he will see pt because, he (ER Physician) doesn't believe pt. will survive transfer. ERP on phone with ____ (Staff #8), ____ (Staff #8) denies being on call and states he won't see pt."

2:06PM ED RN documented, "Dr._______ on phone with surgeon from ________ (local facility), spoke with air vac and states they would be available if needed also called ________ (local) EMS and states that they would be available".

3:21PM ED RN documented "Dr._______ spoke with Dr. ____ (ER Physician) from _________(local facility)states that _____ (surgeon) will accept, still pending administration approval."

The ED physician documented: ED course
"4/11/2018 10:14 stable

4/11/2018 at 14:03(2:03PM) stable. Bp dropped for a while. Dehydrated. Also bowel is shifting the mediastinum to the right. MT

4/11/2018 at 15:10 (3:10PM) unstable Bp is dropping again. Lactate is very high as is WBC count. I am concerned about bowel ischemia and a mediastinum shift. Need emergency surgery to try to save the bowel. Dr. ____ (staff #8) is listed as our on call General Surgeon. Apparently Dr. ____ (staff# 7) is the surgeon who should be on call. Dr. ____(staff#7) is out of town. Called Tyler surgeon Dr. _____ and also talked to thoracic surgeon Dr. ____. Advised to send to________(Cancer Hospital in Houston)who did the cancer surgery 2 years ago. We called them. We were told "It will be a long time". We called __________(local facility). I talked to DR. ____ (ER Physician) who talked to the general surgeon Dr. ____. Dr. ____ (general surgeon) will accept. Note: This is a surgical emergency. Need surgery ASAP. The general surgeon at the hospital 3 miles away is the best choice."

The transfer was arranged. The patient coded in the ambulance prior to exiting the hospital property. He was brought back into the ED and a full code was conducted. The patient was intubated and stabilized as much as possible. Verification to transfer to receiving hospital post code was insured. The patient was transferred to ____________(local facility)and died shortly after surgery.

Interview with the CNO revealed the following:
Staff #7 (surgeon) has been the responsible party to make the on-call schedule for the surgeons. If the surgeons needed to be off or request certain dates off, then they would submit a written request to his office. Staff #7 would then make the schedule. Staff #7 had submitted a written notification to the office of General & Vascular Surgery on 3/12/2018, he would not be available for call April 6 through April 11 and May 31-June 4. The fax was verified during the investigation The request was not verified on the schedule and Staff #8 was still scheduled to work on 4/11/18.

On 4/10/2018 Staff #8 was in Las Vegas Nevada for mandatory CME training and realized he was still on the schedule for surgical coverage for the ED. He notified his office and the hospital's administrator that notified he would not be available April 11, he was still scheduled and could not cover the on-call time. He asked that the other surgeons be called to see if any would change call rotation with him and take his call as he was out of the state.
Staff #7 is a private practice physician/surgeon who was responsible for coordinating the on-call scheduling and providing it to the ED of the hospital. Staff #7 told the hospital he had not received the fax requesting time off from Staff# 8. Staff #7 had spoken with the CNO and indicated he was available to cover the on-call schedule until 4:00 PM 4/11/2018.

The CNO indicated the hospital had been in phone contact with Staff #8 who would be home by midnight and would pick up the remainder of his call schedule. She stated the plan was to go on divert from 4:00 PM until midnight, at which time staff #8 would be available for call.

On the morning of 4/11/2018 ____ (staff #8) was notified of the likely need for surgery. ____ (staff #8) said no one had confirmed with him he was needed and he would not be coming in for surgery.

The third surgeon was also called and refused to come in. A 4th surgeon was never reached by phone.

The hospital was placed on divert at 12:45 PM. Patient#1 had arrived in the ED at 9:51 AM. It was not determined that patient #1 would require emergency surgery until 1:37PM. A transfer was arranged with _____ (ER Physician) at the__________(local facility)across town. Patient #1 was being placed in to the ambulance when he coded. He was brought back into the Hospital's ED; a full code was in progress. He was intubated, stabilized as much as possible and again ____ (ER Physician) was notified of the change in condition. _____ (ER Physician) again agreed to accept the patient. Patient #1 was transferred to __________(local facility). He died in _________(local facility) shortly after surgery.

"The Medical Executive Committee met on 5/15/2018 at 11:55 AM. The discussion was a Peer review, reviewed by _____ (Staff #16). It was determined _____ (Staff #7) failed to check the on call schedule when it was mailed to him on 3/27/2018. On 4/11/2018 the staff were informed ____ (Staff #8) would not accept call. ____ (Staff # 11) was in another surgery so he stated "no". _____ (staff #17) would not return the call and ____ (Staff #8) said no. _____ (Staff #14) was acting Chief of Staff on this day and has recommended the physicians appear before the MEC for explanation. ______ (staff #8) has received notification he was turned into the Texas Medical Board."

The committee discussed the fact that the backup surgeon was______ (staff #8).


Review of the facility "Medical Staff Bylaws and Rules and Regulations", revealed the following:
"3.1 Active Category
3.1.3 Responsibilities
e. "Take unassigned call (exception of primary care providers as long as hospitalist provide this coverage)"


Review of the medical Staff policy, "Trauma Surgeon backup", indicated:

"Nacogdoches Memorial Hospital has a General/Trauma Surgeon as a designated member of the Trauma Team. A General/Trauma Surgeon will evaluate all major and multisystem trauma patients presenting to the Emergency Department (ED) and meeting Trauma Team Activation criteria. If no general surgeon is available, arrangements will be made for immediate transfer of the trauma patient for surgical evaluation. If other sub-specialty surgical (Orthopedics, Neurosurgery, OMFS) are needed and not readily available, arrangements will be made for transfer of the trauma patient for sub-specialty surgical evaluation."

"A monthly General/Trauma Surgeon call schedule & a monthly back-up call schedule will be published in the Emergency Department. A daily call schedule listing the General/Trauma Surgeon on call will be prominently displayed in the ED"


32143



During an interview on 5-29-18 staff #1 stated the facility did not have a policy and procedure on how the facility will respond when a physician does not respond or refuses to come into the hospital when on call. Staff #1 stated that the facility personnel will call the next scheduled surgeon until they find one available. However, the facility does not have that in a policy.



.

Based upom record review and interview, the facility failed to ensure the emergency department on-call surgeon was available to provide surgical stabilizing treatment for a deemed surgical emergency causing a delay in treatment for 1 of 1(#1) patients reviewed.

Review of patient #1's chart revealed the patient came into the facility via EMS on 4/11/18 at 9:51AM. Review of the ED physician notes at 10:03AM stated, ""abdominal cramping and pain since 0500 this morning with nausea. Abdomen tender to touch. Pale and diaphoretic upon arrival. States bowel movements are regular at this time. History of stomach cancer" The physician also stated, "all GI removed and small intestine connected to throat."
Review of the chart revealed the physician ordered IV of ringer's lactate, stat lab that included blood cultures. IV antibiotics were ordered. Chest x-ray was ordered. At 11:23 AM The Radiologist recommended obtaining a CT.
1:37 PM written CT report indicated a "Large defect at the level of the esophageal hiatus with multiple loops of intestine, mostly small intestine, herniated into the lower hemithorax."

1:58 PM ED RN documented, "Pt back in bed, ask ERP (Emergency Room Provider) for a diagnosis to attempt transfer. States, he wants to talk with _____(Staff#8) first to see if he will see pt because, he (ER Physician) doesn't believe pt. will survive transfer. ERP on phone with ____ (Staff #8), ____ (Staff #8) denies being on call and states he won't see pt."

2:06PM ED RN documented, "Dr._______ on phone with surgeon from ________ (local facility), spoke with air vac and states they would be available if needed also called ________ (local) EMS and states that they would be available".

3:21PM ED RN documented "Dr._______ spoke with Dr. ____ (ER Physician) from _________(local facility)states that _____ (surgeon) will accept, still pending administration approval."

The ED physician documented: ED course
"4/11/2018 10:14 stable

4/11/2018 at 14:03(2:03PM) stable. Bp dropped for a while. Dehydrated. Also bowel is shifting the mediastinum to the right. MT

4/11/2018 at 15:10 (3:10PM) unstable Bp is dropping again. Lactate is very high as is WBC count. I am concerned about bowel ischemia and a mediastinum shift. Need emergency surgery to try to save the bowel. Dr. ____ (staff #8) is listed as our on call General Surgeon. Apparently Dr. ____ (staff# 7) is the surgeon who should be on call. Dr. ____(staff#7) is out of town. Called Tyler surgeon Dr. _____ and also talked to thoracic surgeon Dr. ____. Advised to send to________(Cancer Hospital in Houston)who did the cancer surgery 2 years ago. We called them. We were told "It will be a long time". We called __________(local facility). I talked to DR. ____ (ER Physician) who talked to the general surgeon, Dr. ____. Dr. ____ (general surgeon) will accept. Note: This is a surgical emergency. Need surgery ASAP. The general surgeon at the hospital 3 miles away is the best choice."

The transfer was arranged. The patient coded in the ambulance prior to exiting the hospital property. He was brought back into the ED and a full code was conducted. The patient was intubated and stabilized as much as possible. Verification to transfer to receiving hospital post code was insured. The patient was transferred to ____________(local facility)and died shortly after surgery.

Interview with the CNO revealed the following:
Staff #7 (surgeon) has been the responsible party to make the on-call schedule for the surgeons. If the surgeons needed to be off or request certain dates off, then they would submit a written request to his office. Staff #7 would then make the schedule. Staff #7 had submitted a written notification to the office of General & Vascular Surgery on 3/12/2018, he would not be available for call April 6 through April 11 and May 31-June 4. The fax was verified during the investigation The request was not verified on the schedule and Staff #8 was still scheduled to work on 4/11/18.

On 4/10/2018 Staff #8 was in Las Vegas Nevada for mandatory CME training and realized he was still on the schedule for surgical coverage for the ED. He notified his office and the hospital's administrator that notified he would not be available April 11, he was still scheduled and could not cover the on-call time. He asked that the other surgeons be called to see if any would change call rotation with him and take his call as he was out of the state.
Staff #7 is a private practice physician/surgeon who was responsible for coordinating the on-call scheduling and providing it to the ED of the hospital. Staff #7 told the hospital he had not received the fax requesting time off from Staff# 8. Staff #7 had spoken with the CNO and indicated he was available to cover the on-call schedule until 4:00 PM 4/11/2018.

The CNO indicated the hospital had been in phone contact with Staff #8 who would be home by midnight and would pick up the remainder of his call schedule. She stated the plan was to go on divert from 4:00 PM until midnight, at which time staff #8 would be available for call.

On the morning of 4/11/2018, Dr. ____ (staff #8) was notified of the likely need for surgery. Dr. ____ (staff #8) said no one had confirmed with him he was needed and he would not be coming in for surgery.

The third surgeon was also called and refused to come in. A 4th surgeon was never reached by phone.

The hospital was placed on divert at 12:45 PM. Patient#1 had arrived in the ED at 9:51 AM. It was not determined that patient #1 would require emergency surgery until 1:37PM. A transfer was arranged with _____ (ER Physician) at the__________(local facility)across town. Patient #1 was being placed in to the ambulance when he coded. He was brought back into the Hospital's ED; a full code was in progress. He was intubated, stabilized as much as possible and again ____ (ER Physician) was notified of the change in condition. _____ (ER Physician) again agreed to accept the patient. Patient #1 was transferred to __________(local facility). He died in _________(local facility) shortly after surgery.

"The Medical Executive Committee met on 5/15/2018 at 11:55 AM. The discussion was a Peer review, reviewed by Dr. _____ (Staff #16). It was determined Dr._____ (Staff #7) failed to check the on call schedule when it was mailed to him on 3/27/2018. On 4/11/2018 the staff were informed Dr.____ (Staff #8) would not accept call. Dr. ____ (Staff # 11) was in another surgery so he stated "no".
Dr._____ (staff #17) would not return the call and Dr.____ (Staff #8) said no. Dr._____ (Staff #14) was acting Chief of Staff on this day and has recommended the physicians appear before the MEC for explanation. Dr.______ (staff #8) has received notification he was turned into the Texas Medical Board."

The committee discussed the fact that the backup surgeon was______ (staff #8).


Review of the facility "Medical Staff Bylaws and Rules and Regulations", revealed the following:
"3.1 Active Category
3.1.3 Responsibilities
e. "Take unassigned call (exception of primary care providers as long as hospitalist provide this coverage)"


Review of the medical Staff policy, "Trauma Surgeon backup", indicated:

"Nacogdoches Memorial Hospital has a General/Trauma Surgeon as a designated member of the Trauma Team. A General/Trauma Surgeon will evaluate all major and multisystem trauma patients presenting to the Emergency Department (ED) and meeting Trauma Team Activation criteria. If no general surgeon is available, arrangements will be made for immediate transfer of the trauma patient for surgical evaluation. If other sub-specialty surgical (Orthopedics, Neurosurgery, OMFS) are needed and not readily available, arrangements will be made for transfer of the trauma patient for sub-specialty surgical evaluation."

"A monthly General/Trauma Surgeon call schedule & a monthly back-up call schedule will be published in the Emergency Department. A daily call schedule listing the General/Trauma Surgeon on call will be prominently displayed in the ED"

During an interview on 5-29-18 staff #1 stated the facility did not have a policy and procedure on how the facility will respond when a physician does not respond or refuses to come into the hospital when on call. Staff #1 stated that the facility personnel will call the next scheduled surgeon until they find one available. However, the facility does not have that in a policy.

Based on chart reviews and interview the facility failed to:

1.) provide a dated and timed physician certification in 4 (#1, 7, 15, and 16) out of 20 patient charts reviewed.
2.) provide a signature from the patient/guardian and witness that the patient was informed of the risk and benefits regarding the transfer and consent for transfer in 4 (#1, 7, 15, and 16) out of 20 (#1-20) patient charts reviewed.

Review of the facility's Physician Assessment and Certification Form revealed a section of the form where the physician signs (Physician Certification) stating the physician has explained to the patient their risks and benefits of transfer. The physician then signs the certification. Below the physician signature is a section for "Patient's Consent/Request/ Refusal to Transfer. In this section the form states,

"I acknowledge that my medical condition has been evaluated and explained to me by the Emergency Department physician and /or my attending physician who has recommended and offered to me further medical examination and treatment. The potential benefits/risks of such further medical examination and treatment as well as the potential risks associated with transfer to another facility have been explained to me and I fully understand."

There is a section to agree or refuse by the patient or legal guardian, a signature spot for the patient or guardian, and witness signature with a time and date.

Review of patient #1's chart revealed the patient had two Physician Assessment and Certification Forms. The first one had the patients signature and consent to transfer but no witness signature, date, or time. The patient was transferred out to a facility and suffered a cardiac arrest in the ambulance. The patient was brought back into the Emergency Department( ED) and stabilized. Another Physician Assessment and Certification Form was attached with a Registered Nurses (RN) signature but no date, time, or patient/guardian consent.

Review of patient #7, #15 and #16 charts revealed the physician signed the certification but did not date or time their signature. The Patient's Consent/Request/ Refusal to Transfer section was blank. There was no date, time, witness signature, or consent of the patient for transfer. There was no confirmation that the patient understood or agreed to the transfer. The surveyor was unable to determine that the patient was given this information in a timely matter, close to the discharge date, and time.

An interview was conducted with staff #4 on 5/29/18. Staff #4 confirmed the findings on the Physician Assessment and Certification Form and stated, "yes, I see they are just not filling them out."