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review of facility documentation and staff interviews (EMP). It was determined that the facility failed to develop policies and procedures for on call physicians to respond, examine, and treat patients who present to the Emergency Department (ED) with a potential emergency medical condition (EMC) and failed to define the qualified medical person to perform the initial medical screening examination (MSE) in order to determine if an underlying emergency medical condition existed.

Findings include:

1) On September 29, 2016, at approximately 11:00AM a request was made for a copy of the facility's policy and procedure for the On Call Physicians in the ED. In response to the Department's request EMP1 stated, "We do not have an on call policy."


2) A review of the facility's "Department of Emergency Medicine Rules and Regulations" dated September 14, 2016, revealed that the facility failed to define and identify who the qualified medical person is to perform the initial medical screening examination and make the determination if an underlying emergency medical condition exists.


3) On September 30, 2016, at approximately 1:00 PM EMP1 confirmed the above findings.

Based on review of facility documentation, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to follow its policy for appropriate transfer, for physician to physician discussion between the sending and accepting facility, and accepting physician for one medical record reviewed (MR1).

Findings include:

Review of facility policy "Transfers to other Hospitals" last reviewed October 2015, revealed, "PURPOSE: To provide appropriate medical screening and stabilizing treatment to any individual prior to transfer. To ensure proper professional care of the patient throughout the transfer. To ensure appropriate communication of information regarding the transfers. POLICY: ... B. The receiving hospital and physician have available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer of the individual and to provide the appropriate medical treatment. The transferring physician will make the arrangements. ...11. Documentation shall include: ... Communications with the receiving hospital and/or physician."

1. Review of MR1's Emergency Department Provider Documentation, dated September 16, 2016, revealed, "ED Course/Decision Making ... The case was discussed with (obstetrician on call at sending hospital) who requested that the patient be transferred to (receiving hospital) for monitoring for preterm labor."

Further review of MR1 revealed, "Accepting Physician: (sending hospital on call obstetrician.)" No documentation of an accepting physician at the receiving hospital was noted.

2. Interview with EMP9, (sending physician) on September 29, 2016, at 9:45 AM, "[Obstetrician on duty at accepting hospital] called me and said that she did not hear about this transfer, so I told her a history, high risk twin pregnancy, was admitted last month for pre-term labor. ... I don't think she was in active labor but [the sending hospital on call obstetrician] said we need to transfer her for a non-stress test. When I spoke with [obstetrician on duty at accepting hospital], she wanted us to discharge the patient and have her come in as an outpatient. I told [obstetrician on duty at accepting hospital] that I respectfully disagree. [Obstetrician on duty at accepting hospital] wanted to speak with [obstetrician on call at sending hospital] first. The ambulance came and I stopped them from leaving until they accepted the patient. [Obstetrician on call at sending hospital] called me and said to transfer the patient." When asked if obstetrician on call at sending hospital was at the receiving hospital, EMP stated, "No, he wasn't."