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Based on review of hospital documents, Medical Staff Rules and Regulations, Medical Staff Credentialing and interviews with hospital staff, the hospital failed to enforce policies and procedures to ensure compliance with the requirements of 42 CFR 489.24. The hospital failed to enforce it's policy and procedure and Medical staff rules and regulations concerning treatment and stabilization of patients within their capabilities.

Findings:

1. Upon arrival at the hospital on the morning of 07/13/2010, the surveyors requested to review the Medical Staff Bylaws, rules and regulations regarding EMTALA (Emergency Medical Treatment and Active Labor Act) requirements. Medical Staff Rules and Regulations requires on page 21, 2.(b)(3) " The following represents a listing of emergencies, but are not all inclusive, of conditions that will require that the on back up physician on call be notified immediately and that he comes in person to the ER within the shortest time possible. Specific emergencies ...2(b)(3)(F) fractures of any kind. "

Patient #13 - had a fractured radus and ulna. The on-call orthopedist did not present to examine the patient. The on-call orthopedist had privileges to provide care to"patients of all ages".

2. The hospital's policies and procedures stipulated that patient's would be treated within the hospital's capabilities. For Patients #13, 17 and 22, the patients were transferred to another acute care hospitals when the hospital had the capabilities to treat the patients. The hospital had specialists on-call who had privileges to treat the patients.

Based on review of medical records and hospital documents and interviews with hospital staff, the hospital failed to provide further treatment within its capability in three (Patient #1, #17, and #22) of thirty patients who presented to the emergency room (ER) whose medical records were reviewed.

Findings:

1. A. Patient #1 - a 13 year old, presented by private auto to the ER on 07/06/10 at 11:10 with complaints of a left forearm injury after a 4 wheeler accident. The patient's medical record indicates the patient received an x-ray of the forearm "ap & lat 2 views" at 11:20. The ER physician (Dr. B) documented the following:
-"Patient's pain rating was 10/10" on arrival.
-"Musculoskeletal/extremity: left upper extremity: Forearm--Obvious bony deformity is present. Severe tenderness to palpation. Tenderness most marked at mid-forearm, anterior aspect. Range of motion appropriate for age."
-"Associated signs and symptoms: "negative lacerations to the left forearm."
- "Consultation and critical thinking section of the record "case discussed with Dr. A. He recommends transfer of patient to pediatric ortho." The documentation was timed 11:26 7/6/2010.
-"Clinical Impression: Acute fracture of radius and ulna left" timed at 11:49, 7/6/10.
- "X-Ray interpretation by Emergency Department Physician. Left Forearm--Acute displaced fracture of the middle third of the ulna and Radius" timed at 11:47, 7/6/2010.
-"Disposition 7/6/2010 12:49 Patient will be transferred to St Francis ER Tulsa"

Nursing documentation states the patient had lab work, x-rays, intravenous pain medication, intravenous anti-emetic medication, and placement of ortho glass splint. Nursing documentation also included in "transfer" section of the nursing section "Transfer initiated for: Ortho not available. Dr. B arranged transfer." The same nurse documented on the transfer sheet under "reason for transfer" - The equipment or services not available at this facility (list) "pedi ortho".

1.B. During a interview with the ER physician (Dr. B) on 7/13/2010 at 1555 , he told the surveyors that the patient's fracture was an angulated forearm fracture of both bones and it was displaced. Dr. B stated he spoke with Dr. A (on call orthopedist) who told him he (Dr. A) was "not comfortable" working on this type of fracture. Dr. B stated the orthopedist said he would be better served by someone who could do flexible intermedullary rods and that he (Dr. A) had never done those. Dr. B was asked by surveyors if he usually reduced fractures prior to transfer. Dr. B stated he only reduced dislocations not displacements.

1.C. During a interview with the orthopedic surgeon (Dr. A) at 1630 on 7/13/2010, he confirmed he was on call 7/6/2010 and he did review Patient #1's radiographs and medical records from his clinic. He also stated he discussed the case with the ER physician. He did not present to the ER to examine the patient as required by the Medical Staff rules and regulations on page 21, 2.(b)(3) which says, " The following represents a listing of emergencies, but are not all inclusive, of conditions that will require that the on back up physician on call be notified immediately and that he comes in person to the ER within the shortest time possible. Specific emergencies ...2(b)(3)(F) fractures of any kind." Dr. A initially stated he did not treat pediatric patients. He also stated he did not feel comfortable caring for the Patient #1 because of the nature of the fracture and displacement. Dr. A also stated he did not come in and see the patient only reviewed information on-line. Later in the conversation Dr. A stated he did do pediatric work within his skill set. He stated he felt he did not have the skills to do an adequate job for this patient. He was also asked by surveyors if he reduced displaced fractures. Dr. A affirmed he did do reductions but did not reduce this fracture because he thought it might cause further complications.

1.D. Review of the on-call physician's (Dr. A) credential file demonstrated the physician had privileges to treat a patient with Patient #1's injury. The credential file also indicated the Dr. A was privileged to treat "patient's of all ages".

The hospital did not provide further treatment for Patient #1 within its capability.


2. Patient #17, a 58 year old, presented to the emergency room (ER) on 1/16/2010 at 18:41 after sustaining a fall at home and dislocating her hip. The ER physician Dr. J and two other physicians attempted to place the prosthetic hip back into the socket but were unsuccessful. Dr. A was consulted by the ER physician at 2010 at which time Dr. A recommended transfer of the patient. Disposition notes state "ortho is not willing to treat the patient". In an interview with Dr. A on 07/13/2010 at 1630, he stated he did not present to examine the patient. Dr. A was credentialed and privileged to perform this procedure.

The hospital did not provide further treatment for Patient #17 within its capability.


3. A. Patient #22, a 51 year old, presented to the emergency room (ER) on 5/27/2010 at 13:14 with a chief complaint of abdominal pain. The ER physician Dr.I documented "symptoms located in the abdomen but are generalized, without localization. Patient describes quality of symptoms as aching, cramping. Patient states symptoms are of moderate intensity. On 0 to 10 scale, patient rates pain as 7/10 at this time". Dr. I documented on physical examination: "Abdomen: Mild diffuse tenderness without localization. Bowel sounds are normoactive." Diagnostic tests were performed and documented as follows: Hct 36.7, Hgb 12.6, Platelets 390-all reviewed as normal. Computerized Tomography (CT) scan results were as follows: "Abdomen/Pelvis--Study done without contrast. Consistent with acute appendicitis. Dr. I documented in the "past medical and surgical history" the following: "positive gall stones removed, past medical and surgical history reviewed." Dr. I documented in the "family and social histories, allergies and meds section: "Medications: none 000, Medications reviewed". The preassessment form (triage) in the "pre-hospital treatment" section there is "2 aspirin" listed. In this same section there is "past medical history: gallstones removed, no etoh (alcohol), no some" documented.

Dr. I documented at 15:28 on 5/27/2010, "case discussed with Dr. C. He recommends transfer of the patient to another facility because the pt has taken two 325 mg asa (aspirin) and needs to be at a facility that has platelets readily available. Dr.C was not available for interview at the time of survey. Surveyors reviewed findings at the exit conference on 7/14/2010 at which time Staff D was informed a faxed statement could be sent to the Department.

3.B. On 7/14/2010 the Department received a faxed statement signed by Dr. C in which it is documented: "Regarding the case of Pt. #22 and the question of transfer, it was detailed in her history that she was currently on antiplatelet therapy and full strength aspiring. Standard of care dictates that these patient have platelets readily available and infusing at the time of incision. With her diagnosis of acute appendicitis and her history of multiple abdominal procedures she was not a candidate for a laparoscopic procedure.

3.C. A follow-up call was placed to Staff #D the afternoon of 7/14/2010. Surveyors left a message and asked if there were any other medical records or chart documents to coincide with Dr. I's faxed documentation. On 7/16/2010 at 10:33 am Staff #D returned call and stated there were no further documents.

3.D. Review of Dr. I indicates he was credentialed and privileged to perform an appendectomy.

The hospital did not provide further treatment for patient #22 within it's capability.

Based on interviews with hospital staff and review of medical records and administrative documents, the hospital failed to effect appropriate transfers. In three of eleven records reviewed for the last six months, of patients who were transferred to another facility, the hospital did not execute a proper transfer. The hospital did not provide medical treatment within it's capability.


Findings:
1. Patient #1, a 13 year old, presented to the emergency room (ER) on 7/6/2010 at 11:10 after having a four wheeler accident and injuring his arm. The ER physician (Dr. B) obtained x-rays which showed a displaced forearm fracture of the radius and ulna. Dr. B called the on-call orthopedic surgeon (Dr.A) who reviewed the patient's films from his office and stated to Dr. B he was not comfortable handling the displaced fracture and the patient needed to be transferred to a facility with pediatric orthopedic care. Dr. A was credentialed and privileged to provide care to "patients of all ages" and "fractures of any kind".

On 7/13/2010 surveyors were provided copies of the Medical Staff Bylaws, rules and regulations. Medical Staff rules and regulations page 21 2.b (3). documents "the following represents a listing of emergencies, but are not all inclusive of conditions that will require that the on back up physician on call be notified immediately and that he come in person to the emergency room within the shortest time possible. Specific emergencies 2.b.(3)(f) fractures of any kind". The physician on call for orthopedics (Dr.A) did not present to the emergency room to care for patient #1although he was privileged to care for patients of all ages and all types of fractures. Dr. A called Dr. B (ER physician) and stated he reviewed the patient #1's films but was not comfortable treating the patient

2. Patient #17, a 58 year old, presented to the emergency room (ER) on 1/16/2010 at 18:41 after sustaining a fall at home and dislocating her hip. The ER physician Dr. J and two other physicians attempted to place the prosethetic hip back into the socket but were unsuccessful. Dr. A was consulted by the ER physician at 2010 at which time Dr. A recommended transfer of the patient. Disposition notes state "ortho is not willing to treat the patient". Dr. A was credentialed and privileged to perform this procedure.

3. Patient #22, a 51 year old, presented to the emergency room (ER) on 5/27/2010 at 13:14 with a chief complaint of abdominal pain. The ER physician Dr.I documented "symptoms located in the abdomen but are generalized, without localization. Patient describes quality of symptoms as aching, cramping. Patient states symptoms are of moderate intensity. On 0 to 10 scale, patient rates pain as 7/10 at this time". Dr. I documented on physical examination: "Abdomen: Mild diffuse tenderness without localization. Bowel sounds are normoactive." Diagnostic tests were performed and documented as follows: Hct 36.7, Hgb 12.6, Platelets 390-all reviewed as normal. Computerized Tomography (CT) scan results were as follows: "Abdomen/Pelvis--Study done without contrast. Consistent with acute appendicitis. Dr. I documented in the "past medical and surgical history" the following: "positive gall stones removed, past medical and surgical history reviewed." Dr. I documented in the "family and social histories, allergies and meds section: "Medications: none 000, Medications reviewed". The preassessment form (triage) in the "pre-hospital tratment" section there is "2 aspirin" listed. In this same section there is "past medical history: gallstones removed, no etoh, no some" documented.

Dr. I documented at 15:28 on 5/27/2010, "case discussed with Dr. C. He recommends transfer of the patient to another facility because the pt has taken two 325 mg asa (aspirin) and needs to be at a facility that has platelets readily available. Dr.C was not available for interview at the time of survey. Surveyors reviewed findings at the exit conference on 7/14/2010 at which time Staff D was informed a faxed statement could be sent to the Department.

On 7/14/2010 the Department received a faxed statement signed by Dr. C in which it is documented: "Regarding the case of Pt. #22 and the question of transfer, it was detailed in her history that she was currently on antiplatelet therapy and full strength aspiring. Standard of care dictates that these patient have platelets readily available and infuisng at the time of incision. With her diagnosis of acute appendicitis and her history of multiple abdominal procedures she was not a candidate for a laparoscopic procedure. A follow-up call was placed to Staff #D the afternoon of 7/14/2010. Surveyors left a message and asked if there were any other medical records or chart documents to coincide with Dr. I's faxed documentation. On 7/16/2010 at 10:33 am Staff #D returned call and stated there were no further documents.Review of Dr. I indicates he was credentialed and privileged to perform an appendectomy.


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