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Based on medical record review, staff interview and review of facility policy and procedures it was determined the facility was not in compliance with 42 CFR 489.24. The facility failed to ensure the availability of on-call physicians, on its medical staff, were maintained to best meet the needs of the patients for one (#9) patient and failed to ensure written policies and procedures were in place to respond to situations in which the on-call physician could not respond because of circumstances beyond the physician's control for one (#17) of twenty two patients sampled. (see A2404).

Based on medical record review, staff interview, facility document review and review of policy and procedures it was determined the facility failed to ensure the availability of on-call physicians on its medical staff were maintained to meet the needs of the patients for one (#9) patient. The facility failed to ensure written policies and procedures were in place to respond to situations in which the on-call physician could not respond because of circumstances beyond the physician's control for one (#17) of twenty two patients sampled.

Findings included:

Review of the facility policy "Screening, Stabilization and Transfer of Individuals with Emergency Medical Conditions" last revised 10/2012, stated (4) the transfer from this Hospital to a receiving medical facility of an individual with an non stabilized Emergency Medical Condition is carried out as follows: (a) the Hospital, within its capability, provides medical treatment which minimizes the risks to the individual's health; (c) If the necessary on-call services remain unavailable despite efforts for the required on-call specialty, the ED physician or designee notes the name and address of the on-call physician who unreasonably refused or failed to appear in Section III of the Inter-facility Transfer Form.

1. Review of the medical record for patient #9 revealed the patient presented to the ED (Emergency Department) on 5/22/2017 at 7:57 p.m. with complaints of severe abdominal and lower back pain that started abruptly, approximately 40 minutes prior. Review of the physician documentation revealed the patient was seen immediately upon arrival. The patient had a documented systolic manual blood pressure of 300, a critical reading. Physician assessment revealed the skin was dry, pale and the right lower extremity was cool to touch. Arterial pulses to the right lower extremity, femoral and dorsalis pedis were absent. Review of the documentation revealed immediate care and treatment was initiated including IV (Intravenous) fluid, IV antihypertensive medication, IV pain medication and STAT laboratory and radiological tests.

Review of the CT scans revealed a type B aortic dissection extending from the level of the left subclavian artery down through the thoracic aorta, abdominal aorta and into bilateral iliac vessels with extension of the dissection flap into multiple branch vessels including the mesenteric vessels. Hemorrhage was present within the right hemipelvis surrounding the right common iliac artery which demonstrated abrupt occlusion shortly beyond its origin. The findings were most suggestive of right common iliac artery rupture with probable subsequent thrombosis. Documentation by the radiologist stated the results were communicated directly to the ED physician immediately after the patient was scanned.

Review of the ED physician documentation revealed immediate calls were placed to the facility's on-call Cardio-Thoracic (CT) surgeon (#A) and Vascular surgeon (#C) at 8:50 p.m. Documentation noted multiple phone calls and conversations were made with each surgeon. The ED physician documented the CT surgeon (#A) stated the facility did not have the resources required to care for the patient and recommended to transfer the patient.

An interview with the Chief Operating Officer (COO) on 6/1/2017 at 1:30 p.m. confirmed the facility had an on-call CT surgeon (#A) and on-call OR (Operating Room) team of clinical staff on the date of the event.

Documentation revealed the transfer center was called to request transfer of the patient. It was determined two close-by acute care facilities, which could provide CT and Vascular care and services, were on divert/bypass at the time of the call. The facility's Administrator on Call (#D) was notified. An interview with the COO on 6/1/2017 at 1:30 p.m. confirmed she spoke with the on-call CT surgeon (#A), on the night of the event, and reiterated the severity of the patient's condition and emergent need for Cardio-Thoracic services.

The ED physician documented a second call was placed to the on-call physician (#A) who stated he reviewed the CT scan and stated the patient needed to be transferred stating the facility lacked the resources to treat the patient. The ED physician documented another local hospital was called and the on-call CT surgeon requested the transferring facility's on-call CT surgeon (#A) to call him directly. Documentation revealed the CT surgeon (#A) refused to call. Another acute care facility was contacted and the on-call CT surgeon accepted the patient. Review of the record revealed the patient was transferred via helicopter to the accepting facility on 5/23/2017 at 12:20 a.m.

An interview was conducted with the on-call CT surgeon (#A) on 6/2/2017 at 12:30 p.m. via telephone. The surgeon was questioned regarding the events of 5/22-5/23/2017. He stated the patient had a highly complex aortic dissection with a high mortality rate and he did not have the resources to treat the patient. He stated he had operated for over 7 hours earlier that day and there was only one CT OR (Operating Room) nurse and she had also been present in the OR for over 7 hours. The surgeon stated he spoke to the ED physician who relayed the condition of the patient. The surgeon stated it was in the best interest of the patient to transfer him.

2. Review of patient #17's medical record revealed the patient presented to the ED on 3/12/2017 for complaint of abdominal pain. Review of the physician medical screening exam revealed the patient was assessed at 1:05 p.m. CT of the abdomen and pelvis revealed the patient had an aortic dissection with extension into the right common carotid artery. The radiologist documented the ED physician was notified immediately.

The ED physician documented the facility's on-call Cardio-Thoracic surgeon (#B) was notified at 2:26 p.m. Documentation revealed the CT surgeon (#B) stated he did not have the capabilities to do the surgery and recommended the patient be transferred. The ED physician documented a CT surgeon at another acute care facility was called to accept transfer of the patient. The CT surgeon stated due to the patient's blood pressure of 103/52 and heart rate of 48 the patient was not stable to transfer and he would not accept the patient.

At 2:45 p.m. the on-call CT surgeon (#B) was called again and was notified the acute care hospital that was called refused to accept the patient due to his unstable vital signs. Documentation revealed the on-call CT surgeon (#B) stated he still could not do it. The ED physician documented at 3:00 p.m. another acute care facility was called and the ED physician spoke to the Cardio-Thoracic surgeon who stated any Cardio-Thoracic surgeon could perform the surgery and they would be bypassing a lot of other closer facilities to get the patient to him.

Review of the transfer center documented summary revealed the ED notified the transfer center of the need to transfer the patient at 2:31 p.m. Multiple phone calls were made between the transfer center, the ED and other acute care facilities. Documentation at 4:02 p.m. between the transfer center and the facility's on-call CT surgeon (#B) revealed the on-call CT surgeon stated he had the flu and could not operate on the patient. Documentation on the transfer summary log revealed the patient was accepted at 4:24 p.m. at another acute care hospital.

An interview with the COO on 6/2/2017 at 9:30 a.m. was conducted. She confirmed the on-call CT surgeon (#B) was sick and could not operate on the patient. She stated the on-call physician (#B) did not notify the facility of his illness or inability to perform his on-call responsibility. An interview was requested with the on-call CT surgeon (#B). The COO stated he was out of the country on vacation. The COO stated the facility did not have a policy in place for on-call specialists to follow if they are ill and cannot fulfill their on-call responsibility to ensure coverage.