HospitalInspections.org

Based on review of facility documents and medical records (MR), and interview with facility staff (EMP) and credentialed staff (OTH), it was determined the facility failed to ensure an on call list was maintained in accordance with the resources available to the hospital, including the availability of on-call physicians, resulting in the transfer of Emergency Department patients to other hospitals for care and failed to to ensure the facility's policies for on call and the Emergency Medical Treatment and Labor Act EMTALA were implemented for five of 18 transfer records reviewed (MR1, MR2, MR3, MR4 and M5).

Findings include:

Review of the WVHCS-Hospital Rules and Regulations dated last revised August 2009 revealed, "Section A. Admission of Patients ... 11 a. (ii) Members of the active and courtesy staff will perform "on-call" coverage in accordance with the rules of their departments. On-call physicians are responsible for examining, treating and stabilizing patients with emergency medical conditions as defined in the Emergency Medical Treatment and Labor Act (EMTALA), who may need hospital admission or transfer. An on-call physician roster will be provided to the Emergency Department by the clinical department chairmen and/or section chief. A Medical Staff physician must come to the Hospital to examine the patient when a request by the Emergency Department is made. The physician must respond in a reasonable amount of time."

Review of Department of Surgery Rules and Regulations, dated modified March 2010, revealed "IV. Rules of The Surgical Department ... C. On call physicians are also responsible for consults on unassigned patients in house or the Emergency Room. Unassigned patients are those who have no pre-existing physician or surgeon and those who have not requested a particular surgeon. Should the surgeon requested by the patient not accept the patient or is unable to see the patient, the on-call physician is responsible to see the patient. D. All sections of the Department of Surgery shall provide rotating call service to the Department of Emergency Services. These services shall be scheduled in advance and the length of time for each service shall be determined by the section. Active members shall provide the service, also courtesy staff at the discretion of the Section Chief."

Review of the facility policy "On-Call" revealed "The following specialties shall be represented on the "on-call" list: Cardiology, ENT (ear, nose and throat), Family Practice/Internal Medicine, Gastroenterology, General Surgery. ... Procedure: 1. A copy of the "On-Call' list will be maintained in the ED (Emergency Department) for reference on an as needed basis. ... 3. It is the responsibility of the "On-Call' physician to respond within a reasonable time frame when needed. 4. If the "On-Call" physician is not available or unable to respond, the Emergency Department will contact the Chief Section for an alternative. If the Chief of the section is not available, the Department Chairman will be contacted. When necessary, the Vice-President, medical affairs may also be contacted to resolve the situation."

Review of the facility "on call" lists from October 2009 thru March 31, 2010, revealed complete coverage by the general surgery service.

Review of an internal memo to the Medical Staff dated March 10, 2010, revealed "RE: On Call Surgery ER Coverage. An emergency meeting of the of the Medical Executive Committee was held on March 1, 2010, following a notification from the Section of General Surgery that they will only take ER calls for the first 10 days of the month. We will not have ER coverage for our surgical patients. If any of your patients present to the ER it is your responsibility to call the surgeon of your choice to provide emergency surgical care and treatment. In the event no one is available, please note that we have no choice but to stabilize and send the patient to the nearest accepting hospital for further care."

Review of a medical affairs memorandum dated March 24, 2010, to the Section Chief of General Surgery and section Members from the Medical Executive Committee (MEC) regarding On-Call Roster revealed "It has come to our attention that the General Surgery service has not provided an on call physician roster for unassigned patients that covers the emergency department for the month of April. The purpose of this memorandum is to outline the Medical Executive Committee's expectation with regard to call coverage going forward. The MEC is cognizant of the EMTALA requirement that all services available to the hospital on a regular basis must be regularly available to the emergency department. This requirement extends to the 'rotating on call service' for unassigned patients. Thus, when a specialty includes at least three staff members, the MEC expects full time coverage of the emergency department for unassigned patients in that specialty. The Bylaws do not contemplate that physicians will receive compensation for this service, and the MEC expects that Medical Staff members will fulfill this responsibility for such services. The MEC therefore formally requests that you as the section chief to submit an on call roster providing full general surgery coverage for the emergency department for the month of April. If the Chair of the Medical Executive Committee does not receive such a roster by the close of business on Monday March 29, 2010, the MEC will move forward to fulfill the obligations of the federal law that requires such a roster. At this time we are in violation of federal Rules and Regulations. Hence the committee has decide to institute a call schedule as per the attached letter to comply with EMTALA rules. Please note as per the existing rules when the emergency department contacts you, you are responsible to assign a member of your section to attend to the patient's need."

Review of the revised general surgery service call schedule for March 2010 revealed coverage for the period March 1 thru March 10, 2010, with a notation on the bottom of the list that stated "Please note that after the tenth, there will be no service coverage until April, at which time, the first 10 days will again be covered. Review of a second revised March on call general surgery schedule revealed coverage from March 24 thru March 31, 2010. Review of the April general surgery service on call schedule revealed coverage for April 1 thru April 18, 2010, and April 26 thru April 30, 2010. There is no coverage for April 19 thru April 25, 2010.

Review of the facility emergency services policy EMTALA guidelines revealed "If the on-call physician is not available in a timely fashion, the Section Chief or Department Chairman will be consulted for appropriate referral. If the section chief is not available, the Vice President of Medical Affairs or his designee will be consulted."

Review of MR1 revealed the patient presented to the Emergency Department on April 18, 2010, with right-sided abdominal pain of sudden onset. Physical examination of the abdomen revealed tenderness in RLQ (right lower quadrant) in McBurney's point, which is mild in intensity. Tender McBurney's point. Doctor notes - I called and spoke with OTH1. OTH1 is unable to come in and would like the patient transferred.. Nurse Notes - 0010 - EMP1 contacted OTH1. OTH1 not available to come in and stated to transfer. The Emergency Services/Obstetrical Transfer Form noted reason for transfer: Diagnosis is acute appendicitis. Reasons for transfer: Need for specialized care: No surgeon available.

Review of MR2 revealed the patient presented to the Emergency Department on March 22, 2010, with abdominal pain. Nursing documentation revealed the patient was transferred at 2335. Diagnosis is acute appendicitis. Reason for transfer: Need for specialized care. Additional: Appendicitis - without peritonitis. Emergency Services/Obstetrics Transfer Form noted the benefits of transfer as "Surgeon on call tonight."

Review of MR3 revealed the patient presented to the Emergency Department on March 27, 2010, with stab wound to the anterior abdominal wall. Nursing documentation noted the patient was transferred at 0518. Diagnosis is stab wound abdomen. Reason for transfer: need for specialized care. Emergency Services/Obstetrics Transfer form noted the Benefits of Transfer as "Trauma team with surgeon in house."

Review of MR4 revealed the patient presented to the Emergency Department on March 16, 2010, for evaluation of abdominal pain, flank pain and fever, gradual onset over 3 days, pain is constant. Pain in the right lower quadrant with radiation to the back (per nursing). Doctor's notes revealed: "5:45 PM spoke to OTH2 who stated that he took a service patient recently and is not going to take every service patient. Suggested we try the other surgeons and if no luck, then transfer the patient." Nursing documentation revealed: Diagnosis is acute appendicitis. Reasons for transfer: Need for specialized care. Emergency Services/Obstetrics Transfer form: 2. Reason for Transfer A. For equipment or services not available at this facility: (list) Service Surgeon.

Review of MR5 revealed the patient presented to the Emergency Department on March 18, 2010, with right-sided abdominal pain, nausea and vomiting times two. Per nursing documentation, the patient was transferred at 2225. Diagnosis is abdominal pain. Reasons for transfer: Need for specialized care. Reason for transfer: Need surgeon. Emergency Services/Obstetrics Transfer Form: 2. Reason for Transfer A. For equipment or services not available at this facility: (list) Surgery unavailable.

Interview with OTH1 on April 27, 2010, at 10:30 confirmed being called for consult for MR1. OTH1 did not come in as he had been in surgery all day. OTH1 further confirmed another surgeon was not called because they were refusing to take call for more than one day a month and wanted to get paid for call. OTH1 further confirmed OTH2 had been refusing to take call for the past two months.

Interview with EMP1 on April 28, 2010, at 11:45 AM confirmed that OTH1 instructed EMP1 to transfer the patient.

Interview with OTH2 on April 27, 2010, at 11:00 AM confirmed general surgery was only providing call one day a month. OTH2 stated "the surgeons feel overwhelmed seeing more uninsured patients." OTH2 was unaware of a facility policy specific for the on-call procedure.

Interview with EMP2 on April 28, 2010, confirmed they were aware that the general surgeons were refusing to take call. EMP2 further confirmed it was the physicians responsibility to provide Emergency Room coverage for surgical call. A phone interview with EMP2 on April 29, 2010, confirmed no disciplinary actions had been taken against the general surgeons who were refusing to provide on call service coverage.

Interview with OTH3 on April 28, 2010, at 11:30 AM confirmed that the surgeons had agreed to only provide on call coverage one day a month, providing coverage for the first 10 days of the month, until they were fairly compensated for their services. OTH3 stated they had 10 general surgeons to rotate call.

Interview with OTH4 on April 27, 2010, at 10:00 AM confirmed there had been difficulties with surgical on call for the months of March and April. OTH4 confirmed that patients had been transferred to other facilities as a result. OTH4 further confirmed that he was not familiar with the facility's Emergency services EMTALA Guidelines.

Interview with EMP3 on April 28, 2010 at approximately 1:30 PM confirmed that the existing facility policies for on call and the Emergency Medical Treatment and Labor Act EMTALA were not followed.