HospitalInspections.org

Based on interviews, record reviews, and a review of policies and procedures, it was determined the facility failed to comply with 42 CFR 489.24 Special Responsibilities of Medicare hospitals in emergency cases for one (1) of twenty (20) patients (patient #1) that presented to the Emergency Department (ED). The facility failed to ensure treatment was provided by an on-call physician in accordance with facility policy and regulatory requirements.

The findings include:

A review of the facility's "Physician On-Call Coverage in Lieu of Availability of On-Call Physician Services" policy effective date March 2011 revealed the on-call physician had a legal obligation under Emergency Medical Treatment and Labor Act (EMTALA) to come to the facility to provide emergency stabilizing treatment for a patient when requested by the Emergency Room physician. The review revealed the on-call physician was to respond by phone to the initial call within 30 minutes. The policy further revealed when an ED physician requested an on-call physician to provide stabilizing medical care, the on-call physician must physically respond within a reasonable timeframe which, according to the policy, was 30 minutes unless a more immediate response was appropriate as determined by the ED physician.

Patient #1 presented to the Emergency Department (ED) of the facility on September 21, 2010, and was assessed by the triage nurse at 11:33 p.m. The triage assessment revealed patient #1's blood pressure was 101/56 (normal range 100-140/60-90), the patient's pulse rate was 107 (normal range 60-100), and the patient's respiratory rate was 33 (normal range 12-20). The patient also complained of dizziness, hypoventilation, "feet numb," and shortness of breath. The triage nurse documented patient #1 had undergone a surgical procedure on September 21, 2010, at 2:30 p.m., the same day the patient presented to the ED. The patient was admitted to the Emergency Department (ED) for assessment and treatment.

Registered Nurse (RN) #5 conducted a nursing assessment of patient #1 on September 21, 2010, at 11:37 p.m., and noted patient #1 was anxious, cool, pale and tachycardiac (rapid pulse rate). The nurse also noted patient #1 had abdominal tenderness with guarding. The nurse documented the patient stated he/she was "Hurting all over, up in left (L) arm, can't breathe." An interview conducted on May 25, 2011, at 9:40 a.m., with RN #5 revealed patient #1 had complained of pain initially but the patient's pain had worsened while he/she was in the ED. RN #5 also stated patient #1's medical condition had worsened during the ED visit. According to RN #5, the patient became pale, "tachycardiac," and received IV fluids and a blood transfusion while in the ED.

A review of the Emergency Department (ED) physician's assessment of patient #1, dated September 22, 2010, at 12:46 a.m., revealed the patient complained of dizziness and abdominal pain. The ED physician documented the patient had undergone a surgical procedure "today" (September 21, 2010) and presented to the ED with complaints of difficulty breathing, abdominal pain, and right (R) shoulder pain. The physician's assessment revealed patient #1 was anxious, short of breath, and was having abdominal pain. Based on documentation, the ED physician contacted the on-call physician on three different occasions from 2:30 a.m. until 6:50 a.m. on September 22, 2010. The on-call physician presented to the facility at 7:10 a.m. on September 22, 2010, and patient #1 was taken to the Operating Room for a surgical procedure at 7:35 a.m. An interview conducted on May 24, 2011, at 2:25 p.m., with the ED physician revealed the on-call physician was telephoned several times related to patient #1's condition. The ED physician stated, "I felt she needed treatment when I called him; that is why I called him." The ED physician stated patient #1 became hypotensive and intravenous (IV) fluids were administered. In addition, according to the ED physician, the patient's Hemoglobin and Hematocrit dropped and the patient received a blood transfusion. The ED physician stated due to the on-call physician's prolonged response time patient #1 experienced a delay in treatment and "suffered a negative outcome."

An interview conducted on May 24, 2011, at 1:45 p.m., with the on-call physician, revealed patient #1 had undergone a surgical procedure earlier in the day on September 22, 2010, and had reportedly presented to the ED due to dizziness and pain. The on-call physician stated patient #1's Hemoglobin and Hematocrit (H & H) were slightly low upon admission and this was not unusual post surgical procedure. The interview revealed the ED physician had contacted the on-call physician a second time to report that the patient's Hemoglobin and Hematocrit had decreased and the on-call physician requested for the patient to receive a blood transfusion. The on-call physician reported patient #1 had received a CT scan of the pelvis/abdomen that had been incorrectly interpreted as normal. The on-call physician stated he was misled by the incorrect results of the CT scan and, as a result, this led to the delay in treatment.

Refer to 42 CFR 489.24 (A2404).

Based on interviews, record review, and a review of policies and procedures, it was determined the facility failed to ensure an on-call physician for specialty services provided a timely evaluation and/or treatment necessary to stabilize one (1) of twenty (20) patients (patient #1) that presented to the Emergency Department (ED) with complaints of an emergency medical condition. A review of the medical record for patient #1 revealed the ED physician telephoned the on-call physician three times (at 2:30 a.m., 4:57 a.m., and 6:20 a.m.) before the on-call physician came to the facility at 7:10 a.m., to evaluate and treat patient #1 with surgical intervention.

The findings include:

A review of the facility's "Physician On-Call Coverage in Lieu of Availability on On-Call Physician Services" policy, effective date March 2011, revealed the on-call physician had a legal obligation under Emergency Medical Treatment and Labor Act (EMTALA) to come to the facility to provide emergency stabilizing treatment for a patient when requested by the Emergency Room physician. The review revealed the on-call physician was to respond by phone to the initial call within 30 minutes. The policy further revealed when an ED physician requested an on-call physician to provide stabilizing medical care, the on-call physician must physically respond within a reasonable timeframe which, according to the policy, was 30 minutes unless a more immediate response was appropriate as determined by the ED physician.

A review of patient #1's medical record revealed the patient was triaged in the ED on September 21, 2010, at 11:33 p.m. The triage assessment revealed patient #1's blood pressure was 101/56 (normal range 100-140/60-90), the patient's pulse rate was 107 (normal range 60-100), and the patient's respiratory rate was 33 (normal range 12-20). The patient also complained of dizziness, hypoventilation, "feet numb," and shortness of breath. The triage documentation revealed the patient had undergone a surgical procedure on September 21, 2010, at 2:30 p.m., the same day the patient presented to the ED. Registered Nurse (RN) #5 conducted a nursing assessment of patient #1 on September 21, 2010, at 11:37 p.m.; patient #1 was anxious, cool, pale, and tachycardiac (rapid pulse rate). The nurse also noted patient #1 had abdominal tenderness with guarding. The nurse documented the patient stated he/she was "Hurting all over, up in left (L) arm, can't breathe." A review of the Emergency Department (ED) physician's assessment of patient #1, dated September 22, 2010, at 12:46 a.m., revealed the patient complained of dizziness and abdominal pain. The ED physician documented the patient had undergone a surgical procedure "today" (September 21, 2010) and presented to the ED with complaints of difficulty breathing, abdominal pain, and right (R) shoulder pain. The physician's assessment revealed patient #1 was anxious, short of breath, and was having abdominal pain. The medical record revealed laboratory study results were obtained at 12:50 a.m. on September 22, 2010, and revealed a Hemoglobin of 10.1 (normal range 12.3-15.3) and a Hematocrit of 31.1 (normal range 36.0-45.0). The review revealed at the same time, patient #1's blood pressure was 68/45 (lower than the normal range) and the patient's pulse rate was elevated at 96 beats per minute. The record revealed patient #1 received 1,000 cubic centimeters (cc) of Normal Saline intravenously (IV) at 12:53 a.m. and again at 3:15 a.m. The ED physician documented at 1:05 a.m., patient #1's blood pressure was "103/68" and his/her pulse rate was "104." RN #5 documented at 1:30 a.m., the patient's blood pressure was "100/52" (low). A second set of laboratory study results obtained at 1:55 a.m. on September 22, 2010, revealed patient #1 experienced a decrease in his/her Hemoglobin from 10.1 to 9.0 and a decrease in Hematocrit from 31.1 to 29.9. RN #5 documented at 2:30 a.m., there had been no change in the patient's condition and the patient became "tachy" (rapid pulse rate) when he/she tried to sit up right. Documentation by the ED physician revealed the ED physician had contacted the on-call physician on September 22, 2010, at 2:30 a.m. A review of RN #5's notes revealed at 3:00 a.m. on September 22, 2010, the patient continued to complain of pain and the nurse noted the patient was still very pale, his/her blood pressure was 89/53 (low), and his/her pulse was 114 (high). The nurse's notes at 3:56 a.m. on September 22, 2010, revealed patient #1 received Morphine (narcotic analgesic) for complaints of pain. RN #5 documented at 4:15 a.m. on September 22, 2010, the patient's pain had worsened and the ED physician was aware. The nurse's notes revealed at 4:30 a.m., the patient received Fentanyl (narcotic analgesic), Zofran (antiemetic), and had an indwelling urinary catheter inserted. A review of patient #1's third set of laboratory study results obtained at 4:35 a.m. on September 22, 2010 (2 hours and 50 minutes since the previous results), revealed a decrease in the patient's Hemoglobin from 9.0 to 6.2 and a decrease in Hematocrit from 29.9 to 19.5. On September 22, 2010, at 4:45 a.m., patient #1 had a CT scan of the abdomen and pelvic area. At 4:45 a.m., the ED physician requested for the patient to receive 2 units of Packed Red Blood Cells (PRBC). The ED physician documented at 4:57 a.m. on September 22, 2010, that the on-call physician had been called and informed that the patient was receiving a blood transfusion. RN #5 documented at 4:58 a.m., that patient #1's pre-transfusion blood pressure was "86/46" and his/her pulse rate was "110". The nurse's notes revealed patient #1 continued to receive medication for his/her complaints of pain. On September 22, 2010, at 6:18 a.m., RN #5 documented patient #1 was in "moderate distress" and the patient's pulse rate ranged from 98 beats per minute to 120 beats per minute, and the patient's pulse was "thready." The nurse's documentation revealed the patient was "guarding" his/her abdomen and "rebound" tenderness was noted. The nurse also documented the patient's abdomen had an increase of approximately one inch in height. The ED physician attempted to contact the on-call physician at 6:20 a.m. on September 22, 2010, without success. The review revealed the ED physician informed the on-call physician of patient #1's deteriorating condition at 6:50 a.m. on September 22, 2010. At 7:10 a.m. on September 22, 2010, the on-call physician presented to the facility and discussed the need for surgical intervention with patient #1.

A review of the facility's physician on-call list for the ED revealed the on-call physician was the only physician on call for that specialty service on September 21, 2010, for consultation and/or to further manage the care of patients that presented to the ED with complaints related to that particular specialty area.

An interview conducted on May 24, 2011, at 2:25 p.m., with the ED physician revealed the on-call physician was telephoned several times related to patient #1's condition. The ED physician stated, "I felt she needed treatment when I called him, that is why I called him." The ED physician stated patient #1 became hypotensive and intravenous (IV) fluids were administered. In addition, according to the ED physician, the patient's Hemoglobin and Hematocrit dropped and the patient received a blood transfusion. The ED physician stated that due to the on-call physician's prolonged response time, patient #1 experienced a delay in treatment and "suffered a negative outcome."

An interview conducted on May 24, 2011, at 1:45 p.m., with the on-call physician revealed patient #1 had undergone a surgical procedure earlier in the day on September 22, 2010, and had reportedly presented to the ED due to dizziness and pain. The on-call physician stated patient #1's Hemoglobin and Hematocrit (H & H) were slightly low upon admission and this was not unusual post surgical procedure. The interview revealed the ED physician had contacted the on-call physician a second time to report that the patient's Hemoglobin and Hematocrit had decreased and the on-call physician requested for the patient to receive a blood transfusion. The on-call physician reported patient #1 had received a CT scan of the pelvis/abdomen that had been incorrectly interpreted as normal. The on-call physician stated he was misled by the incorrect results of the CT scan and, as a result, this led to the delay in treatment.

A review of patient #1's preliminary report dated September 22, 2010, at 6:05 a.m., of the CT scan revealed there was a moderate amount of free fluids seen throughout the abdomen and pelvis, no apparent acute enteric, hepatobiliary, pancreatic, splenic, renal, or adrenal abnormalities were noted. However, the Radiology report dated September 22, 2010, at 8:22 a.m., of the same CT scan revealed a large amount of fluid present within patient #1's abdomen. In addition, the report revealed the fluid density was noted to be greater than simple fluid, and there was high "attenuation in the left anterior abdomen near the umbilicus consistent with extravasated contrast and active hemorrhage. This is adjacent to an oval intermediate-density 62 x 30 mm mesenteric mass that may be a large hematoma."

An interview conducted on May 25, 2011, at 9:40 a.m., with RN #5 revealed patient #1 had complained of pain initially but the patient's pain had worsened while he/she was in the ED. RN #5 also stated patient #1 became pale, "tachycardiac," and received IV fluids and a blood transfusion while in the ED.

Based on interviews and record reviews, patient #1 presented to the ED at 11:33 p.m. on September 21, 2010. The ED physician contacted the on-call physician on three different occasions from 2:30 a.m. until 6:50 a.m. on September 22, 2010. The on-call physician presented to the facility at 7:10 a.m. on September 22, 2010, and patient #1 was taken to the Operating Room for a surgical procedure at 7:35 a.m.