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Based on review of a 20 patient sample of emergency department medical records, interview with physicians and facility staff members and review of the policies and procedures, it was determined that the hospital failed to comply with the provider agreement for 1 patient as defined in 42 CFR 489.24(r)(2) and 489.209(j)(1-2). Patient identifier: 7.

Findings include:

The hospital failed to comply with 42 CFR 489.24(r)(2) and 489.24(j)(1-2), by not providing an on-call physician for the stabilization of a patient's emergency medical condition.

Based on review of a patient sample of 20 patients who were seen in the Emergency Department (ED), interview with two physicians and hospital staff members, and review of the hospital's EMTALA (Emergency Medical Treatment and Labor Act) policies and procedures, it was determined that the hospital failed to maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize 1 patient who presented with an emergency medical condition. Patient identifier: 7. Physician identifiers: 1, 2 and 3.

Findings include:

1. Review of patient 7's ED medical record dated 12/15/13, revealed the following information:

Patient 7 a 45 year old female presented to the ED at 6:33 pm, with the chief complaint of right ankle pain.

a. Review of the ED physician's hand written notes on a template form, titled "EMERGENCY PHYSICIAN RECORD" for lower extremity problem revealed the following: Patient 7 had undergone a right ankle arthroscopy on 12/2/13 (13 days before this ED visit). The physician noted that patient 7 had a erythemic pustule (red inflamed area) on the right ankle and had a fever. The physician's note indicated that the patient's white blood cell count was 14.00 (an indicator of infection). The note indicated that 2 blood cultures were drawn and sent to the laboratory. The physician documented that his clinical impression was that patient 7 had an abscess of the right ankle medical port (small incision as a result of the arthroscopic surgery).

b. Review of the ED physician's dictated progress note dated 12/15/13, at 12:00 AM, revealed the following information:

Patient 7 reported to the ED complaining of fever (101.8), chills, fatigue, poor appetite and redness and tenderness over the inside of the right ankle. The patient had been treated with a right ankle arthroscopic surgical procedure at the hospital by the orthopedic surgeon, Doctor 2, on 12/2/13. Prior to that, patient 7 was treated by a different orthopedic surgeon, Doctor 1, who had aspirated her ankle joint. The patient then opted to go to doctor 2 who performed the arthroscopic surgery.

The ED physician documented that he aspirated the ankle and obtained about 2.5 cc (1/2 teaspoon) of purulent material (pus). The ED physician sent the purulent material to the hospital laboratory to be cultured. A blood culture was sent as well. The ED physician documented that he first called physician 2 because he had done the arthroscopy. "I discussed the circumstance with (physician 2) before doing the aspiration. He agreed to the above. He asked that I return a call to him. Instead I called and spoke with (physician 3 who was a family practice physician who was on call) about potentially admitting the patient for inpatient antibiotics. It turns out the patient lives 50 minutes away and driving back and forth with Clindamycin (antibiotic) every 8 hours (by IV infusion) did seem a somewhat arduous responsibility for her husband, although he seemed willing to do it. (Physician 3) expressed reluctance to take care of the patient in the absence of orthopaedic participation so he declined that option (to admit patient 7). I then spoke with (physician 1). Physician 1 was concerned that by providing care of such patient when such an agreement between the two does not exist. So he declined providing that option. (Physician 1 was scheduled for orthopaedic on call that day). I then called physician 2. Physician 2 suggested relaxing the schedule of the clindamycin to 7:00 am and then about 3:00 pm in the afternoon and then at that point treating her with oral antibiotics. He recommended continuing those for nine days". He recommended follow up with her family doctor. "Sensing the difficulty of providing care, I (ED physician) offered to at least be available to review the culture and sensitivity and advise her with regard to that... (Physician 2) will not be back in Moab for twelve days, 12/27/13. The patient was apprised of these logistical complications, the positions (physician 1 and 3) in terms of care. And she was aware of some of the controversy regarding physician 2's position at the hospital".

Under the section of the note titled ASSESSMENT:

The ED physician documented the following: "Final diagnosis then is apparent superficial abscess involving the right medical (inside part of ankle) port of the right ankle approximately twelve days following orthoscopic surgery to remove foreign body cartilaginous extra material. She did have reasonable motion of the ankle more to suggest that the ankle is not directly involved. The CBC, CRP and sed rate have been documented. She will have two more doses of outpatient IV antibiotics and then subsequently, oral and then we will have subsequent followup as yet not specifically determined."

b. Review of the ED nurse's documentation revealed the following:

Patient 7 arrived in the ED on 12/15/13 at 6:45 pm. complaining of right ankle pain. The patient's temperature was 101.8. The nurse documented that the right ankle was swollen, tender, painful and patient 7 could not bear weight.

The nurse's discharge note at 10:10 pm stated the following: "Knows to return worsening. Discussed medications. Lortab (pain) and Clindamycin (antibiotic). Given form for no doctor and list of options for follow-up Culture results and long term." Patient 7's discharge temperature was 101.9 F.

c. Review of patient 7's laboratory results revealed the following:

The complete blood count results dated 12/15/13, listed a white blood cell count of 14.15. The normal range is 4.00 to 10.50. The elevated white blood cell count is an indicator of infection.

The final report for the wound culture sample indicated the wound drainage had 4+ gram positive cocci Staphylococcus Aureus.

2. Patient 7 was admitted to the hospital on 12/20/13, to have an incision and drainage of the right ankle. This was five days after the ED visit. Review of the medical record for this admission revealed the following information:

The operative report for patient 7 documented the pre-operative diagnosis was post-operative infection and septic arthritis. The findings of the surgery were documented as a purulent abscess with joint involvement. The final culture results of the wound drainage indicated a continuing Staphylococcal infection.

3. Upon entrance to the hospital on 1/13/14, an interview was conducted with the hospital's Chief Clinical Officer. She stated that presently there were 2 orthopedic surgeons with hospital contracts. She stated that both took call. She stated there was a third orthopedic surgeon who had been a hospital employee until December of 2012. She stated that he did not have a contract with the hospital but was back in town seeing patients at the clinic once a month. She stated that he did surgeries at the hospital but did not take call.

4. A telephone interview was conducted on 1/15/14 with the ED physician who was on duty the day patient 7 came into the ED. He stated that physician 1 was on call for orthopedics that day. (Review of the On Call schedule that was provided revealed that Doctor 1 was indeed on call that day). He stated patient 7 came into the ED with a fever and redness at a arthroscopy surgical incision which had been done a couple of weeks previously. The ED doctor stated that he called the surgeon physician 2 first because he had done the surgery. The ED doctor stated that doctor 2 was several miles away in Colorado and not readily available. He spoke with the surgeon physician 2 who recommended he aspirate the ankle. Which he did. Cultures were sent to the lab. The surgeon Doctor 2 recommended IV antibiotics. The ED physician called a family practice Doctor 3, who was on call to find out if he would admit the patient for the IV antibiotic therapy. Physician 3 stated he was not comfortable admitting the patient to the hospital without an orthopedist involved. The ED doctor then called physician 1, the orthopedist who was on call that day. He stated that Doctor 1 spent several minutes on the phone stating why he would would not become involved with patient 7. He stated this was because physician 2 did the initial surgery and he did not want to be responsible for any complications which may result due to the calibar of physician 2's work. The ED physician stated that patient 7 had gone to physician 1 but then opted to go to physician 2 for the surgery. The ED physician stated that physician 1 was adamant about not becoming involved with patient 7. The ED physician stated that because he could not find anyone to admit patient 7 or provide treatment, he ordered outpatient IV antibiotic therapy for two doses the next day and then gave the patient a prescription for oral antibiotics. The ED physician stated that he informed the patient he would track the culture results, order antibiotics and provide what care he could. The ED physician stated that a few days later the surgeon physician 2 ordered an MRI of the ankle and it showed that the infection now involved the joint and patient 7 went back for more surgery.

5. An interview was conducted with physician 1, who was on call 12/15/13 when patient 7 was in the ED. The Administrator of the hospital, Chief Clinical Officer and a second surveyor were present. He stated that he was called by the ED physician concerning patient 7, but he would not take care of a patient with complications from "that Doctor" (physician 2). He stated that he had cleaned up after physician 2's botched surgeries before. He stated that he would take care of any other physician's patients in a similar situation as patient 7's. He was adamant that he would not do so for physician 2. When asked again he said that he would not even provide a temporary admission for IV therapy and short term treatment for a patient of physician 2. He stated he was not on call that day but then stated he couldn't remember. He was the physician listed on the on-call schedule.

6. The surveyor requested the hospital's EMTALA policies and procedures. The header of the policy stated that they were policies for the Emergency Department and the subject was listed as COBRA requirements. The sixth paragraph stated the following: " Moab Regional Hospital will provide the on-call physician specialty list which includes all specialties privileged at this facility. (Special rules apply if there are not enough physicians to provide coverage on-call.) The on call list will be posted in the Emergency Department and a record of all on-call lists shall be maintained for 5 years. The specialist must respond to Moab Regional Hospital to render an evaluation and care." The orthopedic specialist refused to render evaluation and care to patient 7.