HospitalInspections.org

Based on interviews and record reviews, the hospital failed to abide by the provider's agreement that required a hospital to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements in that 1 of 1 patient (Patient #1) who presented to the center on 02/23/24 and was transferred to Facility 2 without being stablized.

Cross refer to:
Tag A2404 - 42 CFR §489.20(r)(2) and §489.24(j)(1-2) On Call Physicians
Tag A2407 - 42 CFR §489.24 (d)(1-3) Stabilizing Treatment

Based on record review and interview, the facility's on-call physician, Staff #9, MD, failed to respond to a request or page from the Emergency Department resulting in patient #1 being transferred to another hospital for evaulation and treatment. Physician Staff #9 failed to follow Medical Staff Bylaws Rules and Regulations, Revised December 17, 2020, 6.1 Emergency Coverage.

A review of records on 6/26/2024 revealed Patient #1, arrived at Facility #1 on 2/23/2024 at 5:44 PM for "Fever; Code Sepsis" with an ESI Level 2. ESI (Emergency Severity Index) is a five-level triage system used in emergency departments to prioritize patients based on the severity of their condition and the resources they are likely to need. Level 2 patients require urgent care to prevent further deterioration, though they are not as critically unstable as ESI Level 1 patients.

Patient #1 was a 32-year-old, female with a history of kidney stones, tubal ligation, C-Section, Left Below the Knee Amputation (LBKA), and left kidney stent. The patient arrived at Facility #1, via private vehicle on 2/23/2024 at 5:44 PM for complaints of "fever onset 4 days ago". A review of the Intake record revealed, "The patient states she had a stent placed 8/2023 by ____ (Staff #10), on her left side. The patient states she has not followed up since because of insurance and financial difficulties. The patient states she was recently treated for UTI with IV antibiotics. The patient's LBM (last bowel movement) was yesterday. No other complaints at this time."

A ureteral stent is a soft, hollow tube that a urologist places in the ureter to help urine drain from the kidney to the bladder when a kidney stone is blocking the ureter.

"History and Present Illness by Staff 11, MD, 2/23/2024: Reviewed; Complaint: abdominal pain, flank pain-left; Symptoms have been persistent; Timing of symptoms still present;
Pain Severity/Quality/Location
Pain Severity - current 7, Pain Scale: Numeric;
Associated Symptoms
Fever, nausea, vomiting, back pain"

Vital signs
2/23/2024 at 6:27 PM
"Temp: 103 F (H)
Resp: 26 (H)
Pulse:130 (H)
BP: 115/75
O2 Sat: 97% RA"

A review of the progress notes on 2/23/2024 from emergency department physician, Staff #11, MD revealed:

Progress:
"2047: Requested records from (Hospital Facility #3). CT scan results discussed with _____(Staff #9, MD) who is on call urologist this weekend. He states he will not see patient and will wait until Monday for ______(Staff #10, MD) to see his own patient. Discussed with ____(Staff #16, MD), regarding admission - she does not feel comfortable taking admission without urology consulted.
2240: Spoke to _____(Staff #12, MD), urologist at Facility #2 concerning the pt. _____(Staff #12, MD) recommended medical admission to treat the UTI infection. Then when the infection is resolved removal of the stent.
2313: Discussed with ______(Staff #17, MD) regarding patient. She agrees to admission." (sic)

Clinical Impression:
"Left Pyelonephritis
Left Hydronephrosis
Left Hydroureter"

Interview
During an interview with Staff #6, MD, Chief Medical Officer (CMO) on 6/26/2024 at 11:45 AM, it was revealed that she was not aware of the situation that occurred on 2/23/2024 with Staff #9 and his refusal to come see Patient #1. She mentioned that there is an escalation process that should have been followed. Staff #6, MD, CMO explained, "If staff refuse to come to see a patient, there should be a phone call made to me so that I can address it." She also expressed that this situation did not surprise her, as there have been ongoing issues with Staff #9. Staff #9 had a recent incident that required a peer review just a few weeks ago, involving a racial slur. Additionally, Staff #9 has a habit of not using the EMR (electronic medical record), and instead calls after leaving the hospital to have nurses put in telephone orders. Staff #6, MD, CMO described him as hard to get along with and mentioned that he does not get along with Staff #10, the other urologist on staff. Therefore, Staff #6, MD, CMO reported that she was not surprised by Staff #9, MD's refusal to see the patient, and she finds it very concerning.


Interview
In a phone interview with Staff #9, MD on 6/26/2024 at 2:20 PM with Staff #6, MD, CMO, present, the surveyor asked how he handles patients that need consultations in the emergency room, and he stated, "If they can wait, then I do not come up to the hospital. I won't clean up other doctor's messes." During a review of Patient #1's record with Staff #9, MD via telephone, the surveyor asked if the temperature of 103 F, Pulse of 130, Respirations of 26, and WBC of 14.1 with a CODE SEPSIS protocol in place would constitute a visit from him. Staff #9, MD stated, "No one told me this patient was sick and I want all of my interactions with staff recorded going forward!" This surveyor asked Staff #9, MD if he was familiar with Medical Staff Bylaws Rules, and Regulations regarding Emergency Room Coverage for on-call physicians. Staff #9, MD stated "I go see the patient if I feel it is necessary. I am very prompt and see patients that are sick."

This surveyor read the section of the Medical Staff Bylaws to Physician # Staff #9 from page 124, EMERGENCY ROOM SERVICES

"6.1 Emergency Room Coverage ...

...6.1-5 The on-call physician is expected to respond to a request or page from the ED within 30 minutes and to present in the Emergency Department within 30 minutes of a request by the Emergency Department physician (or time frame agreed upon by the on-call physician and the Emergency Department physician) ...."

Interview
In a phone interview on 6/26/2024 at 7:08 PM with Staff #17, MD, Hospitalist, that was treating Patient #1 in the ED and requested consult from on-call Physician Staff #9, stated, "We have chronic problems with the urology team, especially Staff #9, MD. I am always very hesitant when he is involved. This patient had a grossly positive UA, and she had hydronephrosis and hydroureter which is an indicator of a possible obstruction. The CT scan showed there was no obstruction, but this patient was very sick and after discussion with the ER physician and the Nurse Practitioner, in the ER, we felt a transfer was the safest option for the patient. The patient had a temperature of 103 F and WBC over 14 and this man refused to come to see her, saying "The patient can just wait, I am not coming in." This is very frustrating and again, there are lots of problems."

Interview
In a phone interview with Staff #12, MD, urologist, at Facility #2, on 6/27/2024 at 1:00 PM, it was confirmed that Patient #1 was transferred to Facility #2 and treated.

Based on document review and interviews, the facility failed to stabilize 1 of 1 patient (Patient #1) before transfer. The on-call urologist, Staff #9, refused to see the patient and deferred care to another urologist scheduled to return two days later. The hospitalist, Staff #17, declined to admit the patient without a urology consult. After consulting with a urologist from Facility #2, the patient was transferred for further treatment.

A review of records on 6/26/2024 revealed Patient #1, arrived at Facility #1 on 2/23/2024 at 5:44 PM for "Fever; Code Sepsis" with an ESI Level 2. ESI (Emergency Severity Index) is a five-level triage system used in emergency departments to prioritize patients based on the severity of their condition and the resources they are likely to need. Level 2 patients require urgent care to prevent further deterioration, though they are not as critically unstable as ESI Level 1 patients.

On 6/26/2024, a review of records revealed that Patient #1, a 32-year-old female with a medical history including kidney stones, tubal ligation, C-section, left below-the-knee amputation (LBKA), and a left kidney stent, arrived at Facility #1 on 2/23/2024 at 5:44 PM for fever and was triaged as ESI Level 2. The patient, who reported a four-day fever, had a ureteral stent placed in August 2023 but had not followed up due to financial and insurance barriers.

Based on review of Patient #1's medical record, the patient exhibited severe symptoms, including a temperature of 103°F, a heart rate of 130, and left flank pain. Laboratory results indicated a urinary tract infection (UTI) with large amounts of blood and leukocyte esterase in the urine, and a CT scan showed left hydronephrosis, hydroureter, and fat stranding, suggesting a possible infection or obstruction. The patient had early sepsis related to pyelonephritis with a 6-month, indwelling ureteral stent. Patient #1 was dehydrated from vomiting, had ketones present in her urine, mildly acidotic, and had significantly abnormal vital signs. According to the Centers for Disease Control (CDC), sepsis is the body's extreme response to an infection and can lead to tissue damage, organ failure, and death if not treated promptly (https://www.cdc.gov/sepsis/about/?CDC_AAref_Val=https://www.cdc.gov/sepsis/what-is-sepsis.html).

A review of the progress notes on 2/23/2024 from emergency department physician, Staff #11, MD revealed:

Progress:
"2047: Requested records from (Hospital Facility #3). CT scan results discussed with _____(Staff #9, MD) who is on call urologist this weekend. He states he will not see patient and will wait until Monday for ______(Staff #10, MD) to see his own patient. Discussed with ____(Staff #16, MD), regarding admission - she does not feel comfortable taking admission without urology consulted.
2240: Spoke to _____(Staff #12, MD), urologist at Facility #2 concerning the pt. _____(Staff #12, MD) recommended medical admission to treat the UTI infection. Then when the infection is resolved removal of the stent.
2313: Discussed with ______(Staff #17, MD) regarding patient. She agrees to admission." (sic)

Clinical Impression:
"Left Pyelonephritis
Left Hydronephrosis
Left Hydroureter"


Disposition:
"Transfer"

Medical Decision Making
"Differential diagnoses considered are: Pyelonephritis, urosepsis"


Interview
During an interview with Staff #6, MD, Chief Medical Officer (CMO) on 6/26/2024 at 11:45 AM, it was revealed that she was not aware of the situation that occurred on 2/23/2024 with Staff #9 and his refusal to come see Patient #1. She mentioned that there is an escalation process that should have been followed. Staff #6, MD, CMO explained, "If staff refuse to come to see a patient, there should be a phone call made to me so that I can address it." She also expressed that this situation did not surprise her, as there have been ongoing issues with Staff #9. Staff #9 had a recent incident that required a peer review just a few weeks ago, involving a racial slur. Additionally, Staff #9 has a habit of not using the EMR (electronic medical record), and instead calls after leaving the hospital to have nurses put in telephone orders. Staff #6, MD, CMO described him as hard to get along with and mentioned that he does not get along with Staff #10, the other urologist on staff. Therefore, Staff #6, MD, CMO reported that she was not surprised by Staff #9, MD's refusal to see the patient, and she finds it very concerning.

Interview
In a phone interview with Staff #9, MD on 6/26/2024 at 2:20 PM with Staff #6, MD, CMO, present, the surveyor asked how he handles patients that need consultations in the emergency room, and he stated, "If they can wait, then I do not come up to the hospital. I won't clean up other doctor's messes." During a review of Patient #1's record with Staff #9, MD via telephone, the surveyor asked if the temperature of 103 F, Pulse of 130, Respirations of 26, and WBC of 14.1 with a CODE SEPSIS protocol in place would constitute a visit from him. Staff #9, MD stated, "No one told me this patient was sick and I want all of my interactions with staff recorded going forward!" Staff #9, MD was asked if he was familiar with Medical Staff Bylaws Rules and Regulations regarding Emergency Room Coverage for on-call physicians. Staff #9, MD stated "I go see the patient if I feel it is necessary. I am very prompt and see patients that are sick."

A review of the Medical Staff Bylaws, page 124, EMERGENCY ROOM SERVICES, revealed the following:

"6.1 Emergency Room Coverage ...

...6.1-5 The on-call physician is expected to respond to a request or page from the ED within 30 minutes and to present in the Emergency Department within 30 minutes of a request by the Emergency Department physician (or time frame agreed upon by the on-call physician and the Emergency Department physician) ...."


Interview
In a phone interview on 6/26/2024 at 7:08 PM with Staff #17, MD, Hospitalist, that was treating Patient #1 in the ED and requested consult from on-call Physician Staff #9, stated, "We have chronic problems with the urology team, especially Staff #9, MD. I am always very hesitant when he is involved. This patient had a grossly positive UA, and she had hydronephrosis and hydroureter which is an indicator of a possible obstruction. The CT scan showed there was no obstruction, but this patient was very sick and after discussion with the ER physician and the Nurse Practitioner, in the ER, we felt a transfer was the safest option for the patient. The patient had a temperature of 103 F and WBC over 14 and this man refused to come to see her, saying "The patient can just wait, I am not coming in." This is very frustrating and again, there are lots of problems." The surveyor thanked Staff #17, MD, Hospitalist, for her time and asked if she had any further concerns or questions. She denied any additional needs at this time.

Despite the critical findings, the on-call urologist, Physician Staff #9, refused to see the patient, deferring her care to another urologist scheduled to return two days later. The hospitalist, Staff #17, declined to admit the patient without a urology consult. After consulting with a urologist from Facility #2, who recommended medical admission for the UTI, the patient was ultimately transferred for further treatment.

Interview
In a phone interview with Staff #12, MD, urologist, at Facility #2, on 6/27/2024 at 1:00 PM, it was confirmed that Patient #1 was transferred to Facility #2 and treated.