HospitalInspections.org

Based on interview, record review and policy review, the facility failed to comply with the conditions of participation outlined in 489.24 (refer to appendix V). The facility failed to provide stabilizing treatment within the capability and capacity of the hospital for 2 (#'s 8 and 12) patients who presented to the emergency department with emergency medical conditions, of 20 sampled patients reviewed. Patients #8 and 12 were subsequently transferred to another hospital and stabilized. Findings include:

Review of a facility policy titled, "EMTALA - Medical Screening and Stabilization," with an effective date of January 5, 2016, showed, "Policy: Any person who presents to the hospital or any off-campus provider-based department of the hospital requesting assistance for a potential emergency medical condition (EMC) will receive a medical screening exam (MSE) performed by a qualified medical person (QMP) to determine whether an EMC exists. ... If the QMP determines an EMC exists, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the hospital...."

Record review of a facility policy, "EMTALA - On-Call Coverage," dated 1/5/16, showed, " ... Physicians on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with emergency medical conditions (EMC) who are receiving services in accordance with the resources available to the hospital. ... The hospital must maintain a list of physicians who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an EMC in accordance with resources available to the hospital. ... 8. Physician's Responsibility. When a physician is identified as being the On-Call Physician for a given specialty, it shall be that physician's duty and responsibility to assure the following: ... b. Arrival or response to the Emergency Department within a reasonable timeframe (generally, response by the physician is expected within 30 minutes). The Emergency Department Physician, in consultation with the On-Call Physician, shall determine whether the individual's condition requires the On-Call to see the individual immediately. The determination of the Emergency Department Physician or other practitioner who has personally examined the individual and is currently treating the individual shall be controlling in this regard. ..."

Patient #8, a 75-year-old female, presented to the ED on 3/14/24 at 6:58 p.m., seeking care for
chest pain. Patient #8 had a history of a heart attack and significant heart risk factors. Two EKGs (tracing of the electrical conduction of the heart) were conducted and showed ST elevation (indication of a heart attack). The patient was subsequently diagnosed with a STEMI (indicates the blockage of an artery that provides blood to the heart muscle). The hospital had cardiac catheterization lab staff, as well as other specialty staff and surgical teams available, should complications occur. The hospital had a staffed intensive care unit (ICU), and an on-call cardiologist, Staff N, who was privileged in cardiac catheterization. Staff member CC consulted staff member N and was instructed to transfer patient #8 to [another hospital] for further care. Patient #8 was transferred to [another hospital] on 3/14/24 at 7:55 p.m. for emergent heart catheterization.

Patient #12, a 79-year-old male, presented to the ED seeking care for chest pain on 4/26/24 at 4:05 p.m., less than two hours after he was discharged from the hospital for treatment related to a fast and irregular pulse. Patient #12 had a history of heart disease and significant heart risk factors. The patient's vital signs included a consistently slower than normal pulse, elevated blood pressures, and an electrocardiogram (EKG) with changes (can indicate an evolving heart event). Staff member X consulted staff member N, the cardiologist on call, who reviewed the patient's EKG and determined the patent needed a heart catheterization. The hospital had cardiac catheterization lab staff, other specialty staff and surgical teams available should complications arise, and a staffed ICU, however, staff member N instructed staff member X to transfer the patient. Patient #12 was transferred to [another hospital] on 4/26/24 at 8:39 p.m. (Refer to A-2407)

Based on observation, interview, and policy review, the facility failed to post signs specifying the rights of individuals to receive examination and treatment for emergency medical conditions, and the rights of women in labor, in a conspicuous area to be noticed by all individuals entering and receiving care in the emergency department.

Findings include:

During an observation and interview on 6/4/24 at 8:11 a.m., the ED reception area was observed to have no visible EMTALA signs posted, stating the rights of individuals with an emergency medical condition or women in labor seeking care. Staff member C said the ED had undergone a remodel and the signs did not get replaced.

During an observation and interview on 6/4/24 at 8:22 a.m., the ED exam room and nurses station area was observed to have no visible EMTALA signs posted for individuals with an emergency medical condition or women in labor seeking care. Staff member F said he was not aware of any EMTALA signs posted within the ED.

Review of a facility policy, "EMTALA- Medical Screening and Stabilization," dated January 5, 2016, showed:
" ...6. Required Signage: Each department that provides MSEs shall post a sign that is clearly visible within 20 ft, in a place or places likely to be noticed by all individuals that enter the department that includes:
a. A statement that the hospital participates in Medicaid.
b. The rights of patients with EMCs and women in labor.
Such rights include the right to receive, within the capacity and capabilities of the hospital's staff and facilities:
i. An appropriate MSE ...
ii. Necessary stabilizing treatment (including treatment for an unborn child); and
iii. An appropriate transfer to another facility if necessary, even if the individual cannot pay, does not have medical insurance or are not entitled to medicare or Medicaid. ..."

Based on interview, record review, and policy review, a facility provider failed to appear at the facility when requested to provide stabilizing treatment for patients experiencing an emergency medical condition for 1 (#12) of 20 sampled patients. This failure resulted in the patient being transferred to another facility for care.

Findings include:

Patient #12, a 79-year-old male, was admitted to the facility for observation with a fast and irregular pulse on 4/25/24 and discharged to home on 4/26/24 at 4:05 p.m. Patient #12 returned to the ED by private vehicle on 4/26/24 at 6:00 p.m. with complaint of chest pain in the left upper chest which radiated to both arms and the left side of his jaw. Patient #12 described his symptoms of chest pain as a pressure with shortness of breath. Patient #12 stated his symptoms started 45 minutes prior to his arrival at the ED.

Patient #12 had a history of heart disease with multiple stents placed in his heart, an irregular heartbeat, high blood pressure, elevated cholesterol, diabetes, sleep apnea, and an enlarged heart, all of which are significant heart risk factors.

Review of patient #12's medical record showed:
-4/26/24 at 6:00 p.m., the patient presented to the ED via private vehicle complaining of pain in the middle of his chest which radiated to both of his arms and the left side of his jaw. The pain was reported to be a 6/10 by patient #12.
-4/26/24 at 6:08 p.m., an EKG was performed and showed a slow pulse of 53 (normal range is 60 to 100 beats per minute), with delayed electrical conduction through his heart.
-4/26/24 at 6:12 p.m., Vital Signs; BP 216/104 (normal range is less than 120/80), P 58, R 20, Pulse Oximetry 97% on room air, T 98.0.
-4/26/24 at 7:17 p.m., a second EKG was performed and showed a slow pulse of 54 and delayed electrical conduction.
-4/26/24 at 7:53 p.m., a third EKG was performed and showed a slow pulse of 51 and delayed electrical conduction.
-4/26/24 at 8:00 p.m., Vital Signs taken; BP 171/83 (still elevated), P 56, R 12, Pulse Oximetry 97% on room air.
-4/26/24 at 8:39 p.m., patient #12 was transported to [another hospital] via ambulance for further care.

During an interview on 6/5/24 at 5:05 p.m., staff member X stated he was the ED physician that cared for patient #12 on 4/26/24. Staff member X said the patient's chest pain was treated with several medications. A laboratory test (Troponin I) which helps determine if there has been heart muscle damage, was negative. The patient continued to have chest pain, and a second EKG showed mild changes which were a cause for concern. Staff member X stated he confirmed with multiple staff that the hospital had the capability and capacity to conduct emergency cardiac catheterizations and verified with the facility Chief of Staff [staff member E] the capability, capacity, and expectation of the on-call cardiologist to provide necessary care to the patient. Staff member X contacted staff member N and forwarded patient #12's EKG for his review. Staff member N determined the patient needed a heart catheterization, however, despite multiple phone calls from staff member X requesting him to provide the necessary care for the patient, staff member N refused and stated he "was not coming in," that he "was not contractually obligated to come in after hours," and instructed staff member X to transfer the patient.

Review of the facility's on-call schedule for cardiology showed staff member N was on call on 4/26/24.

During an interview on 6/12/24 at 2:30 p.m., staff member N stated he was a Board-certified Cardiologist in non-invasive [external] and invasive [internal] interventional cardiology. Staff member N stated the facility has full Cath lab capabilities and staff are available 24/7. Staff member N confirmed patient #12 was one of his regular patients and the patient would consider him to be his primary cardiologist. Staff member N stated patient #12 presented to the ED on 4/26/24 with a chief complaint of chest pain. Staff member N stated the patient's pain was reported as being similar to a previous MI. He stated he reviewed the patient's EKG and clearly noted ST elevation. Staff member N stated he did not report to the facility to treat the patient, and instructed staff member X to promptly transfer the patient to [another hospital] for immediate cath lab services.

Review of the facility's Medical Staff Rules and Regulations, dated 9/13/23, showed each specialty is responsible for developing an on-call schedule with the name of the physician who is to be available to provide treatment to an individual with an emergency medical condition (EMC).

Review of a facility document titled, "Employment Agreement", with a commencement date of March 1, 2023, showed staff member N entered into an employment contract with the facility for a term of three years. Review of the contract showed, "Practitioner shall practice medicine and provide medical services related to the specialty/subspecialty identified on Exhibit A (the "Services") to patients as set forth herein on and after the date listed on Exhibit A (the "Commencement Date"), consistent with Practitioner's licensure, training and privileges, including but not limited to examining patients; performing medical procedures; prescribing medication or treatment; consulting with other practitioners; and providing call coverage as set forth on Exhibit A. ... EXHIBIT A Certain Contract Terms ... Call Coverage: ... As a requirement under this Agreement, Practitioner shall be required to provide call coverage for the Clinic at the Hospital up to 14 days per month ...Practitioner has historically responded to emergent and STEMI patients during normal clinic hours, which shall be continued. Should Clinic/Hospital adopt a program for STEMI patients, such program shall include the following capabilities: 1. Cardiovascular Thoracic surgeon with availability and on call for additional support and a call schedule posted for confirmation. 2. Full heart surgical support team available to assist with procedures. 3. Confirmed bed capacity at the hospital."

Review of the facility's Cardiothoracic/Vascular on-call schedule showed staff member Z was the Cardiothoracic/Vascular Surgeon on-call on 4/26/24.

Review of the facility's CT Surgery on-call schedule showed eight staff members were assigned for on-call duties on 4/26/24.

Review of the facility's Anesthesia on-call schedule showed staff member BB was the anesthesiologist on-call on 4/26/24.

Review of the facility's Cardiac Cath Lab on-call schedule showed four staff members were assigned on-call duties on 4/26/24.

Review of facility documents showed the facility is licensed for 36 Med/Surg beds and 10 ICU beds.

Review of the facility's ICU daily census report showed there were 7 patients receiving care in the 10 bed ICU on 4/26/24.

Review of patient #12's medical record from the receiving facility showed:
-4/26/24 at 8:59 p.m., the patient arrived at the receiving facility ED. Patient #12 was evaluated by NF2 and NF3. Patient #12's vital signs were recorded as: BP 210/118 (still elevated), P 74, R 12, Pulse Oximetry 94%, T 97.9.
-4/26/24 at 9:04 p.m., an EKG was performed; NF2 interpreted the results as persistent right bundle branch pattern (delayed conduction of electrical impulses through the heart which are responsible for triggering contraction of the heart muscle) and no changes which would indicate the patient was having a heart attack. NF2 compared the EKG from the previous facility and noted there were some subtle ST changes, but not enough to meet the criteria for an acute heart attack. Patient #12 was treated with an intravenous medication used to treat the patient's chest pain and elevated blood pressure (the medication causes the patient's blood vessels to dilate or get bigger around, and improves blood flow to the heart and other vital organs).

During an interview on 6/17/24 at 4:00 p.m., NF3 stated patient #12 was transferred to his facility [another hospital] in an unstable condition. NF3 said it was determined patient #12's cardiac findings did not require immediate heart catheterization, and he was admitted to the progressive care unit. The following morning (4/27/24) patient #12 underwent an ultrasound of his heart and a heart catheterization. NF3 stated patient #12 had a blockage in one of the large arteries which supplies blood to the heart muscle.

Review of a facility policy titled, "EMTALA - Medical Screening and Stabilization", with an effective date of January 5, 2016 showed, "Policy: Any person who presents to the hospital or any off-campus provider-based department of the hospital requesting assistance for a potential emergency medical condition (EMC) will receive a medical screening exam (MSE) performed by a qualified medical person (QMP) to determine whether an EMC exists. ... If the QMP determines an EMC exists, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the hospital.

Record review of a facility policy, "EMTALA - On-Call Coverage," dated 1/5/16, showed, " ... Physicians on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with emergency medical conditions (EMC) who are receiving services in accordance with the resources available to the hospital. ... The hospital must maintain a list of physicians who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an EMC in accordance with resources available to the hospital. ... 8. Physician's Responsibility. When a physician is identified as being the On-Call Physician for a given specialty, it shall be that physician's duty and responsibility to assure the following: ... b. Arrival or response to the Emergency Department within a reasonable timeframe (generally, response by the physician is expected within 30 minutes). The Emergency Department Physician, in consultation with the On-Call Physician, shall determine whether the individual's condition requires the On-Call to see the individual immediately. The determination of the Emergency Department Physician or other practitioner who has personally examined the individual and is currently treating the individual shall be controlling in this regard. ..."

Based on interview, record review, and policy review, the facility failed to provide stabilizing treatment within the facility's capability and capacity, for 2 (#s 8 and 12) patients who presented with emergency medical conditions, of 20 sampled patients who presented to the ED for emergency care. Findings include:

1. Patient #8, a 75-year-old female, presented to the ED on 3/14/24 at 6:58 p.m. seeking care for chest pain. The patient had a history of high blood pressure and diabetes (both cardiac risk factors), and a heart attack that required stent [small tubes placed to open the blocked arteries] placement approximately five years prior. The ED provider notes, completed by staff member CC, showed the patient's chest pain started on 3/13/24, resolved, and then returned at 11:00 a.m. on 3/14/24, and had continuously increased throughout the day. Patient #8 had two EKGs which showed ST elevation (indication of a heart attack). The patient was subsequently diagnosed with a STEMI (indicates the blockage of an artery that provides blood to the heart muscle). Staff member CC consulted staff member N, the cardiologist on-call, and was instructed to transfer patient #8 to [another hospital] for further care. Patient #8 was transferred to [another hospital] on 3/14/24 at 7:55 p.m. for emergent heart catheterization.

Review of patient #8's EHR, dated 3/14/24, showed the following:
-3/14/24 at 6:55 p.m., an EKG was performed and showed ST elevation. The EKG was interpreted as a STEMI and signed at 6:56 p.m. by staff member CC.
-3/14/24 at 7:07 p.m., Labs were drawn. Pertinent abnormal results included an elevated Troponin I of 1.160 (reference range 0.00-0.012 ng/ml) indicating heart muscle damage.
-3/14/24 at 7:28 p.m., a second EKG was performed, was abnormal, and indicated total blockage of a coronary artery. The EKG was interpreted as a STEMI and signed at 7:29 p.m. by staff member CC.

Review of patient #8's "Emergency Department Note," dated 3/14/24 and signed by staff member CC, showed:
" ...Patient is EKG positive for a STEMI spoke with [staff member N] who recommends transfer to [another hospital]. Spoke with [NF5] ER doc at [another hospital] and he agrees to transfer and accepts the patient. Patient is in stable condition upon transfer ..."

During an interview on 7/8/24 at 9:36 a.m., staff member CC stated she consulted staff member N [cardiologist on call] regarding patient #8's care on 3/14/24, who told her to transfer the patient to another hospital. Staff member CC stated she assumed if Cath lab services were available, staff member N would have come in to do the heart catheterization procedure.

Review of the facility's Medical Staff Rules and Regulations, dated 9/13/23, showed each specialty is responsible for developing an on call schedule with the name of the physician who is to be available to provide treatment to an individual with an emergency medical condition (EMC).

Review of the facility's Cardiology on-call schedule showed staff member N was on-call on 3/14/24.

During an interview on 6/12/24 at 2:30 p.m., staff member N stated he was a Board-certified Cardiologist in non-invasive (external) and invasive (internal) interventional cardiology. Staff member N stated the facility has full Cath lab capabilities and staff are available 24/7. Staff member N confirmed patient #8 presented to the ED on 3/14/24 with complaints of chest pain. He stated the patient's EKG results showed she was having an active STEMI. Staff member N stated staff member CC consulted him on the patient and he told staff member CC to transfer the patient to [another hospital] for an emergent cardiac catheterization. Staff member N stated although the facility has full Cath lab capabilities, the facility does not always have a care team in the ICU (Intensive Care Unit), so the facility is only able to treat stable patients during regular business hours when there is full, competent staff available to safely care for STEMI patients. Staff member N stated he had the capacity and privileges to perform the procedure for patient #8, but he did not report to the facility to perform the cardiac catheterization for patient #8.

Record review of a facility document titled, "Cardiac Service 24/7 Growth Plan" showed, "... Notes ...3/11/24 24/7 cath lab call starts today."

During an interview on 6/6/24 at 11:18 a.m., staff member U said he oversaw ancillary support functions. Staff member U stated the facility has a cath lab team on-call and the facility has 24/7 availability to patients for cath lab services. Staff member U stated the 24/7 capabilities have been available since March 2024.

Review of an email provided by staff member C, dated 7/8/24, showed that if cardiac cath lab services were needed after hours prior to 3/18/24, cardiac cath lab staff members were generally on call and would attempt to accommodate the needed services.

During an interview on 6/5/24 at 2:18 p.m., staff member H stated she had been a travel RN in the Cath lab since October of 2023 and was currently the Cath Lab Director. Staff member H stated the Cath lab had been a 24-hour a day, seven days a week service since February of 2024.

During an interview on 6/11/24 at 9:00 a.m., staff member E stated she was the Chief of Medical Staff and that the hospital provided 24/7 Cath lab coverage which began in March of 2024.

During an interview on 6/6/24 at 10:09 a.m., staff member G [former ED Director] stated the facility began the process of expanding the Cath lab services to 24/7 beginning in January of 2024, and was advised by facility leadership there was 24/7 coverage for Cath lab services at the time of patient #8's ED encounter on 3/14/24.

Review of facility document titled, "Employment Agreement", with a commencement date of March 1, 2023, showed staff member N entered into an employment contract with the facility for a term of three years. Review of the contract showed, "Practitioner shall practice medicine and provide medical services related to the specialty/subspecialty identified on Exhibit A (the "Services") to patients as set forth herein on and after the date listed on Exhibit A (the "Commencement Date"), consistent with Practitioner's licensure, training and privileges, including but not limited to examining patients; performing medical procedures; prescribing medication or treatment; consulting with other practitioners; and providing call coverage as set forth on Exhibit A. ... EXHIBIT A Certain Contract Terms ... Call Coverage: ... As a requirement under this Agreement, Practitioner shall be required to provide call coverage for the Clinic at the Hospital up to 14 days per month ...Practitioner has historically responded to emergent and STEMI patients during normal clinic hours, which shall be continued. Should Clinic/Hospital adopt a program for STEMI patients, such program shall include the following capabilities: 1. Cardiovascular Thoracic surgeon with availability· and on call for additional support and a call schedule posted for confirmation. 2. Full heart surgical support team available to assist with procedures. 3. Confirmed bed capacity at the hospital."

Review of the facility's Cardiothoracic/Vascular Surgery on-call schedule showed staff member Z was on-call 3/14/24.

Record review of the facility's CT Surgery on-call schedule showed 8 staff members were assigned for on-call duties on 3/14/24.

Record review of the facility's Anesthesia on-call schedule showed staff member BB was the anesthesiologist on-call on 3/14/24.

Review of facility documents showed the facility is licensed for 10 ICU beds, with 5 patients receiving care in the 10 bed ICU on 03/14/24.

Record review of facility's Telemedicine Contract with Access Services, "Facility Addendum - Telemedicine Pulmonary and Critical Care Services," dated 2/15/2021, showed, "... the Services performed pursuant to this Agreement will occur 24 hours a day, 365 days a year, and will include the following telemedicine pulmonary and critical care services: ...
a. Pulmonary and Critical Care Services: ... will evaluate, stabilize, and appropriately treat or otherwise manage the care of patients requiring internal medicine, pulmonary and critical care, and related medical services in the ICU and Med-Surg wards. ..."

Review of patient #8's [another hospital] EHR, dated 3/14/24, showed the following:
-3/14/24 at 8:04 p.m., arrived at receiving facility ED via ambulance with diagnosis of STEMI.
-3/14/24 at 10:00 p.m., sent emergently to cath lab for left heart catheterization and placement of two stents.

During an interview on 6/18/24 at 3:00 p.m., NF5 stated he was the ED physician at [another hospital] who cared for patient #8 on 3/14/24. NF5 stated he accepted patient #8 for transfer with a diagnosis of a STEMI who required an emergent heart catheterization.

During an interview on 6/11/24 at 9:00 a.m., staff member E [Chief of Medical Staff] stated there had been some resistance from the cardiologists regarding the 24/7 cardiac cath lab coverage, that there had been two incidents of patients being transferred to [another hospital] for cath lab services since she had been informed of the 24/7 Cath lab availability, and that the ED Director posted a sign regarding Cath lab availability after the 3/14/24 incident occurred with patient #8.

During an interview on 6/6/24 at 10:09 a.m., staff member G [former ED Director] confirmed that she posted a notice about coverage for the Cath lab on the wall behind the ED provider's computers on 3/18/24 to ensure everyone was aware the services were available.

2. Patient #12, a 79-year-old male, was initially admitted to the facility for observation with a fast and irregular pulse on 4/25/24 and discharged to home on 4/26/24 at 4:05 p.m. Patient #12 returned to the ED by private vehicle on 4/26/24 at 6:00 p.m. with a complaint of chest pain in the left upper chest which radiated to both arms and the left side of his jaw. Patient #12 described his symptoms of chest pain as a pressure with shortness of breath. Patient #12 stated his symptoms started 45 minutes prior to his arrival at the ED.

Patient #12 had a history of heart disease with multiple stents placed, an irregular heartbeat, high blood pressure, elevated cholesterol, diabetes, sleep apnea, and an enlarged heart. These diagnoses placed patient #12 at a higher risk for complications.

Review of patient #12's medical record showed:
-4/26/24 at 6:00 p.m., the patient presented to the ED via private vehicle complaining of pain in the middle of his chest which radiated to both of his arms and the left side of his jaw. The pain was reported to be a 6/10 by patient #12.
-4/26/24 at 6:08 p.m., an EKG was performed and showed a slow pulse of 53 (normal range is 60 to 100 beats per minute), with delayed electrical conduction through his heart.
-4/26/24 at 6:12 p.m., Vital Signs; BP 216/104 (normal range is less than 120/80), P 58, R 20, Pulse Oximetry 97% on room air, T 98.0.
-4/26/24 at 7:17 p.m., a second EKG was performed and showed a slow pulse of 54 and delayed electrical conduction.
-4/26/24 at 7:53 p.m., a third EKG was performed and showed a slow pulse of 51 and delayed electrical conduction.
-4/26/24 at 8:00 p.m., Vital Signs taken; BP 171/83 (still elevated), P 56, R 12, Pulse Oximetry 97% on room air.
-4/26/24 at 8:39 p.m., patient #12 was transported to [another hospital] via ambulance for further care.

During an interview on 6/5/24 at 5:05 p.m., staff member X stated he was the ED physician that cared for patient #12 on 4/26/24. Staff member X said the patient's chest pain was treated with several medications. A laboratory test (Troponin I) which helps determine if there has been heart muscle damage, was negative. The patient continued to have chest pain, and a second EKG showed mild changes which were a cause for concern. Staff member X stated he confirmed with multiple staff that the hospital had the capability and capacity to conduct emergency cardiac catheterizations and verified with the facility Chief of Staff [staff member E] the capability, capacity, and expectation of the on-call cardiologist to provide necessary care to the patient. Staff member X contacted staff member N and forwarded patient #12's EKG for his review. Staff member N determined the patient needed a heart catheterization, however, despite multiple phone calls from staff member X requesting him to provide the necessary care for the patient, staff member N refused and stated he "was not coming in," that he "was not contractually obligated to come in after hours," and instructed staff member X to transfer the patient.

Review of the facility's on call schedule for cardiology showed staff member N was on call on 4/26/24.

During an interview on 6/12/24 at 2:30 p.m., staff member N confirmed patient #12 was one of his regular patients and the patient would consider him to be his primary cardiologist. Staff member N stated patient #12 presented to the ED on 4/26/24 with a chief complaint of chest pain. Staff member N stated the patient's pain was reported
as being similar to a previous MI. He stated he reviewed the patient's EKG and clearly noted ST elevation. Staff member N stated did not report to the facility to treat the patient, and instructed staff member X to promptly transfer the patient to [another hospital] for immediate cath lab services.

Record review of the facility's Cardiac Cath Lab on-call schedule showed 4 staff members were assigned on-call duties on 4/26/24.

During an interview on 6/6/24 at 10:09 a.m., staff member G stated she was contacted via phone by staff member X on 4/26/24. Staff member G stated staff member X called and confirmed the facility had an emergent cardiac catheterization laboratory (cath lab) team on call.

During an interview on 6/6/24 at 2:15 p.m., staff member W said she was on-call for the cath lab on 4/26/24. Staff member W stated staff member X had called her to confirm the cath lab on-call team was available to treat a patient with an emergency. Staff member W stated she confirmed to staff member X that the cath lab team was available to perform emergent cardiac catheterizations.

Record review of the facility's Cardiothoracic/Vascular on-call schedule showed staff member staff member Z was the Cardiothoracic/Vascular Surgeon on-call on 4/26/24.

Record review of the facility's CT Surgery on-call schedule showed 8 staff members were assigned for on-call duties on 4/26/24.

Record review of the facility's Anesthesia on-call schedule showed staff member BB was the anesthesiologist on-call on 4/26/24.

Review of the facility's ICU daily census report dated 4/26/24, showed there were 7 patients receiving care in the 10 bed ICU.

During an interview on 6/11/24 at 9:00 a.m., staff member E stated she was the facility Chief of Staff. Staff member E stated she received a call from staff member X on the evening of 4/26/24. Staff member E stated she confirmed to staff member X the facility had the capacity to perform emergent heart catheterization's, and a cath lab team was on-call for emergent heart cath's. Staff member E stated the cath lab staff have been on-call and available for emergent cath lab services for some time, and the facility has had at least one cardiologist on call for emergencies.

Review of patient #12's medical record from the receiving facility showed:
-4/26/24 at 8:59 p.m., the patient arrived at the receiving facility ED. Patient #12 was evaluated by NF2 and NF3. Patient #12's vital signs were recorded as: BP 210/118 (still elevated), P 74, R 12, Pulse Oximetry 94%, T 97.9.
-4/26/24 at 9:04 p.m., an EKG was performed; NF2 interpreted results as persistent right bundle branch pattern (delayed conduction of electrical impulses through the heart which are responsible for triggering contraction of the heart muscle). NF2 compared the EKG from the previous facility and noted there were some subtle changes, but not enough to meet the criteria for an acute heart attack. Patient #12 was treated with an intravenous medication used to treat the patient's chest pain and elevated blood pressure. The medication causes the patient's blood vessels to dilate (get bigger around) and improves blood flow to the heart and other vital organs.

During an interview on 6/17/24 at 4:00 p.m., NF3 stated patient #12 was transferred to his facility [another hospital] in unstable condition. NF3 said it was determined patient #12's myocardial findings did not require immediate heart catheterization, and he was admitted to the progressive care unit. The following morning (4/27/24) patient #12 underwent an ultrasound of his heart and a heart catheterization. NF3 stated patient #12 had a blockage in one of the large arteries which supplies blood to the heart muscle.

Review of a facility policy titled, "EMTALA - Medical Screening and Stabilization", with an effective date of January 5, 2016, showed:
"Policy: Any person who presents to the hospital or any off-campus provider-based department of the hospital requesting assistance for a potential emergency medical condition (EMC) will receive a medical screening exam (MSE) performed by a qualified medical person (QMP) to determine whether an EMC exists. ... If the QMP determines an EMC exists, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the hospital, or an appropriate transfer, as defined by and required by EMTALA. ... Stabilizing treatment within hospital capability and transfer.

Record review of a facility policy, "EMTALA - On-Call Coverage," dated 1/5/16, showed:
" ... Physicians on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with emergency medical conditions (EMC) who are receiving services in accordance with the resources available to the hospital. ... The hospital must maintain a list of physicians who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an EMC in accordance with resources available to the hospital. ... 8. Physician ' s Responsibility. When a physician is identified as being the On-Call Physician for a given specialty, it shall be that physician ' s duty and responsibility to assure the following: ... b. Arrival or response to the Emergency Department within a reasonable timeframe (generally, response by the physician is expected within 30 minutes). The Emergency Department Physician, in consultation with the On-Call Physician, shall determine whether the individual ' s condition requires the On-Call to see the individual immediately. The determination of the Emergency Department Physician or other practitioner who has personally examined the individual and is currently treating the individual shall be controlling in this regard. ..."




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