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Based on policy and procedure review, medical record review, on call schedule review and staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 42 CFR 489.24 by failing to ensure a physician who was on call for neurology services was available to provide services upon the request of the dedicated emergency department (DED) physician and failing to ensure a Medical Screening Exam (MSE) was completed within the capabilities of the hospital that provided for the stabilization of a patient.

The findings include:

1. The hospital failed to ensure a physician who was on call for neurology services was available to provide services upon the request of the dedicated emergency department (DED) physician for 1 of 5 patients that were transferred with an emergency medical condition (#7).

~cross refer to 489.20(r)(2) and 489.24(j)(1-2), On Call Physicians - Tag A2404.


2. The Dedicated Emergency Department (DED) physician failed to ensure a Medical Screening Exam (MSE) was completed within the capabilities of the hospital that provided for the stabilization of a patient in 1 of 23 patients presenting to the DED with an Emergency Medical Condition (EMC) (#7).

~cross refer to 489.20(r)(2) and 489.24(r) and 489.24(c) Medical Screening Examination - Tag A2406.

Based on policy and procedure review, medical record review, on call schedule review and staff and physician interviews, the hospital failed to ensure a physician who was on call for neurology services was available to provide services upon the request of the dedicated emergency department (DED) physician for 1 of 5 patients that were transferred with an emergency medical condition (#7).

The findings include:

Review of the "Emergency Medical Treatment and Labor Act (EMTALA)" policy reviewed/revised 08/27/2012 revealed "...II. Personnel: ... B. On-Call Physicians. 1. Physician, including specialists and sub-specialists, who serve on an on-call basis to the Emergency Department must be available to provide necessary treatment to stabilize individuals with EMCs (emergency medical conditions) after the initial MSE (medical screening examination). a. The on-call physician must respond in a reasonable amount of time to requests for his/her services, including requests by the QMP (qualified medical personnel) for the on-call physician to personally appear to treat the individual, but no more than 30 minutes. ... 2. If an on-call physician refuses to appear or is not available in the time needed for a response, then the hospital shall have a back-up plan, which may include calling the next on-call physician on the list. Diligent efforts shall be made to provide the MSE and any stabilizing treatment for the EMC at the originating hospital before arranging for transfer. ..."

Closed DED medical record review of Patient #7 revealed a 39 year-old female, who presented to Hospital A's dedicated emergency department (DED) a total of four visits on 07/06/2014, 07/09/2014, 07/11/2014 and 07/12/2014.

Medical record review of Patient #7 revealed the patient presented to Hospital A Campus 2 on 07/06/2014 at 1541 with a chief complaint of headache and dizziness after a fall at home. Review of nursing notes revealed the patient was triaged at 1547 as a level 3 urgent. Review revealed a medical screening examination was conducted at 1558. Review of a head CT (Computed Tomography) completed and reported on 07/06/2014 at 17:08:00 revealed "no acute disease process, no intracranial hemorrhage, no midline shift, no mass effect, no scull deformity or fracture, interpreted by Radiologist. Cervical spine shows straightening of the normal lordosis with no acute cervical spine fractures. There is noted to be a linear nondisplaced fracture of the occipital bone extending to the occipital condyle. This is stable with no evidence of bleeding." Review of the record revealed the patient was administered medication for pain and nausea and provided a soft cervical collar. Notes recorded the treatment plan, discharge instructions and follow up were discussed with the patient. Review revealed the patient was discharged home with a diagnosis of concussion with brief loss of consciousness, sprain or strain of cervical spine, lumbar strain and nondisplaced skull fracture. Review revealed the patient departed the DED at 1728 in stable condition.

Medical record review of Patient #7 revealed the patient returned to Hospital A Campus 2 on 07/09/2014 at 2349 with a chief complaint of head pain and a new onset of seizure activity after a fall on 07/05/2014. Review of nursing notes revealed the patient was triaged at 2357 as a level 3 urgent. Review revealed a medical screening examination was conducted upon the patient's arrival to the DED. Review of the physician's notes revealed the patient had a seizure on 07/07/2014 and went to her primary care provider and had an MRI done on 07/09/2014. Review on notes revealed the "MRI findings consistent with subtle edema involving the left anterior temporal and bilateral inferior frontal lobes within bilateral cerebral extra-axial hemorrhage." Review revealed a review of systems and physical examination was completed that included a neurological examination. Review of the physician's notes revealed "... Medical Decision Making Rationale: The patient is a 39 year-old white female with posttraumatic seizures. I discussed the case with the neurologist on call at (Hospital B), (name of neurologist). The patient was given a loading dose of Dilantin (anti seizure medication) and will be discharged with a prescription for same and instructions to follow up with her primary care provider for neurology referral as planned. ...." Further review revealed the patient received Dilantin (medication for seizure) 1 Gram intravenous (IV) at 0148. Review of nursing notes revealed the patient had no pain at 0318. Notes recorded the treatment plan, discharge instructions and follow up were discussed with the patient. Review revealed the patient was discharged home with a diagnosis of seizure. Review revealed the patient departed the DED on 07/10/2014 at 0321 in stable condition.

Medical record review of Patient #7 revealed the patient returned Hospital A Campus 2 on 07/11/2014 at 2103 with a chief complaint of "possible seizure activity this evening - no injury to patient prior to episode- p/w/d-a/ox3 (pale, warm dry, alert and oriented times three)." Review revealed the patient was triaged at 2106 at a level 3 urgent. Review revealed the patient denied pain. Review of Physician C's medical screening examination revealed the patient was seen by the physician at 2123. Review of physician's notes revealed the patient was seen in the DED on 07/06/2014 after a fall. Review of the notes revealed "She was diagnosed with a nondisplaced occipital skull fracture. She did follow up with her doctor on July 9 and had an MRI done at that time which did reveal the same fracture as well as some extra axial bleeding both occipitally and frontal. She was seen here again on July 10 secondary to having seizures. The ER physician consulted neurology in Charlotte and it was decided to start her on 300 mg Dilantin HS. The first dose was given last night. Patient presents today with family stating that she was unresponsive for a period of time this evening possibly having had a seizure. Patient states that her headache has been getting worse since this injury. Also states that the last day or two she has had a stuttering speech which is significantly unusual for her." Review revealed a review of systems and physical examination included "Head: Normocephalic, positive tenderness to the occipital scalp. Eyes: Pupils are equal, round and reactive to light, extraocular movements are intact, normal conjunctiva, normal fundus. No hemorrhages. ... Musculoskeletal: Normal ROM (range of motion). There is mild weakness to grip strength on the right and push pull on the right lower extremity. Patient is right-hand dominant. She did mention when she was seen by her family doctor the same findings were obtained. ... Neurological: Alert and oriented to person, place, time and situation. Patient does have short term memory loss from the events of the fall. Stuttering speech as mentioned previously. ... Medical Decision Making Results Review: ... Head Computed Tomography: Time reported 7/11/2014 22:17:00, interpretation by Radiologist, No acute or new findings identified. Reexamination/Reevaluation: 10PM and case discussed with (on call neurologist at Hospital A). Recommends adding Keppra to 50 mg twice a day (medication for seizure activity). This information as well as all lab and CT findings were shared with the patient. Review of nursing notes at 2230 revealed no seizure activity was observed during the DED visit. Further review revealed the patient received Keppra 250 mg orally at 2231 (medication for seizure). Review revealed a head CT was completed and compared to prior studies that reported no obvious hemorrhage and nondisplaced right occipital bone fracture. Notes recorded the treatment plan, discharge instructions and follow up were discussed with the patient. Review revealed the patient was discharged home with a diagnosis of concussion and post concussion syndrome. Review revealed the patient departed the DED at 2233.

Medical record review of Patient #7 revealed the patient returned to Hospital A Campus 1 on 07/12/2014 at 1745 with a chief complaint of "seizure in (Hospital A Campus 1) parking lot 20 minutes ago; patient complains of generalized weakness and stuttering; witnessed by family; patient seen at (Hospital A Campus 2) yesterday diagnosis: concussion." Review revealed the patient was triaged at 1758 at a level 3 urgent. Vital signs were recorded as temperature 98.98 degrees Fahrenheit, pulse 72, blood pressure 107/68, respirations 19 and oxygen saturation 97%. Review revealed the patient complained of pain at a level of 10 described as acute and aching head pain. Review of Physician D's medical screening examination revealed the patient was seen by the physician at 1812. Review of physician's notes revealed the patient was seen in the DED on 07/06/2014 after a fall with no acute process identified. Review of the notes revealed "The patient was seen in the emergency department on 07/10/2014 after she had a seizure. Patient had MRI performed that day outpatient which showed a subtotal skull fracture and a small amount of extra-axial hemorrhage. Neurologist from (Hospital B) was consulted and patient was started on Dilantin (anti seizure medication). She was discharged home. She was seen in the emergency department 07/11/2014 as she had another seizure and began to have stuttering speech. Patient was started on Keppra (anti seizure medication) with CT scan performed yesterday showing no acute process. Patient states since yesterday she has had another seizure with shaking of the upper lower extremities. She states she was told it lasted seconds. Patient states she was originally diagnosed with a concussion and she did not remember the events that occurred immediately before and after striking her head. Patient states she has been taking her Keppra and Dilantin as prescribed. She denies any new onset change in vision or speech. She states she continues to have stuttering speech." Review revealed a review of systems and physical examination included "Head: Atraumatic. ... Eyes: Pupils are equal, round and reactive to light, extraocular movements are intact, normal conjunctiva. ... Musculoskeletal: Normal ROM (range of motion). ... Neurological: Alert and oriented to person, place, time and situation. No focal neurological deficit observed. CN II-XII intact, normal sensory observed, normal speech observed, normal coordination observed. Patient has stuttering speech. She can correctly identify year at age objects such as pen and watch. ... Medical Decision Making 1858 Call placed to neurologist. ... Reexamination/Reevaluation: MRI 7/9/2014 Critical Findings - Findings consistent with subtle edema involving the left anterior temporal and bilateral inferior frontal lobes possibly due to contusion with thin bilateral cerebral extra-axial hemorrhage with associated leptomeningeal enhancement, greatest left. 1944 CT scan head no change from 7/11/2014. ... Procedure: 1945 On repeat exam the patient is alert and oriented to person, place and time, continues to stutter (unchanged). Will admit patient for further workup. 1950 Call placed to hospitalist. ... 2148 (Hospitalist) has seen patient and requested the patient be transferred to (Hospital B). No return call from (neurologist on call)." Further review of the DED record revealed laboratory studies, an EKG, chest x-ray, left hand x-ray and head CT were completed. Morphine (medication for pain) 5mg IV (milligrams intravenously) was administered at 1937. Ativan (medication for anxiety) 1mg IV was administered at 2204 and Dilantin (anti-seizure medication) 500 mg IV was administered at 2311. Review of physician's notes revealed a diagnosis of "Clonic seizure, acute head injury, brain concussion and history of skull fracture." Review revealed a plan to discharge the patient to Hospital B. Review of the transfer form revealed the physician signed the certification at 2330 and documented that the hospitalist requested transfer to Hospital B to obtain neurology services that were not available at Hospital A. Review of the record revealed the patient was transferred via ambulance and departed at 0010.

Medical record review of Patient #7's admission to Hospital B revealed the patient was admitted on 07/13/2014 and discharged home on 07/15/2014. Review revealed a neurology consult note dated 07/13/2014 that revealed the patient continued to have a headache and "occasional stuttering speech with subjective right-sided numbness/weakness that comes and goes as patient is distracted." Review revealed a continuous video EEG was conducted. Review of the physician's Discharge Summary signed 07/16/14 revealed a discharge diagnosis of "Pseudoseizure."

Interview on 08/20/2014 at 1530 with Physician D revealed he was on duty when the patient presented to the DED on 07/12/2014. Interview revealed the physician remembered the patient. The physician stated the patient had an "odd speech pattern." The physician stated he did a head CT scan and a work up and talked with the on call neurologist at the receiving hospital (Hospital B) who recommended admission. Physician D stated the neurologist (Physician E) at Hospital A (transferring hospital) was not available and the patient needed an EEG done. The physician stated the EEG could not be done without a neurologist, who was not available. Physician D stated he felt the patient needed admission and further workup due to "persistent seizures."

Review of the on call schedule for neurology revealed there was only one neurologist on staff (Physician E) and there was not always a neurologist on call. Review of the on call schedule revealed Physician E (neurologist) was on call on 07/12/2014.

Telephone interview on 08/21/2014 at 1405 with Staff #2 revealed she was the person responsible for updating the neurology on call schedule. Interview with Staff #2 revealed Physician E was on call beginning on July 11, 2014 at 1200 and remained on call through July 18, 2014 at 1200. Interview confirmed Physician E was on call for neurology on 07/12/2014. The staff member stated Physician E's cell phone number is posted on the schedule for contacting the physician when he is on call. The staff member verified that the cell phone number listed was correct.

Telephone interview on 08/21/2014 at 1430 with Physician D revealed he tried calling the neurologist (Physician E) and did not get a response back. The physician stated "Someone told me he wasn't on call. (Name of hospitalist) told me he wouldn't admit the patient without a neurologist." The DED physician stated he did not make further attempts to contact Physician E (neurologist). Physician D stated he contacted the on call neurologist at Hospital B for consultation.

An interview was attempted with Physician E (neurologist on call at Hospital A). The physician was out of the country and unable to be reached.

Based on policy and procedure review, medical record review, on call schedule review and staff and physician interviews, the Dedicated Emergency Department (DED) physician failed to ensure a Medical Screening Exam (MSE) was completed within the capabilities of the hospital that provided for the stabilization of a patient in 1 of 23 patients presenting to the DED with an Emergency Medical Condition (EMC) (#7).

The findings include:

Review of the "Emergency Medical Treatment and Labor Act (EMTALA)" policy reviewed/revised 08/27/2012 revealed "... Medical Screening Examination: A. Request for MSE: An appropriate Medical Screening Examination will be performed on any individual who "comes to the emergency department" ... B. Appropriate MSE: The purpose of the MSE is to determine whether the individual has an EMC. 1. The MSE should be appropriate based on the signs and symptoms of the individual and in keeping with the professional standard of care. 2. The MSE should be done within the capacity and capability of the hospital, including using all ancillary services routinely available to the Emergency department. 3. The individual should be appropriately monitored as part of the MSE until the qualified medical personnel confirms that the individual does not have an EMC or an EMC has been identified and the individual is "Stabilized" or appropriately transferred. ..."

Closed DED medical record review of Patient #7 revealed a 39 year-old female, who presented to Hospital A's dedicated emergency department (DED) a total of four visits on 07/06/2014, 07/09/2014, 07/11/2014 and 07/12/2014.

Medical record review of Patient #7 revealed the patient presented to Hospital A Campus 2 on 07/06/2014 at 1541 with a chief complaint of headache and dizziness after a fall at home. Review of nursing notes revealed the patient was triaged at 1547 as a level 3 urgent. Review revealed a medical screening examination was conducted at 1558. Review of a head CT (Computed Tomography) completed and reported on 07/06/2014 at 17:08:00 revealed "no acute disease process, no intracranial hemorrhage, no midline shift, no mass effect, no scull deformity or fracture, interpreted by Radiologist. Cervical spine shows straightening of the normal lordosis with no acute cervical spine fractures. There is noted to be a linear nondisplaced fracture of the occipital bone extending to the occipital condyle. This is stable with no evidence of bleeding." Review of the record revealed the patient was administered medication for pain and nausea and provided a soft cervical collar. Notes recorded the treatment plan, discharge instructions and follow up were discussed with the patient. Review revealed the patient was discharged home with a diagnosis of concussion with brief loss of consciousness, sprain or strain of cervical spine, lumbar strain and nondisplaced skull fracture. Review revealed the patient departed the DED at 1728 in stable condition.

Medical record review of Patient #7 revealed the patient returned to Hospital A Campus 2 on 07/09/2014 (3 days later) at 2349 with a chief complaint of head pain and a new onset of seizure activity after a fall on 07/05/2014. Review of nursing notes revealed the patient was triaged at 2357 as a level 3 urgent. Review revealed a medical screening examination was conducted upon the patient's arrival to the DED by Physician B. Review of the physician's notes revealed the patient had a seizure on 07/07/2014 and went to her primary care provider and had an MRI done on 07/09/2014. Review of notes revealed the "MRI findings consistent with subtle edema involving the left anterior temporal and bilateral inferior frontal lobes within bilateral cerebral extra-axial hemorrhage." Review revealed a review of systems and physical examination was completed that included a neurological examination. Review of the physician's notes revealed "... Medical Decision Making Rationale: The patient is a 39 year-old white female with posttraumatic seizures. I discussed the case with the neurologist on call at (Hospital B), (name of neurologist). The patient was given a loading dose of Dilantin (anti seizure medication) and will be discharged with a prescription for same and instructions to follow up with her primary care provider for neurology referral as planned. ...." Further review revealed the patient received Dilantin (medication for seizure) 1 Gram intravenous (IV) at 0148. Review of nursing notes revealed the patient had no pain at 0318. Notes recorded the treatment plan, discharge instructions and follow up were discussed with the patient. Review revealed the patient was discharged home with a diagnosis of seizure. Review revealed the patient departed the DED on 07/10/2014 at 0321.

Review of the on call schedule for neurology revealed there was only one neurologist on staff (Physician E) and there was not always a neurologist on call. Review of the on call schedule revealed Physician E (neurologist) was not on call on 07/09/2014.

Interview on 08/21/2014 at 1300 with Physician F revealed he was a radiologist. Interview revealed he had reviewed the MRI results that were completed on 07/09/2014 and stated the findings were consistent with an intracranial hemorrhage (brain bleed) outside of the brain, beneath the dura or outside the dura. The physician stated treatment should be considered for any current or new symptoms that the patient developed. Interview revealed further testing of CT or MR studies might need to be completed if new symptoms presented.

Medical record review of Patient #7 revealed the patient returned to Hospital A Campus 2 on 07/11/2014 (2 days later) at 2103 with a chief complaint of "possible seizure activity this evening - no injury to patient prior to episode- p/w/d-a/ox3 (pale, warm dry, alert and oriented times three)." Review revealed the patient was triaged at 2106 at a level 3 urgent. Review revealed the patient denied pain. Review of Physician C's medical screening examination revealed the patient was seen by the physician at 2123. Review of physician's notes revealed the patient was seen in the DED on 07/06/2014 after a fall. Review of the notes revealed "She was diagnosed with a nondisplaced occipital skull fracture. She did follow up with her doctor on July 9 and had an MRI done at that time which did reveal the same fracture as well as some extra axial bleeding both occipitally and frontal. She was seen here again on July 10 secondary to having seizures. The ER physician consulted neurology in Charlotte and it was decided to start her on 300 mg Dilantin HS. The first dose was given last night. Patient presents today with family stating that she was unresponsive for a period of time this evening possibly having had a seizure. Patient states that her headache has been getting worse since this injury. Also states that the last day or two she has had a stuttering speech which is significantly unusual for her." Review revealed a review of systems and physical examination included "Head: Normocephalic, positive tenderness to the occipital scalp. Eyes: Pupils are equal, round and reactive to light, extraocular movements are intact, normal conjunctiva, normal fundus. No hemorrhages. ... Musculoskeletal: Normal ROM (range of motion). There is mild weakness to grip strength on the right and push pull on the right lower extremity. Patient is right-hand dominant. She did mention when she was seen by her family doctor the same findings were obtained. ... Neurological: Alert and oriented to person, place, time and situation. Patient does have short term memory loss from the events of the fall. Stuttering speech as mentioned previously. ... Medical Decision Making Results Review: ... Head Computed Tomography: Time reported 7/11/2014 22:17:00, interpretation by Radiologist, No acute or new findings identified. Reexamination/Reevaluation: 10PM and case discussed with (on call neurologist at Hospital A). Recommends adding Keppra to 50 mg twice a day (medication for seizure activity). This information as well as all lab and CT findings were shared with the patient. Review of nursing notes at 2230 revealed no seizure activity was observed during the DED visit. Further review revealed the patient received Keppra 250 mg orally at 2231 (medication for seizure). Review revealed a head CT was completed and compared to prior studies that reported no obvious hemorrhage and nondisplaced right occipital bone fracture. Notes recorded the treatment plan, discharge instructions and follow up were discussed with the patient. Review revealed the patient was discharged home with a diagnosis of concussion and post concussion syndrome. Review revealed the patient departed the DED at 2233.

Interview on 08/20/2014 at 1500 with Physician C revealed he was the DED physician that evaluated Patient #7 on 07/11/2014. Physician C stated he remembered the patient. The physician stated "She did not meet criteria for admission. There was no reason for admission. All of the tests were unchanged." The physician stated that he had reviewed the patient's MRI completed on 07/09/2014. The physician stated he was aware that the patient's family had complained about the patient not being admitted and that the patient had never requested admission. Interview revealed the physician discussed the patient's case with the on call neurologist who suggested treatment with medication (Keppra) which was followed. Interview confirmed the neurologist was not asked to come see the patient and did not evaluate the patient, only provided a telephone consult. Physician C stated "Based on my conversation with the neurologist, I was comfortable with discharging the patient."

Medical record review of Patient #7 revealed the patient returned to Hospital A Campus 1 on 07/12/2014 (1 day later) at 1745 with a chief complaint of "seizure in (Hospital A Campus 1) parking lot 20 minutes ago; patient complains of generalized weakness and stuttering; witnessed by family; patient seen at (Hospital A Campus 2) yesterday diagnosis: concussion." Review revealed the patient was triaged at 1758 at a level 3 urgent. Vital signs were recorded as temperature 98.98 degrees Fahrenheit, pulse 72, blood pressure 107/68, respirations 19 and oxygen saturation 97%. Review revealed the patient complained of pain at a level of 10 described as acute and aching head pain. Review of Physician D's medical screening examination revealed the patient was seen by the physician at 1812. Review of physician's notes revealed the patient was seen in the DED on 07/06/2014 after a fall with no acute process identified. Review of the notes revealed "The patient was seen in the emergency department on 07/10/2014 after she had a seizure. Patient had MRI performed that day outpatient which showed a subtotal skull fracture and a small amount of extra-axial hemorrhage. Neurologist from (Hospital B) was consulted and patient was started on Dilantin (anti seizure medication). She was discharged home. She was seen in the emergency department 07/11/2014 as she had another seizure and began to have stuttering speech. Patient was started on Keppra (anti seizure medication) with CT scan performed yesterday showing no acute process. Patient states since yesterday she has had another seizure with shaking of the upper lower extremities. She states she was told it lasted seconds. Patient states she was originally diagnosed with a concussion and she did not remember the events that occurred immediately before and after striking her head. Patient states she has been taking her Keppra and Dilantin as prescribed. She denies any new onset change in vision or speech. She states she continues to have stuttering speech." Review revealed a review of systems and physical examination included "Head: Atraumatic. ... Eyes: Pupils are equal, round and reactive to light, extraocular movements are intact, normal conjunctiva. ... Musculoskeletal: Normal ROM (range of motion). ... Neurological: Alert and oriented to person, place, time and situation. No focal neurological deficit observed. CN II-XII intact, normal sensory observed, normal speech observed, normal coordination observed. Patient has stuttering speech. She can correctly identify year at age objects such as pen and watch. ... Medical Decision Making 1858 Call placed to neurologist. ... Reexamination/Reevaluation: MRI 7/9/2014 Critical Findings - Findings consistent with subtle edema involving the left anterior temporal and bilateral inferior frontal lobes possibly due to contusion with thin bilateral cerebral extra-axial hemorrhage with associated leptomeningeal enhancement, greatest left. 1944 CT scan head no change from 7/11/2014. ... Procedure: 1945 On repeat exam the patient is alert and oriented to person, place and time, continues to stutter (unchanged). Will admit patient for further workup. 1950 Call placed to hospitalist. ... 2148 (Hospitalist) has seen patient and requested the patient be transferred to (Hospital B). No return call from (neurologist on call)." Further review of the DED record revealed laboratory studies, an EKG, chest x-ray, left hand x-ray and head CT were completed. Morphine (medication for pain) 5mg IV (milligrams intravenously) was administered at 1937. Ativan (medication for anxiety) 1mg IV was administered at 2204 and Dilantin (anti-seizure medication) 500 mg IV was administered at 2311. Review of physician's notes revealed a diagnosis of "Clonic seizure, acute head injury, brain concussion and history of skull fracture." Review revealed a plan to discharge the patient to Hospital B. Review of the transfer form revealed the physician signed the certification at 2330 and documented that the hospitalist requested transfer to Hospital B to obtain neurology services that were not available at Hospital A. Review of the record revealed the patient was transferred via ambulance and departed at 0010.

Interview on 08/20/2014 at 1530 with Physician D revealed he was on duty when the patient presented to the DED on 07/12/2014. Interview revealed the physician remembered the patient. The physician stated the patient had an "odd speech pattern." The physician stated he did a head CT scan and a work up and talked with the on call neurologist at the receiving hospital (Hospital B) who recommended admission. Physician D stated the neurologist (Physician E) at Hospital A (transferring hospital) was not available and the patient needed an EEG done. The physician stated the EEG could not be done without a neurologist, who was not available. Physician D stated he felt the patient needed admission and further workup due to "persistent seizures."

Telephone interview on 08/21/2014 at 1430 with Physician D revealed he tried calling the neurologist (Physician E) and did not get a response back. The physician stated "Someone told me he wasn't on call. (Name of hospitalist) told me he wouldn't admit the patient without a neurologist."

An interview was attempted with Physician E (neurologist on call at Hospital A). The physician was out of the country and unable to be reached.

Medical record review of Patient #7's admission to Hospital B revealed the patient was admitted on 07/13/2014 and discharged home on 07/15/2014. Review revealed a neurology consult note dated 07/13/2014 that revealed the patient continued to have a headache and "occasional stuttering speech with subjective right-sided numbness/weakness that comes and goes as patient is distracted." Review revealed a continuous video EEG was conducted. Review of the physician's Discharge Summary signed 07/16/14 revealed a discharge diagnosis of "Pseudoseizure."

In summary, Patient #7 presented to Hospital A's dedicated emergency department (DED) a total of four visits on 07/06/2014, 07/09/2014, 07/11/2014 and 07/12/2014. Review revealed the patient had sustained a skull fracture with concussion without intracranial bleeding on the first visit on 07/06/2014. Review revealed she presented to the DED on 07/09/2014 after three seizures and an MRI that demonstrated a new intracranial bleed. She received medication for seizure activity and was discharged. She returned for a third DED visit on 07/11/2014 with a new onset of stuttering speech, worsening headaches and weakness in the right upper and lower extremities. Review revealed a telephone neurology consult was done. Review revealed a neurologist did not examine the patient during this DED visit. The patient was discharged the home. Review revealed the patient returned to the DED on 07/12/2014 with seizure activity, continued stuttering and worsening headache. The decision was made to admit the patient , but the on call neurologist failed to respond to the call and the patient was transferred to another hospital. The DED physician failed to ensure a Medical Screening Exam was completed within the capabilities of the hospital that provided for the stabilization of Patient #7 on 07/09/2014, 07/11/2014 and 07/12/2014.