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Based on review of ED (emergency department) policies and procedures, the medical record for 1 of 15 sampled OB (obstetric) patients (#1) who presented to the hospital with complaints of abdominal cramping, review of the ED medical record for patient #1 from receiving Hospital A, review of the Physician On-call Schedule, and interviews, the hospital failed to be in compliance with CFR 489.24. This was evidenced by the failure of the on-call OB/GYN physician to come to the ED after being requested by the ED physician to rule out a possible ectopic pregnancy or an intrauterine death for patient #1 who was 15 weeks pregnant and had vaginal bleeding/spotting earlier that day. The failure of the OB/GYN physician to report to the ED resulted in the patient having to be transferred to Hospital A for treatment. See findings cited at A2404.

Based on record review and interviews the hospital failed to ensure the on-call OB/GYN (obstetrics/gynecology) physician came to the hospital to assist in the care of 1 of 15 sampled OB patients in a total sample of 25 (patient #1) who presented to the ED with complaints of abdominal pains. The ED physician requested assistance from the on-call OB physician to rule out an ectopic pregnancy or an intrauterine death for patient #1 who was 15 weeks pregnant and complained of vaginal bleeding/spotting earlier that day. The failure of the on-call physician to report to the hospital and assist in the care of patient #1 resulted in the transfer of the patient to Hospital A for the purpose of obtaining an ultrasonography study to rule out potential complications. Findings:

Review of the closed medical record revealed patient #1 was a 20 year-old who presented to the ED at Morehouse General Hospital on 9/12/2010 at 9:56 PM with complaints of lower abdominal cramping. The patient reported she was 15 weeks pregnant and that she had vaginal spotting (bloody) earlier that day. According to documentation by S4 ED/RN triage nurse, patient #1 rated her pain an 8 on a numerical scale of 0-10 (0-no pain, 10-worst pain).

Continued review of the medical record revealed ED/Dr. S1 documented patient #1 gave an obstetrical history of gravida 1 (number of pregnancies) para 0 (number of viable births) and that her estimated due date according to ultrasound was 3/08/2011. The record indicated the patient reported she was seen on 8/31/2010 by a nurse practitioner at an OB (obstetrics) clinic in a nearby town and that she intended to continue her prenatal visits and subsequent delivery through services at the clinic.

Documentation of the 9/12/2010 physical examination at 10:22 PM by ED/Dr. S1 revealed patient #1 had abdominal tenderness and guarding in the lower abdomen, her uterine cervix was closed and bulky, there was no blood in the vaginal vault, and he was unable to detect fetal heart tones. S1 noted at 11:35 PM that he called Dr. S2 OB/GYN (obstetrics/gynecology), who was on call for unassigned obstetric patients in the ED, to discuss his findings. S1 noted that S2 asked him what he wanted him to do and that he told Dr. S2 that he wanted him to do an ultrasound on patient #1 to rule out a possible ectopic pregnancy or an intrauterine death. S1 further noted that Dr. S2 OB/GYN told him that he was not an ultrasound technician and to send the patient to see her doctor at the OB clinic. Dr. S2 did not go to the hospital to evaluate patient #1. The record indicated Dr. S1 executed a transfer for patient #1 and she was transferred on 9/13/2010 at 1:30 AM by ambulance to Hospital A.

Review of the electronic medical record from Hospital A revealed patient #1 arrived at the ED by ambulance on 9/13/201 at 1:54 AM. Review of the 2:20 AM triage assessment revealed the patient's vital signs were stable, and she rated her pain 5 on a scale of 0-10. Review of 9/13/20 nursing documentation revealed at 2:50 AM the nurse obtained fetal heart tones which were recorded at 150 beats per minute.

Review of 9/13/2010 ED physician documentation at Hospital A revealed he examined patient #1 at 2:46 AM and noted the patient's pain at that time was minimal and did not radiate. The physician diagnosed patient #1 with a urinary tract infection and vaginitis and gave the patient a prescription for Flagyl (antibacterial agent). She was instructed to follow-up with her primary physician and was discharged to home with a family member on 9/13/2010 at 3:01 AM.

In an interview on 10/14/2010 at 12:27 PM S8 Radiology Manager reported that the hospital has always had a certified sonographer on staff, but because of budget constraints they had not had one on call for emergencies in several years. S8 reported on 10/11/2010 the hospital started on-call staffing for ED emergencies. S8 said until then, the sonographer was available from 8:00 AM-4:00 PM five days a week and if a patient needed a sonogram after regular hour, they had to transfer the patient to another hospital. The survey team questioned S8 why did the hospital began on-call staffing for sonograms, and he responded it was because of the problems that the ED had with obtaining a sonogram for patient #1.

On 10/15/2010 at 9:05 AM an interview was held with Dr. S2 OB/GYN who stated he did recall when the ED physician called him about patient #1. He recalled that the patient was approximately 16 weeks pregnant and had a sonogram performed 5 days earlier at an OB clinic in another town. He stated he was willing to see the patient in the emergency room, but he wanted to examine and evaluate the patient himself to determine if a sonogram was indicated. S2 stated the ER physician, Dr. S1 had already examined the patient and did not want him to examine or evaluate the patient. Dr. S2 said the ED physician only wanted him (S2) to perform an ultrasound because the hospital did not have a sonogram technician on duty or on call after regular working hours. Dr. S2 stated he told Dr. S1 that he was not a sonogram technician and that he would need to evaluate the patient before performing an ultrasound. Dr. S2 further stated he instructed ED/Dr. S1 to contact Hospital A, which is affiliated with the OB clinic where patient #1 had her sonogram five days before presenting to the ED. He stated Dr. S1 did inform him that the patient had a sonogram done five days earlier.

Continued interview with Dr. S2 OB/GYN revealed that ED/Dr. S1 wanted to rule out an ectopic pregnancy on patient #1 and that he (S2) did not believe the patient had an ectopic pregnancy because the OB clinic where the patient #1 attended only sees low risk OB patients. He added by 16 weeks gestation the patient would feel fetal movement and that Dr. S1 had examined the patient and the uterus would have been enlarged and that the sonogram performed five days before would have detected an ectopic pregnancy if it had existed. S2 stated he was willing to evaluate and examine the patient to determine if a sonogram was indicated, but Dr. S1 did not want this service. Dr. S2 further stated that he received three phone calls from Dr. S1, but he was not aware that Dr. S1 could not detect fetal heart tones, or that he was transferring the patient to Hospital A for a sonogram.

A telephone interview on 10/15/2010 at 10:05 AM with ED/Dr. S1 revealed that he recalled patient #1 and stated the patient arrived at the emergency department around 10 PM. and that he evaluated the patient around 10:20 PM. Dr. S1 stated the patient gave a vague history and indicated she was a patient at an OB clinic and was seen by a nurse practitioner, but not a physician. Dr. S1 stated the patient was approximately 15 weeks pregnant, her vital signs were stable except for an elevated heart rate, and that she had lower abdominal tenderness upon examination. Dr. S1 stated he called Dr. S2 who was the OB physician on call and discussed the patient with Dr. S2 but the doctor would not do an ultrasound on the patient. He further stated they were unable to detect fetal heart tones on patient #1.

Dr. S1 said Dr. S2 told him that he was not on call for everyone as an ultrasound technician and asked Dr. S1 what he wanted him to do. Dr. S1 said he replied that he wanted an ultrasound on the patient to rule out an ectopic pregnancy or intrauterine death. S1 further stated he called Hospital A and spoke to a nurse who transferred him to the ED physician who accepted the patient since they had been unable to detect fetal heart tones.

An interview with Dr. S7 ED Medical Director was held on 10/15/2010 at 2:00 PM. During the interview Dr. S7 reported that he reviewed patient #1's medical record and felt there was miscommunication between ED/Dr. S1 and Dr. S2 OB/GYN. He stated the patient needed an ultrasound, but if the physician on call was asked just to perform an ultrasound on the patient, he was unsure if it was appropriate. He stated someone knew an ultrasound had recently been done on the patient but he was unsure how this information was conveyed. Dr. S7 stated he spoke to ED/Dr. S1 and suggested to the physician that the patient could have stayed in the hospital and had an ultrasound the following morning.

In an interview on 10/18/10 at 11:00 AM S6 ED/LPN confirmed she was on duty on 9/12/2010 when patient #1 presented to the ED. S6 stated the patient did not have a local OB physician so she was considered unassigned. S6 indicated at that time the procedure for unassigned OB patients was for the ED physician to initially see the patients. S6 stated that after Dr. S2 refused to do the sonogram on patient #1 that she referred to the 9/2010 physician call schedule and saw that Dr. S2 was on call for all unassigned OB patients and that she shared this information with ED/Dr. S1.

Review of policy titled "On Call Responsibilities Policy" (reference number MS.01.21.10 effective 2/11/2010) revealed that physicians in a specialty area where there is only one member are considered to be on call unless they notify the hospital switchboard in advance of the dates and times of their unavailability. The policy indicated that the physicians are expected to respond to the hospital in a timely manner when called as required by EMTALA (Emergency Medical Treatment and Labor Act).

Review of policy titled "Initial Management of Obstetrical Patients" (reference number ER09.14.15) revealed when an OB patient presents to the ED at Morehouse General Hospital if the patient is not in labor or if there is "a question as to the nature of the problem" then the OB physician on call will be consulted and will evaluate the patient to determine the care needed. An interview on 10/15/2010 at 11:25 AM with S3 Quality and Risk Manager confirmed policy ER09.14.15 was in effect on 9/12/2010 when patient #1 presented to the ED.

Review of policy titled "Initial Management of Obstetrical Patients" (reference number ER09.14.15) revealed when an OB patient presents to the ED at Morehouse General Hospital if the patient is not in labor or if there is "a question as to the nature of the problem" then the OB physician on call will be consulted and will evaluate the patient to determine the care needed.

Based on record review and interviews, the hospital failed to provide a complete medical screening examination for 1 of 1 sampled ED patients in a total sample of 25 (patient #1) who was 15 weeks pregnant, had experienced vaginal bleeding/spotting earlier that day and presented to the ED with abdominal pain. This was evidenced by the failure of the on-call OB/GYN physician to respond to a request by the ED physician to provide assistance with patient #1 to rule out a possible ectopic pregnancy or intrauterine death when the resources were available at the hospital to perform testing to complete the medical screening examination. Findings:

Review of the closed medical record revealed patient #1 was a 20 year-old who presented to the ED at Morehouse General Hospital on 9/12/2010 at 9:56 PM with complaints of lower abdominal cramping. The patient reported she was 15 weeks pregnant and that she had vaginal spotting (bloody) earlier that day. According to documentation by S4 ED/RN triage nurse, patient #1 rated her pain an 8 on a numerical scale of 0-10 (0-no pain, 10-worst pain).

Documentation of the 9/12/2010 physical examination at 10:22 PM by ED/Dr. S1 revealed patient #1 had abdominal tenderness and guarding in the lower abdomen, her uterine cervix was closed and bulky, there was no blood in the vaginal vault, and he was unable to detect fetal heart tones. S1 noted at 11:35 PM that he called Dr. S2 OB/GYN (obstetrics/gynecology), who was on call for unassigned obstetric patients in the ED, to discuss his findings. S1 noted that S2 asked him what he wanted him to do and that he told Dr. S2 that he wanted him to do an ultrasound on patient #1 to rule out a possible ectopic pregnancy or an intrauterine death. S1 further noted that Dr. S2 OB/GYN told him that he was not an ultrasound technician and to send the patient to see her doctor at the OB clinic. Dr. S2 did not go to the hospital to evaluate patient #1. The record indicated Dr. S1 executed a transfer for patient #1 and she was transferred on 9/13/2010 at 1:30 AM by ambulance to Hospital A.

Review of the electronic medical record from Hospital A revealed patient #1 arrived at the ED by ambulance on 9/13/201 at 1:54 AM. Review of the 2:20 AM triage assessment revealed the patient's vital signs were stable, and she rated her pain 5 on a scale of 0-10. Review of 9/13/20 nursing documentation revealed at 2:50 AM the nurse obtained fetal heart tones which were recorded at 150 beats per minute.

Review of 9/13/2010 ED physician documentation at Hospital A revealed he examined patient #1 at 2:46 AM and noted the patient's pain at that time was minimal and did not radiate. The physician diagnosed patient #1 with a urinary tract infection and vaginitis and gave the patient a prescription for Flagyl (antibacterial agent). She was instructed to follow-up with her primary physician and was discharged to home with a family member on 9/13/2010 at 3:01 AM.

In an interview on 10/14/2010 at 12:27 PM S8 Radiology Manager reported that the hospital has always had a certified sonographer on staff, but because of budget constraints they had not had one on call for emergencies in several years. S8 reported on 10/11/2010 the hospital had begun 24-hour sonography coverage for ED emergencies. S8 said until then, the sonographer was available from 8:00 AM-4:00 PM five days a week and if a patient needed a sonogram after regular hour, they had to transfer the patient to another hospital. The survey team questioned S8 why was the hospital providing 24-hour coverage for sonograms, and he responded it was because of the problems the ED had with obtaining a sonogram for patient #1.

On 10/15/2010 at 9:05 AM an interview was held with Dr. S2 OB/GYN who stated he did recall when the ED physician called him about patient #1. He recalled that the patient was approximately 16 weeks pregnant and had a sonogram performed 5 days earlier at an OB clinic in another town. He stated he was willing to see the patient in the emergency room, but he wanted to examine and evaluate the patient himself to determine if a sonogram was indicated. S2 stated the ER physician, Dr. S1 had already examined the patient and did not want him to examine or evaluate the patient. Dr. S2 said the ED physician only wanted him (S2) to perform an ultrasound because the hospital did not have a sonogram technician on duty or on call after regular working hours. Dr. S2 stated he told Dr. S1 that he was not a sonogram technician and that he would need to evaluate the patient before performing an ultrasound. Dr. S2 further stated he instructed ED/Dr. S1 to contact Hospital A, which is affiliated with the OB clinic where patient #1 had her sonogram five days before presenting to the ED. He stated Dr. S1 did inform him that the patient had a sonogram done five days earlier.

Continued interview with Dr. S2 OB/GYN revealed that ED/Dr. S1 wanted to rule out an ectopic pregnancy on patient #1 and that he (S2) did not believe the patient had an ectopic pregnancy because the OB clinic where the patient #1 attended only sees low risk OB patients. He added by 16 weeks gestation the patient would feel fetal movement and that Dr. S1 had examined the patient and the uterus would have been enlarged and that the sonogram performed five days before would have detected an ectopic pregnancy if it had existed. S2 stated he was willing to evaluate and examine the patient to determine if a sonogram was indicated, but Dr. S1 did not want this service. Dr. S2 further stated that he received three phone calls from Dr. S1, but he was not aware that Dr. S1 could not detect fetal heart tones, or that he was transferring the patient to Hospital A for a sonogram.

A telephone interview on 10/15/2010 at 10:05 AM with ED/Dr. S1 revealed that he recalled patient #1 and stated the patient arrived at the emergency department around 10 PM. and that he evaluated the patient around 10:20 PM. Dr. S1 stated the patient had lower abdominal tenderness upon examination. Dr. S1 stated he called Dr. S2 who was the OB physician on call and discussed the patient with Dr. S2 but the doctor would not do an ultrasound on the patient. He further stated they were unable to detect fetal heart tones on patient #1.

Dr. S1 said Dr. S2 told him that he was not on call for everyone as an ultrasound technician and asked Dr. S1 what he wanted him to do. Dr. S1 said he replied that he wanted an ultrasound on the patient to rule out an ectopic pregnancy or intrauterine death. S1 further stated he called Hospital A and spoke to a nurse who transferred him to the ED physician who accepted the patient since they had been unable to detect fetal heart tones.

In an interview on 10/18/10 at 11:00 AM S6 ED/LPN confirmed she was on duty on 9/12/2010 when patient #1 presented to the ED. S6 stated the patient did not have a local OB physician so she was considered unassigned. S6 indicated at that time the procedure for unassigned OB patients was for the ED physician to initially see the patients. S6 stated that after Dr. S2 refused to do the sonogram on patient #1 that she referred to the 9/2010 physician call schedule and saw that Dr. S2 was on call for all unassigned OB patients and that she shared this information with ED/Dr. S1.

Review of policy titled "On Call Responsibilities Policy" (reference number MS.01.21.10 effective 2/11/2010) revealed that physicians in a specialty area where there is only one member are considered to be on call unless they notify the hospital switchboard in advance of the dates and times of their unavailability. The policy indicated that the physicians are expected to respond to the hospital in a timely manner when called as required by EMTALA (Emergency Medical Treatment and Labor Act).

Review of policy titled "Initial Management of Obstetrical Patients" (reference number ER09.14.15) revealed when an OB patient presents to the ED at Morehouse General Hospital if the patient is not in labor or if there is "a question as to the nature of the problem" then the OB physician on call will be consulted and will evaluate the patient to determine the care needed. An interview on 10/15/2010 at 11:25 AM with S3 Quality and Risk Manager confirmed policy ER09.14.15 was in effect on 9/12/2010 when patient #1 presented to the ED.