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Based on interviews and record review, for 1 of 20 sampled patients, Patient #1, the Hospital failed on 10/16/11 to ensure:

1) that the On-call Surgeon responded to the Emergency Department (ED) Attending Physician's request for urgent surgery and

2) that the On-call Surgeon and the ED Attending Physician followed the Hospital's policy and procedure for the Chain of Command, to notify the Department Chief when patient care was questioned.

Findings include:

Review of the ED Nursing Chart Summary, dated 10/16/11, indicated that at 8:21 P.M., Patient #1 presented with a fever and increased pain from an abscess on his/her right buttock. The ED Nursing Chart Summary indicated that at 9:40 P.M., Patient #1 had a medical screening examination performed by a physician assistant and at 9:59 P.M., Patient #1 was seen by the ED Attending Physician.

The ED Attending Physician was interviewed on 11/22/11 at 1:35 P.M. The ED Attending Physician said that he saw Patient #1 after receiving report from the Physician Assistant who first evaluated Patient #1. He said that Patient #1 was in poor shape and the Surgical Team needed to get involved with Patient #1. The ED Attending Physician said that a computerized tomography (CT) scan was done; antibiotics were ordered; and a surgical resident evaluated Patient #1.

The ED Nursing Chart Summary indicated that Patient #1 was seen at 10:49 P.M. by a surgical resident for surgical consult.

Review of the surgical consult form, dated 10/16/11 at 11:42 P.M., indicated that urgent debridement (removal of dead or damaged tissue) in the Operating Room (OR) was needed for Patient #1's perianal abscess described as extensive purple skin color and foul smelling drainage, concerning for necrotizing fasciitis (A dangerous infection of soft-tissue that starts in the tissue just below the skin and spreads along the flat layers of tissue. The degree of pain is great, emergency diagnosis and treatment are essential, antibiotic treatment and prompt surgical removal of dead and infected tissue decreases the death rate).

The On-call Surgeon was interviewed on 11/22/11 at 2:00 P.M. The On-call Surgeon said that he received a telephone call from a Surgical Resident (on 10/16/11) who reported Patient #1 had necrotizing fasciitis and surgery was needed. The On-call Surgeon said that after speaking with the Surgical Resident, the On-call Surgeon decided to admit Patient #1 to the Hospital to the intensive care unit and perform the surgery on 10/17/11 at 6:00 A.M. The On-call Surgeon said that the Surgical Resident agreed.

The ED Attending Physician said that about an hour after first speaking with the Surgical Resident, he asked the Surgical Resident what was going on with Patient #1's care. The ED Attending Physician said the Surgical Resident reported to him that the On-call Surgeon wanted Patient #1 to be admitted to the ICU and the On-call Surgeon would do the surgery in the morning. The ED Attending Physician said he called the On-call Surgeon and the On-call Surgeon stated various reasons why he planned surgery in the morning. The ED Attending Physician said later he called the On-call Surgeon back and stated he was going to do what was best for the Patient. The ED Attending Physician said that every hour passing was taking away from Patient #1's chance of survival. The ED Attending Physician said that he knew the On-call Surgeon's plan for Patient #1 was unreasonable management and he called the Nursing Supervisor.

The On-call Surgeon said that he received a telephone call from the Attending ED Physician who stated that he preferred the surgery be done emergently. The On-Call Surgeon said that it was better for him to come to the Hospital in the morning and that is what he told the ED Attending Physician.

Review of the ED Provider Chart Summary documented by the ED Attending Physician, dated 10/17/11 at 12:24 A.M., indicated that he became aware that Patient #1 was not going to the OR until 6:00 A.M.; Patient #1 was at high risk for an adverse outcome if not taken immediately to an OR and the safest care for Patient #1 would be to transfer Patient #1 to another hospital to meet Patient #1's immediate need for surgery. The Summary indicated the On-call Surgeon agreed with the transfer.

The ED Attending Physician said that he called the Nursing Supervisor, who called the Hospital's Risk Management Department to report this high risk situation. The ED Attending Physician said that he arranged the transfer of Patient #1 to another acute care hospital so Patient #1 could receive immediate surgery. The ED Attending Physician said that he did not want any more time lost waiting for Patient #1 to receive surgery. The ED Attending Physician said that he explained to Patient #1 that his/her condition needed immediate surgery and the Hospital could not accommodate immediate surgery. Therefore, Patient #1 would receive the needed surgery at the local acute care hospital.

Further review of Patient #1's ED Nursing Chart Summary, dated 10/17/11, indicated that at 2:02 A.M., Patient #1 was transferred to another acute care hospital for surgery after the transfer order was written; the ED Attending Physician spoke with the receiving hospital physician; and the authorization forms were completed.

The Hospital Rules and Regulations of the Medical Staff were reviewed. The Rules and Regulations indicated that each department chief shall be responsible for providing a schedule of Department members for the purposes of on-call coverage for the Emergency Room. The rules and regulations indicated that if for any reason the physician on-call is not able to see the patient, it is the responsibility of the physician on-call to make arrangements for that patient to be seen by a physician of his appropriate speciality in a timely manner.

The Chief of Surgery was interviewed on 11/22/11 at 10:30 A.M. The Chief of Surgery said that the actions of the On-call Surgeon were not acceptable standards of practice. Patient #1 should have gone from the ED to the OR and if an on-call surgeon could not perform surgery, the Chain of Command policy should have been followed.

The Chief of Emergency Medicine was interviewed on 11/22/11 at 11:05 A.M. The Chief of Emergency Medicine said that the ED Attending Surgeon was administratively acting as the Chief because he (the Chief of Emergency Medicine) and the Associate Chief were away at a conference.

The ED Attending Physician said that now, after the transfer occurred, he realized that he should have called the Chief of Surgery or the Chief Medical Officer regarding Patient #1.

The Hospital Policies/Procedures titled Chain of Command for Patient Related Issues for Direct Care Providers indicated that any member of the medical staff follow guidelines in instances where patient care is questioned. The policy and procedure indicated that when it is believed there are patient care practices that may represent a threat to patient safety and issues regarding any patient provider, he/she must promptly notify his/her Department Chief.