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Based on information from the complainant, record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure a qualified medical provider was on call and immediately available by telephone or radio contact, and available on site within 30 minutes for 2 of 20 (#4 and #5) closed emergency department records reviewed. Failure to have a qualified medical provider immediately available by telephone and available on site within 30 minutes placed these patients and all patients presenting to the emergency department at risk for complications related to illness or injury, and caused a delay in assessment and treatment.

Findings include:

Review of the CAH's "Emergency Medical Services Plan" occurred on 01/10/12. This undated plan stated, "St. Andrews Health Center offers emergency medical services 24 hours a day with a physician, physician assistant, or nurse practitioner available to the emergency care area immediately by telephone/pager and onsite within 20 minutes. Physician assistants and nurse practitioners have physician back-up when on-call (telephone and onsite). . . . "

Review of the "Emergency Room Staffing" document occurred on 01/10/12. This undated document stated, "PURPOSE: St. Andrew's Health Center provides emergency care necessary to meet the needs of it's inpatients and outpatients. Physicians/Physician Assistant/Nurse Practitioner: A practitioner with training or experience in emergency care is identified as "on call" 24 hours a day. . . . The practitioner is notified: . . . 2) when a patient presents to the emergency room for services . . . The practitioner is notified by pager, beeper, or telephone. Each practitioner identified in advance the contact method to be used. Once notified, the practitioner calls the acute charge nurse and establishes immediate contact by telephone. The practitioner is available on-site within 20 minutes of the initial notification. . . ."

- Review of Patient #4's closed emergency department record occurred on January 10-11, 2012. Patient #4 presented to the emergency department on 11/11/11 at 6:35 a.m. with chest pain and diaphoresis. The record does not identify the time staff notified the CAH's on-call provider (#3) of the patient's arrival in ER. The record identified the CAH's on-call provider (#3) arrived at 7:50 a.m. (75 minutes after patient arrival).

The record identified the CAH transferred Patient #4 to an acute care hospital at 8:55 a.m. via air ambulance in stable condition. Review of Patient #4's History and Physical Report from the acute care facility identified, ". . . IMPRESSION: . . . admitted with acute ST-segment elevation inferior and possible posterior wall infarct. Though she is not having pain, she has not electrocardiographically reperfused and is at high risk for an acute event. Recommendations: 1. We will have the patient undergo emergent cardiac catheterization. 2. We will treat her for standard acute coronary syndrome . . ." Patient #4's Discharge Summary, dated 11/13/11, stated, " PERTINENT DISCHARGE DIAGNOSES include: 1. Acute ST-segment elevation inferior wall myocardial infarction. . . HOSPITAL COURSE: . . . We emergently took her to the cardiac catheterization lab where she was found to have a completely occluded proximal right coronary artery. . . . She underwent uncomplicated angioplasty and stent of the right coronary artery with drug-eluting stent. . . ."

A review of Patient #4's CAH emergency record by a supervisory physician (#4) dated 11/23/11, stated "Unacceptable delay in assessment and evaluation and treatment of this pt [patient] with Acute STEMI [ST-segment elevated myocardial infarction]."

- Review of Patient #5's closed emergency department record occurred on January 10-11, 2012. Patient #5 presented to the emergency department on 11/11/11 at 6:40 a.m. with rectal bleeding and weakness. The record does not identify the time staff notified the CAH's on-call provider (#3) of the patient's arrival in ER. The record identified the CAH's on-call provider (#3) arrived at 9:00 a.m. (2 hours and 20 minutes after patient arrival). (NOTE: Medical record review indicated the on-call provider (#3) arrived at the hospital at 7:50 a.m. and was attending to another patient.) The record identified the CAH transferred Patient #5 to an acute care hospital via ambulance at 9:20 a.m. in stable condition.

A review of Patient #5's CAH emergency record by a supervisory physician (#4) dated 11/23/11, stated "Unacceptable delay in providing care to pt [with] acute GI [gastrointestinal] bleed."

During interviews with the CAH's medical staff (#3, #4, and #5) on 01/10/12 at 2:15 p.m., 3:00 p.m., and 4:30 p.m. respectively, all three providers stated they are required to come in to the hospital to evaluate every patient that presents to the emergency room. All three providers stated they are expected to arrive at the hospital within 30 minutes, and within 20 minutes if it is a cardiac or trauma patient.

During interview on 01/10/12 at 1:30 p.m., an administrative nursing staff member (#2) stated she was aware staff were not able to contact the on-call provider (#3), as the provider's phone was not working. The staff member (#2) stated staff eventually went to the provider's home to notify him/her of the patient's in the emergency room.

During interview on 01/11/12 at 8:45 a.m. regarding the delay in treatment of Patients #4 and #5 on 01/11/11, two administrative staff members (#1 and #2) confirmed they were aware of the provider's phone not working on 11/11/11 and that the on-call provider arrived late.

Based on information from the complainant, record review, policy review, meeting minute review, and staff interview, the Critical Access Hospital (CAH) failed to implement corrective action to ensure the on-call healthcare provider was notified of a patient requiring care in the emergency department when the primary form of communicating with the provider (via telephone) was not functioning for 2 of 20 (#4 and #5) closed emergency department records reviewed. Failure to follow-up with corrective action or provide an alternative way of contacting the on-call provider placed these patients and all patients presenting to the emergency department at risk for complications related to illness or injury, and caused a delay in assessment and treatment.

Findings include:

Review of the CAH's "Emergency Medical Services Plan" occurred on 01/10/12. This undated plan stated, "St. Andrews Health Center offers emergency medical services 24 hours a day with a physician, physician assistant, or nurse practitioner available to the emergency care area immediately by telephone/pager and onsite within 20 minutes. Physician assistants and nurse practitioners have physician back-up when on-call (telephone and onsite). . . . "

Review of the "Emergency Room Staffing" document occurred on 01/10/12. This undated document stated, "PURPOSE: St. Andrew's Health Center provides emergency care necessary to meet the needs of its inpatients and outpatients. Physicians/Physician Assistant/Nurse Practitioner: A practitioner with training or experience in emergency care is identified as "on call" 24 hours a day. . . . The practitioner is notified: . . . 2) when a patient presents to the emergency room for services . . . The practitioner is notified by pager, beeper or telephone. Each practitioner identified in advance the contact method to be used. Once notified, the practitioner calls the acute charge nurse and establishes immediate contact by telephone. The practitioner is available on-site within 20 minutes of the initial notification. . . ."

- Review of Patient #4's closed emergency department record occurred on January 10-11, 2012. Patient #4 presented to the emergency department on 11/11/11 at 6:35 a.m. with chest pain and diaphoresis. The medical record does not identify the time staff notified the CAH's on-call provider (#3) of the patient's arrival in ER. The record identified the CAH's on-call provider (#3) arrived on-site at 7:50 a.m. (75 minutes after patient arrival). The record identified the CAH transferred Patient #4 to an acute care hospital at 8:55 a.m. via air ambulance in stable condition.

A review of Patient #4's CAH emergency record by a supervisory physician (#4) dated 11/23/11, stated "Unacceptable delay in assessment and evaluation and treatment of this pt [patient] with Acute STEMI [ST-segment elevated myocardial infarction]."

- Review of Patient #5's closed emergency department record occurred on January 10-11, 2012. Patient #5 presented to the emergency department on 11/11/11 at 6:40 a.m. with rectal bleeding and weakness. The medical record does not identify the time staff notified the CAH's on-call provider (#3) of the patient's arrival in ER. The record identified the CAH's on-call provider (#3) arrived on-site at 9:00 a.m. (2 hours and 20 minutes after patient arrival). (NOTE: Medical record review indicated the on-call provider (#3) arrived at the hospital at 7:50 a.m. and was attending to another patient). The record identified the CAH transferred Patient #5 to an acute care hospital via ambulance at 9:20 a.m. in stable condition.

A review of Patient #5's CAH emergency record by a supervisory physician (#4) dated 11/23/11, stated "Unacceptable delay in providing care to pt [with] acute GI [gastrointestinal] bleed."

During interviews with the CAH's medical staff (#3, #4, and #5) on 01/10/12 at 2:15 p.m., 3:00 p.m., and 4:30 p.m. respectively, all three providers stated they are required to come in to the hospital to evaluate every patient that presents to the emergency room. All three providers stated they are expected to arrive at the hospital within 30 minutes, and within 20 minutes if it is a cardiac or trauma patient.

During interview on 01/10/12 at 1:30 p.m., an administrative nursing staff member (#2) stated she was aware staff were not able to contact the on-call provider (#3), as the provider's phone was not working. The staff member (#2) stated staff eventually went to the provider's home to notify him/her of the patients in the emergency room.

During interview on 01/11/12 at 8:45 a.m. regarding the delay in treatment of Patients #4 and #5 on 01/11/12, two administrative staff members (#1 and #2) confirmed they were aware of the on-call provider's (#3) home phone not working on 11/11/11 when nursing staff tried to notify him/her. An administrative staff member (#1) stated they talked about having a second back-up (pager/beeper system) but the facility had not implemented this as the failure of the phone system was an event that rarely happens. The administrative nursing staff member (#2) provided minutes from a nursing staff meeting, dated November 17, 2011, which stated, "In the event you are unable to reach a provider for an ER patient, Call the clinic manager. . . ."

Although the facility identified the problem (first line of communication with on-call provider failed) and identified a corrective action (pager/beeper system, etc.) the facility failed to implement the corrective action to ensure the problem does not occur again.