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Based on policy review, Emergency Department (ED) Log, ED Medical Record reviews, Medical Staff Rules and Regulations, Physician On-Call Schedules and interviews, the facility failed to stabilize, within its capability and capacity, one patient (#1) out of 21 sampled ED records reviewed from April 2018 through October 15, 2018, that presented to the ED seeking care.

The facility had the capability and capacity to stabilize Patient #1, who presented to the ED with a two day history of right lower abdominal pain, rebound tenderness (increased pain when pressure is removed) and intermittent fever. Computerized Tomography (CT, x-ray testing that produces images of the body using those x-rays and a computer) revealed acute appendicitis (inflammation of the appendix organ) with perforation (hole or tear or the organ) and the patient was diagnosed with ruptured (burst open) appendix, acute appendicitis with localized peritonitis (inflammation of the lining that surrounds the organs in the abdomen, indicates infection). The facility had a general surgeon (Staff B) on-call to the ED that was credentialed to provide surgical care to the patient. The surgeon declined care of the patient and the patient was transferred to Hospital B (nearby hospital), where the patient was admitted and underwent an appendectomy (surgical removal of the appendix).

Refer to A2407 for additional information.

Based on interview, record review and policy review, the facility failed to provide necessary stabilizing treatment when an emergency medical condition (EMC) existed for one patient (#1) out of 21 Emergency Department (ED) records reviewed from April 2018 through October 15, 2018. The facility had the capability and capacity to admit and treat Patient #1 with his unstable EMC when he presented with abdominal pain that resulted in a ruptured (burst open) appendix. This failed practice by the facility had the potential to cause harm to the patient when stabilizing treatment was delayed when the patient was transferred to another facility. Over the past six months, the facility saw on average 1,086 ED cases monthly and transferred a total of 267 patients.

Findings included:

1. Review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act)," dated 01/01/18 showed:
- If an Emergency Medical Condition is deemed to exist after a Medical Screening Examination, the Hospital will provide medical treatment within its capacity and capabilities to stabilize that emergency medical condition.
- If an EMCondition exists, the emergency department can provide the patient with treatment necessary to stabilize the condition, the hospital can admit the patient for further stabilizing care; or if the hospital is unable to stabilize the patient either in the emergency department or by admission, it can transfer the patient appropriately to a facility that has the capability to stabilize the patient.
- Capability is defined as services normally available to any patient in any area of the hospital. This includes available ancillary services. Capability is also determined by the availability of specialty services, which at times may be determined by the on-call physician schedule.

Review of the facility's policy titled, "Physician Coverage Emergency Room Call," reviewed 06/05/18, showed:
- Monthly physician call schedules must identify who is responsible for daily specialty coverage. The specialty for General Surgery must establish a call schedule to examine and treat, when necessary, patients in the Emergency Room.
- For purposes of this policy, a day will be defined as beginning at 7:00 AM and ending at 7:00 AM the following day.
- It is the responsibility of each on-call physician to provide emergency care to all patients in his/her specialty when requested, or if he/she cannot provide that care, to assist in the emergency evaluation, stabilization, and (if necessary) the transfer to a referral physician or facility.

Review of Patient #1's Electronic Emergency Department Record (EEDR) showed that the patient presented to the facility's ED on 07/27/18 at 7:38 PM by personal transportation, and the following was documented:
- Chief Complaint of abdominal pain, right lower quadrant (RLQ, area right of the middle abdomen, and below the bellybutton) pain, which had worsened since Wednesday night (two day history) and intensified when the patient walked. There was rebound tenderness (increased pain when pressure is removed) and intermittent (off and on) fevers since Wednesday night.
- Physical Exam that showed gross tenderness at McBurney's point (area in the right side of the abdomen) with mild rebound. Positive heel tap pain (clinical test used to produce abdominal pain by striking the patient's heel).
- Laboratory test dated 07/27/18 that showed the White Blood Count was 13.1 (high, normal range between 4.0 - 10.5, can indicate infection).
- Radiology test dated 07/27/18 at 10:26 PM, that showed a Computerized Tomography Scan (CT Scan, x-ray testing that produces images of the body using those x-rays and a computer) of the abdomen and pelvis resulted as appendicitis (inflammation of the appendix organ) with perforation (hole or tear) but no abscess (collection of pus).
- Progress Note dated 10/11/18 showed that Staff A, ED Physician, documented that he waited until Staff B (on-call surgeon) was available from a surgical procedure, an appendectomy (surgical removal of the appendix organ) that Staff B took from the ED to the Operating Room (OR) earlier. Staff A discussed Patient #1 with Staff B, and Staff B refused to take the patient because the patient's appendix was ruptured, because it was Staff B's "last day," he could not continue the patient's care and recommended transfer.
- Progress Note dated 07/28/18 at 1:29 AM, showed Staff A documented that the patient should be transferred out to Hospital B (nearby facility).
- EMTALA Transfer Form dated 07/28/18 showed that the patient consented to transfer, and the patient was transferred to Hospital B by ambulance on 07/28/18 at 1:48 AM.

Review of the Surgery On-Call Schedule showed Staff B, was on-call from Thursday, July 26, 2018 through Tuesday, July 31, 2018. The facility had the capability and capacity to care for Patient #1's EMC and delayed his care when he was transferred to Hospital B for surgical intervention for his ruptured appendix.

During an interview on 10/17/18 at 5:45 PM, Staff A, ED Physician, stated that he was not able to speak to Staff B (on-call surgeon), about Patient #1's need for an appendectomy until Staff B came out of surgery. When Staff A spoke to Staff B, he declined the care of Patient #1 and stated that the patient required additional post-operative care because his appendix had ruptured, because he would not be available after 07/29/18 and because it would benefit the patient to have a doctor that could care for him from start to finish. Staff A stated that Staff B historically transferred more patients than other on-call surgeons to Hospital B (nearby hospital).

During an interview on 10/17/18 at 9:28 AM, Staff D, ED Registered Nurse (RN), stated that she was working the night when Patient #1 presented to the ED and was his nurse. Staff B was the scheduled on-call surgeon for the ED on 07/27/18 when the patient presented, and was in-house doing an appendectomy on another patient that presented to the ED earlier in the shift. Staff B informed Staff A, ED Physician, that since the patient's "Appy" (appendix) was ruptured, it would take more care and would require antibiotic therapy for the next couple of days and therefore, it would be better for the patient to be transferred. After Staff B stated that he would not perform the surgery, Staff A started the process to transfer the patient.

During an interview on 10/17/18 at 9:46 AM, Staff C, Physician, Medical Affairs Regional Vice President, stated that Staff B could have done the surgery for the patient and it was within Staff B's capability.

During an interview on 10/18/18 at 9:50 AM, Staff G, ED Physician, stated that Staff B frequently declined care of emergent patients while on-call for the ED. It was previously reported to the Chief of Staff because it became such a pattern and concerned medical staff.

During an interview on 10/18/18 at 10:23 AM, Staff H, Physician, Medical Group Regional President, stated that he had verbally addressed concerns with Staff B about his responsibilities when he was scheduled for surgical on-call services. Staff H stated that Staff B's behavior would improve and he would not be aware of reoccurrence of his lack of responsiveness, especially to the ED unless another physician, typically an ED Physician, brought this to his attention. Staff H stated that each time the issue was addressed with Staff B, at least temporarily, there was improvement in his responsiveness.

During a telephone interview on 10/22/18 at 12:10 PM, Staff B stated that when he provided on-call services for surgery it was from 7:00 AM until 7:00 AM the following morning for 24-hours of surgical coverage. To be on-call for surgery meant that you were to take care of general surgery and be available for either consultation or actual surgical services for both inpatient and ED patients. He was the on-call surgeon for Friday, July 27, 2018 and he did have privileges at the facility to perform abdominal surgeries that included appendectomy. He informed Staff A, ED Physician, that since he was leaving employment at the facility, he would not be able to follow-up with the patient post-operation, and it was in the patient's best interest to transfer him so he could have continuity of care at Hospital B, since he would not be available for follow-up care.

During a telephone interview on 10/24/18 at 11:05 AM, Staff J, Surgeon, Chief of Surgery, stated that Staff B, had surgical privileges to perform abdominal surgeries that included both appendectomies and ruptured appendectomies, and the facility had the capacity to take care of Patient #1. Staff J would have provided follow-up care for Patient #1 if Staff B was no longer available to provide post-operative care for the patient.

The facility had the capability per on-call surgeon and capacity to provide Patient #1 with surgical intervention for his ruptured appendix, however; since Staff B did not provide surgical intervention for the patient, his care was delayed when he was transferred to Hospital B.


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