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Based on medical record review, facility policy review, on-call schedule, physician and staff interviews, the facility failed to ensure the physician-on-call presented to the Emergency Room to best meet the needs of the hospital ' s patients who are receiving emergency services for one of 30 patients reviewed. This failure resulted in the unnecessary transfer of one patient (#9). Refer to finding in A-2404.

Based on medical record review, On-Call ED Schedule, facility policy review, physician and staff interviews, the facility failed to provide stabilizing treatment within its capability as this resulted in the unnecessary transfer of one patient (#9) of thirty patients reviewed.
Refer to finding in A-2407.

Based on medical record review, ED On-Call schedule, facility policy review, physician and staff interviews, the facility failed to provide medical treatment that was within its capacity, resulting in the unnecessary transfer of one patient (#9) of thirty patients reviewed.

Based on medical record review, facility policy review, on-call schedule, physician and staff interviews, the facility failed to ensure the physician-on-call presented to the Emergency Room to best meet the needs of the hospital ' s patients who are receiving emergency services for one of 30 patients reviewed. This failure resulted in the unnecessary transfer of one patient (#9).

The findings included:

Medical record review revealed Patient #9 presented to the Emergency Department (ED) on May 27, 2010, at 3:31 p.m., with "lac (laceration) to lt (left) first digit, bleeding controlled w/ (with) pressure gauze". Continued review of the medical record revealed the ED physician examined the patient at 3:35 p.m. and determined the patient "cut off end of finger" listing the finger as left index finger. Further review revealed a statement by the ED physician "Pt. (patient) with complete avulsion of distal index. Will call Ortho." Further review of the medical record revealed no documentation of the status of the finger; exact location of the avulsion; or bleeding situation. Review of the ED Encounter Form revealed an entry timed 4:09 p.m. "phone call to Dr. ...(Orthopedic Surgeon). Continued review of the medical record revealed no documentation the Orthopedic Surgeon returned the call. Review of the medical record revealed a physician's entry at 5:24 p.m., which stated "Pt. still having bleeding. Called Dr. ... (Orthopedic Surgeon) from the ED. He insisted that the patient does not need to be seen today and that ... can be seen in the office tomorrow. ...(MD) stated that the patient will stop bleeding if pressure dressing in place."

Review of the " EMTALA Memorandum of Transfer " form, dated 5/27/10, specified in part (1) Reason for Transfer .... " On call physician failed to respond within a reasonable period of time. " This document was completed by the ED physician. Review of the hospital physician on-call list confirmed the Orthopedic Surgeon who was called on 5/27/10, was the doctor on-call. Continued review of the medical record revealed an entry at 5:44 p.m., "D/W (discussed with) Dr. (named physician who is a hand surgeon at the receiving facility) and ... agrees pt. needs to be seen today and they will accept the transfer." Facility failed to assure that the " on-call " physician met the needs of Patient #9 who required the services of an orthopedic surgeon.

Review of untimed nursing notes revealed "Pt. states was at work and cut the tip of ... left third finger off. Blood spurting from tip of finger and in large amounts. Pressure dressing applied." Continued review revealed an entry at 5:00 p.m. "Pt. bleeding through pressure drsg (dressing). Dr. at bedside to assess." Further review revealed an entry at 6:35 p.m., "Ambulance at bedside for transport."

Medical record review from the receiving facility dated May 27, 2010, at 11:34 p.m., revealed the patient arrived at 19:05 and had "...clean guillotine-type amputation of the distal tip of ... left middle digit. The distal portion of the nail is gone; approximately half of the nail is still present." Continued review of the medical record revealed the patient underwent "shortening and closure of the finger", was given antibiotics and was discharged from the ED.

Interview with Physician #1, Medical Director of Emergency Services, on July 8, 2010, at 9:15 a.m., in the Quality Management (QM) conference room revealed if there are problems with the on-call physician then the ED physician would be expected to follow the Chain of Command and notify the Charge Nurse of the ED as well as the Administrator on Call. Physician #1 stated every point of contact, including calls to the on-call physician, is to be documented in the patient's record with the time the call was made and the results of the call. Physician #1 stated the facility will transfer patients to a higher level of care if the facility is "not able to supply the patient with services needed. "Physician #1 stated ... would have expected better communication between the ED physician and the on-call physician including telling the on-call physician "I need you to come to the ED to assess this patient."

Telephone interview with Physician #2, Orthopedic Surgeon on call, on July 8, 2010, at 9:50 a.m., revealed confirmation ... was the physician on-call for Orthopedics on May 27, 2010. Physician #2 stated the ED physician called to say a patient had an amputation of the tip of a finger and asked what to do. Physician #2 stated ... told ED physician to "clean it well; apply a pressure dressing; have patient come to office next day to set up for surgery." Physician #2 stated the ED physician called back "about half an hour later and said the tip was still bleeding and confirmed the tip was completely cut off." Physician #2 stated .... advised the ED physician "The vessels will close off and the bleeding will stop. The patient will not bleed to death from this." Physician #2 stated ... told the ED physician to call back if there were still concerns. Physician #2 stated ... was not aware patient was transferred to an outside facility. Physician #2 also stated the ED physician did not ask ... to come to the ED to evaluate the patient. Physician #2 stated "We had the capability to care for the patient."

Telephone interview with Physician #3, ED physician on duty on May 27, 2010, on July 8, 2010, at 11:10 a.m., revealed the on-call Orthopedic Surgeon was called regarding a patient with an amputation of the distal portion of a finger with a "fair amount of bleeding from arterioles." Physician #3 stated the on-call physician said to apply a pressure dressing and the bleeding would stop; and the patient was to go to the Orthopedic office in the morning. Physician #3 stated the on-call physician was called a second time because "the bleeding continued; two pressure dressings were saturated." Physician #3 stated the on-call physician stated the bleeding would come under control and would stop but Physician #3 was not comfortable with this. Physician #3 stated ... spoke with the patient who "was not happy about going home and having to sit with the finger all night. ... (patient) stated if ... was sent home ... would probably go to another hospital." Physician #3 stated the Case Manager felt there were two options available: to call an outside facility or notify the nursing supervisor. Physician #3 stated ... call an outside facility to "question if patients with amputations went home and go to the office the next day." Physician #3 stated the physician at the outside facility accepted the patient in transfer. Physician #3 stated ... did not specifically request Physician #2 to come to the ED to evaluate the patient. Physician #3 also confirmed ... did not notify Physician #2 the patient was being transferred to an outside facility.

Interview with the ED Nursing Director and Charge Nurse #1 on July 8, 2010, at 9:00 a.m., in the QM conference room, revealed a patient is transferred when the diagnosis is beyond the facility's capability or the on-call physician for that service is unavailable. Further interview with the Director revealed when an on-call physician is notified the unit secretary should write which physician is call and the time of the call on the bottom of the Encounter form. Continued interview with the Director and Charge Nurse revealed if an issue arose with an on-call physician, the nursing supervisor and Administrator on Call should be notified immediately to intervene.

Review of the facility's policy entitled "Chain of Command" revealed the purpose is to "provide professional staff the appropriate direction for the prompt handling of patient care issues." Further review of the policy revealed the procedure included "Notify and document contact with the immediate supervisor and nursing supervisor who "should investigate the issue thoroughly..... and notify the Department Director as soon as possible. The Department Director will notify the Chief Nursing Officer or Administrator-on-Call. If a problem is not immediately resolved the Administrator-on-Call will notify the Chief of Staff."

The facility ' s Emergency Screening, Stabilization and Transfer Policy with an effective date of 3/99 and revised on 02/10, was reviewed. The policy indicated "3. Services of On-Call physicians:" " The emergency physician shall determine whether the additional stabilizing services of such on-call physician are necessary. If so, Emergency Department personnel shall immediately send for the on-call physician who shall respond as soon as possible or in accordance with hospital policy. "

The facility ' s EMTALA-Provision of On-Call Coverage Policy with an effective date of 02/10 was reviewed. Under Physician ' s Responsibility: " The emergency physician , in consultation with the on-call physician, shall determine whether the individual ' s condition requires the on-call physician to see the individual immediately. The determination of the emergency physician or other practitioner who has personally examined the individual and is currently treating the individual shall be controlling in this regard. "

Based on medical record review, On-Call ED Schedule, facility policy review, physician and staff interviews, the facility failed to provide stabilizing treatment within its capability as this resulted in the unnecessary transfer of one patient (#9) of thirty patients reviewed.

The findings included:

Medical record review revealed Patient #9 presented to the Emergency Department (ED) on May 27, 2010, at 3:31 p.m., with "lac (laceration) to lt (left) first digit, bleeding controlled w/ (with) pressure gauze". Continued review of the medical record revealed the ED physician examined the patient at 3:35 p.m. and determined the patient "cut off end of finger" listing the finger as left index finger. Further review revealed a statement by the ED physician "Pt. (patient) with complete avulsion of distal index. Will call Ortho." Further review of the medical record revealed no documentation of the status of the finger; exact location of the avulsion; or bleeding situation. Review of the ED Encounter Form revealed an entry timed 4:09 p.m. "phone call to Dr. ...(Orthopedic Surgeon). Continued review of the medical record revealed no documentation the Orthopedic Surgeon returned the call. Review of the medical record revealed a physician's entry at 5:24 p.m., which stated "Pt. still having bleeding. Called Dr. ... (Orthopedic Surgeon) from the ED. He insisted that the patient does not need to be seen today and that ... can be seen in the office tomorrow. ...(MD) stated that the patient will stop bleeding if pressure dressing in place." Review of the hospital physician on-call list dated 5/27/10, confirmed the Orthopedic Surgeon who was called was the doctor on-call. Continued review of the medical record revealed an entry at 5:44 p.m., "D/W (discussed with) Dr. (named physician who is a hand surgeon at the receiving facility) and ... agrees pt. needs to be seen today and they will accept the transfer." The facility failed to ensure that stabilizing treatment was provided for Patient #9 on 5/27/10.

Review of untimed nursing notes revealed "Pt. states was at work and cut the tip of ... left third finger off. Blood spurting from tip of finger and in large amounts. Pressure dressing applied." Continued review revealed an entry at 5:00 p.m. "Pt. bleeding through pressure drsg (dressing). Dr. at bedside to assess." Further review revealed an entry at 6:35 p.m., "Ambulance at bedside for transport."

Medical record review from the receiving facility dated May 27, 2010, at 11:34 p.m., revealed the patient arrived at 19:05 and had "...clean guillotine-type amputation of the distal tip of ... left middle digit. The distal portion of the nail is gone; approximately half of the nail is still present." Continued review of the medical record revealed the patient underwent "shortening and closure of the finger", was given antibiotics and discharged from the ED.

Interview with Physician #1, Medical Director of Emergency Services, on July 8, 2010, at 9:15 a.m., in the Quality Management (QM) conference room revealed if there are problems with the on-call physician then the ED physician would be expected to follow the Chain of Command and notify the Charge Nurse of the ED as well as the Administrator on Call. Physician #1 stated every point of contact, including calls to the on-call physician, is to be documented in the patient's record with the time the call was made and the results of the call. Physician #1 stated the facility will transfer patients to a higher level of care if the facility is "not able to supply the patient with services needed. "Physician #1 stated ... would have expected better communication between the ED physician and the on-call physician including telling the on-call physician "I need you to come to the ED to assess this patient."

Telephone interview with Physician #2, Orthopedic Surgeon on call, on July 8, 2010, at 9:50 a.m., revealed confirmation ... was the physician on-call for Orthopedics on May 27, 2010. Physician #2 stated the ED physician called to say a patient had an amputation of the tip of a finger and asked what to do. Physician #2 stated ... told ED physician to "clean it well; apply a pressure dressing; have patient come to office next day to set up for surgery." Physician #2 stated the ED physician called back "about half an hour later and said the tip was still bleeding and confirmed the tip was completely cut off." Physician #2 stated .... advised the ED physician "The vessels will close off and the bleeding will stop. The patient will not bleed to death from this." Physician #2 stated ... told the ED physician to call back if there were still concerns. Physician #2 stated ... was not aware patient was transferred to an outside facility. Physician #2 also stated the ED physician did not ask ... to come to the ED to evaluate the patient. Physician #2 stated "We had the capability to care for the patient."

Telephone interview with Physician #3, ED physician on duty on May 27, 2010, on July 8, 2010, at 11:10 a.m., revealed the on-call Orthopedic Surgeon was called regarding a patient with an amputation of the distal portion of a finger with a "fair amount of bleeding from arterioles." Physician #3 stated the on-call physician said to apply a pressure dressing and the bleeding would stop; and the patient was to go to the Orthopedic office in the morning. Physician #3 stated the on-call physician was called a second time because "the bleeding continued; two pressure dressings were saturated." Physician #3 stated the on-call physician stated the bleeding would come under control and would stop but Physician #3 was not comfortable with this. Physician #3 stated ... spoke with the patient who "was not happy about going home and having to sit with the finger all night. ... (patient) stated if ... was sent home ... would probably go to another hospital." Physician #3 stated the Case Manager felt there were two options available: to call an outside facility or notify the nursing supervisor. Physician #3 stated ... call an outside facility to "question if patients with amputations went home and go to the office the next day."

Review of facility ' s policy entitled " EMTALA Medical Screening Examination and Stabilization Policy " was reviewed. It stated: " When an individual comes to a dedicated emergency department and a request is made on his or her behalf for an examination or treatment for a medical condition or a prudent layperson observer would believe that the individual presented with an emergency medical condition (EMC) an appropriate medical screening examination, within the capabilities of the hospital's DED (including ancillary services routinely available and the availability of on-call physicians) shall be performed by an individual qualified to perform such examination to determine whether an EMC exists. "


Review of the facility's policy entitled "Chain of Command" revealed the purpose is to "provide professional staff the appropriate direction for the prompt handling of patient care issues." Further review of the policy revealed the procedure included "Notify and document contact with the immediate supervisor and nursing supervisor who "should investigate the issue thoroughly..... and notify the Department Director as soon as possible. The Department Director will notify the Chief Nursing Officer or Administrator-on-Call. If a problem is not immediately resolved the Administrator-on-Call will notify the Chief of Staff."

Based on medical record review, ED On-Call schedule, facility policy review, physician and staff interviews, the facility failed to provide medical treatment that was within its capacity, resulting in the unnecessary transfer of one patient (#9) of thirty patients reviewed.

The findings included:

Medical record review revealed Patient #9 presented to the Emergency Department (ED) on May 27, 2010, at 3:31 p.m., with "lac (laceration) to lt (left) first digit, bleeding controlled w/ (with) pressure gauze". Continued review of the medical record revealed the ED physician examined the patient at 3:35 p.m. and determined the patient "cut off end of finger" listing the finger as left index finger. Further review revealed a statement by the ED physician "Pt. (patient) with complete avulsion of distal index. Will call Ortho." Further review of the medical record revealed no documentation of the status of the finger; exact location of the avulsion; or bleeding situation. Review of the ED Encounter Form revealed an entry timed 4:09 p.m. "phone call to Dr. ...(Orthopedic Surgeon). Continued review of the medical record revealed no documentation the Orthopedic Surgeon returned the call. Review of the medical record revealed a physician's entry at 5:24 p.m., which stated "Pt. still having bleeding. Called Dr. ... (Orthopedic Surgeon) from the ED. He insisted that the patient does not need to be seen today and that ... can be seen in the office tomorrow. ...(MD) stated that the patient will stop bleeding if pressure dressing in place." Review of the hospital physician on-call list confirmed the Orthopedic Surgeon who was called was the doctor on-call. The facility failed to provide medical treatment that was within its capacity for patient #9. Medical record review revealed an entry at 5:44 p.m., "D/W (discussed with) Dr. (named physician who is a hand surgeon at the receiving facility) and ... agrees pt. needs to be seen today and they will accept the transfer."

Review of untimed nursing notes revealed "Pt. states was at work and cut the tip of ... left third finger off. Blood spurting from tip of finger and in large amounts. Pressure dressing applied." Continued review revealed an entry at 5:00 p.m. "Pt. bleeding through pressure drsg (dressing). Dr. at bedside to assess." Further review revealed an entry at 6:35 p.m., "Ambulance at bedside for transport."

Medical record review from the receiving facility dated May 27, 2010, at 11:34 p.m., revealed the patient arrived at 19:05 and had "...clean guillotine-type amputation of the distal tip of ... left middle digit. The distal portion of the nail is gone; approximately half of the nail is still present." Continued review of the medical record revealed the patient underwent "shortening and closure of the finger" was given antibiotics and was discharged from the ED.

Interview with Physician #1, Medical Director of Emergency Services, on July 8, 2010, at 9:15 a.m., in the Quality Management (QM) conference room revealed if there are problems with the on-call physician then the ED physician would be expected to follow the Chain of Command and notify the Charge Nurse of the ED as well as the Administrator on Call. Physician #1 stated every point of contact, including calls to the on-call physician, is to be documented in the patient's record with the time the call was made and the results of the call. Physician #1 stated the facility will transfer patients to a higher level of care if the facility is "not able to supply the patient with services needed. "Physician #1 stated ... would have expected better communication between the ED physician and the on-call physician including telling the on-call physician "I need you to come to the ED to assess this patient."

Telephone interview with Physician #2, Orthopedic Surgeon on call, on July 8, 2010, at 9:50 a.m., revealed confirmation ... was the physician on-call for Orthopedics on May 27, 2010. Physician #2 stated the ED physician called to say a patient had an amputation of the tip of a finger and asked what to do. Physician #2 stated ... told ED physician to "clean it well; apply a pressure dressing; have patient come to office next day to set up for surgery." Physician #2 stated the ED physician called back "about half an hour later and said the tip was still bleeding and confirmed the tip was completely cut off." Physician #2 stated .... advised the ED physician "The vessels will close off and the bleeding will stop. The patient will not bleed to death from this." Physician #2 stated ... told the ED physician to call back if there were still concerns. Physician #2 stated ... was not aware patient was transferred to an outside facility. Physician #2 also stated the ED physician did not ask ... to come to the ED to evaluate the patient. Physician #2 stated "We had the capability to care for the patient."

Telephone interview with Physician #3, ED physician on duty on May 27, 2010, on July 8, 2010, at 11:10 a.m., revealed the on-call Orthopedic Surgeon was called regarding a patient with an amputation of the distal portion of a finger with a "fair amount of bleeding from arterioles." Physician #3 stated the on-call physician said to apply a pressure dressing and the bleeding would stop; and the patient was to go to the Orthopedic office in the morning. Physician #3 stated the on-call physician was called a second time because "the bleeding continued; two pressure dressings were saturated." Physician #3 stated the on-call physician stated the bleeding would come under control and would stop but Physician #3 was not comfortable with this. Physician #3 stated ... spoke with the patient who "was not happy about going home and having to sit with the finger all night. ... (patient) stated if ... was sent home ... would probably go to another hospital." Physician #3 stated the Case Manager felt there were two options available: to call an outside facility or notify the nursing supervisor. Physician #3 stated ... call an outside facility to "question if patients with amputations went home and go to the office the next day." Physician #3 stated the physician at the outside facility accepted the patient in transfer. Physician #3 stated ... did not specifically request Physician #2 to come to the ED to evaluate the patient. Physician #3 also confirmed ... did not notify Physician #2 the patient was being transferred to an outside facility.

Interview with the ED Nursing Director and Charge Nurse #1 on July 8, 2010, at 9:00 a.m., in the QM conference room, revealed a patient is transferred when the diagnosis is beyond the facility's capability or the on-call physician for that service is unavailable. Further interview with the Director revealed when an on-call physician is notified the unit secretary write which physician is call and the time of the call on the bottom of the Encounter form. Continued interview with the Director and Charge Nurse revealed if an issue arose with an on-call physician, the nursing supervisor and Administrator on Call should be notified immediately to intervene.

The facility's policy entitled, "EMTALA-Transfer Policy" was reviewed. Under "Transfer of Individuals Who Have Not Been Stabilized", point, b. i., it states, "The transferring hospital provdes medical treatment within its capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child."

Review of the facility's policy entitled "Chain of Command" revealed the purpose is to "provide professional staff the appropriate direction for the prompt handling of patient care issues." Further review of the policy revealed the procedure included "Notify and document contact with the immediate supervisor and nursing supervisor who "should investigate the issue thoroughly..... and notify the Department Director as soon as possible. The Department Director will notify the Chief Nursing Officer or Administrator-on-Call. If a problem is not immediately resolved the Administrator-on-Call will notify the Chief of Staff."