HospitalInspections.org

Based on review of the facility's medical staff by-laws, medical staff rules and regulations, medical record review, review of urology on-call schedules, review of a list of "unattached call physicians," review of facility policy, and interview, the facility failed to implement the on-call physician obligation policy for two (#9, #13) of twenty sampled patients, resulting in transfer to other facilities for emergency urological care.

The findings included:

The facility is a Level I Trauma regional referral center (a hospital with personnel and equipment to manage a patient's injuries, usually without the need to sent the patient to another hospital) and has 505 certified beds. Review of the Responsibilities of Medicare Participating Hospitals In Emergency Cases Investigation Report revealed the emergency department saw 6,427 cases in September, 2009; 6,845 cases in October, 2009; 6,145 cases in November, 2009; 6,133 cases in January, 2010; and 1,993 cases in February, 2010, as of February 18, 2010. Continued review revealed the following regarding the number of emergency patients transferred to another facility: 12 in September, 2009; 8 in October, 2009; 19 in November, 2009; 14 in December, 2009, 12 in January, 2010; and 5 in February, 2010, as of February 18, 2010.

Review of the facility's medical staff by-laws revised September 22, 2008 revealed "...The Medical Staff is organized for the following purposes:...Promote care for those patients admitted to or treated in any of the hospital's faclities, departments...Respond to requests for consultations in a timely fashion...Responsibilities of Department Chairs. Each Department Chair shall: ...Monitor and evaluate the quality and appropriateness of patient care provided within the department...Be responsible for the development and implementation of policies and procedures that support the provision of care, treatment, and service...Medical Staff Rules and Regulations, as may be necessary to implement more specifically the general principles found in these Bylaws, shall be adopted in accordance with this Article...If there is a conflict between the Bylaws and the Rules and Regulations, the Bylaws shall prevail..."

Patient #9 was admitted to the facility (#1) on November 24, 2009, with diagnoses including Symptomatic Anemia and Acute Abdominal Pain. Medical record review of an emergency physician record dated November 29, 2009, revealed, "1:00 a.m...chief complaint: dysuria (difficulty urinating)...abnormal bleeding (started) 3-4 d (days)...blood in urine, frequent urination, burning, urgency, pain..." Medical record review of a physician's order dated November 24, 2009, at 1:40 a.m., revealed, "...Type and cross (crossmatch) 4 units PRBCs (packed red blood cells) transfuse 2 units PRBCs now..." Patient #9's Hemoglobin taken on November 24, 2009 was 5.9. The normal range is 11.7 to 15.0. Patient #9's Hematocrit taken on November 24, 2009 was 17.8 with the normal range being 35-46.0. Medical record review of an abdominal CT scan dated November 24, 2009, at 3:49 a.m., revealed, "...An obstructing stone is noted in the left mid ureter...approximately 8 x 6 x 5 mm (millimeters)...Mild right hydronephrosis (dilation of the pelvis and calices (recess) of...kidney because of the accumulation of urine resulting from obstruction to urine outflow) and hydroureter (distention of ureter with urine due to blockage) is noted..." Medical record review of physician Admission Note revealed that "the patient related that over the past 2-3 days she has been passing intermittent blood in her urine with a difficult stream and feels this is adding to her abdominal distention." Medical record review of a physician's progress note dated November 24, 2009, at 5:15 a.m., revealed, "...attempted to consult urology through operator and (urologist #1) was paged however...is not on...call...DW (discussed with)...urology @ (facility #2) pt accepted..." Medical record review of a physician's progress note dated November 24, 2009, at 5:30 a.m., revealed, "After discussion with (urologist #1) and...ER (emergency room) physician, given the patient symptomatic anemia/hematuria...is considered a urologic emergency and thus requires transfer to a hospital accepting...urologic patients..." Medical record review of a Patient Transfer Order dated November 24, 2009, revealed,"...Time of transfer 7:12 a.m..."

Medical record review revealed Patient #13 was admitted to the facility on November 24, 2009, with diagnoses including Abdominal Pain. Medical record review of a CT scan of the abdomen and pelvis dated November 24, 2009, at 4:25 p.m., revealed,"...mild left hydronephrosis and hydroureter...obstructing stone in the left distal ureter...approximately 4 x 4 x 2 mm..." Medical record review of a history and physical dated November 24, 2009, at 6:23 p.m., revealed, "...Patient with left ureteral stone with hydronephrosis, increase in white blood cell count. Discussed with (Urologist #2). There is no urology coverage for eight days here at (facility #1)...back to the emergency room physician to arrange transfer to a facility that has urology coverage..." Medical record review of a nurse's note dated November 24, 2009, at 10:15 p.m., revealed, "Out to (facility #2)."

Review of facility policy revised in August 2009, revealed, "Policy Title: Medical Staff Call Obligation...To provide a mechanism by which active/associate medical staff members shall participate in a rotating call schedule for their respective specialty in order to provide continuous coverage of every services. Emergency Call coverage obligations, will be divided equally among individual medical staff members holding clinical privileges within particular specialities...Individual medical staff member will not be expected to provide emergency call coverage more frequently than an average of one day in four. This expectation shall not apply to coverage of the physician's own patients, for which he/she must provide or arrange for provision of continuous coverage...The Medical Executive Committee and Clinical Departments will decide the specialties for which separate call schedules must be developed...Physicians within particular specialties are encouraged to develop mutually agreed upon call schedules...submitted at least 10 days in advance of the first day of each month...If the physicians within a specialty cannot develop a mutually agreed call schedule, the Emergency Department Administrative Secretary will assign a schedule under the direction of the Departmental Chairpersons..."

Review of facility policy revised in December 2009, revealed, "Physician Notification and Consultation...Rationale: The medical staff leadership has become aware of several instances where physicians have not been notified of consultations in a timely manner or where physicians have refused to provide consultation when requested...Definition: Unassigned patient - A patient that resides in the emergency department or other outpatient area who has not been admitted to the hospital and assigned an attending physician. Inpatients (who have attending physicians) are not considered 'unassigned'...Routine consultations, which are not time critical, will be called to the consultant's office during normal business hours...by the ward secretary or nursing service. It is strongly encouraged that when possible, even routine consultations be called directly to the consultant...All other consultations (emergency, urgent and all after hours consulations) require direct communication between the referring and consulting physician...It is the consulting physician's responsibility to be easily available by pager or phone and to respond promptly to referring physicians...If the referring physician is not available, it is his/her responsibility to clearly indicate in the medical record or published call schedule which physician is currently responsible for the patient...A referring physician's communication attempt shall be deemed adequate if the following procedure is followed: a) The consultant is paged. If no answer is received at the specified number within 10 minutes the requesting physician or staff member repeat the page. b) If no answer to the second page within 10 minutes the operator will call the consultant's office (during business hours), cell phone and home phone in that order and again page the consultant to that operator. c) If the above attempts to reach the consultant have been unsuccessful after 30 minutes, attempts will be made to reach other members of the physician's call group using the above procedure. If the consultant's partner/covering physician is reached, he or she must assume responsibility for the consultation until the on-call consultant is reached. d) If the above attempts are unsuccessful, the operator will notify the referring physician and he/she may attempt to contact another group. e) Failure of a consultant to respond to the above communication attempts shall be considered unavailability and will be reported by the referring physician to the medical staff office for further action/investigation...In general, the referring physician should specify which consultant/group is being consulted based on patient preference, previous relationship or referring physician preference. If a preference is indicated, the specified consultant/group is responsible for providing the consultation regardless of the unassigned call schedule. A specified consultant may refuse a consultation if...is overwhelmed or unavailable and does not have back-up within his/her group. In that case the consultation may be passed to the unassigned call physician...In emergency department patients who are not admitted, the emergency department physician is considered the attending physician...If no preference is indicated by the referring physician, the consultation will be given to the physician on unassigned call...Consultants who are responsible for the care of a patient under the above provision and who express a desire to evaluate the patient on an outpatient basis are expected to treat the patient in the outpatient setting in the manner that other (facility) patients of the practice are treated. with regard to emergency department patients, repeated failure on the part of consulting physicians to adhere to this provision may result in the requirement that the consultant come to the emergency department to see each consultation. (Note: this provision applies only to situations where there has been direct communication between the consultant and referring physician and where an urgent medical condition requiring prompt follow-up exists...It is the responsibility of the hospital to maintain a functional paging and telephone system consistent with the requirements of a level I trauma center. This includes but is not limited to providing the equipment, personnel and processes necessary to initiate, maintain and monitor compliance with this policy..."

Review of a Urology Unattached schedule dated September, 2009, revealed the facility had no urology coverage for eight days from September 4th-11th, 2009. Review of a Urology Unattached schedule dated October, 2009, revealed the facility had no urology coverage for seven days from October 4th-10th, 2009. Review of a Urology Unattached schedule dated November, 2009, revealed the facility had no urology coverage for eight days from November 23rd-30th, 2009. Review of a Urology Unattached schedule dated December, 2009, revealed the facility had no urology coverage for eight days from December 24th-31st, 2009. Review of a Urology Unattached schedule dated January, 2010, revealed the facility had no urology coverage for seven days from January 17th-23rd, 2010. Review of a Urology Unattached schedule dated February, 2010, revealed the facility had no urology coverage for seven days from February 15th-21st, 2010. Review of an "Unattached Call Physicians" list provided by the risk manager on February 11, 2010, revealed the facility had six urologists. Interview with the risk manager on February 12, 2010, at 11:27 a.m., in the risk management office, revealed, "unattached" referred to patients with no primary care physician.

Interview with the director of the Emergency Room (ER) on February 11, 2010, at 12:30 p.m., in the risk management office, revealed the facility did not have daily on-call coverage for urology patients. Interview with the director of the ER on February 12, 2010, at 12:00 p.m., in the risk management office, revealed the facility did not have urology coverage on November 24, 2009, and confirmed the facility had failed to implement the on-call physician policy and provide the required emergency urological/medical care for patients #9 and #13.

C/O: #25047