HospitalInspections.org

Based on review of medical records, policies/procedures and staff interviews, it was determined that the hospital failed to comply with the provider agreement as defined in ?489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

The findings were:

Refer to findings for Tag A 2404 - On-call Physicians:
The facility failed to maintain an accurate specialist on-call list that included a back-up contact number if there was not a timely response from the main contact number for the on-call specialist. Because the on-call system did not ensure that a back-up contact number was available to the emergency department staff attempting to contact a spinal surgeon, the surgeon could not be reached timely, and the patient had to be transferred to another hospital for the emergency spinal surgery.


Refer to findings for Tag A 2407 - Stabilizing Treatment:
The facility failed to ensure that the specialty on-call physician was available to provide emergency spinal surgery to stabilize the epidural abscess, acute osteomyelitis and discitis with acute neurological deterioration for sample patient #1. Because the specialty on-call system failed to provide an emergency spinal surgery intervention for the patient, a transport to another hospital had to be arranged, creating a delay in the patient receiving spinal surgery intervention.

Based on staff/physician interview and review of medical records and other facility documents, the facility failed to maintain an accurate specialist on-call list that included a back-up contact number if there was not a timely response from the main contact number for the on-call specialist. Because the on-call system did not ensure that a back-up contact number was available to the emergency department staff attempting to contact a spinal surgeon, the surgeon could not be reached timely, and the patient had to be transferred to another hospital for the emergency spinal surgery. The failure created the potential for negative patient outcome.

Findings:

The facility failed to maintain an accurate specialist on-call list that included a back-up contact number if there was not a timely response from the main contact number for the on-call specialist.

a. Review on 11/13/12 of the medical record for sample patient #1 revealed that the patient was an adult patient with history of a fall with back injury approximately one month prior to presenting to the Emergency Department (ED) with severe lower back pain and recent onset of bowel and bladder incontinence. The medical screening exam, including an MRI revealed, revealed that the patient had an epidural abscess, acute osteomyelitis and discitis, indicating the need for emergent spinal surgery to prevent further/permanent neurological deterioration.

The patient presented to the ED on 10/25/12 at 6:14 p.m., medical screening exam at 6:26 p.m., MRI at 8:37 p.m., results from MRI provided to ED physician at 9:45 p.m. and the ED physician initiated first call to the on-call spinal surgeon at 9:51 p.m.. Two additional calls were placed to the on-call spinal surgeon at 10:28 p.m., and 11:00 p.m., with no response to any of the 3 calls.

At 11:19 p.m., a call was placed to the physician's practice number, since the surgeon did not respond to the primary number, which was his/her cell phone number. The spine surgeon's partner responded to the call to the practice number, but s/he stated that s/he was not a spinal surgeon, and did not have an alternate number to contact his/her partner, the spinal surgeon.

The ED physician then attempted to find a spinal surgeon by contacting the neurosurgery and orthopedic surgery on-call physicians and was able to reach them, but neither was a spine surgeon. At 12:00 a.m., the ED physician made the decision to arrange a transfer to another facility, if s/he could find a spine surgeon that was available to accept the patient.

The transfer to another facility was arranged with appropriate doctor-to-doctor and nurse-to-nurse hand-off calls, preparation of transfer form and transfer records and appropriate transportation. The patient was transferred out of the facility at 1:04 p.m..

The on-call spine physician for the transferring hospital called in response to the three earlier calls at 3:08 a.m., and was told that the patient had already been transferred to another facility for treatment/surgery. The spine surgeon apologized for not responding to the calls earlier and stated that there had been technical problems with his/her cell phone.

b. Review on 11/13/12 of the specialist on-call lists for 10/25/12 revealed that the physician listed on the spine list was the same surgeon that the ED physician attempted to contact three times and that failed to respond prior to the patient being transferred to another facility for surgery.

c. During an interview with the ED physician, conducted on 11/14/12 at 9:40 a.m., s/he confirmed the findings in the medical record and the attempts to contact the spine surgeon, the attempts to find an alternate surgeon and the lack of an alternate direct number to contact the on-call spine surgeon. S/he further confirmed that the patient had to be transferred to another facility for emergency surgery.

d. During an interview on 11/14/12 at 9:15 a.m. with the ED unit secretary that was helping the ED physician make the calls and documented the calls in the medical record, s/he confirmed the attempts to contact the on-call spine surgeon and to locate an alternate spinal surgeon, which s/he had documented in the medical record. S/he stated that they did not have an alternate contact number for the surgeon. S/he stated that the only number for the surgeon was his/her cell phone. S/he stated that sometimes they had an alternate or home number or the physician's answering service sometimes had an alternate contact number, but they did not have one for the spine surgeon.

e.. During a telephone interview, conducted on 11/14/12 at 12 p.m., the on-call spine physician confirmed the fact that s/he had not responded to the three calls from the ED about sample patient #1 on 10/25/12. S/he stated that the ringer on his/her cell phone had inadvertently gotten turned off during the evening. S/he stated that sometime during the night s/he checked the phone and realized that s/he had missed 3 phone calls. S/he called the ED and learned that the patient had already been transferred to another facility for surgery. S/he stated that s/he thought that the hospital had his/her home number, as well, and was surprised to learn that they did not. S/he stated that s/he took steps to ensure that the hospital, his/her practice and all of his/her partners had his/her home number to prevent this from happening again.

Based on staff/physician interview and review of medical records and other facility documents, the facility failed to ensure that the specialty on-call physician was available to provide emergency spinal surgery to stabilize the epidural abscess, acute osteomyelitis and discitis, with acute neurological deterioration, for sample patient #1. Because the specialty on-call system failed to provide an emergency spinal surgery intervention for the patient, a transport to another hospital had to be arranged, creating a delay in the patient receiving the spinal surgery intervention. The failure created the potential for negative patient outcome.

Findings

Reference Tag A 2404 for findings related to the delay for spinal surgery for sample patient #1.