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Based on review of medical records, policies and procedures, Medical Staff Bylaws, on-call lists and staff interviews the facility failed to ensure that the facility' s policy and procedure was followed when an on-call specialty physician was asked to come to the hospital to provide treatment in response to a request from the emergency room physician to provide specialty services to meet the needs of the hospital 's patients who are receiving services requested, including the availability of the on-call physicians for 1 of 23 sampled patients (#1). As this resulted in a delay in treatment by the on -call physician for patient #1. The facility also failed to list on the call schedule back up coverage on all specialty physicians, who are on call to provide treatment to respond to situations where a particular specialty, through its emergency room on-call physician, is not available to respond because of circumstances beyond his control, such as having an on-call status at more than one hospital simultaneously and being needed at both places simultaneously.

Refer to findings under Tag -A2404.

Based on review of medical records, policies and procedures, Medical Staff Bylaws, on-call lists and staff interviews the facility failed to ensure that the facility's policy and procedure was followed when an on-call specialty physician was asked to come to the hospital to provide treatment in response to a request from the emergency room physician to provide specialty services to meet the needs of the hospital 's patients who are receiving services requested , including the availability of the on-call physicians for 1 of 23 sampled patients (#1). As this resulted in a delay in treatment by the on -call physician for patient #1. The facility also failed to list on the call schedule back up coverage on all specialty physicians, who are on call to provide treatment to respond to situations where a particular specialty, through its emergency room on-call physician, is not available to respond because of circumstances beyond his control, such as having an on-call status at more than one hospital simultaneously and being needed at both places simultaneously.

Findings:

1. The facility's policy and procedure titled, "On-Call Responsibilities" effective date 11/2011, revised 3/2012 was reviewed. The policy and procedure revealed in part,.. "RESPONSE TO CALL . . . 5. When an on call physician is requested to respond by the Emergency Department Physician the physician must: ...(b) Respond in person, if so requested, within a reasonable time period. Generally, response is expected within 30 minutes. The Emergency Department physician, in consultation with the on-call physician, will determine whether the patient ' s condition requires the on-call physician to see the patient as soon as possible. (c) Physicians who are on -call and asked to come in to the Emergency Department for an STAT patient care need must comply with all EMTALA regulations ...Concurrent Call/Elective Surgery: 12. Notwithstanding an on-call physician's obligation to respond when on call, the on call physician may perform elective surgery or other patient care services at the Hospital while on call, and may be at on call at another hospital. The on call physician is obligated to arrange for back- up coverage in the even he/she is not able to respond immediately to call from the Emergency Department. The on-call physician is responsible for being sure he/she or the back -up physician responds to the Emergency Department with in thirty minutes"

2. The facility's Medical Staff Bylaws were reviewed. The Medical Staff By-Laws specified in part, "3.5 Basic obligations accompanying staff appointment and/or the granting of clinical privileges. . . The applicant shall agree to: 3.5.6. Discharge such Medical Staff Department , Division, committee, and Hospital functions, for which he/she is responsible based upon appointment , election, or otherwise, including as appropriate, providing on call coverage for emergency care services within his/her clinical specialty, as required by the Medical Staff."


3. A review of the medical record of patient #1 was performed. The patient arrived at 3:35 PM on 6/28/12 and was triaged at 3:38 PM. The stated complaint was "stabbing." The Emergency Room physician first encountered the patient at 3:37 PM. The Rapid Initial Assessment, written by a nurse at 3:40 PM on 6/28/12, read,"... arrived via FD (Fire Department) EMS (Emergency Medical Services) as a code blue (A medical emergency in which a team of medical personnel work to revive an individual in cardiac arrest) S/P (status post) stabbing to left chest. Pt (patient) was pulseless (no heart beat) on EMS arrival." A nurse's note at 3:51 PM read, "Mechanism of injury: Penetrating trauma stabbing left chest." A nurse's note at 3:41 PM read,"... recd (received) to ER (emergency room) 5 as code blue per FD EMS, S/P stabbing to the left chest. Pt was pulseless for EMS, CPR (Cardio Pulmonary Resuscitation) in progress and intubated 7.5 FR. (Dr. #A) is attending ER MD (Medical Doctor) with (Dr. #B) emergency room physician.... Pt has chest tube inserted per (Dr. #A) and connected to water seal at 20 cm wall sx (suction).) STAT (urgent) calls to blood bank for 4 units of blood. ...CVC (Central Venous Catheter-a catheter placed in a large i.e., groin, chest to administer medications and fluids) Rt (right) groin per Dr (#B). Pt now has a pulse."

A nurse's note at 3:45 PM read, "(Dr. #C), cardiothoracic surgeon on-call, is on phone, 2nd unit blood hanging ....Pt. . . has lost his pulse/cpr resumed" A nurse's note at 3:54 PM described the care being provided to the patient and read, "(Dr. #E) vascular surgeon at bedside. (Dr. #C) has not come in. CPR continues." A nurse's note at 4:02 PM read, " ... (Dr. #A) went to talk to (Dr. #C)/CV surgeon on call, on phone ... (Dr. #C) apparently has informed that he is not coming in for this pt. Call out to . . . (Dr. #F) cardiothoracic surgeon (was not on-call on 6/28/2012)." Review of nurse's note at 4:06 p.m. read, (Dr. #D) general surgeon, here at bedside. . . epi (epinephrine- medication used to treat cardiac arrest) x (times) 1 given at 4:09 PM. per (Dr. #A). 36 min (minutes) into the code. " Further review of the nurses note at 4:10 P.M. read, " Pt has recd 4 liters of IVF (intravenous fluid), pt has a pulse now rate of 90 femoral (groin) site. 5th unit prc (packed red cells) hung now. (Dr. #F) returned call, he will be here in 10 min, call to OR (operating room) team per (Dr. #D) for surgery. b/p (blood pressure) 98/65." A nurse ' s note at 4:14 PM read, 42 minutes into the code. 6/7 hung prc. OR team on the way ....pericardiocentesis (a procedure used in an emergency situation to remove excess accumulations of blood or fluid from the covering the heart (pericardial sac). being done per (Dr. #E). Pulse back into the 50's. The nurse ' s note read at 4:21 PM, " no pulse, cpr continues. (Dr. #F) surgeon performing thoracotmy (a process of making a cut into the chest wall to provide access to the heart) at bedside. Call for 4 more units blood. The nurse notes reads at 4:27 PM, " Thoracotomy procedures continues per (Dr. #F), with assist from anesthesiologist, (Dr. #E), (Dr. #D) ... radiologist (Radiology physician). (Dr. #C), on call CVT surgeon, arrived to rm (room). The on-call physician for Thoracic surgeon delayed nearly an hour for evaluation of patient 1 on 6/28/2012. Now at the 1 hour mark in code 3:33 PM to 4:33 PM."The nurse's notes read at 4:33 PM, "cpr resumed 4:42 PM. all surgeons still suturing thoracotmy ...b/p 82/33. "The nurse's note read at 4:57 p.m. code called per (Dr. #F) in agreement with all surgeons at 4:57 PM. 1 hr 24 min code on the pt was performed." In summary, Patient #1 was pronounced dead by (Dr. #F) at 4:57 PM on 6/28/2012. The facility failed to ensure that their policy and procedure was followed when the on- call Cardio Thoracic surgeon was asked to come in by the ED physician STAT for the care of patient #1 on 6/28/2012.

4. Review of the Hospital's "Emergency Call Schedule" for 6/28/2012 was reviewed. The on call schedule verified that (Dr. #C) Thoracic surgeon (CVT-cardio vascular thoracic) was on call on 6/28/2012. There was no documented evidence on the on-call schedule that back up coverage for the Thoracic surgeon was listed on the call schedule on 6/28/2012. There was no way to determine who was available to respond because the on call cardio vascular thoracic surgeon was on call at another acute care hospital simultaneously. On 7/11/12, the hospital where (Dr. #C) was on simultaneous call on 6/28/20122 was visited. A review of the emergency room on-call list at this facility for the date of 6/28/12 revealed that (Dr. #C) who was requested to come to Central Florida Hospital on the same day, to treat patient #1 was also designated as an on-call physician.


5. (Dr. #A's) note written of 5:29 PM on 6/28/2012 referenced, "Call was placed to (Dr. #C) on pt arrival, (Dr. #B) spoke with him when he called back as I was placing chest tube. Was requested to come in STAT but he told (Dr. #B) to call General Surg... . (Dr. #C) called back again He requested we get a stat ECHO (uses sound waves to build up a detailed picture of the heart) but was told there was no time for this that patient probably had tampanode (is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle and the pericardial sac) and needed emergent thoracotomy. . .( Dr. #E) here and performed pericardiocentesis. (Dr. #F) was called who came in and ....performed L (left) lateral thoratocotomy. Found stab wound to the heart and repaired. Clinical impression: Chest injury: . Penetrating heart injury. " Another physician note by Dr. #A, entered at 8:54 PM on 6/28/12, read, "(Dr. #C), thoracic surg on call, was called when pt arrived to ED (Emergency Department) at 3:34 PM. (Dr. #B) spoke with him on phone at approx.(approximately) 3:45 as I was inserting chest tube and could not leave pt side. He requested him to come immediately in but he refused, stated that since only 500 cc (cubic centimeters) of blood came out of chest tube pts injury must be abdominal, possibly spleen, and we were to call general surg (surgeon) (Dr. #D). (Dr. #B) disagreed but (Dr. #C) still refused to come in. (Dr. #D) was called... After (Dr. #C) had refused to come in and (Dr. #F) was on his way. . . (Dr. F) arrived at 4:20 PM ... Dr. #C arrived at approx 4:30 PM."

6. A physician note by Dr. #B, entered at 6 PM on 6/28/12 read, "Thoracic on call was paged and (Dr. #C) called back. I spoke with him at 3:45 PM. I discussed with him the situation and that this patient had a stab wound in his lower chest/upper abd (abdomen) area. He asked how much blood came out of the chest tube. I told him about 500 cc of blood. He replied, 'with that amount of blood you don't need to open the chest'. He then asked if he was on back-up for general surgery and I told him 'no. it was (Dr. #D). He responded, 'you need to call him, that's your man'. (Dr. #E) was in the department and offered his help. "

7. (Dr. E 's) "Operative Report " dated on 6/28/2012 at 6:02 PM, read in part, " I was called emergently by both (Dr. #A) and (Dr. #B), to please come to the emergency room as they had a patient with a stab wound to the left chest. . . (Dr.# A)and (Dr. #B) informed me that they had contacted the thoracic surgeon on call who happened to be (Dr. # C). (Dr #C) reportedly told them that if only 500 cc of blood came out of the chest, then he was not coming in to take care of this patient. If this patient had a problem, then they were to contact the general surgeon on call. (Dr.# D) was appropriately contacted as he was on call and he was in transit. I was thus overhead paged to please come to the emergency room to assist with the management of this patient as (Dr. #C) had refused to honor his emergency room call duties. . . The patient was aggressively resuscitated and (Dr. #F) was now called emergently to please come as (Dr. #C) had once again refused to do so despite the fact that he was on the emergency room call duty for thoracic surgery. (Dr. #F) was in transit."

8. During an interview of (Dr. #B) on 7/11/12 at 12:41 PM, he stated that he had requested (Dr. #C) to come in, and that his call was not a consultation request. He stated that after explaining the case to (Dr. #C) and requesting his presence, he was told that he (Dr. #B the caller) did not need him (the call recipient, (Dr. #C). He said he was told to call another, specific physician, (Dr. #D). (Dr. #B) stated that he did not voice any agreement with (Dr. #C's) decision or voice a consensus with (Dr. #C) regarding it.

During an interview of the Quality Director at Central Florida Hospital on 7/12/12 at 1:09 PM, she confirmed that the facility could not provide evidence of compliance with the requirement in Federal statute?489.24(j)(2)(i), which states, "When the on-call physician is simultaneously on call at more than one hospital in the geographic area, all hospitals involved must be aware of the on-call schedule as each hospital independently has an EMTALA obligation."

Based on review of medical records, policies and procedures, Medical Staff Bylaws, on-call lists and staff interviews the facility failed to ensure that the facility's policy and procedure was followed when an on-call specialty physician was asked to come to the hospital to provide treatment in response to a request from the emergency room physician to provide specialty services to meet the needs of the hospital 's patients who are receiving services requested , including the availability of the on-call physicians for 1 of 23 sampled patients (#1). As this resulted in a delay in treatment by the on -call physician for patient #1. The facility also failed to list on the call schedule back up coverage on all specialty physicians, who are on call to provide treatment to respond to situations where a particular specialty, through its emergency room on-call physician, is not available to respond because of circumstances beyond his control, such as having an on-call status at more than one hospital simultaneously and being needed at both places simultaneously.

Findings:

1. The facility's policy and procedure titled, "On-Call Responsibilities" effective date 11/2011, revised 3/2012 was reviewed. The policy and procedure revealed in part,.. "RESPONSE TO CALL . . . 5. When an on call physician is requested to respond by the Emergency Department Physician the physician must: ...(b) Respond in person, if so requested, within a reasonable time period. Generally, response is expected within 30 minutes. The Emergency Department physician, in consultation with the on-call physician, will determine whether the patient ' s condition requires the on-call physician to see the patient as soon as possible. (c) Physicians who are on -call and asked to come in to the Emergency Department for an STAT patient care need must comply with all EMTALA regulations ...Concurrent Call/Elective Surgery: 12. Notwithstanding an on-call physician's obligation to respond when on call, the on call physician may perform elective surgery or other patient care services at the Hospital while on call, and may be at on call at another hospital. The on call physician is obligated to arrange for back- up coverage in the even he/she is not able to respond immediately to call from the Emergency Department. The on-call physician is responsible for being sure he/she or the back -up physician responds to the Emergency Department with in thirty minutes"

2. The facility's Medical Staff Bylaws were reviewed. The Medical Staff By-Laws specified in part, "3.5 Basic obligations accompanying staff appointment and/or the granting of clinical privileges. . . The applicant shall agree to: 3.5.6. Discharge such Medical Staff Department , Division, committee, and Hospital functions, for which he/she is responsible based upon appointment , election, or otherwise, including as appropriate, providing on call coverage for emergency care services within his/her clinical specialty, as required by the Medical Staff."


3. A review of the medical record of patient #1 was performed. The patient arrived at 3:35 PM on 6/28/12 and was triaged at 3:38 PM. The stated complaint was "stabbing." The Emergency Room physician first encountered the patient at 3:37 PM. The Rapid Initial Assessment, written by a nurse at 3:40 PM on 6/28/12, read,"... arrived via FD (Fire Department) EMS (Emergency Medical Services) as a code blue (A medical emergency in which a team of medical personnel work to revive an individual in cardiac arrest) S/P (status post) stabbing to left chest. Pt (patient) was pulseless (no heart beat) on EMS arrival." A nurse's note at 3:51 PM read, "Mechanism of injury: Penetrating trauma stabbing left chest." A nurse's note at 3:41 PM read,"... recd (received) to ER (emergency room) 5 as code blue per FD EMS, S/P stabbing to the left chest. Pt was pulseless for EMS, CPR (Cardio Pulmonary Resuscitation) in progress and intubated 7.5 FR. (Dr. #A) is attending ER MD (Medical Doctor) with (Dr. #B) emergency room physician.... Pt has chest tube inserted per (Dr. #A) and connected to water seal at 20 cm wall sx (suction).) STAT (urgent) calls to blood bank for 4 units of blood. ...CVC (Central Venous Catheter-a catheter placed in a large i.e., groin, chest to administer medications and fluids) Rt (right) groin per Dr (#B). Pt now has a pulse."

A nurse's note at 3:45 PM read, "(Dr. #C), cardiothoracic surgeon on-call, is on phone, 2nd unit blood hanging ....Pt. . . has lost his pulse/cpr resumed" A nurse's note at 3:54 PM described the care being provided to the patient and read, "(Dr. #E) vascular surgeon at bedside. (Dr. #C) has not come in. CPR continues." A nurse's note at 4:02 PM read, " ... (Dr. #A) went to talk to (Dr. #C)/CV surgeon on call, on phone ... (Dr. #C) apparently has informed that he is not coming in for this pt. Call out to . . . (Dr. #F) cardiothoracic surgeon (was not on-call on 6/28/2012)." Review of nurse's note at 4:06 p.m. read, (Dr. #D) general surgeon, here at bedside. . . epi (epinephrine- medication used to treat cardiac arrest) x (times) 1 given at 4:09 PM. per (Dr. #A). 36 min (minutes) into the code. " Further review of the nurses note at 4:10 P.M. read, " Pt has recd 4 liters of IVF (intravenous fluid), pt has a pulse now rate of 90 femoral (groin) site. 5th unit prc (packed red cells) hung now. (Dr. #F) returned call, he will be here in 10 min, call to OR (operating room) team per (Dr. #D) for surgery. b/p (blood pressure) 98/65." A nurse ' s note at 4:14 PM read, 42 minutes into the code. 6/7 hung prc. OR team on the way ....pericardiocentesis (a procedure used in an emergency situation to remove excess accumulations of blood or fluid from the covering the heart (pericardial sac). being done per (Dr. #E). Pulse back into the 50's. The nurse ' s note read at 4:21 PM, " no pulse, cpr continues. (Dr. #F) surgeon performing thoracotmy (a process of making a cut into the chest wall to provide access to the heart) at bedside. Call for 4 more units blood. The nurse notes reads at 4:27 PM, " Thoracotomy procedures continues per (Dr. #F), with assist from anesthesiologist, (Dr. #E), (Dr. #D) ... radiologist (Radiology physician). (Dr. #C), on call CVT surgeon, arrived to rm (room). The on-call physician for Thoracic surgeon delayed nearly an hour for evaluation of patient 1 on 6/28/2012. Now at the 1 hour mark in code 3:33 PM to 4:33 PM."The nurse's notes read at 4:33 PM, "cpr resumed 4:42 PM. all surgeons still suturing thoracotmy ...b/p 82/33. "The nurse's note read at 4:57 p.m. code called per (Dr. #F) in agreement with all surgeons at 4:57 PM. 1 hr 24 min code on the pt was performed." In summary, Patient #1 was pronounced dead by (Dr. #F) at 4:57 PM on 6/28/2012. The facility failed to ensure that their policy and procedure was followed when the on- call Cardio Thoracic surgeon was asked to come in by the ED physician STAT for the care of patient #1 on 6/28/2012.

4. Review of the Hospital's "Emergency Call Schedule" for 6/28/2012 was reviewed. The on call schedule verified that (Dr. #C) Thoracic surgeon (CVT-cardio vascular thoracic) was on call on 6/28/2012. There was no documented evidence on the on-call schedule that back up coverage for the Thoracic surgeon was listed on the call schedule on 6/28/2012. There was no way to determine who was available to respond because the on call cardio vascular thoracic surgeon was on call at another acute care hospital simultaneously. On 7/11/12, the hospital where (Dr. #C) was on simultaneous call on 6/28/20122 was visited. A review of the emergency room on-call list at this facility for the date of 6/28/12 revealed that (Dr. #C) who was requested to come to Central Florida Hospital on the same day, to treat patient #1 was also designated as an on-call physician.


5. (Dr. #A's) note written of 5:29 PM on 6/28/2012 referenced, "Call was placed to (Dr. #C) on pt arrival, (Dr. #B) spoke with him when he called back as I was placing chest tube. Was requested to come in STAT but he told (Dr. #B) to call General Surg... . (Dr. #C) called back again He requested we get a stat ECHO (uses sound