HospitalInspections.org

Based on review facility policy and procedure, and staff interview (EMP), it was determined that the facility failed to comply with ?489.24 and failed to follow their adopted policies in relation to the Emergency Medical Treatment and Active Labor Act [EMTALA].

Findings include:

Review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated December 30, 2011, revealed "V. Procedure 1. If an individual seeking emergency medical care comes to the hospital's Dedicated Emergency Department, physicians or other Qualified Medical Person (QMP) shall offer a medical Screening Exam to such person."

1) Interview with EMP46 on December 18, 2012, at approximately 10:20 AM revealed
"The patient came in carrying a jar with something white in it and said he knocked his teeth out during a seizure. I told him that we don't have a dentist in the ED but maybe they could provide him some pain medication and antibiotics. I went to go write down his information and by the time I asked if he still wanted to be seen he was already on his way out the door."

Based on review of facility documents and staff interviews (EMP), it was determined that the facility failed to maintain a list of physicians who are on call for duty in the Emergency Departments in five speciality areas for the campuses of UPMC Presbyterian-Shadyside.

Findings Include:
Review of Policy HS-LE0007, "Emergency Medical Treatment and Active Labor Act (EMTALA)" reviewed December 30, 2011 states, "... Procedure: ... 11. Each UPMC hospital's Emergency Department shall maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an Emergency Medical Condition. Physicians on call are required to personally attend to the patient when requested to do so by the treating physician ..."
Review of Policy CP-PUH01, "Emergency Department Requests for Consultation" reviewed June 28, 2012, states, "... Procedure: Responses to paging: When a need for Consultation from a Specialty is recognized in a patient in the Emergency Department (ED): The Emergency Department staff will page on-call physicians by referencing MedTrack (utilizing the "ED View" when applicable)....."
Review of Policy "Communication Policy for Emergency Inpatient Care and Emergency Department Call" dated November 11, 22, 2012, stated, "....Purpose: To provide quality patient care, timely communication between physicians is imperative. Therefore, it is the expectation of the UPMC Shadyside Medical staff that physicians return calls from their colleagues in a timely fashion ... Scope: this policy applies to the physicians who are required to be available or to have an arrangement for coverage. Examples: 1) physicians providing coverage to the Emergency Department for a subspecialty service. 2) Physicians who admit patient to the hospital ... "
1. On December 17, 2012, at 10:45 AM, lists of on call physicians were provided by EMP10. The "On Call Dentist" list stated that the Dental Residency office was to be called from 8:00 AM to 4:00 PM, Monday through Friday. However, the list did not include the name of the doctor on call.
2. On December 17, 2012, at 10:45 AM, the "On Call Dermatology" list was provided by EMP10. The list stated, "Dermatology Consult Rotator" from February 1, 2004, to February 29, 2020. However, the list did not include the name of the doctor on call.
3. During an interview on December 20, 2012, at approximately 2:00 PM, EMP 21 was asked if there was a specific doctor to called during the hours of 8:00 AM and 4:00 PM for the on-call dentist and on call dermatologist. EMP 21 stated, "No there is not [a specific doctor], it just says to call this pager number [the department of residents]."
4. On December 17, 2012, at 12:18 PM, the "Summary of On-call Schedules - week of 12-17-12 thru 12-24-12" listed three doctors to call for Orthopedics. However, the list did not specify which doctor was on call. The "Summary of On-call Schedules" listed two doctors to call for Cardiovascular. However, the list did not specify which doctor was on call. The "Summary of On-call Schedules" also listed two doctors to call for Cardiology. However, the list did not specify which doctor was on call.

5. During an interview on December 17, 2012, at 12:18 PM, EMP 36 confirmed that the doctor on call was not specified. EMP 36 stated, "We call the group [Ortho Associates of Pittsburgh] and they call us back with the name of the doctor on call." (Shadyside facility-SHY)

6. During an interview on December 17, 2012, 12:30 PM, EMP 38 confirmed that the doctor on call was not specified. EMP 38 indicated, "In the evenings we call the group [Cardiology], and the office will call us back or give us the name of the physician on-call. " (SHY)

Based on review of medical records and staff interview (EMP), it was determined the facility failed to ensure all elements of appropriate transfer were documented in the medical record (MR) prior to patient transfer for three of 10 medical records (MR33, MR64, and MR65).

Findings include:

Review of facility policy "Patient Transfer from the Emergency Department to an Acute Care Facility " dated April 26, 2012 revealed " ...It is the policy of UPMC ...to ensure that the process of transferring a patient to another acute care facility is consistent for all patients and in compliance with the Emergency Medical Treatment and Active Labor Act ... III. Physician Responsibility ... B. The physician must certify that based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh any increased risks to the individual ... The certification must also contain a summary of risks and benefits. ... D. The physician must review and sign the transfer form. ... VI. Transfer A. The ED physician will determine the level of support personnel and transportation equipment for a condition-appropriate and safe transfer. B. The following will be sent to the receiving facility with the patient: 1. A copy of pertinent medical records related to the patient's emergency condition which are available at the time of the transfer, ... 2. The signed informed consent to transfer and certification regarding risks and benefits of transfer."

1. On December 18, 2012, at 10:00 AM review of MR33 revealed the patient was transferred to an outside facility on August 11, 2012, for continued care of an acute medical condition. There was no documentation of a physician certification of the need for transfer, the patient's consent for transfer, or documentation that the benefit outweighed the risk of the transfer.
Interview with EMP23 on December 18, 2012, at 11:30 AM confirmed the above findings and revealed, "The form is not in the record."


3. On December 18, 2012, at approximately 10:30 AM review of MR64 and MR65 revealed the patients were transferred to an outside facility on October 10, 2012, for continued care of an acute medical condition. There was no documentation the medical records were sent with the patients.
Interview with EMP21 on December 18, 2012, at approximately 12:30 AM confirmed the above findings and revealed "It's[Transfer form] not there"