HospitalInspections.org

Based on review of medical records, on-call lists, Root Cause Analysis investigation
report, Medical Staff By-Laws and staff interviews, the facility failed to ensure that
policies were in place to provide emergency services that are available to meet the
needs of patients with emergency medical conditions when an on-call surgeon was
performing elective cases, while on call, at another facility location for 1 of 24 patients
(#7). Refer to findings in Tag A-2404.

Based on record reviews, Medical Staff By-Laws, and interview, the facility failed to
specifically designate individuals qualified to conduct medical screening examinations in
the emergency department (ED), and failed to ensure 3 of 3 pregnant patients (#5, 12 &
18) of a sample of 24 patients reviewed, presenting to the ED received complete and
appropriate medical screening examinations. Refer to finding in Tag A-2406.

Based on review of medical records, on-call lists, Root Cause Analysis investigation report, Medical Staff By-Laws and staff interviews, the facility failed to ensure that policies were in place to provide emergency services that are available to meet the needs of patients with emergency medical conditions when an on-call surgeon was performing elective cases, while on call, at another facility location for 1 of 24 patients (#7).

Findings:

1. Review of the Medical Staff By-Laws, dated as approved 9/09/2010 by the Viera Hospital Board, states the following regarding on-call physician response time: "It is the responsibility of the on-call physician to respond in an appropriate time frame. The appropriate time frame is defined as: (1) a return call to the Emergency Department within thirty (30) minutes or (2) an appearance in the Emergency Department of the physician or appropriate patient disposition within an additional thirty (30) minutes if requested by the Emergency Department physician. If the on-call physician does not respond to being called or paged, the physician's service Chair shall be contacted. Failure to respond in a timely manner may result in the initiation of disciplinary action."

2. Review of the on-call general surgery medical staff call list for the emergency department (ED) June/2012 showed surgeon C was on-call for the ED on 6/29/12.

3. Review of the medical record for patient #7 showed she presented to the ED on 6/29/2012 at 8:32 a.m. by ambulance with a chief complaint of abdominal pain. This was the second visit to the ED in two days for the same complaint. A review of the ED Report dated 6/29/2012 revealed the patient was triaged at 8:34 a.m. Documentation on the T-Sheet (Emergency Physician Record- Abdominal pain/Flank Pain) by the ED physician indicated the onset of the patient ' s pain began 2 days ago, "Seen yesterday for the same. " Further documentation by the ED physician revealed the patient ' s abdominal pain was circled as " persistent/worse. " The physician documented that the patient rated her pain as a level 10 on a scale of 1-10 with 1 being pain and 10 being severe pain.

Documentation by the ED physician also revealed the associated symptoms with the abdominal pain circled was " nausea " and " loss of appetite. " The section of the form titled "Physical Exam " the ED physician circled the patient ' s abdomen, as " tenderness/guarding and rebound" (Where pain is felt on the release of applied pressure upon the abdomen), "and bowel sounds were decreased" (bowel sounds include a reduction in the loudness, tone or regularity of the bowel sounds. They are a sign that intestinal activity has slowed).

Documentation by the ED physician revealed that patient #7 ' s case was discussed with the On Call surgeon (Physician C). The ED physician also documented that the " Clinical Impression " for patient #7 was " Abdominal Pain/Acute " . (Acute abdomen can be defined as severe, persistent abdominal pain of sudden onset that is likely to require surgical intervention).

4. Review of the root cause analysis (RCA)/investigation, completed 7/10/2012 by the director of risk management, showed the following documentation for patient #7 for the 6/29/2012 ED visit:

9:16 a.m. - ED physician A called surgeon C (on-call on 6/29/2012). Provided the patient's history of present illness and her history of a previous gastric bypass and expressed concern that he believed the patient had an ischemic bowel. Surgeon C stated that he was in Titusville and had a very busy day with 4 patients that still he had to do surgery on. He (surgeon C) suggested that the patient might have an internal hernia and he would be uncomfortable dealing with it due to not knowing if he would have to take down the bypass. He then requested that either surgeon E or D be contacted to ask if they would be willing to see the patient and, if not to give him a call back.

9:22 a.m. - ED physician A called surgeon D, who state that he was in Orlando. He offered his opinion that the patient may be suffering from an internal hernia and directs him to call surgeon E (his partner).

9:24 a.m. - ED physician A called surgeon E. He (ED physician A) provided an overview of the present illness as well as her history of previous bypass and told him that he was ordering a CT scan but that it was his impression that the patient may have an ischemic bowel. Surgeon E questioned why surgeon C was not seeing the patient and was told he was engaged in surgery in Titusville. To that, surgeon E expressed his belief that surgeon C should be available if he is on call. The call ended with no definitive decision made on whether he will see the patient.

10:58 a.m. - ED physician A calls hospitalist I and agrees to admit the patient.

11:10 a.m. - ED physician A called surgeon E with the results of the CT scan which shows a twisted mesentery. Surgeon E told ED physician A to call surgeon C and ED physician agreed to do so.

11:17 a.m. - ED physician A then indicated he had placed a call to surgeon C.

11:18 a.m. - Call placed to surgeon C and message left on his answering machine requesting that he call back.

Review of the RCA/investigation through 5 p.m. showed there was no documented return call timed or documented by the surgeon on-call.

5. During an interview on 10/24/2012 at 1:10 p.m., ED physician A was interviewed and said, "The patient presented to the ED, he assessed, testing was ordered, and even before the testing was completed he called the surgeon on-call, (surgeon C)." He said he was calling the surgeon even before the labs and x-rays were returned because he felt the case was emergent/urgent. He said he called (surgeon C) to let him know the patient would possibly need surgery. ED physician A confirmed he worked till about 5 p.m. and never received a call back from the surgeon on-call (C). He said he does not think he asked surgeon E to come in, but he believed by calling surgeon E back with the requested results of the CT, he assumed surgeon E was coming in to see the patient and assume responsibility for her care.

This entire interview was reviewed and confirmed by ED physician A on 10/24/2012 at 4:10 p.m. The facility failed to have an effective system in place as it related meeting the needs of patients with an emergency medical condition, when the on call surgeon was performing elective cases, at another facility, as this resulted in a significant delay in surgical evaluation for patient #7 on 6/29/2012. Physician C who was on the General Surgeon on call on 6/29/2012 did not come to the hospital as requested by the ED physician (physician A), despite the fact that patient #7 had an identified emergency medical condition (Abdominal/pain acute) and needed surgery.

The hospital did not have a back-up surgeon's list policy, as it relates to what should happen if the on-call surgeon is not able to come to the ED. This is a systems problem due to not having a policy. The policy for providing care to ED patients when the on-call surgeon performs elective cases at another hospital was requested. The hospital responded that there was no such policy.

During an interview on 10/25/2012 at 12:30 p.m., the director of risk management confirmed the facility did not currently have a policy related to a provision for providing care for emergency department patients when an on-call surgeon was performing elective cases, while on call, at another facility location. He said a policy was worked on in the past, but never completed and implemented.

6. Review of the Risk Management Investigative Report form dated 7/10/2012 showed the following entry, "Although the on-call surgeon was contacted less than one hour after the patient arrived in the ED on the second visit, the surgeon did not visit the patient until 35 hours later. In the regulations for providing Emergency Care, there is a requirement to have a list of services that are provided. Additionally, an on-call list is required to be maintained. If a physician who is on-call decides to perform elective surgery while he is on-call, he is required to have a back-up available to respond if he is unable to do due to being in surgery. Per information obtained from ED physician A, surgeon C had a full day of elective surgical cases while on-call. If he had an agreement with Surgeon E, D, or someone else, it was not offered by him as being in place nor did any of the physicians suggest they were covering for him. Upon being called by ED physician A the next day, Surgeon C stated his lack of understanding that he was responsible for patient #7. The last recorded call to surgeon C was placed by the HUC (secretary) where a voice message was left asking surgeon C to call the ED back. There is no recording or documentation that clearly shows that this was done."

Based on record reviews, Medical Staff By-Laws, and interview, the facility failed to specifically designate individuals qualified to conduct medical screening examinations in the emergency department; and failed to ensure 3 of 3 pregnant patients (#5, 12 & 18) of a sample of 24 patients reviewed, presenting to the emergency department (ED) received complete and appropriate medical screening examinations.


Findings:

1. Review of the medical staff bylaws dated as approved by the Viera Hospital Board, states the following: "The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that for all patients who present to the Emergency Department, the Hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. Screening and immediate steps to stabilize patients shall be provided by assigned Emergency Department staff and practitioners on call to the Emergency Department and by other qualified practitioners approved by the board." Qualified practitioners were not defined. During an interview on 10/24/2012 at 2:30 p.m., the director of risk management confirmed this is the only reference in the by-laws related to designation of qualified personnel and direction.

2. Medical record review for patient #5, age 24, showed the patient presented to the ED on 6/28/2012 at 8:16 p.m. with a chief complaint of vaginal fluid leakage. The medical record past history stated the patient was 20 weeks pregnant. Review of the T-sheet (emergency record) showed the physician documentation of assessment for labor/contractions is blank. It also documents the vaginal fluid is clear and started 3-4 days prior. No pelvic examination was conducted. The facility failed to ensure that an appropriate medical screening examination was completed for patient # 5 on 6/28/2012. The progress note read, "Pt (patient) seen with clear vaginal fluid leakage, cramps, vss (vital signs stable). U/S (ultrasound-a type of x-ray exam) done. No sterile speculum available. Discussed with OB (obstetrician) on-call at another acute care hospital will accept in transfer." The clinical impression is pregnancy-rupture of membranes. The ED physician documented intention of transferring the patient for higher level of services, however, the patient was in the ED from 8:16 p.m. until 2 a.m. when she signed herself out of the hospital against medical advice (AMA). The only fetal heart tones assessed during patient #5's ED visit were during the pelvic ultrasound performed on 6/28/2012 at 11:30 p.m.

3. Medical record review for patient #12, age 21, showed the patient presented to the ED on 8/17/2012 at 11:15 a.m. with a chief complaint of abdominal pain-epigastric. The ED physician T-sheet showed the chief complaint as abdominal pain, and vomiting, with onset/duration stating (unreadable) pregnant. The ultrasound documentation read, "22 week, intrauterine pregnancy." Review of the T-sheet (emergency record) showed no physician documentation for assessment of labor/contractions. No pelvic examination was conducted. The facility failed to ensure that an appropriate medical screening examination was completed for patient #12 on 8/17/2012. The clinical impression is improved abdominal pain and discharge to home. The patient was in the ED from 11:15 a.m. until 5:01 p.m. when she was discharged. The only fetal heart tones assessed during patient #12's ED visit were during the pelvic ultrasound performed on 8/17/2012 at 2:41 p.m.

4. Medical record review for patient #18, age 20, showed the patient presented to the ED on 10/05/20128:56 a.m. with a chief complaint of pregnant-occasional abdominal pain. The ED physician T-sheet showed the chief complaint as abdominal pain. Review of the T-sheet (emergency record) showed no physician documentation for assessment for labor/contractions. No pelvic examination was conducted. The facility failed to ensure that an appropriate medical screening examination was completed on patient #18 on 10/05/2012. HCG (pregnancy test) showed a level of 45, 270 (indicating a pregnancy of 5 weeks to 3 months or greater). The clinical impression was pregnancy, condition same/stable, and discharge to home. The patient was in the ED from 8:56 a.m. until 12:01 p.m. when she was discharged.

5. Review of the facility policy "Maternal Transport", dated as last reviewed on 04/01/2012, read, "Transport to be consider after obstetrician/physician assessment and evaluation to determine appropriate transfer to a higher level of care."

During an interview on 10/25/2012 at 1:30 p.m., ED physician, medical director said when the obstetrician on call was consulted with, he requested a test to determine if the fluid was amniotic, but the test is not available in the facility, and no sterile speculum was available to examine the patient. He also said the ultra sound scan was more accurate to measure the fetal heart tones than staff checking. He also said there was no obstetrician available at the facility since the facility does not have an obstetrical department.