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Based on facility policy review, review of Bylaws Of The Medical Staff, medical record review, review of physician call schedules, review of audio recordings, and interviews, the facility failed to provide on-call ENT/Otolaryngology (a physician specializing in treating diseases of ears, nose, and throat) physician services, for 1 patient (#14) of 34 Emergency Department (ED) patients reviewed.

Review of the facility's investigations, communications, and action plans revealed the facility had identified the past non-compliance and had placed interventions (primarily directing the ED physicians and Administrators on Call to bypass the Transfer Center and bypass the physician specialists on call and accept all appropriate transfers) and the facility is currently in compliance with 42 CFR 489.20 and 489.24, Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

Refer to A 2404 for failure to provide on-call physician.

Based on facility policy review, review of Bylaws Of The Medical Staff, medical record review, review of physician call schedules, review of audio recordings, review of credentialing files, and interviews, the facility failed to provide on-call ENT/Otolaryngology (a physician specializing in treating diseases of ears, nose, and throat) physician services for 1 patient (#14) of 34 Emergency Department (ED) patients reviewed.

Review of the facility's investigations, communications, and action plans revealed the facility had identified the past non-compliance and had placed interventions in place (primarily directing the ED physicians and Administrators on Call to bypass the Transfer Center and bypass the physician specialists on call and accept all appropriate transfers) and the facility is currently in compliance with 42 CFR 489.20 and 489.24, Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

The findings included:

Review of the facility's policy EMTALA-Provision of On-Call Coverage last revised 3/2013, revealed, "...Physicians on the list must be available after the initial examination to provide treatment...Immediate availability...or to secure a qualified alternate...Arrival or response to the DED (Dedicated Emergency Department) within a reasonable timeframe...The on-call physician has a responsibility to provide specialty care services as to needed...The on-call list maintained for the main hospital Emergency Department shall be the on-call list for the hospital, including any Off-Campus Provider-based Emergency Departments "

Review the facility's Bylaws of the Medical Staff dated 2014 revealed, "...Obligations of Active Staff...accept emergency on-call coverage for emergency care services within his/her clinical specialty...or arrange a suitable alternative..."

Review of the medical record revealed Patient #14 presented to the ED at Hospital #1's West campus (A satellite facility of Hospital #1 with a DED but no surgical or medical inpatient services. The West Campus is located 28 miles from Hospital #1's Main campus, a 275-bed hospital which did have surgical and inpatient services) on 1/23/16 at 3:24 AM, with a police officer, for complaint of auditory and visual hallucinations and paranoia. Further review of the medical record revealed the patient had a Medical Screening by a physician beginning at 3:24 AM, which included a physical examination and laboratory tests. The patient was medically cleared and diagnosed with Homicidal Ideation and Paranoia, and a consultation with Crisis Intervention services was made on 1/23/16 at 4:30 AM. The patient was kept on 1:1 (one to one) observation and was assessed by Crisis Response staff. The physician signed a commitment form for the patient and arrangements were made for transfer to an area psychiatric hospital on 1/23/16 at 6:20 AM.

Review of the medical record revealed Patient #14 complained of a sore throat on 1/23/16 at 8:45 AM and was re-evaluated by the physician. Further medical record review revealed on 1/23/16 at 9:02 AM the physician applied topical analgesia, treated the patient with oral pain medication, then performed a strep swab (laboratory test for group A Streptococcus infection) and attempted twice to aspirate a tonsillar pillar abscess without success. The patient was treated with Rocephin 1 gram IM (an injection into the muscle of antibiotics to fight the infection) and Dexamethasone 8 mg (milligrams) IM (an injection into the muscle of a steroidal anti-inflammatory drug to reduce swelling) at 9:15 AM on 1/23/16.

Review of the medical record revealed a CT Scan (computerized tomography scan, a series of computer assisted 3 dimensional x-ray images) was ordered by the ED Physician on 1/24/16 10:21 PM and revealed "...Tonsillitis with right peritonsillar abscess..."

Review of the medical record revealed a nurses note dated 1/24/16 at 11:27 PM stating, "...Spoke to...at...transfer center to arrange transfer to...main for admission ..." Further review of nurse's note dated 1/24/16 at 11:33 PM revealed, "...spoke to...at transfer center, arranging ER to ER transfer..."

Review of the transfer form revealed Patient #14's transfer form was completed on 1/25/16 at 1:00 AM to transfer the patient by ambulance from Hospital #1's West Campus to Hospital #2 . Further review of the transfer sheet revealed the medical benefits of the transfer were, "...Obtain a level of care/service unavailable at this facility...Service ENT/Admission..."

Review of a physician's addendum note dated 1/25/16 at 1:06 AM, revealed the physician reassessed Patient #14 for continued complaint of throat pain and the doctors note stated, "...The patient's clinical condition seems to be worsening and his pain persists. It was decided to obtain a CT Scan to see the extent of the peritonsillar abscess. The patient has an abscess measuring 2.4 inches in diameter...It was decided to transfer the patient to a facility for in patient management of this condition..."

Review of the medical record from Hospital #2 (a large medical center located 26.9 miles from Hospital #1's West Campus) revealed Patient #14 presented to the ED there on 1/25/16 at 2:58 AM and was admitted as an inpatient with diagnosis which included Right Peritonsillar Abscess and Tonsillitis, Reported History of Homicidal Ideation, more likely, Paranoia and Auditory Hallucinations secondary to Methamphetamine Use, and Polysubstance Abuse. Further review of the medical record revealed the patient was seen by an ENT/Otolaryngologist and had an Incision and Drainage of the Peritonsillar Abscess while still in the ED on 1/25/16. Further review revealed the patient's medical and mental condition improved significantly and he was discharged home in stable condition on 1/26/16.

Review of Hospital #1's Emergency Department Unattached Call Schedule for January 2016 revealed the facility had an ENT/Otolaryngologist on call 1/23/16, 1/24/16, and 1/25/16. The schedule showed ENT/Otolaryngology on call coverage every night except 1/1, 1/2, and 1/18 in January 2016.

Review of an undated and untimed recording, identified by the Compliance Officer and Risk Manager as the recording of a conversation regarding Patient #14's transfer to the main campus on 1/25/16, between the facility's Transfer Center and the main campus ED Physician revealed the ED Physician told the Transfer Center, "...don't send unless [ENT on-call physician] agrees to take patient..."

Review of an undated and untimed recording, identified by the Compliance Officer and Risk Manager as the recording of a conversation regarding Patient #14's transfer to the main campus on 1/25/16, between the facility's Transfer Center and the facility's on-call ENT/Otolaryngologist revealed the on-call physician was asked if he would be available to treat the patient and the ENT told the Transfer Center, "...No, I would not be available to come in and evaluate...transfer to [Hospital #2] or [Hospital #3]..."

Review of an undated and untimed recording, identified by the Compliance Officer and Risk Manager as the recording of a conversation regarding Patient #14's transfer to the main campus on 1/25/16, between the facility's Transfer Center and the ED physician at the West Campus revealed the Transfer Center staff told the West ED physician, "[Hospital #1 main campus] is not able to take the patient there...ENT unable to come in and see the patient..."

Review of physician credentialing files revealed Physician #1 is a licensed Medical Doctor, Board Certified in Otolaryngology, and had privileges at this facility which included Otolaryngological procedures.

Telephone interview with Physician #1 (the ENT on-call on 1/25/16) on 3/16/16 at 3:00 PM, revealed he did not remember Patient #14's case or the phone call from the Transfer Center.

Interview with the Marketing Compliance Officer and the Risk Manager on 3/15/16 at 1:14 PM, in the Risk Management Conference Room, revealed they had investigated the incident that involved Patient #14 and confirmed Physician #1 was on-call for ENT coverage on 1/25/16 and had told the transfer center he was unavailable to see the patient if transferred to the main campus ED. Further interview confirmed the on-call physicians were to be available to examine and treat patients in the Main Campus ED when needed for their specialty. Further interview revealed the ENT physician had stated he was busy at another facility when the transfer center had contacted him on 1/25/16. Further interview revealed the on-call ENT physician had not notified this facility's ED or Medical Staff Office of his unavailability.

Review of a letter from the facility given to the surveyor on 3/15/16, during the entrance conference, revealed, "...Enclosed is a set of facts that we have determined constitutes a potential violation of the Emergency Medical Treatment and Labor Act ("EMTALA")...declined the transport of a patient when the facility appeared to have the capability and capacity to accept the request...On 1/24/16 at 11:22 PM...House Supervisor was contacted by...Transfer Center to request...[Patient #14]...be moved from...West...to the main campus...was diagnosed with a peritonsillar abscess...would need to be seen by an Otolaryngologist...The transfer center then contacted...ED Physician regarding the request...The ED Physician responded that he accepted the transfer request but the On-Call ENT would need to evaluate the Patient...On 1/25/16 at approximately 12:00 a.m., the Transfer Center Representative telephoned the On-Call ENT and asked if he was available to evaluate a patient in the ED. The On-Call ENT stated he was unavailable and recommended transferring the patient to another facility...In a discussion with the On-Call ENT he claimed he was at another facility when the Transfer Center contacted him about the transfer request...Medical Staff Office (MSO) and ED had not been notified that he would be unavailable...the Transfer Center notified West's ED Physician...and facilitated a transfer...the patient was transferred..."

Interview with the Marketing Compliance Officer and the Risk Manager on 3/15/16 at 1:14 PM, in the Risk Management Conference Room, revealed their investigation identified additional information. The West Campus did not have an ENT on-call there, but the Main Campus did have an ENT on call. Patient #14 was a Certificate of Need (CON) patient committed to a psychiatric facility for but there were no ICU Beds available, and this patient having been committed for Homicidal Ideation and Paranoia and required an ICU bed or a bed in the ED with 1:1 observations. At the time of the referral, the ICU was full with no beds available and the ED had 3 patients on hold in the ED for an ICU bed.

Review of the facility's actions to correct the EMTALA violation revealed, "...we have taken immediate measures to ensure this type of incident does not occur in the future..." The facility's interventions were verified during the survey and included:

1. On 3/7/16 the CEO spoke with the On-Call ENT about his obligations under EMTALA and explained the ENT must present to the ED upon request when he is scheduled for call coverage
2. On 3/7/16 the 1/24/16 incident that involved the on-call ENT refusing to accept an in-house transfer from the West campus to the Main Campus was submitted to Medical Staff Peer Review. At the next Peer Review Committee on April 12, 2016, this case will be reviewed then.
3. On 3/8/16 the CEO sent a letter to all physicians taking on-call coverage notifying them of their obligations under EMTALA regulations, which require the physicians to come to the ED upon request.
4. On 3/4/16 the Medical Director spoke with all ED physicians about the requirement to accept all transports and transfers when the facility has the capability and capacity to provide the care requested. The ED physicians are going to bypass the specialist and the transfer center and accept any transfers that are requested if they have the capacity and capability to treat.
5. On 3/15/16 the Chief Nursing Executive and the Ethics and Compliance Officer (ECO) met with all Administrators on Call (AOCs) and explained the importance of gathering information from the transfer center representative to ensure a declined transfer is appropriate.
6. The Facility ECO and Division ECO (DECO) developed an improved process for ED staff and House Supervisors to utilize when a transport vs a transfer (a transfer is from another hospital, the transport is from one of the satellite hospitals) is requested. The ECO and DECO also incorporated scenarios involving behavioral health patients.
7. The Facility ECO and Division ECO developed scripting for the ED staff, House Supervisors and Transfer Center Representatives to utilize when a transport vs a transfer is requested. This scripting is going to be an algorithm form that helps staff make decisions regarding transfers vs transports and provides scripted responses for physicians that refuse transfers or transports.
8. On or before 4/11/16, the Transfer Center Director will review appropriate scripting with the Transfer Center Representatives and provide education on the difference between a transfer and a transport. Until this is completed, the ED medical staff and hospitalist have been told to bypass the Transfer Center and accept any appropriate transfers requested.
9. EMTALA education with all House Supervisors and AOC which was completed 3/15/16. Similar education is provided to the ED Nursing Staff every year now, and updated education has already been provided 3/4/16. The new scripting is being developed and education on this will be provided when it is developed.
10. All ED physicians have been assigned the Sullivan EMTALA training course. The required completion date for all ED Physicians is 4/15/16.
11. All house supervisors, including the House Supervisors at issue, are assigned the online Health Stream EMTALA Education Course. The required completion date is 4/25/16. The Marketing Compliance Officer confirmed she is currently in the process of entering all the House Supervisors and Managers into the computer system and will monitor for completion of all education.

Interview with the Marketing Compliance Officer (MCO) and the Risk Manager on 3/15/16 at 1:14 PM, in the Risk Management Conference Room, revealed 100% of patient transfers and transports are being audited for appropriateness and completeness of transfers. Further interview revealed 100% of incoming transfer and requests for transfer are being reviewed by the ED Directors and the MCO for compliance with EMTALA requirements. Completion of all EMTALA education and training is being monitored by the ED Directors and the MCO.