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Based on review of medical records(MR), facility documents and interview with staff (EMP), it was determined that the facility failed to ensure on-call physician services were provided for further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition for one of 21 medical records reviewed (MR1).

Findings include:

Review on May 22, 2015, of facility "Medical Staff Rules & Regulations," reviewed January 2015, revealed " ... ARTICLE III General Conduct of Care 3.4 Questioning of Care If a nurse or other provider has any reason to question the care provided to any patient, or believes that consultation is needed and has not been obtained, he/she shall call this to the attention of his/her supervisor, who in turn may refer the matter to the Chief Medical Officer or the Chief Nursing Officer. ARTICLE V Emergency Medical Screening, Treatment, Transfer & On-Call Roster Policy 5.1(a) Screening (1) Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition. Generally, an "emergency medical condition" is defined as ... a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual ... 5.1(b) Stabilization (1) Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge ... (2) A patient is Stable for Discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions; or when the patient requires no further treatment and the treating physician has provided written documentation of his/her findings. (3) A patient is Stable for Transfer if the treating physician has determined, within reasonable clinical confidence, that the patient is expected to leave the Hospital and be received at a secondary facility, with no material deterioration in his/her medical condition; and the treating physician reasonably believes the receiving facility has the capability to manage the patient's medical condition and any reasonable foreseeable complication of that condition. The patient is considered to be Stable for Transfer when he/she is protected and prevented from injuring himself/herself or others. (4) A patient does not have to be stabilized when: ... (ii) Based on information available at the time of the transfer, the medical benefits to be received at another facility outweigh the risks of transfer to the patient, and a physician signs a certification which includes a summary of the risks and benefits to this effect. ... 5.1(c) Transfers ... (3) Upon transfer, the Emergency Department shall provide a copy of appropriate medical records regarding its treatment of the individual including, but not limited to ... and the name and address of any on-call physician who has refused or failed to appear within a reasonable period of time in order to provide stabilizing treatment. 5.2 Consultations, Referrals & Emergency Department Call 5.2(a) When the Emergency Department Physician determines that a consultation or specialized treatment beyond the capability of the Emergency Department Physician is needed ... 5.2(d)In the event that the patient does not have a private physician, ... the rotation call list shall be used to select a private physician to provide the necessary consultation or treatment for the patient. A physician who has been called from the rotation list may not refuse to respond. The Emergency Department physician's determination shall control whether the on-call physician is required to come in to personally assess the patient. Any such refusal shall be reported to the CEO for further action and may constitute grounds for revocation of the physician's Medical Staff appointment and clinical privileges. ... "

Review of a "Service Agreement," effective October 1, 2010, revealed that a contract agency provides a number of physicians and mid-level practioners to staff the Emergency Department at the hospital. Further review of the "Agreement" revealed that "... 5.15 Compliance Policies and Procedures. Contractor and each employee, independent contractor, and other entity or person performing Services pursuant to the Agreement shall participate in Facility's Compliance Program and adhere to all policies and procedures of the facility ... ."

Review on May 22, 2015, of the on-call "Specialty Roster," revealed that the facility maintains a list of various specialists who are on-call twenty-four hours a day/seven days a week; urology is one of the listed specialty services.

Review of MR1 Emergency Department (ED) physician documentation, dated November 23, 2014, timed 11:42 AM, completed by EMP5 revealed "History of Present Illness the patient presents with abdominal pain. Additional history: this is a mentally ill ... lives in a long term care facility ... complains of nonspecific abdominal pain and vomiting since yesterday but ... can not describe anything else about the complaint. ... does not appear ill. I am immediately skeptical that any of this exists. ... Impression and Plan ... Disposition: Discharge: Time 12:27 PM ... ."

Review of MR1 ED physician documentation, dated November 23, 2014, timed 14:20, completed by EMP5 revealed that the patient returned to the ED with a "urethral foreign body." Further review of MR1 revealed " ... according to the staff worker ... this may be the 20th time [the patient] has done this. Both the charge nurse and the other EM attending recognize the patient from ED visits at other institutions for the same issue. The patient is in no distress but there is a small amount of blood ... Medical Decision Making ... Rationale: After demonstrating that there is a foreign body in the urethra by radiology I will notify Urology who will have to come in to perform a procedure. ... Impression and Plan: ... Disposition: Discharge: Time 15:03 Notes: [OTH1] from Urology called me back and told me that [OTH1] and every urology physician in the City knows this patient from the last 35 years of doing this. [OTH1] refuses to come in. [OTH1] said the patient is stable to go to [another healthcare clinic] tomorrow afternoon and they can remove the objects in the office."

Review of additional documentation, dated November 24, 2014, timed 15:50, revealed that the patient presented to the ED, of another healthcare facility, with pain and an inability to urinate. A catheter was placed in the patient to facilitate voiding and on November 25, 2014 the patient underwent a surgical procedure to remove the urethral foreign bodies.

Review of MR1 ED physician documentation, dated February 20, 2015, timed 12:10 PM, completed by EMP6, revealed that the patient presented to the ED with a chief complaint of "foreign body in penis." Further review of MR1 revealed "Genitourinary: ... small amount of dried blood at urethral meatus ... no evidence of radiopaque foreign body. ... Impression and Plan: Disposition: Discharge: Time 13:15 Notes: d/w Urology who know patient very well for decades of similar behavior. They refuse to treat patient based on previous interactions and lack of urgency ... Urology recommended FU with Urology clinic where patient is known. Pt cleared for d/c by Urology."

Review of MR ED physician documentation, dated April 9, 2015, timed 12:10, completed by EMP5, revealed that the patient presented to the ED with a chief complaint of "urethral foreign body." Further review of MR1 revealed " ...this is a schizophrenic [patient] known all over [city] for a lifetime history of placing objects in [patient] penis. This usually requires surgery to remove them. ... ambulance brought [patient] to the closest hospital. ... Therapy today: emergency medical services. Medical Decision Making: ... Rationale: Urology consult. I would not be surprised if the urologist tells me to send the patient elsewhere for care. ... x-ray findings Impression: Metallic foreign body compatible with a battery projecting over the lower pelvis. ... Impression and Plan: Disposition: Transfer to other location Notes: I spoke with [OTH2] at 1400 hrs. [OTH2] wants me to transfer the patient to [another healthcare facility.]

Review of additional documentation, dated April 9, 2015, timed 18:40, revealed that the patient was received at the ED, of another healthcare facility, with a diagnosis of " foreign body in: urethral, bladder, perineum. " A catheter was placed in the patient to facilitate voiding and on April 10, 2015, the patient underwent a surgical procedure to remove the urethral foreign body.

Interview on May 23, 2015, at 10:10 AM, with EMP4, revealed that on-call specialists are considered independent contractors but do have staff privileges at the hospital. EMP4 confirmed that if an on-call specialist refuses to respond then there is a protocol in place to escalate the situation to designated facility personnel to ensure appropriate services are delivered to the patient.

Interview on May 23, 2015, at 11:47 AM, with EMP5, confirmed that the patient presented with foreign body in the urethra and that the patient required surgical removal of the items. EMP5 revealed that these events were not considered medical emergencies and that it was the discretion of the urology specialist as to when and where the surgical procedures would be performed.

Interview on May 23, 2015, at 12:15 PM,with EMP4 confirmed that facility is equipped to provide specialty surgical services through the use of the contract specialists as designated on the facility's on-call "Specialty Roster;" and that the on-call urology specialist(s) could have performed the surgery necessary to resolve the patient's medical condition at the facility instead of transferring or discharging the patient.

The facility failed to ensure on-call physician services were provided for further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition

Based on review of medical records (MR), facility documents and interview with staff (EMP), it was determined that the facility failed to provide treatment, that was within the capabilities of the on-call urology specialists and facilities available at the hospital, necessary to stabilize a patient for one of 21 medical records reviewed (MR1).

Findings include:

Review on May 22, 2015, of facility "Medical Staff Rules & Regulations," reviewed January 2015, revealed " ... ARTICLE III General Conduct of Care 3.4 Questioning of Care If a nurse or other provider has any reason to question the care provided to any patient, or believes that consultation is needed and has not been obtained, he/she shall call this to the attention of his/her supervisor, who in turn may refer the matter to the Chief Medical Officer or the Chief Nursing Officer. ARTICLE V Emergency Medical Screening, Treatment, Transfer & On-Call Roster Policy 5.1(a) Screening (1) Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition. Generally, an "emergency medical condition" is defined as ... a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual ... 5.1(b) Stabilization (1) Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge ... (2) A patient is Stable for Discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions; or when the patient requires no further treatment and the treating physician has provided written documentation of his/her findings. (3) A patient is Stable for Transfer if the treating physician has determined, within reasonable clinical confidence, that the patient is expected to leave the Hospital and be received at a secondary facility, with no material deterioration in his/her medical condition; and the treating physician reasonably believes the receiving facility has the capability to manage the patient's medical condition and any reasonable foreseeable complication of that condition. The patient is considered to be Stable for Transfer when he/she is protected and prevented from injuring himself/herself or others. (4) A patient does not have to be stabilized when: ... (ii) Based on information available at the time of the transfer, the medical benefits to be received at another facility outweigh the risks of transfer to the patient, and a physician signs a certification which includes a summary of the risks and benefits to this effect. ... 5.1(c) Transfers ... (3) Upon transfer, the Emergency Department shall provide a copy of appropriate medical records regarding its treatment of the individual including, but not limited to ... and the name and address of any on-call physician who has refused or failed to appear within a reasonable period of time in order to provide stabilizing treatment. 5.2 Consultations, Referrals & Emergency Department Call 5.2(a) When the Emergency Department Physician determines that a consultation or specialized treatment beyond the capability of the Emergency Department Physician is needed ... 5.2(d)In the event that the patient does not have a private physician, ... the rotation call list shall be used to select a private physician to provide the necessary consultation or treatment for the patient. A physician who has been called from the rotation list may not refuse to respond. The Emergency Department physician's determination shall control whether the on-call physician is required to come in to personally assess the patient. Any such refusal shall be reported to the CEO for further action and may constitute grounds for revocation of the physician's Medical Staff appointment and clinical privileges. ... "

Review of a "Service Agreement," effective October 1, 2010, revealed that a contract agency provides a number of physicians and mid-level practioners to staff the Emergency Department at the hospital. Further review of the "Agreement" revealed that "... 5.15 Compliance Policies and Procedures. Contractor and each employee, independent contractor, and other entity or person performing Services pursuant to the Agreement shall participate in Facility's Compliance Program and adhere to all policies and procedures of the facility ... ."

Review on May 22, 2015, of the on-call "Specialty Roster," revealed that the facility maintains a list of various specialists who are on-call twenty-four hours a day/seven days a week; urology is one of the listed specialty services.

Review of MR1 ED physician documentation, dated November 23, 2014, timed 14:20, completed by EMP5 revealed that the patient returned to the ED with a "urethral foreign body." Further review of MR1 revealed " ... according to the staff worker ... this may be the 20th time [the patient] has done this. Both the charge nurse and the other EM attending recognize the patient from ED visits at other institutions for the same issue. The patient is in no distress but there is a small amount of blood ... Medical Decision Making ... Rationale: After demonstrating that there is a foreign body in the urethra by radiology I will notify Urology who will have to come in to perform a procedure. ... Impression and Plan: ... Disposition: Discharge: Time 15:03 Notes: [OTH1] from Urology called me back and told me that [OTH1] and every urology physician in the City knows this patient from the last 35 years of doing this. [OTH1] refuses to come in. [OTH1] said the patient is stable to go to [another healthcare clinic] tomorrow afternoon and they can remove the objects in the office."

Review of MR ED physician documentation, dated April 9, 2015, timed 12:10, completed by EMP5, revealed that the patient presented to the ED with a chief complaint of "urethral foreign body." Further review of MR1 revealed " ...this is a schizophrenic [patient] known all over [city] for a lifetime history of placing objects in [patient] penis. This usually requires surgery to remove them. ... ambulance brought [patient] to the closest hospital. ... Therapy today: emergency medical services. Medical Decision Making: ... Rationale: Urology consult. I would not be surprised if the urologist tells me to send the patient elsewhere for care. ... x-ray findings Impression: Metallic foreign body compatible with a battery projecting over the lower pelvis. ... Impression and Plan: Disposition: Transfer to other location Notes: I spoke with [OTH2] at 1400 hrs. [OTH2] wants me to transfer the patient to [another healthcare facility.]

Interview on May 23, 2015, at 12:15 PM, with EMP4, confirmed that facility is equipped to provide specialty surgical services through the use of the contract specialists as designated on the facility's on-call "Specialty Roster;" and that the on-call urology specialist(s) could have performed the surgery necessary to resolve the patient's medical condition at the facility instead of transferring or discharging the patient.

The facility failed to provide treatment, that was within their capabilities, necessary to stabilize and resolve a patient's emergent medical condition.