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Based on medical record review, hospital policies and procedures review, and staff interviews, the hospital failed to comply with their policy and procedures to provide an appropriate and timely medical screening examination within its capabilities, including the use of on call physicians, for one of twenty sampled records (Patient #10).

The hospital's failure to provide an appropriate and timely medical screening exam within its capabilities placed the patient at risk for further deterioration of her medical condition including death, and had the potential to affect all patients treated at the hospital.

Findings include:

The "Medical Staff Rules and Regulations" reviewed on 6/21/2017 at 1:30 PM directed " ... On-Call physicians shall respond within 30 minutes to a request to come to the facility to provide further evaluation and/or treatment ..."

Emergency Medical Treatment and Labor Act (EMTALA) Policy and Procedure reviewed on 6/21/2017 at 2:00 PM directed " ... As soon as the on call physician (or the physician requested by the individual) provides or directs treatment of the individual, including giving any orders over the telephone, the individual becomes the responsibility of that physician ... and ... A Provider who is identified on the on-call rotation schedule as being "on-call" to the Communication Center shall be responsible for the following: (C) Coming to the dedicated emergency department (ED) to either provide a medical screening examination or stabilizing treatment to an individual when personnel in the Emergency Department request such assistance whether or not the Provider believes his/her physical presence is medically necessary. The on-call Provider shall arrive at SCH (Stanton County Hospital) within thirty (30) minutes from the time of a request for immediate service unless circumstances beyond the Provider's control prevent the Provider from doing so ..."

Review of a closed medical record showed that patient # 10 presented to the ED on 5/19/17 at 6:40 a.m. complaining of chest pain which began several days ago. Documentation showed the patient stated her chest pain was in the mid chest area and radiated to both arms. ED nurse D connected patient # 10 to a heart monitor which showed a rhyhm that suggested the patient was having a heart attack, an emergency medical condition. The ED nurse D called the on call provider Physician B and received orders to start an IV, obtain blood for lab testing including cardiac markers (enzymes that are used to evaluate heart function), and a 12 lead EKG (a test that checks for problems with the electrical activity of your heart).

ED nurse E attempted to contact Physician B three different times to obtain further orders and provide the results of the EKG tracing which demonstrated an ST elevated myocardial infarction (STEMI, a very serious type of heart attack with a particular EKG heart-tracing pattern indicating blockage in the arteries of the heart) and results of the blood tests which indicated elevated cardiac enzymes demonstrating probable damage to the heart muscle.

At 7:44 a.m., ED nurse E contacted Advanced Practice Registered Nurse (APRN) C who began taking call on 5/19/17 at 7:00 a.m. APRN C arrived in the ED at 8:07 a.m. and assumed care of patient # 10, approximately one and a half hours after the patient presented to the ED with an emergency medical condition. APRN Staff C contacted the on-call cardiologist at Hospital B located approximately 78 miles away. Hospital B's on call cardiologist requested that APRN C order a dose of Heparin 5,000 units (blood thining medication) to be administered to patient # 10 followed by a continuous Heparin infusion at 100 cc/hr before transport to Hospital B's cardiac catheterization lab as soon as possible.

At 9:05 a.m., approximately two and one half hours after arriving at the ED, the ambulance crew arrived to transport patient # 10 to Hospital B's cardiac catheterization lab for stabilizing treatment of her emergency medical condition.

The hospital failed to follow their policy to provide an appropriate medical screening examination within its capabilities, including the use of an on call physician for a patient with an unstable emergency medical condition.

Refer to tag A-2404 for further details.

Based on medical record review, review of medical Staff Rules and Regulations, the facility's EMTALA (Emergency Medical Treatment and Labor Act) policy, On-Call Schedules, and staff interviews the facility failed to provide one individual (patient # 10) with a timely and appropriate examination within its capabilities, including the use of the scheduled on-call physician (Physician B) out of 20 patients reviewed from July 2016 to June 2017.

The findings include:

- Hospital/CAH (Critical Access Hospital) Database Worksheet updated by the CEO on 6/19/2017 revealed the CAH had a dedicated emergency department (ED) and an on-call physician available to come to the emergency department (ED) to provide medical screening examinations and stabilizing treatment within the CAH's capabilities and capacity, or to arrange an appropriate transfer.

- On-Call Schedule reviewed on 6/21/2017 at 1:00 p.m. revealed Physician B as the on call provider scheduled from 7:00 a.m. on 5/18/2017 until 7:00 a.m. on 5/19/2017 and Advanced Practice Registered Nurse C on call from 7:00 a.m. on 5/19/2017 until 7:00 a.m. on 5/20/2017.

- Review of a closed medical record showed that patient # 10 presented to the ED on 5/19/2017 at 6:35 AM complaining of chest pain which started the night before and had progressively worsened. The patient rated her pain a 6 or 7 out of 10 (10 being worst pain ever). Documentation showed the patient's pain was located at the sternum (breastbone located in the center of the chest that protects the vital organs lying behind it - the heart and lungs) and radiated to both arms. Further documentation showed patient # 10 described her pain as sharp, that it "comes and goes", and had a burning sensation causing both arms to ache and tingle. Patient #10 also reported intermittent sweating and that she had a history of smoking and high blood pressure (significant risk factors for a heart attack). ED nurse F placed the patient on the cardiac monitor and documented the patient had an elevated ST segment (a type of heart attack that carries a great risk of disability or death and is diagnosed by the findings from an electrocardiogram, EKG).

- ED nurse D contacted the provider on call, Physician B at 6:43 a.m. Physician B gave orders for laboratory studies, an IV (needle inserted into a vein to administer fluids or medications) and an electrocardiogram. At 6:53 a.m., the lab technician performed the EKG testing and drew the patient's blood for lab testing as ordered. Night shift nurse, ED nurse F gave report to ED nurse E who assumed care of the patient at 7:22 a.m. and performed an assessment. Results of the 12 lead EKG showed an ST elevation in three leads (indicating a possible heart attack) and lab results revealed an elevated Troponin l level (enzyme excreted by the heart when it's damaged). ED nurse E attempted to call Physician B to report the results of the EKG and lab values three times (7:26 a.m., 7:31 a.m., and 7:42 a.m.). Physician B did not answer or respond to the phone calls. ED nurse E documented in the medical record that she left voicemail messages for the physician on all three attempts.

-At 6:55 a.m. patient # 10's blood pressure was abnormally high at 138/101 (normal range between 120-139 / 80-89). At 7:55 a.m., the ED nurse documented patient # 10 complained of chest pain she rated a 6-7 out of 10, and described the patient as anxious. At 8:00 a.m. the ED nurse documented patient # 10's chest pain increased to 8 out of 10 and received Morphine (narcotic pain medication) 5 mg by intravenous (IV) catheter. Documentation showed that patient # 10's blood pressure dropped to an abnormally low level 89/54 at 8:00 a.m., and lower still 69/42 at 8:06 a.m. Further documentation showed that patient # 10 rated her chest pain an 8 out of 10 and was perspiring.

At 8:07 a.m., approximately one and a half hours after patient # 10 presented to the ED, APRN C arrived. Documentation showed that APRN C contacted the on-call cardiologist at Hospital B and received orders to prepare patient # 10 for transfer to Hospital B's cardiac catheterization lab. At 8:30 a.m., the ED nurse documented patient # 10's chest pain had diminished and that the ambulance was at the ED to transport the patient to Hospital B. At 8:59 a.m. documentation showed that patient # 10's blood pressure remained significantly low at 78/49.

During an interview on 6/21/2017 at 11:00 a.m., ED nurse E indicated she tried calling Physician B three times on 5/19/17 to give him the results of the EKG indicating the patient looked like they were having a heart attack and laboratory studies that revealed elevated cardiac enzymes which indicated some heart damage may have occurred, but Physician B did not answer the phone. ED nurse E stated she called Advanced Practice Registered Nurse (APRN) Staff C at 7:44 a.m. to report EKG and lab values. ED nurse E received no new orders. ED nurse E then called the Director of Nursing (DON) to discuss next steps after Physician B failed to return her phone calls. ED nurse E stated the DON instructed her to contact APRN Staff C and request that she assume care of the patient. ED nurse E stated she called APRN C at 7:49 a.m. and that she arrived to the ED at 8:07 a.m. on 5/19/17.

In an interview on 6/21/17 at 11:30 a.m., APRN Staff C stated she was contacted by ED nurse E about 7:45 a.m. on 5/19/17 and was informed about a patient who came to the ED at about 6:30 a.m. complaining of chest pain for two days and that Physician B had provided orders but the nursing staff were unable to reach him to provide the test results. APRN C stated staff contacted me and I told them I would be right there. When I looked at Patient #10's EKG and lab work, I determined she was having a heart attack. I asked the nurse if they had done the standard cardiac care like administer aspirin (the use of aspirin has been shown to reduce mortality from a heart attack) and nitroglycerin (medication that treats and prevents chest pain), and they said no. I ordered four baby aspirin and a nitro tablet. The patient's chest pain got better. I called Acute Care Hospital B's transfer center and spoke with the on-call cardiologist who ordered a heparin bolus (a blood thinner) and heparin maintenance IV drip and directed us to send Patient #10 to their cardiac catheterization lab right away. I started intravenous fluids to help elevate the patient's low blood pressure and ordered another EKG since it had been over an hour since the first one. The patient transferred to Hospital B around 9:05 a.m. I heard later from the cardiologist that Patient #10 underwent a procedure to open a clogged heart vessel. Physician B called me while I was in assessing patient #10 and I told him that the patient was having a heart attack and I was transferring her to another hospital. Physician B stated he should have called me himself, and that he hadn't heard his phone ring. My understanding is if I am on call and get called at 6:55 a.m., I come in unless I call the other provider directly and ask them to take over the patient's care. APRN C confirmed she had not received a telephone call from Physician B requesting her to assume patient # 10's care on 5/19/2017.

Physician Staff B interviewed on 6/21/2017 at 3:30 p.m. confirmed he was on call until 7:00 a.m. on 5/19/2016. Physician B verified he received a call from ED nurse D on 5/19/2016 at 6:43 a.m. informing him there was a patient (Patient #10) in the emergency department complaining of chest pains. Physician B revealed he ordered an IV placement, cardiac labs, and an electrocardiogram (EKG) and requested ED nurse D call APRN C and have them assume care of the patient. ED physician B stated he should have come in to the facility or made the call to the Nurse Practitioner himself. Physician B stated, "It is my fault, it was my responsibility". "I was going to be off on Friday and that may have influenced this situation. I live 20 minutes away, the biggest problem was that I did not call APRN C directly.

ED nurse D interviewed on 6/21/2017 at 2:00 p.m. confirmed she called Physician B on 5/19/2017 at 6:43 a.m. to inform him about a patient that arrived complaining of chest pain. ED nurse D stated Physician B provided orders for the IV, EKG and lab. Soon thereafter, shift changed and ED nurse D reported off to the day shift nurse, ED nurse E. "I asked (Physician Staff B) about giving aspirin and nitroglycerin, but he did not want it given. ED nurse D denied that Physician B requested her to call the mid-level provider (APRN Staff C) to come and see the patient.

The DON interviewed on 6/21/2017 at 9:30 a.m. stated that Physician B was on call when Patient #10 arrived and that ED nurse D denied that Physician B requested her to call the next provider on call with the results of the lab work and EKG. The DON stated that ED nurse D told her that Physician B requested she call him back with the test results. The DON stated that the expectation is for the provider to be on call from 7:00 a.m. to 7:00 a.m. It is up to the provider on call to arrange for the next provider to assume care of a patient.

The "Medical Staff Rules and Regulations" reviewed on 6/21/2017 at 1:30 PM directed "... On-Call physicians shall respond within 30 minutes to a request to come to the facility to provide further evaluation and/or treatment ..."

EMTALA Policy and Procedure reviewed on 6/21/2017 at 2:00 PM directed " ... As soon as the on call physician (or the physician requested by the individual) provides or directs treatment of the individual, including giving any orders over the telephone, the individual becomes the responsibility of that physician ... and ... A Provider who is identified on the on-call rotation schedule as being "on-call" to the Communication Center shall be responsible for the following: (C) Coming to the dedicated emergency department to either provide a medical screening examination or stabilizing treatment to an individual when personnel in the Emergency Department request such assistance whether or not the Provider believes his/her physical presence is medically necessary. The on-call Provider shall arrive at SCH (Stanton County Hospital) within thirty (30) minutes from the time of a request for immediate service unless circumstances beyond the Provider's control prevent the Provider from doing so ..."

According to the most current Acute Coronary Syndrome algorithim from the 2015 American Heart Association, a patient showing ST Elevation on an EKG should receive within 10 minutes of arrival to the ED:
1. Aspirin (160 to 325 mg).
2. Administer nitroglycerin 0.4mg q 5 minutes, either sublingual, spray. Withhold Nitroglycerin on the patient who is experiencing Right Ventricular Infarction.
3. Give the patient a narcotic pain reliever such as Fentanyl, Morphine or Dilaudid if pain is not relieved by nitroglycerin. Morphine is the drug of choice for infarction, but should be used with caution in the unstable angina patient.

Physician Staff B (identified as the on call physician) failed to appear in person to complete a timely medical screening exam (MSE), provide stabilizing treatment and transfer Patient #10.