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Based on hospital policy, medical record review, physician on-call schedules and interviews, the hospital failed to comply with 42 CFR 489.20 and 489.24.

The findings included:

The hospital failed to ensure an on-call physician came to the emergency department to evaluate a patient for one (1) of 27 Emergency Department (ED) records reviewed (Patient #6).

Cross Refer to 2404.

Based on hospital policy and procedure, medical record review, physician on-call schedule and physician interviews, the hospital failed to ensure an on-call physician came to the emergency department to evaluate a patient for one (1) of 27 Emergency Department (ED) records reviewed (Patient #6).

The findings included:

Review of the EMTALA (Emergency Medical Treatment and Labor Act) policy, reviewed 05/2022, revealed "...PURPOSE To ensure that Hospital complies with the requirements of ....'EMTALA' and associated regulations....On-Call Physicians....If a medical screening exam indicates that a person requires the services of an on-call physician, the Hospital shall contact the on-call physician to provide necessary consultation.... The physician must come to the Hospital if requested by the emergency room physician or qualified medical personnel. ..."

Review of the Dedicated Emergency Department (DED) medical record, on 03/13/2024, revealed Patient #6 arrived to Hospital A on 03/10/2023. The ED Provider Note, date of service 03/10/2023 at 2256, revealed "...HISTORY OF PRESENT ILLNESS:.... Presents to the emergency department for pelvic pain. Patient states sudden onset of right pelvic pain at 6:30 this evening, same pain as she had yesterday. Seen yesterday, possible ovarian torsion on ultrasound, was sent to the OR and on review of the op note no torsion was found....Patient writhing around on the bed.... Abdominal:....There is abdominal tenderness (RLQ).... ED COURSE AND TREATMENT....Time... 2142 Comment: Spoke with Dr. (Medical Doctor [MD] #6), OB, states that she heard about the surgery patient had yesterday, patient with normal GYN anatomy, recommends a surgery consult instead. Patient headed to ultrasound .... Time.... 2305 Comment: Spoke with Dr. (Name), OB, about the US results showing no blood flow to the right ovary. She is refusing to see patient at this time. Adamant that patient needs surgical evaluation instead. CT abdomen/pelvis ordered. ..." Review of Consults note by MD #6 (on call physician), date of service 03/10/2023 electronically signed at 2333, revealed "....Contacted by ED attending physician regarding patient return with continued RLQ pain. Reviewed pelvic ultrasound imaging from 3/9/2023 .... Due to the normal appearance of the right ovary, size consistent with that measured one day prior and operative findings suggestive of pelvic adhesive disease and incomplete visualization of the appendix, further evaluation by general surgery and additional imaging is recommended. Ovarian torsion is not the likely source of continued pelvic pain when given normal laparoscopic findings 24 hours ago and consistent size of right ovary on serial ultrasound imaging. No further gyn recommendations pending further imaging/evaluation. If patient evaluated and cleared by general surgery will admit for pain management and serial pelvic ultrasound."

Review of the DED record including the consult note did not reveal if MD #6 came to ED to evaluate Patient #6, as requested. Review of the ED Care Timeline revealed the disposition was set to transfer on 03/11/2023 at 0033. Record review did not reveal whether Patient #6 was examined by a OB-GYN prior to transfer to Hospital C for further examination and treatment.

Review of the Hospital C Medical Record, received 04/12/2024, revealed Patient #6 arrived to Hospital C on 03/11/2023 at 0142 via ambulance. Review of the Triage Notes, timed at 0148, revealed "Pt a transfer from (Hospital A). Pt had ovarian torsion surgery at (Hospital A). Pt having increased pain over the day. Pt here for surgical consult. ..." Review of ED Provider Notes, dated 03/11/2023 at 0142 revealed "... presents to the emergency room as a transfer from (Hospital A) due to concerns of ovarian torsion....Medical Decision Making ....OB team consulted immediately upon arrival for evaluation of patient. OB evaluated at bedside and will admit for serial abdominal exams. ...Will defer further work-up and management to OB team. ..." Review of the H&P Notes, date/time of service 03/11/2023 at 0257, revealed " ...Per discussion with ED provider, OB/GYN not readily available for consultation at (Hospital A), and ED elected for transfer to (Hospital C) for OB/Gyn consultation ...."

Review of Hospital A's physician on-call schedules revealed MD #6 was on-call on 03/10/2023.

Interview on 03/13/2023 at 1715 with MD #6 revealed the statement that MD #6 refused to see Patient #6 was "patently untrue". Interview revealed when MD #6 was made aware of the patient, she contacted MD #5. Interview revealed it was the same complaint as the day before. Interview revealed the ultrasound was not suggestive of torsion, there was no change in size of ovaries. MD #6 thought the issue was non-GYN and wanted "convergent evidence" from a surgeon. Interview revealed MD #6 suggested a surgery consult. Interview revealed MD #6 did not recall whether the physician saw Patient #6 in the ED on 03/10/2023.

Telephone interview on 03/14/2024 at 0915 with MD #7, an ED resident, revealed that upon seeing the ultrasound result, which indicated there was no observed blood flow to the ovary, the physician determined it needed to be addressed right away. Interview revealed MD #7 consulted the on-call GYN, MD #6, who refused to come and indicated the patient was ok re: GYN, that the ED really needed to consult surgery. Interview revealed MD #7 called and spoke directly with MD #6 but did not know MD #6 wrote a consult note. In relation to the surgeon, interview revealed before calling one, they needed a CT. MD #7 stated without a CT and with an ultrasound which suggested no blood flow to an ovary, a surgeon would ask exactly what the ED wanted the surgeon to do. So, MD #7 was working to get the CT and did not know where to go from there. Another ED physician was in the department, not involved in patient care, and MD #7 told this physician about the situation. That physician stated they were going to "carry it forward." Interview revealed MD #7 signed off the case to the attending in the ED, DO #9, and did not know what happened afterwards.

Request to interview DO #9 revealed the physician no longer worked at the hospital and was not available for interview.

Telephone interview on 03/14/2024 at 1205 with MD #5, the OB/GYN physician who performed Patient #'6's surgery on visit #1, revealed the surgery on 03/09/2023 did not show an ovarian torsion. Interview revealed on the patient's second visit, MD #5 was not on-call but thought MD #6 called to discuss the case and looked at the ultrasound. MD #5 stated it was not impossible for there to be torsion a day later even though there was none found in surgery, but with the very same pain and the results of the previous surgery, you would start to look elsewhere.

Interview with MD #8, on 03/14/2024 at 1318, revealed the MD recalled this situation. Interview revealed DO #9 came with a concern that a patient had an ovarian torsion and the on-call physician would not come. MD #8 stated "if that's what you think, we need to kick that up." Interview revealed MD #8 contacted a medical staff leader and someone spoke with the OB-GYN who thought there was low probability of a torsion. Interview revealed DO #9 indicated the work-up was not complete but remained concerned that there was a possible torsion, which was very time sensitive. Interview revealed MD #8 then told DO #9 that if he was not comfortable waiting, to "get the patient somewhere they can manage the patient" and they could "sort out the rest later." MD #8 expressed responsibility for the decision, stating at that moment it was most important to get the patient taken care of. Interview revealed there were not a urologist on call, but at the time the primary concern was a potential ovarian torsion.