HospitalInspections.org

Based on review of hospital policy, medical staff rules and regulations, on-call schedules, medical record review, and staff and physician interviews the hospital failed to ensure a general surgeon on call for general surgical specialty in the dedicated emergency department (DED) responded to a request from the DED physician to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition for 1 of 2 sampled DED patients needing surgery (Patient #23).

~cross refer to 482.24 (j)(1-2) On Call Physicians - Tag A2404

Based on review of hospital policy, medical staff rules and regulations, on-call schedules, medical record review, and staff and physician interviews the hospital failed to ensure a general surgeon on call for general surgical specialty in the dedicated emergency department (DED) responded to a request from the DED physician to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition for 1 of 2 sampled DED patients needing surgery (Patient #23).

The findings include:

Review of the hospital's policy, "Emergency Medical Treatment and Patient Transfer", revised 03/2002, revealed, "...For the purpose of this emergency medical treatment and transfer policy, the following terms shall have the meaning defined in 42 C.F.R. ' 489.24(b): 1. Capacity means the ability of the Hospital to accommodate the individual requesting examination or treatment of the transferred individual. Capacity encompasses such things as numbers and availability of qualified staff...3. Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including pain...) such that the absence of immediate medical attention could reasonably be expected to result in: A. placing the health of the individual ...in serious jeopardy; B. serious impairment to bodily functions; or C. serious dysfunction of any bodily organ or part; or ...II. Transfer of Individuals After Stabilization Transfer to another medical facility by appropriate means may occur after stabilization, under the following circumstances: 1. Specialized Treatment. The individual requires specialized treatment not available at the Hospital...III. Administrative Procedures ...B. On-Call List The Hospital shall maintain a list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition...".

Review of the medical staff's Rules and Regulations, revised 12/07/2012, revealed, "...6.2 CONSULTATIONS, REFERRALS & EMERGENCY DEPARTMENT CALL 6.2 (f) All members of the Active Staff shall participate in the on-call backup to the Emergency Department as required by the Board, upon recommendation of the MEC (Medical Executive Committee). ...Physicians called are required to respond to Emergency Department call by telephone within ten (10) minutes. If requested to come in, they are required to do so within thirty (30) minutes after responding by telephone...".

Review of the DED's specialty on-call list for December 2012 revealed Physician A (General Surgeon) was listed as the on-call general surgeon for 12/29/2012.

Closed medical record review of Patient #23 revealed a 69 year-old male who presented to the hospital's DED on 12/29/2012 at 0816 with abdominal pain, nausea and vomiting. Record review revealed the patient was triaged at 0820. Review of the triage notes revealed the patient's BP (blood pressure) was 167/116 (elevated) and abdominal pain described as 6 of 10 (on a scale of 1 to 10, with 10 being the most severe). Record review revealed an MSE (medical screening exam) was started at 0830 by a DED physician. Record review revealed the physician ordered and the nurse administered Zofran (anti-nausea medication) 8 mg (milligrams) IV (intravenously), Morphine (narcotic pain medication) 10 mg IV and Valium (muscle relaxant) 5 mg IV at 0944. Record review revealed a CT (computerized tomography) scan with contrast dye of the abdomen/pelvis was ordered and completed at 1323. Record review revealed the radiologist's impression of the CT scan was "small bowel obstruction secondary to an incarcerated small bowel loop in a ventral hernia". Further record review revealed Physician A (General Surgeon) was in the DED at the patient's bedside at 1500. Further review revealed nurse's notes at 1500, "(Physician A) in. Will take to OR. Orders written. Patient would not sign OP permit until he talks with his wife. Unable to reach. Left message to call ASAP (as soon as possible). Called (Physician A) for same". Further record review revealed Zofran 8 mg IV was ordered and administered at 1710. Further review revealed nurses' notes at 1807, "Pt signed AMA form pt competent, verbalized understanding of situation...". Further record review revealed patient left the DED at 1800. Further record review of Patient #23 revealed he presented to DED on 12/29/2012 at 1927 (1 hour, 27 minutes after leaving AMA[Against Medical Advice]) with chief complaint of nausea, vomiting and abdominal pain. Record review revealed Patient #23 was triaged at 1943 and vital signs were obtained as follows: BP 159/111 (elevated), heart rate 99 (rapid) and abdominal pain intensity of 5 (on a scale of 1 to 10, with 10 being the most severe). Record review revealed a nurse's note at 2000, "...Was here earlier today and was seen by surgeon. They wanted to do surgery, but patient would not sign the permit without his wife. He was discharged by surgeon home because he would not sign permit. Presents now with continued nausea and abdominal pain. He states he thought the surgery was going to be tomorrow and he was not comfortable having it done without his wife being here...". Further record review revealed an MSE was started at 2137. Further record review revealed nurse's notes at 2025, "(Physician B) called to speak with (Physician A) about patient and he again refused the patient". Review of the DED's physician (Physician B) dictated notes at 2217 revealed, "Pt was here earlier dx (diagnosed) with incarcerated hernia, left and came back with same, surgeon refused to see again, pt was given pain medication and would be transferred to (Hospital B)". Record review revealed Patient #23 received Lopressor (anti-hypertensive medication) 5 mg IV at 2249. Further record review revealed, "Patient left the department at 12/29/2012 at 2310. Transferred disposition: (Hospital B) ...Patient was transferred by Ground EMS (Emergency Medical Services...".

Interview on 02/13/2013 at 1300 with the hospital's chief nursing officer revealed she was the administrator on-call on 12/29/2012. Interview further revealed, "I received a call from the House Supervisor. She told me we had a patient here (in the DED) who had signed out AMA earlier had come back and (Physician A) refused to see him. I called (Physician A) and asked him what was going on with (Patient #23). He said he (Patient #23) needed surgery. When the nurses went to consent for surgery, he (Patient #23) was not comfortable signing the consent without his wife present. When (Physician A) was called back, he said he wasn't coming to see (Patient #23) because he didn't feel comfortable operating on him. I told him it was an EMTALA violation. The ED doc (Physician B) called (Physician A) again and he refused to come but offered to call and get him a doctor at (Hospital B). I called the CEO to make her aware of the situation".

Interview on 02/13/2013 at 1315 with Physician A revealed he was on-call for general surgery for the DED on 12/29/2012. Interview revealed, "The ED physician called me about a patient with an incarcerated hernia. I came in to see him between 3 and 5 p.m. I told him he had an early hernia that I could do laparoscopically (surgical operation performed in the abdomen or pelvis through small incisions with the aid of a camera can be used to diagnose of perform surgery). I called the OR (operating room) staff. When they went to get him to sign the consent, he would not sign it because his wife wasn't there with him. He had received pain meds and he wasn't in any pain. I sent the OR staff home and I left. I got a call back around 7 pm from the House Supervisor then the ED doc (Physician B). He asked me why I wouldn't come in and I told him he didn't want our surgery this afternoon and he may be better served in (Hospital B). I then called (Chief of Staff - Physician C). He wasn't sure what to do. I'm not sure if he said EMTALA. I never knew as much about EMTALA as I do now. I understand it now". The facility failed to ensure that Physician C followed the hospital ' s Policy and Procedure and Medical Staff Rules and regulations related to failing to come to the emergency department when requested by the ED physician, and failing to provide treatment necessary to stabilize patient (#23) who had an identified emergency medical condition on12/29/2013.


Interview on 02/13/2013 at 1345 with Physician C revealed he is the hospital's chief of the medical staff. Interview revealed, "I received a call from (Physician B) early evening of December 29. He wasn't sure by him not coming to the ED (emergency department) would be an EMTALA violation. He was uncomfortable operating on him (Patient #23) because he didn't want surgery that afternoon. I told him it wasn't an EMTALA violation but I wasn't sure. I called (Chief Nursing Officer) because she was the administrator on call. She told me she didn't think it was an EMTALA violation either. I called him back and told him what I had discussed with (Chief Nursing Officer). After speaking with our attorney, I wish I had told him differently".

Interview on 02/13/2013 at 1515 with Physician B revealed he was the DED physician on 12/29/2012 beginning at 1900. Interview revealed, "I called (Physician A) to come in to see (Patient #23) because he was on call for general surgery. He wouldn't come in. I went to Administration and they asked me to transfer the patient to (Hospital B). I just wanted (Physician A) to come in and see the patient. It was up to him to decide about surgery". Interview further revealed, "there was a conflict about whether him not coming was an EMTALA violation. I thought he should have come in to see the patient".

NC00085492
NC00087005