HospitalInspections.org

Based on review of medical records, policies/procedures and staff interviews, it was determined that the hospital failed to comply with the provider agreement as defined in ?489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

The findings were:

Refer to findings for Tag A 2404 - On-call Physicians:
The facility failed to maintain an accurate specialist on-call list specifying the doctors that were on call for each specialty each day, rather than posting the name of the practice group or just the numbers of the practice groups' answering services. In addition, the facility failed to have/enforce written policies/procedures that ensured that emergency services were available to meet the needs of patients with emergency medical conditions, when it elected to permit on-call physicians to have simultaneous specialty on-call duties at multiple facilities.

Refer to findings for Tag A 2409 - Appropriate Transfer:
The transferring hospital failed to include in the transfer paperwork the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment, as required.

Based on staff/physician interviews, tours/observations, and review of medical records, policies/procedures and other facility documents,the facility failed to maintain an accurate specialist on-call list specifying the doctors that were on call for each specialty each day, rather than posting the name of the practice group or just the numbers of the practice groups' answering services. In addition, the facility failed to have/enforce written policies/procedures that ensured that emergency services were available to meet the needs of patients with emergency medical conditions, when it elected to permit on-call physicians to have simultaneous specialty on-call duties at multiple facilities. The failures created the situation on 2/25/12 in which sample patient #11 was exposed to the risk of delayed treatment

The findings were:

1. On 3/6/12 the hospital policy/procedure entitled "Treatment and Transfer of Individuals in Need of Emergency Medical Services (EMTALA)" was reviewed and revealed the following findings, in pertinent parts:
"...V. PROCEDURES
...H. On-Call Physicians
1. The Hospital shall maintain an on-call list of physicians, including specialist, who are on the Hospitals's medical staff or who have privileges at the Hospital...Any practitioner who turns call over to another practitioner must be certain the practitioner to who call is being transferred notifies the appropriate personnel so that On-Call lists are updated as appropriate.
2. On-call physicians shall respond to hospital calls for emergency coverage within a reasonable time after receiving communication indicating that their attendance is required. The appropriate time to respond to personally assess the patient will be determined by the ED physician or by predetermined categories that have been developed by specialty divisions as clinically relevant..."

2. Review on 3/5/12 of the Emergency Department On-Call Physician list for February, 2012 revealed the following findings::
- For the Cardiologist on-call there was no designated physician on-call each day. Instead, the list contained the cardiology group's answering service number.
- Additional review revealed that for some specialty categories an individual physician and a contact number listed each day, whereas for other specialties, such as Ear, Nose and Throat, Orthopedic, Family Practice, a community clinic, Pulmonary and on some days, Gastrointestinal, did not have an individual physician designated as being on call. The list contained only a phone number or the number and a group name.
- These findings were confirmed with the unit secretary for the Emergency Department (ED), who helped maintain the log, during an interview on 3/6/12 at approximately 11:45 a.m.. This was also confirmed by the ED manager on 3/5/12 at approximately 10:40 a.m..

3. On 3/6/12 the medical staff rules and regulations were reviewed and revealed the following findings related to on-call physician responsibilities and response time:
"...XII. ROLE OF THE ATTENDING STAFF
A. Call
...3. All appointees to the Medical Staff shall personally address call responsibilities or assure that these obligations are covered by an eligible, alternate Physician with who prior arrangements have been made. Each appointee shall assure timely, adequate professional care for his Patients in the Hospital or for Patients currently under his care presenting themselves to the emergency room and/or obstetrical ward.
4. The Medical Staff shall adopt policies and a method of providing medical coverage in the emergency services area that is acceptable to the Hospital. This shall be in accord with the Hospital's basic plan for the delivery of such services, including on-call availability and the delineation of clinical privileges for all Staff Appointees who render emergency care. The Medical Executive Committee shall supervise call panels through each department.
5. Active Staff will be required to take equal rotations on emergent call rosters to which they have been assigned....
8. ...Physicians on call for the emergency department must respond by phone or in person within 30 minutes..."

4. Review on 3/6/12 of the medical record for sample patient #11 revealed that the patient was brought to the ED by ambulance/paramedics on 2/25/12 at 12:52 p.m. with chest pain. The patient had experienced significant chest pain while dining out with friends and the ambulance/paramedics were called at 12:28 p.m.. The paramedics called in a Cardiac Alert to the hospital ED at 12:47 p.m., and the hospital immediately activated the Cardiac Alert/STEMI (ST-segment elevation myocardial infarction) Alert at 12:47 p.m., in preparation to receive the patient and gather the STEMI/cardiac catheterization team to initiate rapid evaluation and treatment once the patient arrived. As part of the notification, the cardiology group's answering service was called at 12:47 p.m., to summon the on-call cardiologist to initiate an emergent cardiac catheterization. The STEMI team/cardiac catheterization team responded, but multiple calls to the answering service requesting a cardiologist to respond to the Cardiac Alert were not returned. The ED staff and physician initiated assessment and treatment, while they awaited the arrival of the STEMI team and interventional cardiologist. At 1:13 p.m., the ED physician made the decision to consult with an interventional cardiologist at an affiliated hospital and to potentially transfer the patient to that hospital for an emergent cardiac catheterization, since an on-call cardiologist could not be reached. The call was placed at 1:13 p.m., and the interventional cardiologist from the other hospital responded at 1:20 p.m.. After a discussion about initiating thrombolytic therapy on-site versus transferring the patient, the interventional cardiologist recommended emergent transport of the patient by medical helicopter for emergent cardiac catheterization. The helicopter was dispatched at 1:36 p.m., and arrived at 1:50 p.m.. The patient left the hospital by medical helicopter at 2:05 p.m., and arrived at the other facility at 2:16 p.m.. The patient was taken directly to the other hospital's cardiac catheterization lab at 2:26 p.m. to begin the emergent procedure. Review of the medical records from the receiving hospital revealed that the the patient had a clot at the site of a previous stent. The clot was removed and a new medicated stent was placed. The procedure was completed at 3:39 p.m. and the patient tolerated the procedure well. The cardiologist noted that there were no complications during the procedure, but documented the following: "TECHNICAL DIFFICULTIES: Anomalous location of the right coronary artery requiring multiple catheters before an (specific trade name) diagnostic catheter was used." The patient was admitted to the intensive care unit for post-procedure evaluation and care and was discharged home on 2/27/12.

5. On 3/06/12, 11:45 a.m., the unit secretary for the ED was interviewed about his/her efforts to summon the STEMI team for sample patient #11 on 2/25/12. S/he reviewed and confirmed the information on a time line of events related to the incident, which had been prepared by the hospital leadership staff and presented to the surveyors on 3/6/12. S/he confirmed the following timeline, which was a combination of his/her notes, the medical record and a time line based on a hospital management review:
On 2/25/12 at 12:47 p.m., the ED received a call from local fire department stating they were transporting a "Cardiac Alert"/STEMI patient with an estimated arrival time of 5 minutes.
At 12:47 p.m. the hospital Cardiac Alert/STEMI team was paged and called placed to service of interventional cardiologist on-call (MD #1). All of team had responded except by 12:49 p.m., except for cardiologist, who had still not been reached yet. The full catheterization team, excluding the cardiologist, was present at 1: 16 p.m.
The patient arrived in ED at 12:52 p.m. and was seen immediately by the ED physician (MD #6). EKG completed at 12:55 p.m..

Summary of attempts to contact a cardiologist:
12:57 p.m. - Initial call to answering service for MD #1. The unit secretary noted that the answering service did not immediately answer a call, the caller went into a hold mode. S/he stated s/he was on hold with no pick-up by an answering service operator until 12:53 p.m.., at which time she told the operator that they "had a patient with ST elevation in three leads," and that they needed the cardiologist. At 12:59 p.m., the secretary attempted to contact the service again because the cardiologist had not responded. S/he stated that s/he was on hold again for 5 minutes before the operator picked up the call. S/he stated she was on two separate phones at once attempting to get through to the operator. The answering service had stated that MD #1 was on call. At 1 p.m., the ED staff also attempted to contact MD #1 through his/her direct cell phone, which also went into message. They left an urgent contact message for MD #1 on his/her cell phone. At 1: 11 p.m., at the urging of the ED physician (MD #6), s/he attempted to contact the patient's own cardiologist from that group, (MD #3). The answering service stated that MD #3 was not on call and was not available, and a call was placed to his/her back-up (MD #4) at 1:21 p.m...
Attempts were made to contact the cardiologist (MD #1) and his/her back-up MD #2 at 1:11 p.m. and 1:14 p.m., with no pick-up until 1:19 p.m., at which time the answering service stated they would contact MD #2. S/he stated that the nursing supervisor also got on the phone to the answering service to stress the urgency of the situation and the need to reach a cardiologist. As of 1:32 p.m., no call-backs had been received from any of the cardiologists paged. At 1:13 p.m., the ED physician (MD #6) made the decision to contact a cardiologist from an affiliated hospital to try to expedite the cardiac catheterization the patient required. The affiliated hospital cardiologist ( MD #7) returned the call at 1:20 p.m. and accepted the patient for transfer to that hospital. The emergency medical helicopter transport was dispatched at 1: 26 p.m. and arrived to pick up the patient at 1:50 p.m.. The patient departed the ED at 1:56 p.m. and departed the facility grounds at 2:05 p.m.. The secretary stated they finally got a call back from MD #1 at 2:08 p.m.. S/he stated that MD #1 had been performing a cardiac catheterization at another hospital in a neighboring community. At the point that MD #1 called in, the patient had already been transported to the other facility.

The ED unit secretary also stated that the delay in the answering service answering the phone was not unusual. S/he stated that it was not uncommon for the call to go in to a long hold cue before the operator actually came on the phone. S/he also stated that despite the call response delays by the groups answering service, the ED staff had not previously (prior to 2/25/12 incident) had a problem with the cardiologist responding timely.


6. On 03/06/12, at 3:37 p.m. a telephone interview was conducted with MD #6. S/he stated that they had received an advance call from paramedics that they were inbound with sample patient #11 with a Cardiac Alert status. S/he stated the Cardiac Alert/STEMI team was activated and all team responded, except for a cardiologist. S/he stated that the staff were making multiple calls to attempt to contact the cardiologist on call or his/her back-ups, so that the patient could be taken for emergent cardiac catheterization/intervention. S/he stated that s/he became concerned about the delay in initiating cardiac catheterization/intervention because of the lack of response by the on-call cardiologist. S/he stated that s/he initiated contact with the interventional cardiologist at an affiliated hospital. The cardiologist recommended emergent transport to the other hospital, rather than attempting thrombolysis in the ED, so that the other cardiologist could receive the patient as a transfer and perform emergent cardiac catheterization/intervention. Transportation by medical helicopter was arranged and the patient was transported out. S/he stated that the on-call cardiologist (MD #1) called in after the patient had been transported. The cardiologist stated that s/he had been conducting a cardiac catheterization at a hospital in another community. S/he stated that the attempts to contact the cardiologist had gone to the cell phone message system, but because of a cell phone "dead zone" in the catheterization lab, s/he did not get the message on his/her cell phone until s/he left that area of the hospital. MD #6 stated that MD #1 expressed concern and regret that the patient had required transport because of a lack of response from his/her cardiology group.

7. MD #2 was interviewed by telephone on 3/7/12 at approximately 1 p.m.. During the interview, s/he stated that s/he was not a member of the cardiology group, but shared an on-call schedule with that group and was one of 3 physicians (MD #1, MD #2 and MD #4) for the weekend that included the 25th of February, 2012. S/he stated that s/he was to be on-call in the evening, but was in his/her office and would have been available to respond to the need at the hospital, but did not get a call about the Cardiac Alert for sample patient #11. S/he stated that s/he had his/her own answering service, but was contacted that day by the cardiology group's answering services asking if s/he knew where MD #1 was because the ED physician from the hospital in another community needed to discuss a cardiac case. MD #2 stated that s/he told the answering services that MD #1 was at that hospital in the catheterization ("cath") lab conducting a "cath" at the time. S/he stated that s/he called the called the "cath" lab and told the technician to contact the ED there because the physician was trying to reach MD #1 to discuss a case. MD #2 stated that the answering service never mention the Cardiac Alert or the urgent need to contact the hospital where sample patient #11 was located and requiring an urgent cardiac consult and catheterization. S/he stated that even though s/he was not on call during the day, s/he would have come and done the procedure. S/he stated: "I was in my office and could have come if I had known; this is what I do." S/he stated that interventional cardiology was his/her area and s/he was always ready to do a catheterization when a patient needed it. S/he expressed frustration that s/he was available and could have helped the patient, but did not get notified about sample patient #11.

8. On 3/07/2012 at approximately 12:30 p.m., a telephone interview with MD #4 was conducted. S/he stated that s/he was on call on Friday, 2/24/12. For that weekend, s/he stated that the three cardiologists on-call that weekend were MD #1, MD #2 and him/herself (MD #4). S/he stated that the cardiology group made their schedule a month ahead of time and that there were always three people on call. S/he stated that they would talk to each other and split up the weekend as to who was's going to be primary or back-up interventionalist, and then they would convey that information to the answering service. S/he stated that s/he was paged on 2/25/12 and that s/he called the answering service back and told them that s/he had been on call the night before and was not on call at that time. S/he told the operator that s/he thought MD #1 was on-call, and was in the "cath lab" at the hospital in another community. S/he stated that /she later learned that the hospital caring for sample patient #11 was trying to reach the cardiologist on-call at approximately that time. S/he stated that the service did not mention a Cardiac Alert or emergent need to contact MD#1 or any of the weekend call group. S/he stated that MD #1 used a cell phone to get calls and often was not able to get calls in the "cath lab" at that hospital.
MD #4 stated s/he (MD #4) routinely has his/her cell phone set up so that if s/he does not answer the phone, it will roll over to his/her digital pager so s/he never misses a call. S/he stated s/he prefers that the answering service just put the phone number in and not leave a voice mail because "they don't always get the information right." S/he stated that different doctors have different ways they prefer to be notified, but s/he felt that changing to digital pagers was more reliable with all of the "dead zones" for cell phone coverage in many of the hospitals that they cover.

9. On 3/05/12 at, 1:30 p.m. an interview was conducted with the chief nursing officer (CNO) and the chief medical officer (CMO) regarding the care of sample patient #11. They stated the that the patient was seen in the hospital on Saturday the 2/25/12. They became aware of the failure of the cardiology on-call system on the following Monday, 2/27/12, at their weekly Monday morning clinical review meeting. They stated that they had been working since then with the practice manager and a physician administrator (MD #5) of the cardiology group to try to determine why the on-call system failed and how to correct the problem. They stated that they had made the determination that going forward, they would always tell the answering service that they had a "Cardiac Alert," so there would be no confusion that they needed an interventional cardiology response immediately. The CNO stated that the staff in the ED had already been instructed about that change. (That was later confirmed during the interview with the ED unit secretary on 3/06/12, 11:45 a.m..) The CNO and CMO also stated that the cardiology group was changing their instructions to their answering service about how to respond to a "Cardiac Alert" call. In addition, the cardiology group was also discussing other changes, such as a review of the overall performance of the answering service and use of digital pagers to improve timely communication between physicians and the answering service. On 3/6/12, the CNO provided an e-mail from MD #5 describing a Cardiac Alert that had been paged at the hospital that morning using the new system and that it had resulted in the interventional cardiologist (him/herself, MD #5) reporting to the hospital in 20 minutes. S/he stated that s/he was satisfied with the effectiveness of the new system, and that it demonstrated that the ED staff and the answering service were utilizing the new system. When asked about the feedback from ED staff that there were routine delays in actually getting to talk to an operator when contacting that group's answering service, they stated that the group was also looking at the ED having actual phone or pager numbers or a "back-door" direct line to the doctor or the service, to avoid going into a waiting cue in an emergency situation. They also acknowledged that the group had not been providing the name of the doctor on call, but that that practice was going to change for that group and any other group, going forward.

10. On 3/07/12 at approximately, 11:45 AM the Chief Medical Officer was interviewed about the fact that the physician (MD #6) did not seem to be aware of the requirements around reporting information to the receiving hospital when an on-call physician had failed to respond/report when called, resulting in the transport. When asked if the physicians were routinely provided with training about EMTALA requirements, s/he stated they were not and asked to be shown a regulation that required physician training.


11. On 3/8/12 at approximately 9 a.m., the CNO was interviewed about actions taken to correct the on-call problem for the cardiology group and other identified on-call problems. S/he stated that the hospital was working with all of the on-call groups, including cardiology, to have the name of the specific on-call physicians available on the ED list, rather than just the name of the group and a phone number. In addition, the informal training of ED staff to notify the cardiology group about a cardiac emergency using the language "Cardiac Alert" when the group's answering service. S/he also stated that the cardiology group was working with their answering service to address communication problems and delays in answering the call with an operator. S/he stated the group has already converted the on-call physicians using digital pagers that are more reliable for receiving calls from the answering service or the hospitals. S/he also stated that the hospital had previously hired its own cardiologist, who will begin on 3/9/12. That interventional cardiologist will be available on-call for an average of five days per week. S/he stated that the hospital and the cardiology group with continue to look at additional ways to improve access to the cardiologists.

Based on staff/physician interviews and review of medical records and other facility documents, the facility failed to ensure that the specialty on-call physician was available to provide emergency cardiac catheterization/interventions to stabilize the cardiac condition for sample patient #11. Because the specialty on-call system failed to provide emergency cardiac intervention for the patient, a transport to another hospital had to be arranged, creating a delay in the patient receiving cardiac catheterization/interventions. The failure created the potential for negative patient outcome.

The finding were:

Reference the findings for Tag A 2404 for findings related to the delay in cardiac catheterization for sample patient #11.

Based on review of medical records and facility documents, and staff/physician interviews, the transferring hospital failed to include in the transfer paperwork the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment for sample patient #11, as required. In addition, the hospital failed to ensure that the physician documented his/her determination of the appropriate mode of transport, equipment, and transporting professionals to be used, for the transfer of sample patient #2.

The findings were:

1. Sample #11: Information about on-call doctor(s) who failed to respond was not provided on transfer sheet, as required:

On 3/6/12 the hospital policy/procedure entitled "Treatment and Transfer of Individuals in Need of Emergency Medical Services (EMTALA)" was reviewed and revealed the following findings, in pertinent parts:
"...V. PROCEDURES
...F. An Individual Who Has An Emergency Medical Condition....
3. When the Hospital transfers an individual with an unstable emergency medical condition to another facility the transfer shall be carried out in accordance with the following procedures....d. If an on-call physician has refused or fails to appear within a reasonable time after being requested to provide necessary stabilizing treatment and the transfer is necessary as a result of the unavailable on-call physician, the emergency department physician or designee shall provide the name and address of that physician to the receiving facility on the EMTALA Transfer Form..."
...H. On-Call Physicians...
3. If a scheduled on-call specialist or sub-specialist fails to respond, the emergency department physician or designee shall reasonably attempt to obtain the services of another appropriate specialist or sub-specialist in accordance with the Hospital's medical staff bylaws, enlisting the support of medical staff officers as deemed appropriate. If the necessary on-call services remain unavailable despite these efforts, and the individual requires a transfer in order to obtain the necessary services at another facility, the emergency department physician or designee shall document the name and address of the on-call physician who failed to appear, on the EMTALA Transfer Form (Exhibit A). In addition, the emergency department physician or designee shall inform the president of the medical staff and Chief Medical Officer of the on-call physician's failure to appear..."

Reference Tag A 2404 for findings in the patient record for sample #11, in which the patient required emergent cardiac catheterization/interventions to stabilize his/her condition, The hospital staff were unable to speak to an on-call cardiologist until after the patient had already been transported to another facility for a cardiac catheterization.

Review of the transfer form in sample record #11, revealed that the 2-paged certification form signed by the ED physician (MD #6) had the section "On-Call Physician refused or failed to appear (On-Call Physicians's Name and Address): (with a line for that information)," was checked, but no information was provided, as required.

During a telephone interview with MD #6 on 03/06/2012, 3:50 p.m., when asked about the section on the certification/transfer form that stated "On-Call Physician refused or failed to appear (On-Call Physicians's Name and Address): (with a line for that information) ," which had been checked on the form s/he had signed for sample patient #11, MD #6 stated that the nurse filled out a lot of the form and s/he (MD #6) was unaware that the box had been checked or that the information about the doctor(s) was to be provided on the transfer sheet to the receiving facility.

2. Sample patient #2: Incomplete information about level of medical support needed for transport:

On 3/7/12 the hospital policy/procedure entitled "Treatment and Transfer of Individuals in Need of Emergency Medical Services (EMTALA)" was reviewed and revealed the following findings, in pertinent parts:
"...F. An Individual Who Has An Emergency Medical Condition
...3. When the Hospital transfers an individual with an unstablized emergency medical condition to another facility the transfer shall be carried out in accordance with the following procedures....
e. The transfer shall be effected through appropriately trained professionals and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer. The physician is responsible for determining the appropriate mode of transport, equipment, and transporting professionals to be used for the transfer...."

Review of sample record #2 on 3/6/12 revealed the following findings:

On 12/21/11 at 17:20 (5:20 p.m.), sample patient #2 arrived at the OB department per request of his/her physician for pre-term labor at 23 6/7 weeks gestation. At 17:50 (5:50 p.m.) it was determined that the patient needed to be transferred to a Tertiary Care Center for a higher level of obstetrical/newborn care. Review of the EMTALA transfer Form Page 2 of 2, Section D TRANSPORTATION, Mode of Transport, Transport Agency was checked, but the line provided next to it was blank. Later in that section, it did state that the patient was accompanied by an RN. The information under "Transportation" did not state the mode of transport or the level of transport (BLS or ACLS). Review of the nurses note, dated 12/21/11 at 19:18 (7:18 p.m.), stated that the patient was transported by a medical helicopter team.

Based on review of medical records, policies/procedures and staff interviews, it was determined that the hospital failed to comply with the provider agreement as defined in ?489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

The findings were:

Refer to findings for Tag A 2404 - On-call Physicians:
The facility failed to maintain an accurate specialist on-call list specifying the doctors that were on call for each specialty each day, rather than posting the name of the practice group or just the numbers of the practice groups' answering services. In addition, the facility failed to have/enforce written policies/procedures that ensured that emergency services were available to meet the needs of patients with emergency medical conditions, when it elected to permit on-call physicians to have simultaneous specialty on-call duties at multiple facilities.

Refer to findings for Tag A 2409 - Appropriate Transfer:
The transferring hospital failed to include in the transfer paperwork the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment, as required.

Based on staff/physician interviews, tours/observations, and review of medical records, policies/procedures and other facility documents,the facility failed to maintain an accurate specialist on-call list specifying the doctors that were on call for each specialty each day, rather than posting the name of the practice group or just the numbers of the practice groups' answering services. In addition, the facility failed to have/enforce written policies/procedures that ensured that emergency services were available to meet the needs of patients with emergency medical conditions, when it elected to permit on-call physicians to have simultaneous specialty on-call duties at multiple facilities. The failures created the situation on 2/25/12 in which sample patient #11 was exposed to the risk of delayed treatment

The findings were:

1. On 3/6/12 the hospital policy/procedure entitled "Treatment and Transfer of Individuals in Need of Emergency Medical Services (EMTALA)" was reviewed and revealed the following findings, in pertinent parts:
"...V. PROCEDURES
...H. On-Call Physicians
1. The Hospital shall maintain an on-call list of physicians, including specialist, who are on the Hospitals's medical staff or who have privileges at the Hospital...Any practitioner who turns call over to another practitioner must be certain the practitioner to who call is being transferred notifies the appropriate personnel so that On-Call lists are updated as appropriate.
2. On-call physicians shall respond to hospital calls for emergency coverage within a reasonable time after receiving communication indicating that their attendance is required. The appropriate time to respond to personally assess the patient will be determined by the ED physician or by predetermined categories that have been developed by specialty divisions as clinically relevant..."

2. Review on 3/5/12 of the Emergency Department On-Call Physician list for February, 2012 revealed the following findings::
- For the Cardiologist on-call there was no designated physician on-call each day. Instead, the list contained the cardiology group's answering service number.
- Additional review revealed that for some specialty categories an individual physician and a contact number listed each day, whereas for other specialties, such as Ear, Nose and Throat, Orthopedic, Family Practice, a community clinic, Pulmonary and on some days, Gastrointestinal, did not have an individual physician designated as being on call. The list contained only a phone number or the number and a group name.
- These findings were confirmed with the unit secretary for the Emergency Department (ED), who helped maintain the log, during an interview on 3/6/12 at approximately 11:45 a.m.. This was also confirmed by the ED manager on 3/5/12 at approximately 10:40 a.m..

3. On 3/6/12 the medical staff rules and regulations were reviewed and revealed the following findings related to on-call physician responsibilities and response time:
"...XII. ROLE OF THE ATTENDING STAFF
A. Call
...3. All appointees to the Medical Staff shall personally address call responsibilities or assure that these obligations are covered by an eligible, alternate Physician with who prior arrangements have been made. Each appointee shall assure timely, adequate professional care for his Patients in the Hospital or for Patients currently under his care presenting themselves to the emergency room and/or obstetrical ward.
4. The Medical Staff shall adopt policies and a method of providing medical coverage in the emergency services area that is acceptable to the Hospital. This shall be in accord with the Hospital's basic plan for the delivery of such services, including on-call availability and the delineation of clinical privileges for all Staff Appointees who render emergency care. The Medical Executive Committee shall supervise call panels through each department.
5. Active Staff will be required to take equal rotations on emergent call rosters to which they have been assigned....
8. ...Physicians on call for the emergency department must respond by phone or in person within 30 minutes..."

4. Review on 3/6/12 of the medical record for sample patient #11 revealed that the patient was brought to the ED by ambulance/paramedics on 2/25/12 at 12:52 p.m. with chest pain. The patient had experienced significant chest pain while dining out with friends and the ambulance/paramedics were called at 12:28 p.m.. The paramedics called in a Cardiac Alert to the hospital ED at 12:47 p.m., and the hospital immediately activated the Cardiac Alert/STEMI (ST-segment elevation myocardial infarction) Alert at 12:47 p.m., in preparation to receive the patient and gather the STEMI/cardiac catheterization team to initiate rapid evaluation and treatment once the patient arrived. As part of the notification, the cardiology group's answering service was called at 12:47 p.m., to summon the on-call cardiologist to initiate an emergent cardiac catheterization. The STEMI team/cardiac catheterization team responded, but multiple calls to the answering service requesting a cardiologist to respond to the Cardiac Alert were not returned. The ED staff and physician initiated assessment and treatment, while they awaited the arrival of the STEMI team and interventional cardiologist. At 1:13 p.m., the ED physician made the decision to consult with an interventional cardiologist at an affiliated hospital and to potentially transfer the patient to that hospital for an emergent cardiac catheterization, since an on-call cardiologist could not be reached. The call was placed at 1:13 p.m., and the interventional cardiologist from the other hospital responded at 1:20 p.m.. After a discussion about initiating thrombolytic therapy on-site versus transferring the patient, the interventional cardiologist recommended emergent transport of the patient by medical helicopter for emergent cardiac catheterization. The helicopter was dispatched at 1:36 p.m., and arrived at 1:50 p.m.. The patient left the hospital by medical helicopter at 2:05 p.m., and arrived at the other facility at 2:16 p.m.. The patient was taken directly to the other hospital's cardiac catheterization lab at 2:26 p.m. to begin the emergent procedure. Review of the medical records from the receiving hospital revealed that the the patient had a clot at the site of a previous stent. The clot was removed and a new medicated stent was placed. The procedure was completed at 3:39 p.m. and the patient tolerated the procedure well. The cardiologist noted that there were no complications during the procedure, but documented the following: "TECHNICAL DIFFICULTIES: Anomalous location of the right coronary artery requiring multiple catheters before an (specific trade name) diagnostic catheter was used." The patient was admitted to the intensive care unit for post-procedure evaluation and care and was discharged home on 2/27/12.

5. On 3/06/12, 11:45 a.m., the unit secretary for the ED was interviewed about his/her efforts to summon the STEMI team for sample patient #11 on 2/25/12. S/he reviewed and confirmed the information on a time line of events related to the incident, which had been prepared by the hospital leadership staff and presented to the surveyors on 3/6/12. S/he confirmed the following timeline, which was a combination of his/her notes, the medical record and a time line based on a hospital management review:
On 2/25/12 at 12:47 p.m., the ED received a call from local fire department stating they were transporting a "Cardiac Alert"/STEMI patient with an estimated arrival time of 5 minutes.
At 12:47 p.m. the hospital Cardiac Alert/STEMI team was paged and called placed to service of interventional cardiologist on-call (MD #1). All of team had responded except by 12:49 p.m., except for cardiologist, who had still not been reached yet. The full catheterization team, excluding the cardiologist, was present at 1: 16 p.m.
The patient arrived in ED at 12:52 p.m. and was seen immediately by the ED physician (MD #6). EKG completed at 12:55 p.m..

Summary of attempts to contact a cardiologist:
12:57

Based on staff/physician interviews and review of medical records and other facility documents, the facility failed to ensure that the specialty on-call physician was available to provide emergency cardiac catheterization/interventions to stabilize the cardiac condition for sample patient #11. Because the specialty on-call system failed to provide emergency cardiac intervention for the patient, a transport to another hospital had to be arranged, creating a delay in the patient receiving cardiac catheterization/interventions. The failure created the potential for negative patient outcome.

The finding were:

Reference the findings for Tag A 2404 for findings related to the delay in cardiac catheterization for sample patient #11.

Based on review of medical records and facility documents, and staff/physician interviews, the transferring hospital failed to include in the transfer paperwork the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment for sample patient #11, as required. In addition, the hospital failed to ensure that the physician documented his/her determination of the appropriate mode of transport, equipment, and transporting professionals to be used, for the transfer of sample patient #2.

The findings were:

1. Sample #11: Information about on-call doctor(s) who failed to respond was not provided on transfer sheet, as required:

On 3/6/12 the hospital policy/procedure entitled "Treatment and Transfer of Individuals in Need of Emergency Medical Services (EMTALA)" was reviewed and revealed the following findings, in pertinent parts:
"...V. PROCEDURES
...F. An Individual Who Has An Emergency Medical Condition....
3. When the Hospital transfers an individual with an unstable emergency medical condition to another facility the transfer shall be carried out in accordance with the following procedures....d. If an on-call physician has refused or fails to appear within a reasonable time after being requested to provide necessary stabilizing treatment and the transfer is necessary as a result of the unavailable on-call physician, the emergency department physician or designee shall provide the name and address of that physician to the receiving facility on the EMTALA Transfer Form..."
...H. On-Call Physicians...
3. If a scheduled on-call specialist or sub-specialist fails to respond, the emergency department physician or designee shall reasonably attempt to obtain the services of another appropriate specialist or sub-specialist in accordance with the Hospital's medical staff bylaws, enlisting the support of medical staff officers as deemed appropriate. If the necessary on-call services remain unavailable despite these efforts, and the individual requires a transfer in order to obtain the necessary services at another facility, the emergency department physician or designee shall document the name and address of the on-call physician who failed to appear, on the EMTALA Transfer Form (Exhibit A). In addition, the emergency department physician or designee shall inform the president of the medical staff and Chief Medical Officer of the on-call physician's failure to appear..."

Reference Tag A 2404 for findings in the patient record for sample #11, in which the patient required emergent cardiac catheterization/interventions to stabilize his/her condition, The hospital staff were unable to speak to an on-call cardiologist until after the patient had already been transported to another facility for a cardiac catheterization.

Review of the transfer form in sample record #11, revealed that the 2-paged certification form signed by the ED physician (MD #6) had the section "On-Call Physician refused or failed to appear (On-Call Physicians's Name and Address): (with a line for that information)," was checked, but no information was provided, as required.

During a telephone interview with MD #6 on 03/06/2012, 3:50 p.m., when asked about the section on the certification/transfer form that stated "On-Call Physician refused or failed to appear (On-Call Physicians's Name and Address): (with a line for that information) ," which had been checked on the form s/he had signed for sample patient #11, MD #6 stated that the nurse filled out a lot of the form and s/he (MD #6) was unaware that the box had been checked or that the information about the doctor(s) was to be provided on the transfer sheet to the receiving facility.

2. Sample patient #2: Incomplete information about level of medical support needed for transport:

On 3/7/12 the hospital policy/procedure entitled "Treatment and Transfer of Individuals in Need of Emergency Medical Services (EMTALA)" was reviewed and revealed the following findings, in pertinent parts:
"...F. An Individual Who Has An Emergency Medical Condition
...3. When the Hospital transfers an individual with an unstablized emergency medical condition to another facility the transfer shall be carried out in accordance with the following procedures....
e. The transfer shall be effected through appropriately trained professionals and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer. The physician is responsible for determining the appropriate mode of transport, equipment, and transporting professionals to be used for the transfer...."

Review of sample record #2 on 3/6/12 revealed the following findings:

On 12/21/11 at 17:20 (5:20 p.m.), sample patient #2 arrived at the OB department per request of his/her physician for pre-term labor at 23 6/7 weeks gestation. At 17:50 (5:50 p.m.) it was determined that the patient needed to be transferred to a Tertiary Care Center for a higher level of obstetrical/newborn care. Review of the EMTALA transfer Form Page 2 of 2, Section D TRANSPORTATION, Mode of Transport, Transport Agency was checked, but the line provided next to it was blank. Later in that section, it did state that the patient was accompanied by an RN. The information under "Transportation" did not state the mode of transport or the level of transport (BLS or ACLS). Review of the nurses note, dated 12/21/11 at 19:18 (7:18 p.m.), stated that the patient was transported by a medical helicopter team.