HospitalInspections.org

Based on medical record review, ED On-Call List, facility policies, and staff interviews, the facility failed to be in compliance with 489.24 through 489.20(l)

Cross Reference:


489.20(r)(2) and 489.24(j)(1-2) On Call Physician
489.24(r) and 489.24(c) Appropriate Medical Screening
489.24(e)(1)-(2) Appropriate Transfer

Based on reviews of medical records, policy and procedure, on-call schedules, Joint Medical Staff Rules and Regulations and staff interviews the facility failed to utilize their OB-GYN on -call physician who was listed on the hospital' s on-call schedule and was available to provide treatment necessary after the initial examination to stabilize an individual with an emergency medical condition who was receiving services with the resources available at the hospital for 1 (#3) of 20 sampled patient medical records reviewed.
Findings include:
The hospital's Administrative Policy titled, "EMTALA-Emergency Medical Treatment and Active labor Act", Policy Number: 1102-A effective 10/14/2014 was reviewed. The policy indicated in part, C. Stabilization and Treatment ....2. For all patients presenting to the Emergency Department: An Emergency Department physician shall be responsible for the general care of all patients presenting to the Emergency Department until the patient ' s private physician or the on-call physician assumes that responsibility ...5. The physician listed in the on-all rotation schedule shall be contacted to provide the necessary consultation for treatment for the patient IF: a. the patient does not request a specific physician. "
St. Joseph' s /Candler Joint Medical Staff Rules and Regulations January 2014, Part nineteen: Joint Department of OB/GYN Rules were reviewed. The Rules specified in part, "19.1 ... Only emergency and consulting services are provided at St. Joseph's Hospital, ... 19.3.5 ...In Addition, Active and Provisional members of the Department may be assigned on a monthly rotation basis, to the service list for Emergency Department coverage for obstetrical, gynecological problems. The physician who is on call will be the backup for seeing new consults at ...St. Joseph's Hospitals ...19.3.6 When an OB and a GYN only MD are sharing ED call: Any questionable ectopic pregnancy and any patient with a gestation of 11.6 weeks or less (defined by LMP (last Menstrual Period) or sonogram), the on-call physician should be called."
Review of the OBG ( OB and Gyn- is a specialty with a combines focus on pregnancy, delivery, and female sexual and reproductive health) "ED Call Schedule" for December 2014, revealed that an OB-Gyn physician had been assigned every day of the month (days 1-31).
The patient was triaged on 12/26/2014 at 8:05 PM, and assigned a level 3. The nurse noted the patient reported a cough and headache since Tues (Tuesday), and lower abdominal pain started today. No urinary symptoms, sore throat, or nasal congestion. Vital signs (VS) at 8:05 p.m. were: Temperature 97.5 L (low) -Heart rate 95- Respiratory Rate -18 Blood Pressure- 123/69, pain 7/10 (pain scale 0-10 with 10 being the worst pain).

The patient received an examination by ED (Emergency Department) DO (Doctor of Osteopathic Medicine) #1 on 12/26/2014 at 9:29 PM. The DO documented that the patient complained of a cough, muscle aches, a positive home pregnancy test, vaginal spotting, and intermittent lower abdominal pain. Further review indicated the patient had "Additional problems: Anemia, Asthma and Healing wound. Surgeries: C-Section." Further documentation revealed the Physical examination findings in part, Respiratory: No respiratory distress. Mild bilateral rhonchi (respiratory sounds somewhat like snoring, usually caused by secretions in bronchial airways) present posteriorly. Abdomen: Soft and nontender. The ED DO documented at 10:10 p.m., that the results were reviewed with the patient in detail and at 11:50: The physical exam(examination) findings had improved. "No Active bleeding in the ER ...Will transfuse with unmatched blood ..."
Physician orders on 12/26/14 at 7:45 PM included "Urgent" laboratory tests (UA (urinalysis), CBC (complete blood count), flu swab, CMP (Comprehensive Metabolic Panel), Beta-HCG( pregnancy test), ABO/Rh type(blood test that identifies blood group), 500 cc of 0.9% sodium chloride intravenous fluid bolus, a transvaginal ultrasound (on 12/26/14 at 10:03 PM). Medication Orders: Transfuse total of two (2) units of unmatched packed red blood cells (PRBCs) on 12/27/14 at 12:03 and 12:04 AM).

Review of the Ultrasound Report signed 12/27/14 at 9:13 AM, revealed a right adnexal 2.5 x 1.5 mass highly suspicious for ectopic pregnancy (a pregnancy in which the fetus develops outside the uterus), no intrauterine pregnancy. Laboratory results reported 12/26/2014 at 10:39 PM revealed the patient's hemoglobin was 5.4 (normal reference range 11.3-14.3); hematocrit was 20.4 (normal reference range 33-41), and her positive pregnancy test.

The ED/DO documented the patient (#3) "required critical care due to the acute impairment of vital organ systems (cardiovascular) and high probability of imminent and life threatening deterioration. Multiple emergent interventions were required to prevent sudden life threatening deterioration. Discussed case with on-call health provider (Dr. at receiving acute care hospital). Reviewed test results and need for additional work-up ...Health care provider will see patient in ED." The patient was transferred out by Emergency Management System (EMS) on 12/27/14 at 12:40 AM in stable, improved, condition; pain 2/10 with a final diagnosis of an ectopic pregnancy, profound anemia secondary to bleeding. The form titled "Patient Transfer to Another Facility" dated 12/26/2014 was reviewed. The form revealed in part, "Reason for transfer A. For equipment or services not available at this facility (list) Gyn."

The medical record from the receiving hospital was reviewed. The medical record review revealed that Patient #3 arrived at the receiving hospital on 12/27/2014 at 12:54 a.m. The patient was triaged at 1:04 a.m. The ED physician documented on 12/27/2014 at 8:47 a.m., the chief complaint was. "Pt presents with anemia, Pt transferred from st joe's for ectopic pregnancy and hgb 5.4 ...23 year old female presenting with female genitourinary complaint. ...Episode onset 2-5 days ago ...Vaginal bleeding? Heavier that menses Pregnant now: Pregnant Missed period: Missed her period ...Associated Symptoms: Pelvic pain, vaginal bleeding and vaginal discharge. " The physical examination was completed by the ED physician. Further documentation by the ED physician revealed in part, "Medical Decision making ...Impressions: ....She arrived with blood being transfused ...I contacted the obstetricians for further surgical management. She was taken directly to the operating room." Patient #3 was admitted to the hospital on 12/27/2014.


Interview with the ED Director on 3/4/2015 at 9:14 AM in the conference room, revealed the hospital did not have an OB-Gyn department, but their affiliated hospital did. A patient requiring OB-Gyn services would have to go somewhere, a patient might request to be taken to a specific hospital. There was no documentation in the medical record to indicate that there was no OB-GYN department at the facility. Documentation in the medical record did not include evidence that on 12/26/2014 patient #3 had made a specific hospital request.


During an interview with the ED Director on 3/5/2015 at 10:30 AM in the conference room, he/she stated that the OB-Gyn on-call physician was not consulted on patient #3 because the patient had her own OB-Gyn physician who was not on staff at this hospital. He /She further stated the ED physician phoned the patient's OB-Gyn physician, but had not spoken to him/her; and that the patient was sent to the hospital where her physician was on staff. The hospital failed to ensure that that their policy was followed as evidenced by failing to ensure that the on-call OB-GYN physician was contacted to provide necessary further evaluation and treatment for patient #3 on 12/26/2014, as there was no documentation in the medical record to indicate patient #3 requested a specific physician.

During an interview with the ED Manager on 3/5/2015 at 11:00 AM in the conference room, he/she stated that an OB-Gyn physician is on-call twenty four, seven (24/7). The ED physician would contact the patient's MD or the on-call. If the patient's MD did not respond, the on-call physician would be called. The ED Manager continued to say that the Unit Clerk would actually place the calls for MD to MD consultations, and then connect the calls when both parties were on the line. There is a section in the medical record for the Unit Clerk (or RN) to document MD to MD consultations. Review of patients #3's medical record dated 12/26/2014 did not contain documentation that the ED DO had attempted to contact the patient's MD(OB-GYN) or the OB-GYN on-call physician at St. Joseph's/Candler Health System.

During an interview with DO #1 on 3/5/2015 at 11:20 AM in the conference room, he/she stated that he/she has worked in this hospital's ED for seven (7) years, and had been trained on EMTALA in 2014. The DO recalled that patient#3 had arrived in the ED with complaints of lower abdominal pain and respiratory concerns. The ultrasound results revealed an ectopic pregnancy. He/She stated that the patient had gone to her OB-Gyn MD earlier that day, but had not actually seen the physician, and Patient (#3) came to the Emergency Room. The ED DO stated that he/she was aware the hospital did have an OB-Gyn physician on-call on 12/26/2014 when Patient #3 presented to the ED, but had not contacted the on-call OB-GYN physician at St. Joseph's Hospital/Candler Health System. The DO stated that the Ultrasound preliminary report was discussed with the radiology technician, which revealed a concern that Patient #3 was bleeding in the belly and "Free fluid was present...concern seen ruptured ectopic before and they can downhill fast." The ED physician had attempted to speak to the patient's MD, but was informed by the answering service, the physician was not available, and the patient should be taken to a specified hospital. The goal was to get the patient to an appropriate facility and her own MD. The ED DO had spoken to the referred (receiving) hospital's ED physician, who had accepted patient #3 in transfer on 12/26/2014. The DO confirmed and acknowledged the medical record did not contain documentation of all telephone calls made regarding patient #3 on 12/26/2014. The facility failed to ensure that their Joint Medical Staff Rules and Regulations were followed as evidenced by failing to call the on-call OB-GYN related to questionable ("suspicious") ectopic pregnancies.

Based on reviews of medical records, policy and procedure, OB-GYN on call schedule, and interviews the hospital failed to ensure that an appropriate medical screening examination was provided for an individual that was within the capability of the hospital's ED to include ancillary services (OB-GYN on call physician) routinely available to the ED for 1 (#3) of 20 sampled patient medical records reviewed.
Findings are:
The facility's policy titled, "EMTALA- Emergency Medical Treatment and Labor ACT, Policy Number: 1102-A effective Date: 10/14/2014" was reviewed. Page 3 of 6 of the policy specified in part, "A. PRESENTING FOR CARE AND MEDICAL SCREENING EXAMINATION: 1. Any individual who comes to the DED (Dedicated emergency department) requesting examination or treatment shall be provided with an appropriate medical screening examination by QMP (Qualified Medical Personnel) ...3 The Medical Screening Examination shall include ancillary services where appropriate and routinely available for the DED. "

Review of the OBG( or OB and Gyn) "ED Call Schedule" for December 2014, revealed that an OB-Gyn physician had been assigned every day of the month (days 1-31).
Review of patient #3's medical record revealed the 23 year old patient presented to the facility's Emergency Department on 12/26/2014 at 7:45 PM with complaints of a bad cold and lower abdominal pain. The patient was triaged on 12/26/2014 at 8:05 PM, and assigned a level 3. The nurse noted the patient reported a cough and headache since Tues, and lower abdominal pain started today. No urinary symptoms, sore throat, or nasal congestion. Vital signs (VS) were: 97.5-95-18 123/69, pain 7/10.

The patient received an examination by ED DO #1 on 12/26/2014 at 9:29 PM, who noted that the patient complained of a cough, muscle aches, a positive home pregnancy test, vaginal spotting, and intermittent abdominal pain.

Physician orders on 12/26/14 at 7:45 PM included "Urgent" labs (UA, CBC, flu swab, CMP, Beta-HCG pregnancy test, ABO/Rh type), 500 cc of 0.9% sodium chloride intravenous fluid bolus, a transvaginal ultrasound (on 12/26/14 at 10:03 PM); total of two (2) units of unmatched packed red blood cells (PRBCs 0 12/27/14 at 12:03 and 12:04 AM.

Ultrasound Report signed 12/27/14 at 9:13 AM, revealed a right adnexal 2.5 x 1.5 mass highly suspicious for ectopic pregnancy, no intrauterine pregnancy. Laboratory results reported 12/26/2014 at 10:39 PM revealed the patient's hemoglobin was 5.4 (normal reference range 11.3-14.3); hematocrit was 20.4 (normal reference range 33-41), positive pregnancy test.

Review of the patient's ER Report revealed DO #1 had discussed the case with the on-call health care provider at the receiving facility's ED on 12/26/14 at 11:57 PM, and test results were needed for additional work-up. The treatment plan, and need for patient follow-up were all discussed, and the health care provider would see patient (#3) in the ED.

The patient was transferred out by EMS on 12/27/14 at 12:40 AM in stable, improved, condition. The Final diagnosis was documented as ectopic pregnancy and profound anemia secondary to bleed. There was no documentation in the medical record to indicate that on 12/26/2014 Patient #3 was evaluated by the on-call OB-GYN physician was called.

During an interview with the ED Manager on 3/5/2015 at 11:00 AM in the conference room, he/she stated that a OB-Gyn physician is on-call twenty four, seven (24/7). The ED physician would contact the patient's MD or the on-call, if the patient's MD did not respond, then the on-call physician would be called. The Unit Clerk would actually place the calls for MD to MD consultations, and then connect the calls when both parties were on the line. There is a section in the medical record for the Unit Clerk (or RN) to document MD to MD consultations. It was confirmed during medical record review that patient #3's medical record did not contain documentation that the ED physician had attempted to contact the patient's MD or the on-call physician.

During an interview with DO #1 on 3/5/2015 at 11:20 AM in the conference room, he/she stated that he/she has worked in this hospital's ED for seven (7) years, and had been trained on EMTALA in 2014. The Do recalled the patient (#3) had arrived in the ED with complaints of lower abdominal pain and respiratory concerns; and the ultrasound had revealed an ectopic pregnancy. The ED DO was aware that the hospital did have an OB-Gyn physician on-call, but had not contacted him/her. Review of the OB-GYN on-call schedule verified that on 12/26/2014 an OB GYN on call physician was available to provide further evaluation and treatment for the patient. The facility failed to follow their policy and procedure as evidenced by failing to provide an appropriate medical screening examination, which included the ancillary services routinely available, the availability of the on call OB-GYN physician for patient #3 on 12/26/2014.

Based on reviews of medical records, policy and procedure and OB-GYN physician on call schedules, and interviews the facility inappropriately transferred an individual by failing to provide medical treatment within its capacity to minimize the risks to the individual's health as evidenced by transferring an individual to a facility with the same level of care for 1 (#3) of 20 sampled patients medical records reviewed.
Findings are:
The facility's policy titled "EMTALA -Emergency Medical Treatment and Active Labor Act", Policy number: 11-2-A Effective Date: 10/14/2014 was reviewed. The policy specified in part, Definition of Terms- EMTALA ... Capability- this includes the use of ancillary services and the services of on-call physicians ...Capacity-available beds, space, equipment and personnel. "
The "PATIENT TRANSFER TO ANOTHER FACILITY" form dated 12/26/2014 for patient #3 was reviewed. The review revealed in part, "A. Patient Condition ...The patient may be at risk for deterioration from or during the transport. Based upon my examination of the patient and the information available to me at the time of transfer, I certify that the risks transfer is outweighed by the benefits ...anticipated from proper care at the receiving facility ... B. Reason for transfer A. For equipment and services - not available at this facility. (list) GYN." St. Joseph /Candler Health System had equipment (capacity) and services (on-call OB-GYN physician-capability) were available for patient #3 on 12/26/2014.
Review of the facility's "OBG ED Call Schedule for December 2014" revealed that an OB-GYN physician was on call on 12/26/2014 when patient #3 presented to the ED and at the time of the transfer.

An interview was conducted on 3/5/2015 at 11:20 AM with DO #1 in the conference room. The DO confirmed that the OB-GYN on-call physician could have come to this facility's ED, or requested the patient be sent to our affiliated hospital for surgery. The DO stated that if emergent surgery was necessary, it could be done in this hospital St. Joseph's Hospital). Patient (#3) could have been stabilized, and then discharged home. The hospital inappropriately transferred patient#3 on 12/26/2014 as evidenced by based on the information that was available at time of transfer the hospital had capability (available services of the OB-GYN on call physician) and capacity (space, equipment, and personnel) to provide the needed care for the patient for patient #3 on 12/26/2014, as this resulted in an inappropriate transfer. The same care that was provided at the receiving hospital could have been provided for patient #3 on 12/26/2014 at St. Joseph's Hospital. This was also verified during interview on 3/5/2015 at 11:20 a.m. with ED DO #1.
The medical record from the receiving hospital for Patient #3 was reviewed. The medical record revealed that after Patient #3 was evaluated by the ED physician, the obstetricians were contacted for further surgical management and the patient was taken directly to the operating room. Patient #3's "Physician order and Discharge Instructions" form dated 12/28/2014 was reviewed. The form revealed that principle procedure and/or operation performed for this admission was Laparoscopic Salpingectomy (surgical removal of a fallopian tube, often related to tubal pregnancies). Patient #3 was discharged home on 12/28/2014 with a follow-up visit with an OB-GYN physician.