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Based on reviews of medical records, policies and procedures, Emergency room Logs, physician On-call lists, Urology delineated privileges, facility web- site, and staff and physician interviews, the on-call urologist failed come to the hospital when requested by the emergency room physician to provide further evaluation and or treatment necessary to stabilize an individual with a urological emergency medical condition for one (Patient #15) of the twenty (20) sampled patients. Cross reference A-2404 as it relates to on-call physicians.

Based on reviews of medical record, policies and procedures, Urology on call schedule and physician and staff interviews South Georgia Medical Center failed to provide an appropriate transfer by not providing medical treatment within its capacity to minimize the health risks and transferring an unstable patient to a facility with the same level of care for one (1) patient (#15) of twenty (20) sampled patients. Cross reference A-2409 as it relates to appropriate transfer.

Findings include:

Review of the facility's website (www.SGMC.org ) on 7/6/2014 revealed that urology was among the listed services provided.

Review of facility policy MS 5, Emergency Medical Treatment and Active Labor Act (EMTALA), effective date September 17, 2008, revised 02/09, revealed that members of the Active Medical Staff were required to take ED (emergency department) call, as determined by the individual Medical Staff clinical departments taking into account the needs of the community and the number of active staff. If the ED physician determines that the on-call physician is needed in the ED to provide a Medical Screening Examination or treatment, the on-call physician is required to appropriately respond by coming to the ED in less than forty-five (45) minutes of being called to the ED.


Review of the facility's urology on-call schedule for the month of June 2014 revealed that Urologist (a physician who has specialized knowledge and skills regarding problems or the male and female urinary tract and the male reproductive organs) #2 was on-call from 6/18/2014 7:00 a.m. - 6/19/2014 7:00 a.m.

Review of the on-call urologist's (Urologist #2) delineated privileges on 7/9/2014 revealed that he/she was approved to perform penile dorsal lifts, circumcision, excision of tumor/cyst, biopsy, construction penis, repair (injury), prosthesis for impotence inflatable and non-inflatable, penile brachytherapy/radioactive seed implant, emergency procedures- trauma to penis. The delineation of privileges contained a statement which read "I hereby certify that I have been trained in and am qualified to perform the privileges that I have requested. I further certify that my physical and mental health allows me to perform the requested privileges in a competent manner."


Review of patient #15's emergency room (ER) record revealed a 27 year old male who was transported to the South Georgia Medical Center emergency room by ambulance on 6/18/2014 at 10:57 p.m. with complaints of an erection for five (5) days, with worsening pain that night.

Continued review revealed that patient #15 was triaged by a qualified registered nurse (RN #2) at 11:00 p.m. with a pain level of six (6) on a scale of zero to ten (0-10). The nurse assessed the patient who denied use of erectile dysfunction medication. Patient # 15 stated waking up with an erection and it hasn't gone down, with sharp, intermittent pain and affecting the iliac crest (most prominent bone on the pelvis) and pelvis. Patient #15 was examined by ER physician #1 at 11:00 p.m. who assessed patient #15's course of symptoms as gradual, located in the penis, pain quality was dull, and at worst was rated as mild. Further review revealed in part, " Physical Exam (examination) ...GU (Genitourinary) ...patient has priapism (persistent and painful erection of the penis; the condition is considered a medical emergency). At 11:15 p.m., the ER physician #1 spoke to the on-call urologist #2 from South Georgia Medical Center, who recommended that patient #15 be transferred as the patient was in no acute distress. Continued review revealed that ER physician #1 spoke with a urologist who accepted the transfer of patient #15 (6/18/2014) at an acute care receiving facility.


The medical record from the acute care receiving facility was reviewed. The surgical plan was to irrigate and aspirate blood from the corporal bodies versus a distal shunt. However, review of the surgical report revealed after several attempts to irrigate and remove blood clots a distal shunt was inserted. The Operative report dated 6/19/2014 for Patient #15 was reviewed. The review of the Operative Report revealed in part, " Indications for Procedure: ...presented last night to South Georgia Medical Center ...He also complained of painful erection that had been present for 5 days. Apparently ER physician had had contacted numerous Urologist including their own that denied patient medical care ...it was subsequently decided that the patient should be sent up to an acute care receiving facility. Procedures Performed: 1. Al-Ghorab (procedure to fix or re-establish blood circulation within the structure) distal still penile shunt for priapism; 2. Circumcision. " Pre-operative diagnoses: 1. Priapism, 2.Phimosis Post-operative diagnoses: 1. Priapism, 2. Phimosis, 3. Priapism for 5 days, 4. Distal corporal shunt x 2. "

Interviews were conducted on 7/9/2014 at 8:00 a.m. and on 7/10/2014 at 1:40 p.m. with the On-call urologist #2. The on-call urologist (#2) recalled receiving a phone call from the facility's ER physician #1, about patient #15 with an erection for five (5) days. Urologist #2 confirmed not examining patient #15. Urologist #2 continued to reveal that he was privileged to perform an Al-Ghorab shunt and had performed the procedure once. The Urologist indicated that patient #15 was a high risk case due to his age, duration of the erection, and the procedure needed an expert with time being of the essence. Urologist #2 stated that he felt uncomfortable doing this case and instructed ER physician #1 to transfer the patient to the acute care receiving facility because they had an expert in this field. The on call Urologist (#2) confirmed that he did not go to the ER because he felt the patient needed to be transferred. The on-call urologist failed to come to the ED on 6/18/2014 for patient#15 when requested by the ED physician

Interview on 7/9/2014 at 9:00 a.m., the ER physician #1 recalled the case, that patient #15 arrived by Emergency Medical Service (EMS) with an erection for five (5) days, and he evaluated patient#15 immediately. The ER physician #1 telephoned on-call urologist #2, providing the results of patient #15's history and physical. The on-call Urologist #2 informed ER physician #1 that since it had been 5 days, patient #15 would need surgery that was done at a higher level of care, and recommended the acute care receiving facility, without explaining why that location. The ER physician #1 stated that he phoned Urologist #2 again, prior to transferring the patient stated considered doing some type of procedure, but, the on-call urologist #2 said "no", patient #15 needed a higher level of care.

The facility failed to ensure that their EMTALA policy was followed as evidenced by failing to ensure that once the ED physician determined that the on-call physician (Urologist #2) was needed in the ED for patient#15 on 6/18/2014 to provide medical screening examination or further treatment, the on- call physician was required to appropriately respond by coming to ED in less than 45 minutes of being called to the ED.

Based on reviews of medical record, policies and procedures, Urology on call schedule and physician and staff interviews South Georgia Medical Center failed to provide an appropriate transfer by not providing medical treatment within its capacity to minimize the health risks and transferring an unstable patient to a facility with the same level of care for one (1) patient (#15) of twenty (20) sampled patients.


Findings include:

The facility 's policy titled, " Emergency Medical Treatment and Patient Transfer policy, Number PP105, Effective 6/91, revised 01/14 was reviewed. The policy indicated in part, " E. TRANSFER OF INDIVIDUAL WITH EMERGENCY MEDICAL CONDITION " . . . 3. No individual will be Transferred unless: a) Medical Treatment which minimizes the risks to the individual ' s health... within the DED's (Dedicated Emergency Department) Capacity provided. "

Review of the facility's urology on-call schedule for the month of June 2014 revealed that Urologist #2 was on-call from 6/18/2014 7:00 a.m.- 6/19/2014 7:00 a.m. at the time that patient #15, presented to the ER seeking treatment.

Review of patient #15's ER record revealed, the 27 year old male was transported to South Georgia Medical Center's ER by ambulance on 6/18/2014 at 10:57 p.m. The ER physician #1 at 11:15 p.m., notified the on-call Urologist #2 of patient 15's condition, the on-call- urologist #2 informed ED physician #1, to have the patient transferred to the acute care receiving facility. The ED physician #1 notified the acute care receiving facility and an urologist accepted the transfer of patient #15. Review of nursing notes by Registered Nurse (RN) #1 at 12:00 a.m. revealed telephoning the acute care receiving facility regarding transfer of the patient to urology services per ER physician #1 request. At 12:22 a.m., RN #1 received a telephone call from the acute care receiving facility with notification that patient #15 would be accepted to the ER at the acute care receiving facility, but that the accepting urologist requested the patient not leave the South Georgia Medical Center until 6:00 a.m. for arrival at their facility by 8:00 a.m. After discussion, it was agreed that the patient would remain in the current ER until between 7:00 and 7:30 a.m., when transport services would be available. The EMS shift captain was then notified of the transport request.


Interview on 7/10/2014 at 1:40 p.m., at the initiation of Urologist #2 revealed becoming aware that the receiving acute care facility had reported the transfer, not the patient as an EMTALA violation. Urologist #2 explained that the patient should not have gone to the acute care receiving facility - that was a mistake and revealed understanding why the acute care receiving facility would have been upset about receiving the transfer, because the acute care receiving facility had the same capabilities of South Georgia Medical Center did. The facility failed to ensure that that their EMTALA transfer policy was followed as evidenced by failed to ensure an appropriate transfer of Patient #15 on 6/18/2014 by not providing medical treatment within its capacity to minimize risks to the individual 's health and transferring an unstable patient (#15) to another acute care hospital with the same level of care.


Interview on 7/9/2014 at 9:00 a.m. with the ER physician #1 revealed that a discussion occurred related to completing some type of procedure to treat patient #15, however, the on-call urologist #2, said "no". ER physician #1 stated telephoning on-call urologist #2 a second time prior to transfer of patient #15 did not need a medication or procedure first.