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On the days of the EMTALA (Emergency Medical Treatment And Labor Act) survey based on record reviews, interviews, review of the hospital's emergency department policies and procedures, review of the hospital's Medical Staff By-laws, review of the hospital's Emergency Department's (ED) on - call list for October 2022, Hospital A's ED transferred 1 of 1 patient to Hospital B's ED without securing acceptance of an orthopedic surgeon. (Patient #4)

The findings are:

Cross Reference to A 2404: The hospital failed to ensure one (1) of 1 patient presenting to the hospital's Emergency Department (ED) with an open fracture of the foot from a traumatic injury was assessed by an on-call Orthopedist. (Patient #4)

Based on record review, interview, review of the hospital's on call physician schedule, review of the hospital's medical staff rules and regulations, and review of the hospital's policy and procedure, the hospital failed to ensure one (1) of 1 patient presenting to the hospital's Emergency Department (ED) with an open fracture of the foot from a traumatic injury was assessed by an on-call Orthopedist. (Patient #4)

The findings include:

On 10/19/2022 at 1:30 PM, review of the hospital's Medical Staff Bylaws adopted by the Medical Staff 12/17/2020 and approved by the hospital's Board of Governors on 09/07/2022, reads:

"I. Emergency Department Consultations
Once an Emergency Department consultation is deemed necessary by the Emergency Department practitioner, the appropriate on-call practitioner or the primary practitioner will be notified and the case shall be discussed. The on-call specialist/primary practitioner must respond in a timely manner, generally thirty (30) minutes or less and derive a satisfactory disposition of the patient. The Medical Director of the Emergency Department or Nursing House Supervisor will be notified if the on-call practitioner fails to return calls within thirty (30) minutes. The Medical Director of the Emergency Department or Nursing House Supervisor will then discuss the situation with the Chairman of that service who will either provide orders, make a recommendation to continue calling the on-call practitioner, to call a second practitioner on that specialty, or to place calls to the next practitioner on the on-call list. The practitioner on-call has an obligation to come in the the Emergency Department to examine a patient if requested to do so by the Emergency department practitioner on duty."

M. Medicare
Medicare Acknowledgement Statements will be completed by all practitioner applicants upon initial staff appointment, and these statements will be maintained as a permanent record.

Patient #4
Review of Patient #4's Emergency Department (ED) record on 10/19/2022 at 2:00 PM revealed the patient presented to Hospital A's Emergency Department on 10/05/2022 12:20 PM via Emergency Medical Services (EMS) with multiple dog bites. Upon presentation in the ED, Patient #4 was triaged as a "3- Urgent" with documentation that reads, "(Chief Complaint) Dog Bite to right foot,, [sic]dorsal and Plantar punctures and lac (laceration) to dorsal. Also bites/ punctures to L (left) forearm and left elbow. 22g (gauge needle). 100 Fentanyl .... Tetanus not up to date. ACSO (Animal Control) at bedside and completed animal control report."

Review of the ED Physician #1's Emergency Department assessment dated 10/05/2022 at 12:30 PM revealed:
History of Present Illness: "Patient bit by known dog has a laceration with through and through dog bite with open fracture of the first metatarsal at the base also has dog bites to arm which are noticed significant."

Review of Systems: "Additional review of systems information: All other systems reviewed and otherwise negative."

Physical Examination: (pertinent for) "Musculoskeletal: Double lacerations over the dorsum of the foot with a wound on the plantar aspect near the fracture site over the base of the first metatarsal all of these are approximately 1 to 1.5 cm (centimeters) the foot is well - perfused full range of motion with dorsi and plantar flexion, Small lacerations over the forearm on the left arm 1 over the first MCP (metacarpal) joint of the thumb the others mid forearm there is 3 that were centimeter half in size."

Medical Decision Making: Known animal.

Impression and Plan: Dog bite with fracture of base of first metatarsal neurovascular intact multiple lacerations. Discussed this with orthopedics on-call Orthopedic Physician #2 who notes patient would be best served by a foot trauma Ortho Dr. Orthopedic Physician #2 recommends Orthopedic Physician #4 in Hospital B. the ED is called (ED Physician #6 in Hospital B) graciously accepts. Procedure note by me for the foot was prepped and draped in sterile fashion given local anesthesia ... over a liter was used to irrigate her wounds[sic]. Sterile dressing was applied by me. Procedure note for the left arm patient was prepped and draped in sterile fashion given local anesthesia 1% (percent) lidocaine 3 separate 1 cm lacerations were closed with 230 by Ethylon sutures 1 over her MCP joint area was loosely closed with 1 suture with good homeostasis and tissue approximation diagnosis open fracture of foot multiple dog bites. Of note broad - spectrum antibiotics were given tetanus prophylaxis was given. 10/05/2022 14:07 PM.

Consultation Note Orthopedics On-call
Review of a Consultation note documented by Orthopedic Physician #2 (Hospital A)dated 10/5/2022 at 13:50 PM revealed " I reviewed the patient's x-rays remotely and her case by phone with (ED Physician #1 - Hospital A's ED) Empiric IV (intravenous) antibiotics have been administered to cover typical skin flora, as well as specific flora for the foot and dog saliva. Because of the proximity of the fracture to the first tarsometatarsal joint, and the complexity of the surgical stabilization that ultimately will be required, I recommended that the patient be transferred to a higher level of care where either a fellowship trained orthopedic traumatologist or fellowship trained orthopedic foot and ankle surgeon available."

Review of the data "Phone Call for Consults v 2" revealed Orthopedic Physician #2 was consulted on 10/05/2022 at 12:42 PM by ED Physician #1. Comments revealed "(Orthopedic Physician #2) in OR (Operating Room) gave pt (patient) info to nurse. (Orthopedic Physician #2) to call back."

Review of a Nurse Note on 10/05/2022 at 14:27 PM revealed "Handed over to (Hospital B), spoke to ....RN (Registered Nurse). All needs attended[sic], RN happy to receive."

Review of Hospital A's transfer form was pertinent for "Patient stable, transfer was medically indicated, medical benefits; obtain higher level of care not available at this facility: ortho. Receiving facility (Hospital B). Person accepting transfer was listed as Hospital B's ED Physician #6 and the transferring physician was listed as Hospital A's ED Physician #1. Patient #4 was discharged from Hospital A's ED at 16:54 PM via transport.

Review of the Hospital A's Emergency Department "Current Schedule for All Job assignments" dated 10/05/22 revealed Orthopedic Physician #2 was the on-call physician for the Orthopedics Department for the Emergency Department at Hospital A. Review of Hospital A's surgery schedule dated 10/05/22 at 07:30 AM revealed Orthopedic Physician #2 was listed with an elective surgery at 07:30 AM on 10/05/2022 and an elective surgery on 10/05/2022 at 11:30 AM.

Interviews
Orthopedic Physician #2 (Hospital A)
During an interview on 10/19/22 at 12:41 PM with Orthopedic Physician #2, he/she stated, "I was performing a surgery in the Operating Room (OR) during the time I was on-call. I responded to the call from the ED physician and reviewed the X-rays after my surgery. The ED physician described the injury to me, but I never went to the ED to see the patient, but I would have seen the patient if the physician had requested it. If I can't come see the patient, then I do work with other physicians who can see the patient. I don't remember if I called one of my partners to see the patient." When asked if he discussed the patient with a physician at Hospital B prior to transfer of the patient, Orthopedic Physician #2 reported, " I did not speak with either Orthopedic Physician #10 or Orthopedic Physician #4 at Hospital B. The ED physician (#1) in our ED (Hospital A) stated he would make the arrangements. I did review the x-ray. I let the doctor in the ED (Hospital A) know the proxemity to the first metatarsal joint is a little trickier."

ED Physician #1 (Hospital A)
On 10/19/2022 at 11:00 AM , ED Physician #1 (Hospital A) was interviewed via a telephone call. When asked to explain the process for consulting the on-call physician, ED Physician #1 reported "Normally you consult the doctor on - call, and they generally give you recommendations. Normally the doctor on-call responds within 30 minutes. I have done consults over the phone. The Unit Secretary will place the call for the consult, and it generally within 1/2 hour we hear back." When asked if the on-call consulting physician must come to examine the patient, ED Physician #1 reported "It depends. Sometimes they can look at films and give recommendations. If I cannot take care of it, I describe the issue and most of the time the consulting in-call physician knows yes, I can fix that or nope that is something I can't take of. An example like a gun shot that shattered a bone, the on-call physician will say nope send to another facility." When asked about the patient who presented with dog bites, ED Physician #1 reported "We had a dog bite come in and it was extensive damage to the right foot. ....I called the consult for orthopedics. The on-call orthopedic physician did not see the patient. I described the injuries and I'm sure he looked at the films. Soft tissue damage and any extensive trauma, we usually send across the river." ..... If I can remember the hospital's across the river were on diversion, so we sent the patient to Hospital B. I did talk to the ED Physician at Hospital B, but I did not talk to an orthopedic physician at Hospital B"

ED Physician #6 (Hospital B)
On 10/19/2022 at 10:46 AM, a telephone interview was conducted with ED Physician #6 from Hospital B. ED Physician #6 reported "That is not uncommon to get a patient from another hospital. In our ED we accept anybody that request treatment. We get a phone call from an outpatient facility or another ED and our charge nurse will get the request and plan for the transfer. If a patient was already admitted at another hospital, we would not accept those patients. We have 6 doctors on service in the ED so remembering a particular patient is difficult, but I do remember this patient was bit by a pit bull. I never saw the patient. If a patient has an open fracture, I will consult an orthopedic surgeon."

Hospital A's policy, entitled, "Emergency Medical Treatment and Active Labor Act" revealed, "On-Call List refers to the list that Hospital is required to maintain that defines those physicians who are "on-call" for duty after the initial MSE (Medical Screening Exam) to provide further evaluation and/or treatment to Stabilize an individual with an EMC (Emergency Medical Condition). The list should be maintained in a manner that best meets the needs of Hospital's patients who are receiving emergency services in accordance with the resources of Hospital and should include the name and direct pager or telephone number of each physician who is required to fulfill on-call duties. Merely listing the name of the physician group is not acceptable for EMTALA purposes. The purpose of the on-call list is to ensure that the DED (Dedicated Emergency Department) is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide treatment necessary to Stabilize individuals with EMC's (Emergency Medical Conditions). The services included in the on-call list will be determined by the hospital administration and physicians in order to best meet the needs of the community served by Hospital in accordance with the resources available to the hospital...5. Providing elective surgeries while on call. If an on-call physician scheduled elective surgeries during the time that he/she is on-call at Hospital and is unable to respond to the situation, Hospital and the physician should have planned back-up coverage...7. Physician's Responsibility. Hospital will ensure that when a physician is identified as being "on-call" to the DED (Dedicated Emergency Department) for a given specialty, it shall be that physician's duty and responsibility to assure the following:
a. Immediate availability, at least by telephone, to the DED physician for his or her scheduled "on-call" period, or to secure a qualified alternate if appropriate.
b. Arrival or response to the DED within a reasonable timeframe (generally, response is expected within 30 (thirty) minutes). The DED physician, in consultation with the on-call physician, shall determine whether the individual's condition requires the on-call physician to the individual immediately. The determination of the DED physician or other practitioner who has personally examined the individual and is currently treating the individual shall be controlling in this regard...".