HospitalInspections.org

Based on review of medical records, physician on-call schedule, Physician Consult Log, and hospital policy, and interviews,the hospital failed to maintain a list of physicians on its medical staff in a manner that best meets the needs of the hospital ' s patients who are receiving services required in accordance with the resources available to the hospital, including the availability of on-call physicians for 1 of 20 patients (#1).

Findings:

Review of the hospital policy "EMTALA-Provision of On-Call Coverage", read in part, "Purpose: to establish guidelines for the hospital ...and its personnel to be prospectively aware of which physicians, including specialists and sub-specialists, are available to provide additional medical evaluation and treatment necessary to stabilize individuals with emergency medical conditions in accordance with the resources available to the hospital as required the Emergency Medical Treatment and Labor Act (EMTALA) ....Policy: the hospital must maintain a list on its medical staff who have privileges at the hospital ....Physicians on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with emergency medical conditions (EMC) who are receiving services in accordance with the resources available at the hospital ...Physicians' Responsibility:...when a physician is identified as being 'on-call' to the DED (dedicated emergency department) for a given specialty, is shall be that physician's duty and responsibility to assure....immediate availability, at least by phone, to the DED physician for his or her scheduled 'on-call' period, or to secure a qualified alternate if appropriate....arrival or response to the DED within a reasonable timeframe (generally, response by the physician is expected within 30 minutes)...."

Review of the hospital policy "EMTALA-Provision of On-Call Coverage", read, "when a physician is identified as being 'on-call' to the DED (dedicated emergency department) for a given specialty, is shall be that physician's duty and responsibility to assure....immediate availability, at least by phone, to the DED physician for his or her scheduled 'on-call' period, or to secure a qualified alternate if appropriate. arrival or response to the DED within a reasonable timeframe (generally, response by the physician is expected within 30 minutes)...."

Review of the Osceola Regional Medical Center Physician on call schedule was reviewed. The on-call schedule dated 8/18/2013 verified that a Neurosurgeon (physician who does surgery on the nervous system, especially the brain) was on call. Review of the medical record for patient #1 showed he was age 69 years old, and presented to the emergency department on 8/18/2013 at 10:36 p.m. after falling out of the bed at home. The record documented the chief complaint as, "Fell out of bed at home -Brain hemorrhage." The HPI read, "Patient is a 69 y/o male who was found by his wife on the floor after falling out of bed, unresponsive. EMS was called to the house and state that patient has not returned to normal mentation. States patient has continued to vomit throughout transport but maintained good O2 saturation."

Patient #1 was seen by the emergency physician on 8/18/2013 at 10:38 p.m. and triaged at 10:44 p.m. Further review of the medical record indicated that a central line (intravenous line that is inserted in a large vein - typically the neck) was emergently placed. Oxygen was administered and patient #1 was also on cardiac and oxygen saturation monitoring. The patient was also placed on a ventilator (a method to mechanically assist or replace spontaneous breathing) to protect his airway. The patient's vital signs at 22:50 (10:50 p.m.) were: blood pressure 245/96 (normal range -110/70-130/85), pulse 49 (normal range 60-100). Review of the CT of the Head/Brain at 11:43 p.m., "showed Large intraparenchymal hemorrhage (bleeding into the brain) as well as intraventricular hemorrhage (spaces in the brain that contain protective cerebral spinal Fluid) as described above with midline shift of approximately 1.6 cm. (centimeters) to the right ...."

Additional notes in the medical record read in part, "Spoke with family and of patient due to trying to contact Neurosurgery for over an hour and a half. Consultation:1 Consultant called: Neurosurgery; Requested call time: 23:41; Requested call date: 8/18/2013: Consultation: 2 - Consultant called: Transfer Center: Requested call time:0039; Requested call date 8/19/2013. Call returned: call returned (two (2) physicians from the receiving hospital that will accept patient #1 for transfer to their acute care hospital); Call return time:00:54; Consultant 0054: Spoke with Neurosurgeon (from the receiving hospital) who will consult once Pt (#1) arrives to the Hospital; 0100 spoke with physician ICU (intensive care unit) who accepts transfer to receiving hospital. Disposition: Alt (altered) Mental Status. Primary Impression: ICH (intracerebral hemorrhage) with shift. The transfer certification for patient # 1 was reviewed. The transfer form section titled, "Reason for transfer" revealed the box was checked as, "On call physician refused or failed to respond within a reasonable time ...On call Physician name 'Physician's name was listed 2 hr (Hour)'."

Further review indicated that patient #1 was transferred to another major medical center by helicopter on 8/19/2013 at 1:50 a.m. because the on-call physician did not respond to phone calls. This was also verified by review of the Physician Consult Log.

Review of the Physician Consult Log dated 8/18/2013 revealed that the on-call neurosurgeon office phone number was called three (3) times. The times listed that the neurosurgeon was called at 11:20 p.m., 11:43 p.m. and 11:58 p.m., and messages were left with the answering service. The column of Physician Consult Log titled "Call back time" revealed "Did not call." The facility failed to ensure that their on-call physician coverage policy was followed as evidenced by failing to ensure that physicians (neurosurgeon) on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with an emergency medical condition who are receiving services in accordance with the resources available at the hospital for patient #1 on 8/18/2013.

Review of the medical record from the receiving hospital revealed patient #1 was admitted on 8/19/2013 at 2:35 a.m. A CT Scan of the Head showed intraparenchymal hemorrhage with intraventricular extension 1.5 cm. and midline shift. The hospital's discharge summary read in part, "The patient's family made the decision to move to comfort measures and the patient subsequently passed away."

During an interview on 9/12/2013 at 9:45 a.m., the vice-president of Quality and Risk said the facility investigation showed the physician said he did not get the phone call because his cell phone was not working. Staff did reach his answering service as a usual way of contact.

During a phone interview on 9/12/2013 at 3:20 p.m., the emergency room physician said he has been at the hospital for about 2 months. He said there were no problems with contacting specialists on-call and getting an appropriate response in the past.