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Based on interviews, reviews of medical records, Policies and Procedures, Emergency Department Logs, and Emergency Department Call Schedules, the hospital failed to ensure that the physicians listed on its on-call schedule list met the needs of a patient receiving Emergency Room (ER) services and requiring an otolaryngology consultation for 1 (#1) of 24 sampled patients. Additionally, the hospital did not have specific policies and procedures in place to respond to situations when an on-call specialty physician is not available, involving 1 of 24 sampled ER patients (#1). Refer to finding in Tag A- 2404.

Based on interviews, reviews of medical records, Policies and Procedures, Emergency Department (ED) Logs, and Emergency Department Call Schedules, the hospital failed to ensure that the physicians listed on its on-call list met the needs of a patient receiving Emergency Room (ER) services and requiring an otolaryngology consultation for 1 (#1) of 24 sampled patients. Additionally, the hospital did not have specific policies and procedures in place to respond to situations when an on-call specialty physician is not available, involving 1 of 24 sampled ER patients (#1).

Findings:

A review of the hospital's policy titled "Emergency Department Guidelines" dated revised and reviewed 1/2014 revealed in part, "HEALTH CENTRAL will provide an On-call physician specialty list which includes all specialties privileged at this facility....The on-call list will be openly posted in the Emergency Department....The specialist must respond to HEALTH CENTRAL to render an evaluation and care."

Review of the hospital's ED log revealed that patient #1, a 26 year old, presented to the ED on 6/27/2014 at 7:28 p.m.

A review of the medical record of patient #1 was performed. The patient was triaged in the ER on 6/27/2014 at 7:35 PM. A nurse's note at 7:42 PM on 6/27/2014 read, "Pt is here today for fever and sore throat." A physician assistant's (PA) note at 8:52 PM on 6/27/2014 read, "Exam started at 8:52 PM. Chief complaint: Difficulty swallowing and unable to swallow liquids well." Further review indicated in part, History of Present illness: Patient with Zithromax (steroid medication used to relieve swelling and inflammation) was here a few days ago diagnosed with a throat infection and put on Penicillin VK (antibiotic medication treats infections). Patient back tonight stating fever still persists for is worse and came in for evaluation.... Patient Problems:...Peritonsillar abscess... (A collection of pus around the tonsils, the infection causes severe painful, and swelling. It is a commonly encountered an ENT (ear, nose & throat) emergency).... Physical Exam: ENT: Consistent with Peritonsillar abscess Erythema (red) and local inflammation is noted over the right palatoglossal arch. Edema and local swelling is noted in the area over the right palatoglossal arch. The area over the right palatossal arch is swollen and indurated and inflamed. . . . Handling secretions poorly....Progress Notes: Edema and local swelling is noted...." Attending note read, "I have seen and examined this patient. Peritonsillar abscess(s). Discussed with ENT (physician #B on-call otolaryngologist on 6/27/2014) who was apparently on call by our hospital schedule. He states he is not on-call today and has refused to consult. I then spoke with Dr. ... from the receiving Hospital who did accept the patient in transfer.... Attempt to drain the abscess. The patient was sprayed with Cetacaine spray (spray indicated for use to control pain & gagging). Before the needle placed in the patient's mouth the abscess spontaneously drained. Do not know how much pus was actually obtained as it was not aspirated. Discussed with transfer center who has accepted the transfer."

An ED unit secretary note of 10:34 PM on 6/27/2014 read, "Comment: (on-call physician #B) Notes: Call placed to (on-call physician #B's) service stated that they are only on-call for the patients of the office, recalled at 10:50 PM." A physician assistant's (PA) note of 10:59 PM on 6/27/2014 read, "ENT on-call but the secretary stated that he is on-call for his private patient's. Spoke with (ED physician #A) my attending will now call the transfer center to get patient situated release peritonsillar abscess....History, findings and management plan discussed with ED attending. Attending physically available and saw patient." A nurse's note at 3:23 AM on 6/28/2014 read, "Pt transported via (ambulance) to the receiving hospital."

Review of patient #1's medical record from the receiving hospital revealed that the patient was admitted on 6/29/2014 and discharged on 6/29/2014. His admitting diagnosis was acute pharyngitis. The principal diagnosis was peritonsillar abscess and secondary diagnosis was chronic tonsillitis. The hospital discharge summary read, "Patient was transferred....for further management of peritonsillar abscess. He was started on IV (intravenous) clindomycin upon admission....evaluated by ENT specialist...who administered a one time dose of Decadron 10 mg (milligrams) and recommended discharge on p.o. (by mouth) clindomycin....Patient will follow up with (ENT specialist) to discuss possible tonsillectomy. The patient's symptoms improved significantly prior to discharge. No complications were noted during the hospital stay."

A review of the hospital ED Call schedule for 6/2720/14 revealed that otolaryngologist (a physician specialized in diagnosis and treating diseases of the neck, especially ears, nose & throat) #B, whom ER physician #A had spoken to, was scheduled to cover ENT services. During an interview with the on-call otolaryngologist #B on 7/11/2014 at 1:06 PM, he confirmed that with the case of patient #1, he did not provide any consultation services for the benefit of patient #1.

Review of patient #1's medical record review and interview with on-call physician #B confirmed that the services of the on-call otolaryngologist was requested on 6/27/2014 for patient #1 by ED physician #A. The hospital failed to ensure their "Emergency Department Guidelines" procedure was followed as evidenced by failing to ensure on-call Otolaryngologist physician #B came to the hospital to render an evaluation and care when requested by ED physician #A for patient #1 on 6/27/2014.

During an interview of the Chief Quality Officer on 7/11/2014 at 12:55 PM, he stated that the above mentioned on-call schedule was accurate as of 6/27/2014.

In an interview with the Chief Quality Officer on 7/11/2014 at 12:55 PM, he confirmed that the on-call list which ED physician #A had on 6/27/2014 was accurate and up-to date at the time of patient #1's visit. The Chief Quality Officer also stated that the hospital did not have a specific policy which spelled out what to do for a back-up in situations specific to where an on-call physician does not address patient issues per the call of an ED physician.

Review of the hospital's "Emergency Department Guidelines" revised 01/2014 for EMTALA read in part concerning the on-call physician, "The specialist must respond to HEALTH CENTRAL to render an evaluation and care." The policy did not include policies or practices when an on-call physician does not respond to the ED physician's request for consultation or visits to the ED.

During an interview of the Risk Manager on 7/11/2014 at 1:45 PM, he confirmed that they did not have a policy or by-law which specifically addressed failure of on-call physicians to perform services as required. He confirmed that in the case of patient #1, there was no alternate plan in place to call additional physicians prior to consideration of a transfer.

During an interview with ED physician #A for patient #1 on 7/11/2014 at 3:47 PM, he stated that he was not aware of any back-up system in case an on-call otolaryngology physician was not available, other than transferring a patient to another hospital. The facility failed to have as required a system to address situations where an on-call physician was not available and was not in place at the hospital.

During an interview of the Risk Manager on 7/11/2014 at approximately 4:50 PM, he confirmed the findings.