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Based on clinical record review and staff interview the facility failed to adopt and enforce a policy to ensure compliance with the EMTALA requirements at 42 CFR 489.24 as evidenced by failure to provide appropriate medical screening examination resulting in delay in treatment and failure to appropriately transfer 1 of 20 sampled patients (Patients #2). The facility actions included failure to obtain specialty consults while in the Emergency Department, failure to prevent delay in treatment, failure to provide stabilization prior to transfer by appropriate consultants and failure to obtain surgical consultation when a time sensitive life and limb threatening condition was identified.


The findings included:


1. Based on medical record review, policy and procedure review, on- call schedules review, Physician Core Privileges review, and interviews it was determined the facility failed to maintain an on-call list of physicians on it's Medical Staff in a manner that best meet the needs of the hospital's patients by failing to obtain specialty surgical consultation when a time sensitive life and limb threatening condition Sepsis and Necrotizing Fasciitis was identified for 1 (#2) of 20 sampled patients who required immediate surgical interventions. Refer to findings in Tag A-2404.


2. Based on medical record review, policy and procedure review, Core physician privileges review, on-call schedules review and interview the facility failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary services of surgical on call physicians who were on call and available in the emergency department when patient #2 presented to the ED. This failure affected 1 (#2) of 20 sampled patients (Patient #2) as evidenced by failing to ensure the patient was evaluated by appropriate surgical consults that were available. Refer to findings in Tag A-2406.


3. Based on medical record reviews, policies and procedure review, on-call schedules, Physician Core Privileges review and interviews the facility failed to provide surgical treatment within its capacity that minimized the risks to the individual's health by failing to ensure that on-call surgical consultants that were available evaluated and provided stabilizing treatment for 1 (#2)of 20 sampled patients with an identified emergency medical condition. As this resulted in an inappropriate transfer for patient #2. Refer to findings in Tag A-2409.

Based on medical record review, policy and procedure review, on- call schedules review, Physician Core Privileges review, and interviews it was determined the facility failed to maintain an on-call list of physicians on it's Medical Staff in a manner that best meet the needs of the hospital's patients by failing to obtain specialty surgical consultation when a time sensitive life and limb threatening condition Sepsis and Necrotizing Fasciitis was identified for 1 (#2) of 20 sampled patients who required immediate surgical intervention.


The findings included:



1. Medical Record Review -Patient #2
Clinical record review conducted on 09/05/18 thru 09/06/18 revealed Patient #2 presented to the facility on 01/28/17 at 12:15 PM with chief complaint of Abscess to left shoulder. The patient was triaged at 12:26 PM as urgent. The medical screening exam conducted at 1:04 PM documents the patient complained of shoulder problem, weakness and dizziness. Patient received a testosterone injection three days ago, that evening he started to have pain and it has gotten worse. On arrival, his blood pressure was low 81/59 (Ideal Blood Pressure 100/6-120/80) and had elevated heart rate 20 (normal heart rate 60-100). The physical exam revealed pain and swelling to left arm. There is a palpable abscess, no drainage or tightness.
Laboratory studies indicates, Complete blood Count Normal, Bandemia (usually indication of infection or some inflammation is present) elevated troponin (test that measures proteins released when heart muscles have been damaged) and lactic acid levels(test to document presence of cell tissues that are starting to die) low sodium, elevated AST (SGOT) Liver functions tests, and elevated kidney functions tests BUN (Blood Urea Nitrogen-indicator for kidney function) and Creatinine elevated means impaired kidney function). Elevated Serum Coags(coagulation) Interpretation PT Prothrombin Times- measures amount of time it takes for blood to clot), PTT (partial Prothrombin time (Measures how long it takes for blood to clot) Radiology studies included an ultrasound of the left arm; the impression documents diffuse lateral arm subcutaneous swelling. No evidence of fluid collection or abscess. Patient #2 received antibiotics, pain medicine, antiemetic, anticoagulant and vasopressors to manage his condition.

Physician reevaluation documents the patient's blood pressure continued to be low after three liters of fluid. Patient is complaining of increased pain to the arm but still has a palpable pulse. He has received antibiotic (vancomycin and Rocephin) and started on Norepinephrine(medication used to raise blood pressure). I discussed the case with the admitting doctor and the Physician intensivist and the patient will be admitted to the intensive care unit. The patient's condition was listed as "Guarded" and the Primary diagnosis was Sepsis (Defined by CDC-Sepsis is a body's extreme response to an infection. It is a life threatening medical emergency). The secondary impression was Bandemia, Cellulitis of the left upper extremity, Hypotension, and Positive Troponin.

Documentation on the H&P Addendum note dated 1/28/2017 at 4:39 P.M., revealed that the ED physician consulted a Resident in Internal Medicine Physician, and his reason for the consult was "Septic Shock" (sepsis induced low blood pressure that persist despite treatment with intravenous fluids). The internal medicine documented the patient's chief complaint was "Exquisite L (left) arm pain. Documentation also revealed in part, "in the ER he presented w/ (with) a BP lf 80/40 unresponsive to 3 L (liters) of NS (Normal Saline) boluses after which Levophed was stated through the R (Right) peripheral IV. He reports that his chest and back pain is worse after having received the fluid ...Physical Exam ... BP 83/53, Pulse 123, Oxygen 2 liters, Respirations 20 ... General appearance ...in acute distress due to pain..: Extremities: L arm w/exquisite tenderness to palpitation proximally near the shoulder; tense and red; hot to touch; ... Thready L radial pulse."

Resident documented in the section of the History and Physical note titled "Diagnosis, Assessment & plan that documents "patient presents with acute left shoulder compartment syndrome. Septic shock, acute compartment syndrome with pressures of 40 mm Hg on the anterior, lateral and posterior compartment. Multiple surgeons have been consulted STAT (as soon as possible) and have refused the consult or not responded starting at 4 PM on 01/28/17. General surgery on call (physician name) at 4:16 PM who said to call orthopedic on call. ([Physician Name]) orthopedic called at 4:30 PM who refused the consult. Resident saw patient in ER room 34 at bedside at 5 PM and (Physician Name), after examination said "This was not compartment syndrome". Physician Name (vascular) called at 5:15 PM and refused the consult. ...additional 2 L NS boluses, and fluid at 250 cc/h, intubate as needed for respiratory distress, pain control with Dilaudid, Ct (computerized tomography) Scan of the chest, nephrology and infectious disease consulted. Renal failure secondary to compartment syndrome. "This case was discussed with attending who agrees with assessment and plan."


Attending physician Progress Notes dated 01/28/17 documents "Patient with severe sepsis with septic shock has been associated with acute kidney injury with metabolic acidosis, hypotension and elevated liver function. The non-contrast CT of the shoulder revealed extensive subcutaneous swelling in the posterior left shoulder as well as air and swelling in the deltoids and infraspinatus muscles concerning for infection/myositis with gas forming microorganisms. ER consulted general surgery, (physician name) who reportedly has noted that this is an orthopedic surgery problem since it involved the shoulder/arm. Orthopedics (physician name) was consulted, who initially refused the consult since it involved the patient's arm and referred us to a hand surgeon. (Physician Name) was called from hand surgery, who then stated that this is outside his scope of practice since this is involving a shoulder and arm and he is specifically a hand surgeon. (Physician Name) from vascular surgery also consulted but refused consult, as he reportedly does not take care of compartment syndrome especially in the shoulder. (Physician Name) Chief of Surgery has spoken to the Orthopedic surgeon, who agreed to see the patient tomorrow, he states that per his research in literature, the patient may do well if we have interventional radiology place a drain.

Interventional Radiology was consulted to review the films. In the meantime, with help from the chief nursing officer and chief executive officer, we contacted the transfer center and got in touch with the Trauma Surgeon on call at Hospital B (Trauma Center), and the Trauma surgeon recommended calling general surgery on call at their institution. Spoke to (MD Name) from general surgery (at Hospital B) via transfer center. The general surgeon from Hospital B accepted the patient to be transferred as soon as possible for possible surgical intervention at Hospital B (trauma center). Transfer is being arranged. I have discussed in detail with the patient and wife.

The EMTALA memorandum of Transfer form dated 1/28/2017 was reviewed. The section of the EMTALA form titled "REASON FOR TRANSFER" revealed the transfer was medically indicated because of the presumed diagnosis of Necrotizing Fasciitis was identified.
Further review also revealed that the reason for the transfer was that the "On-call physician refused or failed to respond within a reasonable period of time." The section of the EMTALA transfer form titled "Risks and Benefits for Transfer" revealed in part, "Medical Benefits:" documented "obtain level of care/service unavailable at this facility. The hospital had multiple surgical consultants routinely available and on staff capable of treating Necrotizing Fasciitis (a flesh eating disease, is an infection that results in the death of parts of the body's soft tissue) , a time sensitive life and limb-threatening condition for patient #2 on 1/28/2017.

3. Medical Record Review Patient #2 at Receiving Facility
Review of the receiving facility medical records indicates Patient #2 underwent a debridement and washout of necrotizing fasciitis to the left arm and shoulder on 01/29/17 by a general surgeon specialist. The patient had multiple surgical procedures and debridement and was discharged home with home health and wound care on 02/25/17.


4. On-Call Schedules

Review of the facility's On Call schedules conducted on 09/05/18 and 09/06/18, revealed the facility had surgical, vascular, and orthopedic on-call coverage available on call on 01/28/17, when the patient presented to the hospital's ED on 1/28/2017.


5. Core Privileges Orthopedic Surgeon

The Core Privileges for the Orthopedic Surgeon who was on call and called on 1/28/2017 regarding patient #2 was reviewed. The Core Privileges were approved on 7/18/17 and effective 7/1/2017 through 6/30/2019. His Core Privileges were listed in part, "Privileges to admit, evaluate, diagnose, consult, and provide non-surgical and surgical care to patients 18 or older-except as specifically excluded from Practice and except for those special procedures privileges listed below- to correct or treat various conditions, illnesses, an injuries of the musculoskeletal system including the provision of consults. PROCEDURE LIST ...Fasciotomy (surgical procedure where fascia is cut to relieve tension and/or pain-life saving procedure when used to treat compartment syndrome). The review of this credentialing file verifies the Orthopedic surgeon was privileged to perform fasciotomy, incision and drainage surgical procedures.


6. Interviews

Interview with the Director on 09/05/2019 at 9:55 AM revealed the On Call list is posted daily on the electronic format and all staff has access to the schedule and updates.

Interview with the Physician conducted on 9/5/2019 at 10:20 AM revealed the facility has four to six physicians on duty during peak times and physician coverage is twenty-four hours a day. There is an on call schedule for all the services provided and if a service is needed and not available, the staff contacts the transfer center who makes all of the arrangements.

Telephone interview with The Emergency Department Physician conducted on 09/06/18 at 11:19 AM revealed Patient #2 presented with pain and swelling to the arm. The Physician stated he did not make any consults for this patient as his main concern was addressing the septic shock.


Multiple attempts to interview the orthopedist on-call when Patient#2 presented to the hospital were made throughout the survey. The on-call physician did not return the calls.


7. Policies and Procedures

Facility policy titled "Provision of On Call Coverage" with a review date of 06/2018, documents the following:
"The hospital must maintain a list of physicians on its medical staff who have privileges at the hospital or if it participates in a community call plan, a list of all physician who participate in such plan. Physicians on the list must be available after the initial examination to provide treatment to relieve or eliminate emergency medical conditions to individuals who are receiving services in accordance with the resources available to the hospital. The cooperation of the hospital's medical staff members with this policy is vital to the hospital's success in complying with the on call provisions of EMTALA."

The facility failed to maintain a list of physicians on its Medical Staff who have privileges and were on-call (Orthopedic surgeon, Vascular surgeon and General Surgeons) and available on 1/28/2017 when patient #2 presented to the ED with an identified emergency medical condition, Necrotizing Fasciitis, but refused to evaluate the patient to provide treatment in order to relieve or eliminate an emergency medical condition as stated in their policy and procedure.

2406

Based on medical record review, policy and procedure review, Core physician privileges review, on-call schedules review and interview the facility failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary services of surgical on call physicians who were on call and available in the emergency department when patient #2 presented to the ED. This failure affected 1 (#2) of 20 sampled patients (Patient #2) as evidenced by failing to ensure the patient was evaluated by appropriate surgical consults that were available.

The findings included:

1. Policy and Procedure review

Facility policy titled "Medical Screening Examination (MSE) and Stabilization", last revised 04/01/18, documents the following:
"A hospital must provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available in the emergency department.... Extent of the MSE is an ongoing process. the individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an Emergency Medical Condition (EMC), and if he or she does, until the EMC is relieved or eliminated or the individual is appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer".


2. Medical Record Review -Patient #2
Clinical record review conducted on 09/05/18 thru 09/06/18 revealed Patient #2 presented to the facility on 01/28/17 at 12:15 PM with chief complaint of Abscess to left shoulder. The patient was triaged at 12:26 PM as urgent. The medical screening exam conducted at 1:04 PM documents the patient complained of shoulder problem, weakness and dizziness. Patient received a testosterone injection three days ago, that evening he started to have pain and it has gotten worse. On arrival, his blood pressure was low 81/59 (normal Blood Pressure ) and had elevated heart rate 20 (normal heart rate 60-100). The physical exam revealed pain and swelling to left arm. There is a palpable abscess, no drainage or tightness. Laboratory studies indicates elevated troponin and lactic acid levels, low sodium and elevated kidney functions. Radiology studies included an ultrasound of the left arm; the impression documents diffuse lateral arm subcutaneous swelling. No evidence of fluid collection or abscess. Patient #2 received antibiotics, pain medicine, antiemetic, anticoagulant and vasopressors to manage his condition.

Physician reevaluation documents the patient's blood pressure continued to be low after three liters of fluid. Patient is complaining of increased pain to the arm but still has a palpable pulse. He has received antibiotic (vancomycin and Rocephin) and started on Norepinephrine (drug used to raise blood pressure). Resident History and Physical dated 01/28/17 at 4:39 PM documents "patient presents with acute left shoulder compartment syndrome. Septic shock, acute compartment syndrome with pressures of 40 mm Hg on the anterior, lateral and posterior compartment. Multiple surgeons have been consulted STAT (as soon as possible) and have refused the consults or not responded starting at 4 PM on 01/28/17. General surgery on call (Physician name) at 4:16 PM who said to call orthopedic on call. (Physician Name) orthopedic called at 4:30 PM who refused the consult. Resident saw patient in room 34 at bedside at 5 PM and (Physician Name) examination said "This was not compartment syndrome". (Physician Name) (vascular) called at 5:15 PM and refused the consult. Plan noted intubate as needed for respiratory distress, additional bolus of fluid, pain control with Dilaudid, Ct (computerized tomography) Scan of the chest, nephrology and infectious disease consulted. Renal failure secondary to compartment syndrome. The EMTALA memorandum of Transfer form dated 1/28/2017 was reviewed. The section of the EMTALA form titled "REASON FOR TRANSFER" revealed the transfer was medically indicated because of the presumed diagnosis of Necrotizing Fasciitis was identified.

Further review also revealed that the reason for the transfer was that the "On-call physician refused or failed to respond within a reasonable period of time." The section of the EMTALA transfer form titled "Risks and Benefits for Transfer" revealed in part, "Medical Benefits:" documented "obtain level of care/service unavailable at this facility. The hospital had multiple surgical consultants available and on staff capable of treating Necrotizing Fasciitis, a time sensitive life and limb-threatening condition for patient #2 on 1/28/2017. As this resulted in an inappropriate Medical Screening Examination for patient#2.

3. Medical Record Review for patient #2 at Receiving Facility
Review of the receiving facility medical records indicates Patient #2 underwent a debridement and washout of necrotizing fasciitis to the left arm and shoulder on 01/29/17 by a general surgeon specialist. The patient had multiple surgical procedures and debridement and was discharged home with home health and wound care on 02/25/17.

4. On-Call Schedules

Review of the facility's On Call schedules conducted on 09/05/18 and 09/06/18, revealed the facility had surgical, vascular, and orthopedic on-call coverage available on call on 01/28/17, when the patient presented to the hospital's ED on 1/28/2017.


5. Core Privileges Orthopedic Surgeon

The Core Privileges for the Orthopedic Surgeon who was on call and called on 1/28/2017 regarding patient #2 was reviewed. The Core Privileges were approved on 7/18/17 and effective 7/1/2017 through 6/30/2019. His Core Privileges were listed in part, "Privileges to admit, evaluate, diagnose, consult, and provide non-surgical and surgical care to patients 18 or older-except as specifically excluded from Practice and except for those special procedures privileges listed below- to correct or treat various conditions, illnesses, an injuries of the musculoskeletal system including the provision of consults. PROCEDURE LIST ...Fasciotomy (surgical procedure where fascia is cut to relieve tension and/or pain-life saving procedure when used to treat compartment syndrome). The review of this credentialing file verified the on-call Orthopedic surgeon was privileged to perform fasciotomy surgical procedures when patient #2 presented to the ED on 1//28/2017.


6. Interview
Telephone interview with The Emergency Department Physician conducted on 09/06/18 at 11:19 AM revealed Patient #2 presented with pain and swelling to the arm. The Physician stated he did not make any consults for this patient as his main concern was addressing the septic shock.

Based on medical record reviews, policies and procedure review, on-call schedules, Physician Core Privileges review and interviews the facility failed to provide surgical treatment within its capacity that minimized the risks to the individual's health by failing to ensure that on-call surgical consultants that were available evaluated and provided stabilizing treatment for 1 (#2)of 20 sampled patients. As this resulted in an inappropriate transfer for patient #2.

The findings were;

1. Medical Record Review- Patient #2

Review of the medical record for patient #2, the History and Physical dated 01/28/17 documentation reveals the patient presents with acute left shoulder compartment syndrome and septic shock. Multiple surgeons have been consulted STAT (as soon as possible) and have refused the consults or not responded. Patient #2's transfer form titled "EMTALA Memorandum of Transfer" form documentation revealed in part, "The patient is stable for transfer". Reason for transfer: "On Call physician refused or failed to respond within a reasonable period of time". Medical Benefit documents "Obtain level of care service unavailable at facility. Trauma Surgeon and medical benefits outweighs the risk".

2. Medical Record Review Patient #2 at Receiving Facility

Review of the receiving facility medical records indicates Patient #2 underwent a debridement and washout of necrotizing fasciitis to the left arm and shoulder on 01/29/17 by a general surgeon specialist. The patient had multiple surgical procedures and debridement and was discharged home with home health and wound care on 02/25/17.


3. On Call schedules

Review of the On Call schedules conducted on 09/05/18 and 09/06/18, revealed the facility had surgical, vascular and orthopedic coverage available and on call on 01/28/17, when patient #2 presented to the ED on 1/28/2017.

4. Core Privileges for the Orthopedic surgeon

Review of the Core Privileges for the Orthopedic surgeon on call conducted on 09/06/18 verifies the surgeon has active privileges to perform fasciotomy, incision and drainage: when patient #2 presented to the ED on 1/28/2017.


5. Interviews

Interview with The Vice President of Quality on 09/05/18 at 3:24 PM revealed the case related to Patient #2 has been settled. The facility had no idea this was a concern until they received the notice of intent. The facility did not conduct a peer review or implement a corrective action as a result of this case. The physician felt this case was out of the orthopedic surgeon scope of practice; the surgery was complex and required a trauma surgeon.

Interview with The Chief of Surgery conducted on 09/06/18 at 8:55 AM revealed Patient #2 presented to the Emergency Department with pain and swelling to the arm. The first clinical impression was an abscess and possibly compartment syndrome. The general surgeon was consulted and based on the fact the area affected was the arm, he declined the consult and suggested the orthopedic on call should be contacted. The clinical guidelines related to who should treat compartment syndrome are vague. The Chief recalled he spoke to the orthopedist and the plan was for him to do an incision and drainage and place a drain, the next day. At this time, this was a reasonable plan. In the meantime, the patient was being treated in intensive care for his hypotension. Then the Computed Tomography Scan results indicated possible diagnosis of necrotizing fasciitis and of course, the urgency changed. The orthopedist did not feel comfortable attending to this complicated case and a referral was made to a trauma center for surgical intervention. The Chief stated all the surgeons involved responded in a timely manner, but they felt this case was out of their scope of practice.


6. Policy and Procedure

The facility's policy titled, "FL Transfer Policy" Effective date 2/1/2016, Review date 6/2018 and Approval date 6/2018 was reviewed. Review of the policy revealed in part," Transfer of Individuals Who Have Not Been Stabilized" ...b. A transfer will not be appropriate if the transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health." The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that surgical treatment was provided within its capacity that minimizes the risks to Patient #2's health and time sensitive emergency medical condition, necrotizing fasciitis.