HospitalInspections.org

Based on review of the medical staff bylaws, record review and interview, the facility failed to have quality tracking measures in place to ensure physician response to patients seen in the emergency department was timely.

Findings included:

Review of the quality information for the emergency department (ED) showed there was no data collected currently related to response and arrival times for on-call physicians.

During an interview on 10/25/2012 at 10:35 a.m., the RN nurse manager said she did not know of any problems with getting a physician contact, but times do vary and sometimes there was a delay, like 15 minutes in calling back. She said she did not think any specific physicians have been a problem. She said there was no formal log to track the length of time it takes to contact the on-call physicians or when the physicians return the calls or arrive at the hospital. She said the unit secretary should be documenting the time, tracking if the physician does not call back and recalling the physician when needed. She said that currently no data was collected to determine whether or not physicians returned calls in a timely manner or come to the ED in a timely manner.

Review of the medical staff bylaws, dated as approved 9/09/2010 by the Viera Hospital Board, read the following regarding on-call physician response time: "It is the responsibility of the on-call physician to respond in an appropriate time frame. The appropriate time frame is defined as: (1) a return call to the Emergency Department within thirty (30) minutes or (2) an appearance in the Emergency Department of the physician or appropriate patient disposition within an additional thirty (30) minutes if requested by the Emergency Department physician. If the on-call physician does not respond to being called or paged, the physician's Service Chair shall be contacted. Failure to respond in a timely manner may result in the initiation of disciplinary action."

Based on record review and interview, the facility failed to enforce and demonstrate medical staff comply with a timely in response to peer review inquiries related to the quality of medical care provided to a patient.
Findings included:
1. Review of the risk management investigation findings, dated as completed on 7/10/2012 by the director of risk management, showed the following plan items were not addressed related to the death of a patient in a timely manner: #2-Query the on-call surgeon regarding his consideration of the differential diagnosis (i.e. urologic v bowel) and whether he considered the patient's previous history of bariatric surgery.

2. During an interview on 11/08/2012 at 11:10 a.m., the physician (MD) vice president (VP) of Medical Affairs said that he received a death peer review case in August 2012 for the peer review meeting scheduled for September 2012.

After the peer review was completed in September, there were additional questions related to the case and surgeon staff C was sent a letter titled "Review of the letter to (staff surgeon C)-Case Review Inquiry Letter", dated 9/18/2012: "Based on the information available in the patient's medical record (#7), the preliminary review of the case has raised the following questions - Did you consider consulting with a gastroenterologist or with the bariatric surgeon in view of the patient's persistent symptoms and past history of a gastric bypass? Should you have personally evaluated the patient when she became unstable and was moved to the ICU and was exhibiting signs of SIRS (system inflammatory response syndrome)? We recognize the medical record often does not contain all of the information needed to evaluate care in a complex case. Prior to the committee making a determination on the case, we would like to have your input in writing to the above questions to more fully understand the care provided to this patient . . . ." The last paragraph of the letter read, "It is the policy of the Medical Staff that this response is needed within 14 days of the receipt of the letter so the committee can review cases in a timely manner. If your response is not received within the appropriate time frame, by policy, the committee will have to complete its evaluation without your valuable input. . . ."

The letter documented the physician personally picked up the letter on 9/21/2012, and pick-up date was confirmed by the quality coordinator.

3. During an interview on 11/08/2012 at 11:10 a.m., the VP of Medical Staff said staff surgeon C did not respond or ask for additional time until after the October 3, 2012 quality meeting had met.

The VP of Medical Staff said he personally spoke with staff surgeon C last week to discuss this case. He said staff surgeon C did not provide a written response. In phone conversation with staff surgeon C, the VP Medical Director said staff C was given the choice of attending the meeting on 11/07/2012 or submitting a written response. He said the response was given verbally sometime last week but he did not remember the specific day.

The VP of Medical Staff said the finding from the quality committee meeting last evening were:
Opportunity for improvement of care provided by staff surgeon C in the specific case reviewed.
Staff surgeon C and this case will be referred to the department chair.
Staff surgeon C must attend the future bariatric in-service to be provided-TBD.
Staff C did not return his written response to the case questions within 14 days of the receipt of the letter so the committee can review cases in a timely manner as requested in the letter from the medical staff office.

During a phone interview on 10/25/2012 at 1 p.m.,surgeon staff C said he also said he has not yet returned the query related to this event the hospital asked him to complete.

Based on review of the medical staff bylaws, record review and interview, the facility failed to require on-call physicians to provide a backup plan when performing elective procedures at another facility, failed to enforce physician response time for consultations, and failed to ensure on-call physician response time in the emergency department (ED) was enforced and timely for 1 of 11 sampled patients (#7).

Findings included:

1. Review of the medical staff bylaws, dated as approved 9/09/2010 by the Viera Hospital Board, read the following regarding consultations and on-call physician response time: "It is the responsibility of the on-call physician to respond in an appropriate time frame. The appropriate time frame is defined as: (1) a return call to the Emergency Department within thirty (30) minutes or (2) an appearance in the Emergency Department of the physician or appropriate patient disposition within an additional thirty (30) minutes if requested by the Emergency Department physician. If the on-call physician does not respond to being called or paged, the physician ' s Service Chair shall be contacted. Failure to respond in a timely manner may result in the initiation of disciplinary action. . . .The attending physician will provide documentation requesting the consultation, and permitting the consulting practitioner to attend or examine his/her patient. This request shall specify: 1) the reason for the consultation; 2) the urgency of the consultation (routine-within 24 hours and priority-anything less than 24 hours). . . ."


2. Review of the policy related to a provision for providing care for ED patients when an on-call surgeon was performing elective cases, while on call, at another facility location showed there was none.

During an interview on 10/25/2012 at 12:30 p.m., the director of risk management confirmed the facility did not currently have a policy related to a provision for providing care for emergency department patients when an on-call surgeon was performing elective cases, while on call, at another facility location. He said a policy was worked on in the past, but never completed and implemented.

3. Review of the medical record for patient #7 showed she presented to the ED on 6/29/2012 at 8:32 a.m. by ambulance with a chief complaint of abdominal pain. This was the second visit to the ED in two days for the same complaint.

Medical record review and ED physician interview showed the following sequence of events:
6/29/2012 at 8:32 a.m. - patient #7 arrives by ambulance at the ED and was triaged as urgent. Pain level is assessed as 10/10.

6/29/2012 at 8:38 a.m. - CT scan ordered in the ED showed "Interesting multiple twist in the small bowel mesentery seen in the mid-abdomen without causing obvious signs of bowel obstruction or mesenteric ischemia. This similar twisting appearance the mesentery is evident on the 2010 study."

Review of the hospital's investigation, completed by the director of risk management, showed the following documentation for patient #7 for the 6/29/2012 ED visit:

9:16 a.m. - ED physician A called surgeon C. Provided the patient's history of present illness and her history of a previous gastric bypass and expressed concern that he believed the patient had an ischemic bowel. Surgeon C stated that he was in Titusville and had a very busy day with 4 patients that were still scheduled for surgery. He (surgeon C) suggested that the patient might have an internal hernia and he would be uncomfortable dealing with it due to not knowing if he would have to take down the bypass. He then requested that either surgeon E or D be contacted to ask if they would be willing to see the patient and, if not to give him a call back.

9:22 a.m. - ED physician A called surgeon D, who state that he was in Orlando. He offered his opinion that the patient may be suffering from an internal hernia and directed him to call surgeon E (his partner).

9:24 a.m. - ED physician A called surgeon E. He (ED physician A) provided an overview of the present illness as well as her history of previous bypass and tells him that he is ordering a CT scan but that it is his impression that the patient may have an ischemic bowel. Surgeon E questioned why surgeon C was not seeing the patient and was told he was engaged in surgery in Titusville. To that, surgeon E expressed his belief that surgeon C should be available if he was on call. The call ended with no definitive decision made on whether he will see the patient.

10:58 a.m. - ED physician A calls hospitalist staff I and. . . .she agrees to admit the patient.

11:10 a.m. - ED physician A called surgeon E with the results of the CT scan which showed a twisted mesentery. Surgeon E told him (ED physician A) to call surgeon C and ED physician agreed to do so.

11:17 a.m. - (Physician A) then indicated he had placed a call to surgeon C.

11:18 a.m. - call placed to surgeon C and message left on his answering machine requesting that he call back.

Review of the investigation timeline, completed on 7/10/2012 by the director of the risk management department, through 5 p.m., showed there was no documented return call timed or documented by the surgeon on-call (staff C).

During an interview on 10/24/2012 at 1:10 p.m., ED physician A said, "The patient presented to the ED, he assessed (patient #7), testing was ordered, and even before the testing was completed, he called the surgeon on-call (surgeon C). He said he was calling the surgeon even before the labs and x-rays were returned because he felt the case was emergent/urgent. He said he called surgeon C to let him know the patient would possibly need surgery. He also said he was not 100% sure but he thought he did ask surgeon C to come to the ED to see the patient. ED physician A confirmed he worked until about 5 p.m. and never received a call back from the surgeon on-call (staff C).

He said he did not think he asked surgeon E to come in, but he believed by calling surgeon E back with the requested results of the CT, he assumed surgeon E was coming in to see the patient and assume responsibility for her care.

This entire above interview was reviewed and confirmed by ED physician A on 10/24/2012 at 4:10 p.m.

Further medical record review for patient #7 showed:
On 6/29/2012 at 11: 22 a.m. - patient #7 was discharged from the ED and went to the nursing unit.

6/30/2012 at 8:20 p.m.- surgeon C saw the patient and wrote orders for further testing. This was 35 hours after the consult was requested. Medical record review showed the consult was ordered by hospitalist staff I on 9/29/2012 at 11:19 a.m.

7/01/2012 at 10:50 p.m. - physician order from the facility hospitalist showed an order to notify surgeon C of change in the patient's condition.

7/01/2012 at 11:33 p.m. - telephone orders from surgeon C for a Foley catheter, stop Toradol, Protonix 40 milligrams (mg.) intravenous (IV) now and then every 12 hours, Dilaudid 1 mg. IV now, one time dose, cancel small bowel series in a.m., transfer patient to ICU, and CT scan abdomen and pelvis with and without in a.m. (the original small bowel follow-through and upper GI series was ordered on 6/30/2012).

7/02/2012 at 1:09 a.m. - vital signs in the ICU showed 90/60, heart rate 107, and respirations of 32.

7/02/2012 at 1:54 a.m. - an abdominal x-ray showed extensive gas throughout the bowels. The findings could represent an obstruction but "I believe there is also gas in the colon. If that is the case, this is more likely an extensive ileus."

7/02/2012 at 6:37 a.m. - the results of the CT of the abdomen and pelvis showed "The bowel is diffusely distended with prominent pneumatosis noted in involving multiple small bowel loops ....The impression documents - Diffusely distended intestinal tract, prominent small bowel pneumatosis, portal vein air and small amount of free intraperitoneal air highly suspicious for bowel infarction and early perforation. There is apparent twisting of the mesentery.

7/02/2012 at 7 a.m. - vital signs in the ICU showed 105/75, heart rate 123, and respirations of 55 with a non-rebreather mask. Patient #7 had a pain level of 10/10.

7/02/2012 at 8:20 a.m. - the respiratory therapy notes showed the patient was intubated with a 7.5 tube and placed on mechanical ventilation.

7/02/2012 at approximately 9:30 a.m. - patient #7 was taken to the operating room for an exploratory laparotomy, possible bowel resection, possible ostomy, other indicated procedure. The operative note dictated by surgeon D read, "ischemic bowel, the entire small bowel from the Roux limb all the way to the terminal ileum including the right colon and proximal transverse colon was completely dead. The omentum was completely dead. The only viable portion was the stomach." The note documents discussion with the family, the patient was put on comfort measures, and died on 7/4/2012 at 4:53 a.m.

4. During a phone interview on 10/25/2012 at 1 p.m., surgeon C said he was called by the ED physician A. He informed ED physician A that he did not do bariatric surgery. Later that day he said he found out he was assigned the admitted patient #7. He said based on the patient's history he ordered a urological consult. He said he saw the patient daily, but was not sure if he saw the patient on the day of admission. He said he when he saw her on Saturday (7/01/2012), the patient was still in pain and it was only relieved by Benadryl. He said when he first saw the patient she could not hold still for him to examine. On Sunday, he saw the patient and she was sleeping. Early on Monday morning, at approximately 12:30 a.m., he received a call from the nursing staff the patient was having difficulty breathing and was being transferred to the ICU. At 7 a.m., he received a call from the hospital that the intensive care physician ordered a new CT scan of the abdomen and the patient now had changes on the CT scan. He said he personally called surgeon D and this when surgeon D became involved and assumed care of the patient.

5. During an interview on 10/23/2012 at 5:15 p.m., surgeon D said bariatric patients can have complication many years after their initial surgery. He said surgeon E was no longer on staff at the hospital, but did not know the reason. He said when he was called about patient #7's case, he was out of town. He suggested to the ED physician he should call his partner, surgeon E. He also said he thinks surgeon C thought surgeon E was going to see and assess patient #7.

When asked if the outcome of this case would have been different if patient #7 had surgery on 6/29/2012, the first day of admission, he responded she would have lived. He stated that when he did the surgery, the patient's abdomen was so distended he had difficulty closing the incision. Surgeon D said he is the only general surgeon who does bariatric surgery now that surgeon E has resigned. He said before that it was not documented, but one of them was always on call to care for any of the bariatric patients. Quality Coordinator staff H confirmed there was no documented on-call bariatric surgeon on the emergency department on-call list.

6. Review of the medical staff credential file for staff surgeon E showed a resignation letter dated 7/13/2012.

7. Review of the on-call general surgery medical staff call list for the ED June/2012 showed surgeon C was on-call for the ED on 6/29, 6/30, and 7/01/2012.

Based on review of medical records, on-call lists and staff interviews, the facility failed to ensure a policy was in place to provide care for emergency department (ED) patients when an on-call surgeon was performing elective cases, while on call, at another facility location for 1 of 24 patients (#7), failed to specifically designate individuals qualified to conduct medical screening examinations in the emergency department, and failed to ensure 3 of 3 pregnant patients (#12, 18 & 25) presenting to the emergency department (ED) received a complete assessments in a timely manner resulting in non-compliance with the condition of participation- ?482.55 Condition of Participation: Emergency Services.

Findings:

1. Cross Refer A1101. Based on record review and interview, the facility failed to specifically designate individuals qualified to conduct medical screening examinations in the ED.

2. Cross Refer A1103. Based on record review and interview, the facility failed to ensure 3 of 3 pregnant patients (#12, 18 & 25) presenting to the ED received a complete assessments in a timely manner.

3. Cross Refer A1104. Based on review of medical records, on-call lists and staff interviews, the facility failed to ensure 1 of 11 patients (#7) received timely treatment from an on-call physician, and failed to have a policy in place to provide care for patients requiring an on-call physician when the on-call physician was performing elective surgical cases, while on call, at another facility location.

Based on record review and interview, the facility failed to specifically designate individuals qualified to conduct medical screening examinations in the emergency department (ED).

Findings included:

Review of the medical staff bylaws dated as approved, on 9/09/2010, by the Viera Hospital Board, read, "The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that for all patients who present to the Emergency Department, the Hospital must provide for an appropriate medical screening examination with the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. Screening and immediate steps to stabilize patients shall be provided by assigned Emergency Department staff and practitioners on call to the Emergency Department and by other qualified practitioners approved by the board." Qualified practitioners was not defined.

During an interview on 10/24/2012 at 2:30 p.m., the director of risk management confirmed this was the only reference in the bylaws related to designation of qualified personnel and direction for the ED and did not define qualified personnel.

Based on record review and interview, the facility failed to ensure 3 of 3 pregnant patients (#12, 18 & 25) presenting to the emergency department (ED) received a complete assessments in a timely manner.

Findings included:

1. Medical record review for patient #25, age 24, showed the patient presented to the ED on 6/28/2012 at 8:16 p.m. with a chief complaint of vaginal fluid leakage. The medical record past history read the patient was 20 weeks pregnant. Review of the T-sheet (emergency record) showed the physician documentation of assessment for labor/contractions is blank. It also documents the vaginal fluid is clear and started 3-4 days prior. A pelvic examination was not performed. The progress note read, "Pt (patient) seen with clear vaginal fluid leakage, cramps, vss (vital signs stable). U/S (ultrasound-a type of x-ray exam) done. No sterile speculum available. Discussed with OB (obstetrician) on-call at Holmes Regional Medical Center will accept in transfer."

The clinical impression was pregnancy-rupture of membranes. The ED physician documented intention of transferring the patient for higher level of services. However, the patient was in the ED from 8:16 p.m. until 2 a.m., when she signed herself out the hospital AMA.

The only fetal heart tones assessed during patient #25's ED visit were during the pelvic ultrasound performed on 6/28/2012 at 11:30 p.m.

2. Medical record review for patient #12, age 21, showed the patient presented to the ED on 8/17/2012 at 11:15 a.m. with a chief complaint of abdominal pain-epigastric. The ED physician T-sheet showed the chief complaint as abdominal pain, and vomiting, with onset/duration stating (unreadable) pregnant. The ultrasound documentation read, "22 week, intrauterine pregnancy" Nursing documentation indicated the patient "had not felt the baby move since the night before at 10 p.m."

Review of the T-sheet (emergency record) did not show any physician documentation for assessment of labor/contractions. A pelvic examination was not performed. The clinical impression was improved abdominal pain and discharge to home.

The patient was in the ED from 11:15 a.m. until 5:01 p.m., when she was discharged. The only fetal heart tones assessed during patient #12's ED visit were during the pelvic ultrasound performed on 8/17/2012 at 2:41 p.m.

3. Medical record review for patient #18, age 20, showed the patient presented to the ED on 10/5/20128:56 a.m. with a chief complaint of pregnant-occasional abdominal pain. The ED physician T-sheet showed the chief complaint as abdominal pain. Review of the T-sheet (emergency record) did not show any physician documentation for assessment for labor/contractions. A pelvic examination was nor performed. HCG (pregnancy test) showed a level of 45,270 (indicating a pregnancy of 5 weeks to 3 months or greater). The clinical impression was pregnancy, condition same/stable, and discharge to home to follow-up at a clinic after she made an appointment.

The patient was in the ED from 8:56 a.m. until 12:01 p.m. when she was discharged with instructions to make an appointment to see a physician for follow-up.

Review of the hospital's policies related to obstetrical patients showed the facility had only one policy-Maternal Transport, dated as last reviewed on 04/01/2012, which read, "Transport to be consider after obstetrician/physician assessment and evaluation to determine appropriate transfer to a higher level of care" and "a pregnant patient will not be transferred without being seen by the attending obstetrician who will perform an evaluation of maternal and fetal status."

During an interview on 10/25/2012 at 1:30 p.m., the ED physician and medical director said when the obstetrician on call was consulted, (s/he) requested a test to determine if the fluid was amniotic, but the test is not available in the facility, and a sterile speculum was not available to examine the patient. He also said the ultra sound scan was more accurate to measure the fetal heart tones than staff checking. He also said there was no obstetrician available at the facility since the facility does not provide an obstetrical department.

Based on review of medical records, on-call lists and staff interviews, the facility failed to ensure 1 of 11 patients (#7) received timely treatment from an on-call physician, and failed to have a policy in place to provide care for patients requiring an on-call physician when the on-call physician was performing elective surgical cases, while on call, at another facility location.

Findings included:

Review of the policy related to a provision for providing care for ED patients when an on-call surgeon was performing elective cases, while on call, at another facility location showed there was none.

During an interview on 10/25/2012 at 12:30 p.m., the director of risk management confirmed the facility did not currently have a policy related to a provision for providing care for emergency department patients when an on-call surgeon was performing elective cases, while on call, at another facility location. He said a policy was worked on in the past, but never completed and implemented.

Review of the medical record for patient #7 showed she presented to the ED on 6/29/2012 at 8:32 a.m. by ambulance with a chief complaint of abdominal pain. This was the second visit to the ED in two days for the same complaint.

Medical record review and ED physician interview showed the following sequence of events:
6/29/2012 at 8:32 a.m. - patient #7 arrived by ambulance at the ED and is triaged as urgent. Pain level was assessed as 10/10.

6/29/2012 at 8:38 a.m. - CT scan ordered in the ED showed "Interesting multiple twist in the small bowel mesentery seen in the mid-abdomen without causing obvious signs of bowel obstruction or mesenteric ischemia. This similar twisting appearance the mesentery is evident on the 2010 study."

Review of the hospital's investigation, completed by the director of risk management, showed the following documentation for patient #7 for the 6/29/2012 ED visit:
9:16 a.m. - ED physician A called surgeon C. Provided the patient's history of present illness and her history of a previous gastric bypass and expressed concern that he believed the patient had an ischemic bowel. Surgeon C stated that he was in Titusville and had a very busy day with 4 patients that were still scheduled for surgery. He (surgeon C) suggests that the patient might have an internal hernia and he would be uncomfortable dealing with it due to not knowing if he would have to take down the bypass. He then requests that either surgeon E or D be contacted to ask if they would be willing to see the patient and, if not to give him a call back.

9:22 a.m. - ED physician A called surgeon D, who state that he was in Orlando. He offered his opinion that the patient may be suffering from an internal hernia and directs him to call surgeon E (his partner).

9:24 a.m. - ED physician A called surgeon E. He (ED physician A) provided an overview of the present illness as well as her history of previous bypass and told him that he was ordering a CT scan but that it was his impression that the patient may have an ischemic bowel. Surgeon E questions why surgeon C did not see the patient and was told he was engaged in surgery in Titusville. To that, surgeon E expressed his belief that surgeon C should be available if he is on call. The call was ended with no definitive decision made on whether he would see the patient.

10:58 a.m. - ED physician A calls hospitalist staff I and she agreed to admit the patient.

11:10 a.m. - ED physician A called surgeon E with the results of the CT scan which shows a twisted mesentery. Surgeon E told him (ED physician A) to call surgeon C and the ED physician agrees to do so.

11:17 a.m. - He (physician A) then indicated he had placed a call to surgeon C.

11:18 a.m. - call placed to surgeon C and message left on his answering machine requesting that he call back.

Review of the hospital's investigation timeline, completed on 7/10/2012 by the director of the risk management department, through 5 p.m. showed there was no documented return call timed or documented by the surgeon on-call.

During an interview on 10/24/2012 at 1:10 p.m., ED physician A said, "The patient presented to the ED, he assessed (patient #7), testing was ordered, and even before the testing was completed he called the surgeon on-call, surgeon C. He said he was calling the surgeon even before the labs and x-rays were returned because he felt the case was emergent/urgent. He said he called surgeon C to let him know the patient would possibly need surgery. He also said he was not 100% sure but he thought he did ask surgeon C to come to the ED to see the patient. ED physician A confirmed he worked till about 5 p.m. and never received a call back from the surgeon on-call (C). He said he did not think he asked surgeon E to come in, but he believed by calling surgeon E back with the requested results of the CT, he assumed surgeon E was coming in to see the patient and assume responsibility for her care. This entire above interview was reviewed and confirmed by ED physician A on 10/24/2012 at 4:10 p.m.

Further medical record review for patient #7 showed:
6/29/2012 at 11:22 a.m. - patient #7 was discharged from the ED and went to the nursing unit.

6/302012 at 8:20 p.m. - Surgeon C saw the patient and wrote orders for further testing.

7/01/2012 at 10:50 p.m. - Physician order from the facility hospitalist showed an order to notify surgeon C of change in the patient's condition.

7/01/2012 at 11:33 p.m. - Telephone orders from surgeon C for a Foley catheter, stop Toradol, Protonix 40 milligrams (mg.) intravenous (IV) now and then every 12 hours, Dilaudid 1 mg IV now, one time dose, cancel small bowel series in a.m., transfer patient to ICU, and CT scan abdomen and pelvis with and without in a.m. (the original small bowel follow-through and upper GI series was ordered on 6/30/2012).

7/02/2012 at 1:09 a.m. - Vital signs in the ICU showed 90/60, heart rate 107, and respirations of 32.

7/02/2012 at 1:54 a.m. - An abdominal x-ray showed "extensive gas throughout the bowels. The findings could represent an obstruction but I believe there is also gas in the colon. If that is the case, this is more likely an extensive ileus."

7/02/2012 at 6:37 a.m. - The results of the CT of the abdomen and pelvis showed "The bowel is diffusely distended with prominent pneumatosis noted in involving multiple small bowel loops ....The impression documents- Diffusely distended intestinal tract, prominent small bowel pneumatosis, portal vein air and small amount of free intraperitoneal air highly suspicious for bowel infarction and early perforation. There is apparent twisting of the mesentery."

7/02/2012 at 7 a.m. - Vital signs in the ICU showed 105/75, heart rate 123, and respirations of 55 with a non-rebreather mask. Patient #7 had a pain level of 10/10.

7/02/2012 at 8:20 a.m. - The respiratory therapy notes showed the patient was intubated with a 7.5 tube and placed on mechanical ventilation.

7/02/2012 at approximately 9:30 a.m. - patient #7 was taken to the operating room for an exploratory laparotomy, possible bowel resection, possible ostomy, other indicated procedure. The operative note dictated by surgeon D read, "ischemic bowel, the entire small bowel from the Roux limb all the way to the terminal ileum including the right colon and proximal transverse colon was completely dead. The omentum was completely dead. The only viable portion was the stomach." The note documented discussion with the family, the patient was put on comfort measures, and died on 7/04/2012 at 4:53 a.m.

4. During a phone interview on 10/25/2012 at 1 p.m., surgeon C said he was called by the ED physician A. He informed ED physician A that he did not do bariatric surgery. Later that day he said he found out he was assigned the admitted patient #7. He said based on the patient's history he ordered a urological consult. He said he saw the patient daily, but was not sure if he saw the patient on the day of admission. He said he when he saw her on Saturday, the patient was still in pain and it was only relieved by Benadryl. He said when he first saw the patient she could not hold still for him to examine.

On Sunday he saw the patient and she was sleeping. Early on Monday morning, at approximately 12:30 a.m. he received a call from the nursing staff the patient was having difficulty breathing and was being transferred to the ICU. At 7 a.m., he received a call from the facility that the intensive care physician ordered a new CT scan of the abdomen and the patient now had changes on the CT scan. He said he personally called surgeon D and this when surgeon D became involved and assumed care of the patient.

During an interview on 10/23/2012 at 5:15 p.m., surgeon D said bariatric patients can have complication many years after their initial surgery. He said that surgeon E was no longer on staff at the hospital, but did not know the reason. He said when he was called about patient #7's case he was out of town, he suggested to the ED physician he should call his partner, surgeon E. He also said he thinks surgeon C thought surgeon E was going to see and assess patient #7. When asked if the outcome of this case would have been different if patient #7 had surgery on 6/29/2012, the first day of admission, he responded she would have lived. He stated that when he did the surgery, the patient's abdomen was so distended he had difficulty closing the incision. Surgeon D said he was the only general surgeon who did bariatric surgery now that surgeon E has resigned. He said before that it was not documented, but one of them was always on call to care for any of the bariatric patients. Quality Coordinator staff H confirmed there was no documented on-call bariatric surgeon on the emergency department on-call list.

Review of the medical staff bylaws, dated as approved 9/09/2010 by the Viera Hospital Board, read the following regarding on-call physician response time: "It is the responsibility of the on-call physician to respond in an appropriate time frame. The appropriate time frame is defined as: (1) a return call to the Emergency Department within thirty (30) minutes or (2) an appearance in the Emergency Department of the physician or appropriate patient disposition within an additional thirty (30) minutes if requested by the Emergency Department physician. If the on-call physician does not respond to being called or paged, the physician's Service Chair shall be contacted. Failure to respond in a timely manner may result in the initiation of disciplinary action.

Review of the credential file for staff surgeon E has showed a resignation letter dated 7/13/2012.

Review of the on-call general surgery medical staff call list for the ED June/2012 showed surgeon C was on-call for the ED on 6/29, 6/30, and 7/01/2012.