HospitalInspections.org

Based on medical record review and hospital policies and procedures review, the hospital failed to comply with their provider agreement to provide an on call specialist to provide further medical examination and stabilizing treatment for one of 21 sampled records (Patient #1) and failed to provide stabilizing treatment within their capability to a patient that presented to the hospital Emergency Room (ED) with an emergency medical condition for one of 21 sampled records (Patient #1).


The hospital's failure to provide an on call specialist and to provide stabilizing treatment within their capabilities placed the patient at risk for further deterioration of his medical condition including death and had the potential to affect all patients treated at the hospital.


Findings include:


- The hospital's policy "Emergency On-Call Coverage (EMTALA)" reviewed on 8/17/15 at 1:50pm directed, "...On-Call Schedule. Hospital has the discretion to maintain the on-call schedule in a manner that best meets the needs of Hospital's patients receiving services required by EMTALA in accordance with resources available to the Hospital...When an on-call physician is contacted by the Emergency Department physician and requested to respond, the on-call physician must: be immediately available, respond in person, if so requested, within a reasonable time period...if the responsible on-call physician is unavailable, the designated back-up practitioner will be called for guidance in contacting another appropriate practitioner to handle care of a patient..."

- The hospital's policy "Emergency Medical Treatment and Active Labor Act (EMTALA); Transfer of Individuals with Emergency Medical Conditions" reviewed on 8/17/15 at 1:50pm directed, "...provides triage to all individuals who present at a hospital location and request treatment for an emergency medical condition to determine the order in which they will be given a Medical Screening Examination (MSE) by a qualified medical person (QMP). All such individuals receive the MSE and appropriate medical care within the facility's ability to provide care...Capability: "Capability" refers to the hospitals physical space, equipment, and supplies, as well as service made available by the hospital (e.g. trauma care, surgery, orthopedics, obstetrics, radiology, etc.). The capabilities of hospital staff means the level of care that the hospital's active medical staff, associate medical staff, and nursing staff can provide within the training and scope of their professional licenses...If the MSE determines that a patient has an EMC, the patient's condition is stabilized within the capabilities of the hospital staff and physician. If, in the emergency physician's opinion, further specialty care is required, the emergency physician contacts the on-call specialist, who responds to the call in accordance with the Medical Staff Policy 20, Emergency On-Call Coverage (EMTALA)..."

- Review of closed medical records revealed that the hospital failed to follow their "Emergency On-Call Coverage (EMTALA)" policy and their "Emergency Medical Treatment and Active Labor Act (EMTALA); Transfer of Individuals with Emergency Medical Conditions" policy in that the on call physician specialist failed to respond to a request to appear in person for one patient (Patient #1) out of 21 sampled records reviewed who presented to the hospital seeking assistance. Refer to 2404.

- Review of closed medical records revealed that the hospital failed to follow their "Emergency On-Call Coverage (EMTALA)" policy and their "Emergency Medical Treatment and Active Labor Act (EMTALA); Transfer of Individuals with Emergency Medical Conditions" policy in that they did not provide further medical examination and treatment to stabilize an emergency medical condition within the capabilities of the staff and facilities available at the hospital for one (Patient #1) out of 21 sampled records reviewed who presented to the hospital seeking assistance. Refer to 2407.

Based on medical record review, document review, and staff interviews, the hospital failed to ensure the on-call vascular surgeon reported to the emergency department (ED) on July 20, 2015 to provide stabilizing treatment to an individual (patient # 1) with an emergency medical condition for one of 21 sampled patients selected for review.


The hospital's failure to ensure the on-call Physician reported to the ED to provide stabilizing treatment placed the patient at risk for deterioration of his emergency medical condition including death and had the potential to affect all patients treated at the hospital.


Findings include:

Review of the hospital ' s EMTALA Committee Meeting minutes for September 8, 2014 indicated the hospital identified a problem related to on-call physician availability. Documentation revealed that the on-call cardiovascular surgeon indicated that he was not on-call when receiving a call during the night. " If physicians take concurrent call or do elective procedures while on call, they must arrange for back-up call. The committee agreed that physicians need to be held accountable for their on-call responsibilities and failure to comply will result in peer review. "

Review of the hospital ' s EMTALA Committee Meeting minutes for November 3, 2014 indicated the hospital continued to have concerns related to on-call physician availability. The minutes reflected the hospital established a committee for " EMTALA call only " and that " further physician education was needed as well as documentation of the chain of command when the on-call physician is unavailable. "

Review of the hospital ' s EMTALA Committee Meeting minutes for February 6, 2015 showed that an educational flyer for on-call physician requirements had been provided to physicians during the ED section meeting and that it had been added to the Medical Staff credentialing and re-credentialing packets.

Review of the hospital ' s EMTALA Committee Meeting minutes for July 13, 2015 showed that the hospital continued to have concerns regarding on-call physician availability and that staff would follow up with cardiology to make sure " first call is available. "


- The Hospital's list of on-call Specialty Physician Services for 7/20/15 reviewed on 8/18/15 at 4:00pm revealed on-call services included vascular surgery.

- The Hospital's on-call EMTALA Vascular Peripheral schedule reviewed on 8/17/15 at 12:15pm listed Vascular Surgeon Staff M as the on-call specialist for vascular surgery on 7/20/15.


- The hospital list of Specialty Surgeons reviewed on 8/17/15 included Vascular Surgeon Staff P and Vascular Surgeon Staff Q.


- Review of Patient #1's record revealed ED Physician Staff K accepted the transfer of patient #1 from hospital ZZ on 7/20/15 at 9:36 am. Hospital ZZ's physician staff reported that patient #1 came in with a complaint of abdominal pain over the last week. Assessment and diagnostic tests indicated patient #1 had an abdominal aortic aneurysm (AAA) that had increased in size since 7/16/15 and hospital ZZ's physician staff recommended cardiac evaluation and consideration of stent placement.

- Physician Staff K documented in an ED note addendum 7/21/15 at 6:48 pm that he notified the on call vascular surgeon Physician M on 7/20/15 prior to patient #1's arrival and received a recommendation for the patient to have a "CT abdomen with contrast on arrival and pending results of the CT as well as the presentation of the patient then he could be called and the patient will be evaluated by the resident as needed." At some point later (time unknown) Physician M called Physician K back and indicated that "this patient (patient #1) will not be considered for surgery given that he was not compliant with his follow up." Physician M requested Physician K call hospital ZZ back and tell them this. However, the patient was already in transport. Hospital ZZ's Physician Staff indicated that the patient was ready to hear his options.

- Patient #1's ambulance run sheet from Hospital ZZ's ambulance service reviewed on 8/17/15 and dated 7/20/15 indicated the need for an emergent transfer of Patient #1 to Via Christi St. Francis in Wichita, KS. The paramedic and EMT (emergency medical technician)departed Hospital ZZ on 7/20/15 at 10:30am with patient #1 for the 118-mile trip to Via Christi St. Francis and arrived at 12:12 pm.

- Patient #1's ED record reviewed on 8/17/15 and 8/18/15 revealed the patient presented to Via Christi Hospital St. Francis on 7/20/15 at 12:18pm with complaint of abdominal pain. Triage performed at 12:30 pm indicated the patient transferred from Hospital ZZ for possible AAA dissection (a serious condition in which the inner layer of the aorta, the large blood vessel branching off the heart, tears and can cause life threatening bleeding).

- Documentation indicated ED Physician K assumed care of Patient #1 on 7/20/15 at 2:18 PM and concurred with the APRN (Advanced Practice Registered Nurse) Staff L's assessment and plan. The Abdominal/pelvic CT on 7/20/15 at 2:49 PM revealed an abdominal aortic aneurysm (AAA) suspicious of rupture (an emergency medical condition).

- Physician Staff K documented in an ED-note addendum on 7/21/15 at 6:48 PM, "The patient arrived to our ER (ED) in stable condition, he was quickly assessed upon arrival, labs ordered as well as imaging. I did receive a call from radiology to relay the critical finding of retroperitoneal bleed and likely AAA rupture. Vascular Surgeon Physician M was called with this information, he was also told about the decreasing hemoglobin level (potential signs of active bleeding) and was made aware of the findings and vital signs. Vascular Surgeon Physician M again refused to see the patient. At this point asked him about what we can do with this patient who was actively bleeding and he recommended calling Vascular Surgeon Physician Staff P."

- ED Physician Staff K contacted Vascular Surgeon Physician Staff P on 7/20/15 at 3:23 PM (about 3 hours after the patient's arrival and 6 hours after accepting the patient for transfer) and he indicated that he was unavailable as he was performing surgery at hospital DD (approximately 3 miles away) at the current time and had another case scheduled after that. Vascular Surgeon Physician P recommended ED Physician K contact Vascular Surgeon Physician Q. Surgery records from hospital DD showed that Physician Staff P had three scheduled cases on 7/20/15. His second case of the day (a femoral popliteal bypass surgery used to treat femoral (large blood vessel in the leg) artery disease. It is performed to go around the blocked portion of main artery in the leg using a piece of another blood vessel) started at 11:15 AM and ended at 3:58 PM. Physician P started his third case (a femoral popliteal bypass) at 5:25 PM (about 1 1/2 hours since his last case) and ended at 8:19 PM.

- ED Physician K contacted Vascular Surgeon Q on 7/20/15 at 3:33 PM (about 3 hours after the patient's arrival and 6 hours after accepting the patient for transfer) and he indicated that he was unavailable as he was starting a surgery case at hospital EE (about 7 miles away) and had another case scheduled after that. Surgery records from hospital EE showed that physician Q had four scheduled cases for 7/20/15. His second case of the day (bilateral iliac (blood vessel located in the pelvic region) stent placement (stent is a device that is used to hold open an artery narrowed by disease) started at 10:59 AM and ended at 12:57 PM. His third case of the day (a left femoral popliteal bypass) started at 2:16 PM and ended at 5:26 PM. His fourth case of the day (introperative angiography (imaging of blood vessels during surgery) with revascularization (restoring blood flow) with stents started at 6:20 PM and ended at 6:53 PM.

- ED Physician K's ED Notes on 7/20/15 at 4:22 PM that reads in part, "multiple calls made to Vascular Surgeon M, on-call to the ED, (4 times: does not want to operate on patient due to co-morbidities and noncompliance). Call made to Hospital BB. Hospital BB's Vascular Surgeon Staff CC accepted Patient #1. ED Physician K documented an addendum to Patient #1's medical record on 7/21/15 at 6:48 PM that he "called Vascular Surgeon Physician M one more time as I was concerned and trying to understand why the EMTALA (Emergency Medical Treatment and Labor Act) vascular surgeon will not see this patient. The justification remained the same (non-compliant and co-morbidities)". ED Physician K completed patient #1's transfer to Hospital BB.

- Chief of Medical Staff Physician R interviewed on 8/17/15 at 1:25 PM reported that he received a call from the ED at the time things were happening with patient #1. Pager transaction log reviewed on 8/18/15 showed physician K contacted physician staff R at 4:47 PM (about 7 hours after accepting the patient for transfer and about 4 hours after his arrival). He called Vascular Surgeon Physician M who conveyed that he had seen this patient in the past and at that time the patient was not compliant and refused elective surgery. Chief of Medical Staff Physician R explained to Vascular Surgeon Physician M that he is the EMTALA on-call physician and should come in to stabilized the patient. Vascular Surgeon Physician M indicated he did not feel he would be able to care for patient #1 due to their patient/doctor relationship.

- Vascular Surgeon M, interviewed on 8/17/15 at 2:35 PM indicated they treated Patient #1 four years ago and the patient was noncompliant and felt the ED was calling him for an opinion. Vascular Surgeon Physician M received information from ED physician K regarding the CT results showing a "contained aneurysm which is critical". Vascular Surgeon Physician M indicated that he told Ed Physician K, "Patient #1 did not want surgery in the past and I don't think he wants it". Physician M indicated he received multiple calls from the ED and one from the Hospital's Chief of Medical Staff. Physician M acknowledged he did not report to the ED on 7/20/15 to provide stabilizing treatment to Patient #1 even though he was the on-call EMTALA Vascular Surgeon.

- Patient #1's medical record review from Hospital BB on 8/19/15 revealed an admission date of 7/20/15 with a ruptured Abdominal Aortic Aneurysm (AAA). The medical record indicated Patient #1 received ED treatment at an outside hospital several hours outside of Wichita with complaint of abdominal pain. Diagnostic testing revealed a diagnosis of ruptured AAA. Patient #1 went to a hospital in Wichita, but ultimately did end up transferred to Hospital BB. Upon arrival Patient #1 went to the operating room for open AAA repair.

- Physician staff K was traveling abroad at the time of survey and unavailable for interview.

The hospital failed to ensure an on-call Vascular Surgeon or the "back-up" physicians reported to the ED to provide stabilizing treatment of an emergency medical condition for Patient #1.

Based on medical record review, document review, and staff interviews, the hospital failed to provide stabilizing treatment of an emergency medical condition within their capabilities for one of 21 sampled patients (Patient #1).

The hospital's failure to provide stabilizing treatment within their capabilities placed the patient at risk for their emergency medical condition to deteriorate including death.


Findings include:

- The Hospital Database Worksheet updated by the hospital on 8/17/15 revealed the hospital has 1433 licensed beds, maintains a dedicated Emergency Department, Cardiac-Thoracic Surgery, a Surgical Intensive Care Unit and has 36 operating rooms.

- The Hospital's list of on-call Specialty Physician Services reviewed on 8/18/15 at 4:00pm revealed on-call services included vascular surgery.

- The Hospital's on-call EMTALA Vascular Peripheral schedule reviewed on 8/17/15 at 12:15pm listed Vascular Surgeon Staff M as the on-call specialist for vascular surgery on 7/20/15.

- The hospital list of Specialty Surgeons reviewed on 8/17/15 included Vascular Surgeon Staff P and Vascular Surgeon Staff Q.

- Patient #1's medical record review on 8/19/15 indicated the patient presented to Hospital ZZ on 7/20/15 at 8:23am with complaint of abdominal pain. Patient #1 received an assessment and diagnostic tests which revealed an abdominal aortic aneurysm (AAA) that increased in size since 7/1/15, the upper portion measured 8.5 cm (centimeters) X 8.3 cm X 8.9 cm. Lab test completed on 7/20/15 at 8:44 am revealed a HGB (hemoglobin- protein molecule in red blood cells that carries oxygen throughout the body) of 9.6 (normal reference value 13.5-16.5) and a hematocrit (volume percentage (%) of red blood cells in the blood) of 29 (normal reference value 38.4-50.8). Documentation indicted the patient had abdominal pain, abdominal aortic aneurysm, hernia, and acute hyponatremia (low sodium). The medical record indicated ED Physician Staff K accepted Patient #1 for transfer to Via Christi Hospital at 9:36am.

- Patient #1's ED record reviewed on 8/17/15 and 8/18/15 revealed the patient presented to Via Christi Hospital St. Francis on 7/20/15 at 12:18pm with complaint of abdominal pain. Triage performed at 12:30pm indicated the patient transferred from Hospital ZZ for possible AAA dissection (aortic dissection is a serious condition in which the inner layer of the aorta, the large blood vessel branching off the heart, tears. Blood surges through the tear, causing the inner and middle layers of the aorta to separate), seen for abdominal pain, known aortic aneurysm noted to be increasing in size from Thursday. Triage problems include AAA, hypertension, obesity, and tobacco user.

- Advanced Practitioner Registered Nurse (APRN) Staff L provided Patient #1 with a medical screening examination on 7/20/15 at 12:48pm including as assessment of all systems, history, and condition on arrival. The assessment indicated the patient went to Hospital ZZ with complaint of abdominal pain ongoing for the past 7-10 days. Patient #1 was diagnosed with abdominal aneurysm, decreased hemoglobin an ongoing waves of abdominal pain. Patient #1 transferred to the ED at Via Christi for further evaluation. Patient #1 stated they have known aneurysm for several years and today they thought it was slightly larger than previous. Complains of nausea and vomiting, denies dizziness, shortness of breath or chest pain. Patient #1 had not tolerated food or fluids for the last few days and denies pain if he doesn't move. At 3:14 pm APRN Staff L notes indicated the ED physician staff K spoke with the patient and discussed findings and plan of care. Critical care note indicated critical conditions addressed for impending deterioration including airway, cardiovascular, renal and bleeding. Impression: Abdominal Aortic Aneurysm rupture (an emergency medical condition), anemia, intraperitoneal hemorrhage. Plan: condition critical, admit to Hospital BB, and counseled patient and family, patient indicated understanding of instructions.

- Physician documentation indicated ED Physician Staff K assumed care of Patient #1 on 7/20/15 at 2:18pm and concurred with the APRN Staff L's assessment and plan. Results of the abdominal/pelvic CT on 7/20/15 at 2:49pm revealed an abdominal aortic aneurysm (AAA) measuring 10.1 cm by 8.9 cm with streaky edema and/or hemorrhage retroperitoneal (blood located behind the back of the peritoneum, the membrane lining the abdomen) suspicious of AAA rupture (an emergency medical condition). Lab test completed on 7/20/15 at 1:10 pm revealed a HGB of 7.3 (normal reference values 14-18) (a drop of about two grams since 8:44 am)(an indication of active bleeding) and hematocrit of 21.6 (normal reference value 42-52)( a drop of about 8 since 8:44 am). ED Physician Staff K ordered two units of PRBC's (Packed red blood cells are made from a unit of whole blood by centrifugation and removal of most of the plasma, leaving a unit with a hematocrit of about 60%. One PRBC unit will raise the hematocrit of a standard adult patient by 3%) to be given and two to remain on hold if needed at 3:04 pm. Reexamination by ED Physician K on 7/20/15 at 4:22pm documented, pain decreased, patient stable, critical condition addressed for impending deterioration included: cardiovascular, metabolic, renal, associated risk factors included hypertension, shock, bleeding, dysrhythmia, metabolic changes. Notes indicated multiple calls made to Vascular Surgeon Staff M, on-call to the ED, (4 times: does not want to operate on patient due to co-morbidities and noncompliance). Call made to Hospital BB. Hospital BB's Vascular Surgeon Staff CC accepted Patient #1 for transfer. Hospital BB's Vascular Surgeon recommended patient's blood pressure be maintained between 100 and 120 systolic (the highest arterial blood pressure of a cardiac cycle occurring immediately after the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) with Esmolol (treats high blood pressure). ED Physician Staff K transferred the patient to Hospital BB on 7/20/15 at 4:57 pm.

- Physician Staff K documented in an Ed-note addendum 7/21/15 at 6:48 pm, "The patient arrived to our ER (ED) in stable condition, he was quickly assessed upon arrival, last border (labs ordered) as well as imaging. I did receive a call from radiology to relay the critical finding of retroperitoneal bleed and likely AAA rupture. Vascular Surgeon Physician Staff M was called with this information (around 3:04pm), he was also told about the decreasing hemoglobin level (potential signs of active bleeding) and was made aware of the findings and vital signs. Vascular Surgeon Physician Staff M again refused to see the patient. At this point asked him about what we can do with this patient who was actively bleeding and he recommended calling Vascular Surgeon Physician Staff P.

- ED Physician Staff K contacted Vascular Surgeon Physician Staff P on 7/20/15 at 3:23 pm (about 3 hours after the patient's arrival and 6 hours after accepting the patient for transfer) and he indicated that he was unavailable as he was performing surgery at hospital DD (approximately 3 miles away) at the current time and had another case scheduled after that. Vascular Surgeon Physician Staff P recommended ED Physician Staff K contact Vascular Surgeon Physician Staff Q. Surgery records from hospital DD showed that Physician Staff P had three scheduled cases on 7/20/15. His second case of the day (a femoral popliteal bypass surgery used to treat femoral (large blood vessel in the leg) artery disease. It is performed to go around the blocked portion of main artery in the leg using a piece of another blood vessel) started at 11:15 am and ended at 3:58 pm. Physician Staff P started his third case (a femoral popliteal bypass) at 5:25 pm ( about 1 1/2 hours since his last case) and ended at 8:19 pm.

- ED Physician Staff K contacted Vascular Surgeon Staff Q on 7/20/15 at 3:33 pm (about 3 hours after the patient's arrival and 6 hours after accepting the patient for transfer) and he indicated that he was unavailable as he was starting a surgery case at hospital EE (about 7 miles away) and had another case scheduled after that. Surgery records from hospital EE showed that physician staff Q had four scheduled cases for 7/20/15. His second case of the day (bilateral iliac (blood vessel located in the pelvic region) stent placement (stent is a device that is used to hold open an artery narrowed by disease) started at 10:59 am and ended at 12:57 pm. His third case of the day (a left femoral popliteal bypass) started at 2:16 pm and ended at 5:26 pm. His fourth case of the day (introperative angiography (imaging of blood vessels during surgery) with revascularization (restoring blood flow) with stents started at 6:20 pm and ended at 6:53 pm.

- Vascular Surgeon Staff M, interviewed on 8/17/15 at 2:35pm acknowledged they would be capable of stabilizing the patient but they did not report to the ED on 7/20/15 to provide treatment to Patient #1.

- Pnysician Staff P and Physician staff Q continued their elective surgery cases at nearby hospitals even with the knowledge of physician staff M's refusal to provide treatment to patient #1 who had an emergency medical condition.

- Patient #1's medical record review from Hospital BB on 8/19/15 revealed an admission date of 7/20/15 with a ruptured Abdominal Aortic Aneurysm (AAA). The medical record indicated Patient #1 received ED treatment at an outside hospital several hours outside of Wichita with complaint of abdominal pain. Diagnostic test revealed a diagnosis of ruptured AAA. Patient #1 went to a hospital in Wichita, but ultimately did end up transferred to Hospital BB. Upon arrival, Patient #1 went to the operating room for open AAA repair.

The hospital, Vascular Surgeon Staff M and the "back-up" physicians failed to provide treatment to stabilize an emergency medical condition within their capabilities.

Based on medical record review, document review, and staff interviews, the hospital failed to ensure the on-call vascular surgeon reported to the emergency department (ED) on July 20, 2015 to provide stabilizing treatment to an individual (patient # 1) with an emergency medical condition for one of 21 sampled patients selected for review.


The hospital's failure to ensure the on-call Physician reported to the ED to provide stabilizing treatment placed the patient at risk for deterioration of his emergency medical condition including death and had the potential to affect all patients treated at the hospital.


Findings include:

Review of the hospital ' s EMTALA Committee Meeting minutes for September 8, 2014 indicated the hospital identified a problem related to on-call physician availability. Documentation revealed that the on-call cardiovascular surgeon indicated that he was not on-call when receiving a call during the night. " If physicians take concurrent call or do elective procedures while on call, they must arrange for back-up call. The committee agreed that physicians need to be held accountable for their on-call responsibilities and failure to comply will result in peer review. "

Review of the hospital ' s EMTALA Committee Meeting minutes for November 3, 2014 indicated the hospital continued to have concerns related to on-call physician availability. The minutes reflected the hospital established a committee for " EMTALA call only " and that " further physician education was needed as well as documentation of the chain of command when the on-call physician is unavailable. "

Review of the hospital ' s EMTALA Committee Meeting minutes for February 6, 2015 showed that an educational flyer for on-call physician requirements had been provided to physicians during the ED section meeting and that it had been added to the Medical Staff credentialing and re-credentialing packets.

Review of the hospital ' s EMTALA Committee Meeting minutes for July 13, 2015 showed that the hospital continued to have concerns regarding on-call physician availability and that staff would follow up with cardiology to make sure " first call is available. "


- The Hospital's list of on-call Specialty Physician Services for 7/20/15 reviewed on 8/18/15 at 4:00pm revealed on-call services included vascular surgery.

- The Hospital's on-call EMTALA Vascular Peripheral schedule reviewed on 8/17/15 at 12:15pm listed Vascular Surgeon Staff M as the on-call specialist for vascular surgery on 7/20/15.


- The hospital list of Specialty Surgeons reviewed on 8/17/15 included Vascular Surgeon Staff P and Vascular Surgeon Staff Q.


- Review of Patient #1's record revealed ED Physician Staff K accepted the transfer of patient #1 from hospital ZZ on 7/20/15 at 9:36 am. Hospital ZZ's physician staff reported that patient #1 came in with a complaint of abdominal pain over the last week. Assessment and diagnostic tests indicated patient #1 had an abdominal aortic aneurysm (AAA) that had increased in size since 7/16/15 and hospital ZZ's physician staff recommended cardiac evaluation and consideration of stent placement.

- Physician Staff K documented in an ED note addendum 7/21/15 at 6:48 pm that he notified the on call vascular surgeon Physician M on 7/20/15 prior to patient #1's arrival and received a recommendation for the patient to have a "CT abdomen with contrast on arrival and pending results of the CT as well as the presentation of the patient then he could be called and the patient will be evaluated by the resident as needed." At some point later (time unknown) Physician M called Physician K back and indicated that "this patient (patient #1) will not be considered for surgery given that he was not compliant with his follow up." Physician M requested Physician K call hospital ZZ back and tell them this. However, the patient was already in transport. Hospital ZZ's Physician Staff indicated that the patient was ready to hear his options.

- Patient #1's ambulance run sheet from Hospital ZZ's ambulance service reviewed on 8/17/15 and dated 7/20/15 indicated the need for an emergent transfer of Patient #1 to Via Christi St. Francis in Wichita, KS. The paramedic and EMT (emergency medical technician)departed Hospital ZZ on 7/20/15 at 10:30am with patient #1 for the 118-mile trip to Via Christi St. Francis and arrived at 12:12 pm.

- Patient #1's ED record reviewed on 8/17/15 and 8/18/15 revealed the patient presented to Via Christi Hospital St. Francis on 7/20/15 at 12:18pm with complaint of abdominal pain. Triage performed at 12:30 pm indicated the patient transferred from Hospital ZZ for possible AAA dissection (a serious condition in which the inner layer of the aorta, the large blood vessel branching off the heart, tears and can cause life threatening bleeding).

- Documentation indicated ED Physician K assumed care of Patient #1 on 7/20/15 at 2:18 PM and concurred with the APRN (Advanced Practice Registered Nurse) Staff L's assessment and plan. The Abdominal/pelvic CT on 7/20/15 at 2:49 PM revealed an abdominal aortic aneurysm (AAA) suspicious of rupture (an emergency medical condition).

- Physician Staff K documented in an ED-note addendum on 7/21/15 at 6:48 PM, "The patient arrived to our ER (ED) in stable condition, he was quickly assessed upon arrival, labs ordered as well as imaging. I did receive a call from radiology to relay the critical finding of retroperitoneal bleed and likely AAA rupture. Vascular Surgeon Physician M was called with this information, he was also told about the decreasing hemoglobin level (potential signs of active bleeding) and was made aware of the findings and vital signs. Vascular Surgeon Physician M again refused to see the patient. At this point asked him about what we can do with this patient who was actively bleeding and he recommended calling Vascular Surgeon Physician Staff P."

- ED Physician Staff K contacted Vascular Surgeon Physician Staff P on 7/20/15 at 3:23 PM (about 3 hours after the patient's arrival and 6 hours after accepting the patient for transfer) and he indicated that he was unavailable as he was performing surgery at hospital DD (approximately 3 miles away) at the current time and had another case scheduled after that. Vascular Surgeon Physician P recommended ED Physician K contact Vascular Surgeon Physician Q. Surgery records from hospital DD showed that Physician Staff P had three scheduled cases on 7/20/15. His second case of the day (a femoral popliteal bypass surgery used to treat femoral (large blood vessel in the leg) artery disease. It is performed to go around the blocked portion of main artery in the leg using a piece of another blood vessel) started at 11:15 AM and ended at 3:58 PM. Physician P started his third case (a femoral popliteal bypass) at 5:25 PM (about 1 1/2 hours since his last case) and ended at 8:19 PM.

- ED Physician K contacted Vascular Surgeon Q on 7/20/15 at 3:33 PM (about 3 hours after the patient's arrival and 6 hours after accepting the patient for transfer) and he indicated that he was unavailable as he was starting a surgery case at hospital EE (about 7 miles away) and had another case scheduled after that. Surgery records from hospital EE showed that physician Q had four scheduled cases for 7/20/15. His second case of the day (bilateral iliac (blood vessel located in the pelvic region) stent placement (stent is a device that is used to hold open an artery narrowed by disease) started at 10:59 AM and ended at 12:57 PM. His third case of the day (a left femoral popliteal bypass) started at 2:16 PM and ended at 5:26 PM. His fourth case of the day (introperative angiography (imaging of blood vessels during surgery) with revascularization (restoring blood flow) with stents started at 6:20 PM and ended at 6:53 PM.

- ED Physician K's ED Notes on 7/20/15 at 4:22 PM that reads in part, "multiple calls made to Vascular Surgeon M, on-call to the ED, (4 times: does not want to operate on patient due to co-morbidities and noncompliance). Call made to Hospital BB. Hospital BB's Vascular Surgeon Staff CC accepted Patient #1. ED Physician K documented

Based on medical record review, document review, and staff interviews, the hospital failed to provide stabilizing treatment of an emergency medical condition within their capabilities for one of 21 sampled patients (Patient #1).

The hospital's failure to provide stabilizing treatment within their capabilities placed the patient at risk for their emergency medical condition to deteriorate including death.


Findings include:

- The Hospital Database Worksheet updated by the hospital on 8/17/15 revealed the hospital has 1433 licensed beds, maintains a dedicated Emergency Department, Cardiac-Thoracic Surgery, a Surgical Intensive Care Unit and has 36 operating rooms.

- The Hospital's list of on-call Specialty Physician Services reviewed on 8/18/15 at 4:00pm revealed on-call services included vascular surgery.

- The Hospital's on-call EMTALA Vascular Peripheral schedule reviewed on 8/17/15 at 12:15pm listed Vascular Surgeon Staff M as the on-call specialist for vascular surgery on 7/20/15.

- The hospital list of Specialty Surgeons reviewed on 8/17/15 included Vascular Surgeon Staff P and Vascular Surgeon Staff Q.

- Patient #1's medical record review on 8/19/15 indicated the patient presented to Hospital ZZ on 7/20/15 at 8:23am with complaint of abdominal pain. Patient #1 received an assessment and diagnostic tests which revealed an abdominal aortic aneurysm (AAA) that increased in size since 7/1/15, the upper portion measured 8.5 cm (centimeters) X 8.3 cm X 8.9 cm. Lab test completed on 7/20/15 at 8:44 am revealed a HGB (hemoglobin- protein molecule in red blood cells that carries oxygen throughout the body) of 9.6 (normal reference value 13.5-16.5) and a hematocrit (volume percentage (%) of red blood cells in the blood) of 29 (normal reference value 38.4-50.8). Documentation indicted the patient had abdominal pain, abdominal aortic aneurysm, hernia, and acute hyponatremia (low sodium). The medical record indicated ED Physician Staff K accepted Patient #1 for transfer to Via Christi Hospital at 9:36am.

- Patient #1's ED record reviewed on 8/17/15 and 8/18/15 revealed the patient presented to Via Christi Hospital St. Francis on 7/20/15 at 12:18pm with complaint of abdominal pain. Triage performed at 12:30pm indicated the patient transferred from Hospital ZZ for possible AAA dissection (aortic dissection is a serious condition in which the inner layer of the aorta, the large blood vessel branching off the heart, tears. Blood surges through the tear, causing the inner and middle layers of the aorta to separate), seen for abdominal pain, known aortic aneurysm noted to be increasing in size from Thursday. Triage problems include AAA, hypertension, obesity, and tobacco user.

- Advanced Practitioner Registered Nurse (APRN) Staff L provided Patient #1 with a medical screening examination on 7/20/15 at 12:48pm including as assessment of all systems, history, and condition on arrival. The assessment indicated the patient went to Hospital ZZ with complaint of abdominal pain ongoing for the past 7-10 days. Patient #1 was diagnosed with abdominal aneurysm, decreased hemoglobin an ongoing waves of abdominal pain. Patient #1 transferred to the ED at Via Christi for further evaluation. Patient #1 stated they have known aneurysm for several years and today they thought it was slightly larger than previous. Complains of nausea and vomiting, denies dizziness, shortness of breath or chest pain. Patient #1 had not tolerated food or fluids for the last few days and denies pain if he doesn't move. At 3:14 pm APRN Staff L notes indicated the ED physician staff K spoke with the patient and discussed findings and plan of care. Critical care note indicated critical conditions addressed for impending deterioration including airway, cardiovascular, renal and bleeding. Impression: Abdominal Aortic Aneurysm rupture (an emergency medical condition), anemia, intraperitoneal hemorrhage. Plan: condition critical, admit to Hospital BB, and counseled patient and family, patient indicated understanding of instructions.

- Physician documentation indicated ED Physician Staff K assumed care of Patient #1 on 7/20/15 at 2:18pm and concurred with the APRN Staff L's assessment and plan. Results of the abdominal/pelvic CT on 7/20/15 at 2:49pm revealed an abdominal aortic aneurysm (AAA) measuring 10.1 cm by 8.9 cm with streaky edema and/or hemorrhage retroperitoneal (blood located behind the back of the peritoneum, the membrane lining the abdomen) suspicious of AAA rupture (an emergency medical condition). Lab test completed on 7/20/15 at 1:10 pm revealed a HGB of 7.3 (normal reference values 14-18) (a drop of about two grams since 8:44 am)(an indication of active bleeding) and hematocrit of 21.6 (normal reference value 42-52)( a drop of about 8 since 8:44 am). ED Physician Staff K ordered two units of PRBC's (Packed red blood cells are made from a unit of whole blood by centrifugation and removal of most of the plasma, leaving a unit with a hematocrit of about 60%. One PRBC unit will raise the hematocrit of a standard adult patient by 3%) to be given and two to remain on hold if needed at 3:04 pm. Reexamination by ED Physician K on 7/20/15 at 4:22pm documented, pain decreased, patient stable, critical condition addressed for impending deterioration included: cardiovascular, metabolic, renal, associated risk factors included hypertension, shock, bleeding, dysrhythmia, metabolic changes. Notes indicated multiple calls made to Vascular Surgeon Staff M, on-call to the ED, (4 times: does not want to operate on patient due to co-morbidities and noncompliance). Call made to Hospital BB. Hospital BB's Vascular Surgeon Staff CC accepted Patient #1 for transfer. Hospital BB's Vascular Surgeon recommended patient's blood pressure be maintained between 100 and 120 systolic (the highest arterial blood pressure of a cardiac cycle occurring immediately after the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) with Esmolol (treats high blood pressure). ED Physician Staff K transferred the patient to Hospital BB on 7/20/15 at 4:57 pm.

- Physician Staff K documented in an Ed-note addendum 7/21/15 at 6:48 pm, "The patient arrived to our ER (ED) in stable condition, he was quickly assessed upon arrival, last border (labs ordered) as well as imaging. I did receive a call from radiology to relay the critical finding of retroperitoneal bleed and likely AAA rupture. Vascular Surgeon Physician Staff M was called with this information (around 3:04pm), he was also told about the decreasing hemoglobin level (potential signs of active bleeding) and was made aware of the findings and vital signs. Vascular Surgeon Physician Staff M again refused to see the patient. At this point asked him about what we can do with this patient who was actively bleeding and he recommended calling Vascular Surgeon Physician Staff P.

- ED Physician Staff K contacted Vascular Surgeon Physician Staff P on 7/20/15 at 3:23 pm (about 3 hours after the patient's arrival and 6 hours after accepting the patient for transfer) and he indicated that he was unavailable as he was performing surgery at hospital DD (approximately 3 miles away) at the current time and had another case scheduled after that. Vascular Surgeon Physician Staff P recommended ED Physician Staff K contact Vascular Surgeon Physician Staff Q. Surgery records from hospital DD showed that Physician Staff P had three scheduled cases on 7/20/15. His second case of the day (a femoral popliteal bypass surgery used to treat femoral (large blood vessel in the leg) artery disease. It is performed to go around the blocked portion of main artery in the leg using a piece of another blood vessel) started at 11:15 am and ended at 3:58 pm. Physician Staff P started his third case (a femoral popliteal bypass) at 5:25 pm ( about 1 1/2 hours since his last case) and ended at 8:19 pm.

- ED Physician Staff K contacted Vascular Surgeon Staff Q on 7/20/15 at 3:33 pm (about 3 hours after the patient's arrival and 6 hours after accepting the patient for transfer) and he indicated that he was unavailable as he was s