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400 ROSALIND REDFERN GROVER PARKWAY

MIDLAND, TX 79701

ON CALL PHYSICIANS

Tag No.: A2404

Based on interview and record review the facility failed to have a written policy and procedure in place to respond to situations in which the on-call physician cannot respond when a Neursurgeon did not respond to an emergency transfer request.

Findings include:

During an interview on the afternoon of 7/8/19, in the Martin County Hospital District facility's conference room, the Compliance Officer stated, "We tried to transfer Patient #21 to Midland Memorial Hospital (MMH); first they couldn't get ahold of the house supervisor then the Neurosurgeon wouldn't call them back. The patient became hypertensive and diaphoretic, so we could not delay any longer, we finally transferred him to Lubbock. Midland Memorial called us back two hours later to tell us they still had not heard from the neurosurgeon; we told them he was transferred to Lubbock. We tried to send him by Airevac but the weather was too bad .... "

During an interview on 7/10/19, in a staff office, Staff #12, MMH COO stated, "I was aware of the incident .... Staff #1, Neurosurgeon said he was sick and didn't hear the calls ..."

Review of the facility provided emergency transfer policy Transfer Center- Transfer of Patients to MMH (dated 9/18/2018) did not include a time line for the on-call physician to respond and did not include a procedure if an on-call physician can not be contacted. The medical By-laws Rules and regualtions (dated 4/01/2019) did not reflect a procedure if an on-call physician can not be contacted.

RECIPIENT HOSPITAL RESPONSIBILITIES

Tag No.: A2411

Based on interview and record review Midland Memorial Hospital failed to accept a patient with an unstabilized emergency medical condition when the facility's call center delayed calling the emergency room physician for a requested emergency transfer, as the facility's policy required, placing Patient #21 at risk of worsening condition while the call center was looking for the house supervisor for an unknown reason.

Findings:

On 5/4/19 A 52-year-old- male, Patient #21 arrived at the Martin County Hospital District (CAH) hospital with the worse HA of his life and unequal pupils; the CT revealed a subdural hematoma (swelling of the brain). Patient #21 required an emergency transfer to a higher level of care.

The following is a time line from the records of Martin County Critical Access Hospital (CAH) in Stanton, TX which is located 20 miles from Midland. Midland Memorial is the CAH contracted hospital for emergency transfers. Midland Memorial has a Neurosurgeon on-call and was not on diversion on the evening of 5/4/19.

- 22:58, Midland Memorial's call center was contacted they could not find the house supervisor.
- 23:16, they were called back and still could not find the house supervisor; the CAH initiated a call to an alternate facility in Lubbock.
- 23:27 Midland Memorial contacted the CAH and said they were waiting for the Neurosurgeon to call back; the transfer to Lubbock was cancelled.

During an interview on the afternoon of 7/8/19, in the Martin County Hospital District facility's conference room, the Compliance Officer stated, "We tried to transfer Patient #21 to Midland Memorial; first they couldn't get ahold of the house supervisor then the Neurosurgeon wouldn't call them back. The patient became hypertensive and diaphoretic, so we could not delay any longer, we finally transferred him to Lubbock...."

Review of the facility provided Bylaws and Rules and Regulations Transfer Center- Transfer of Patients to MMH (Midland Memorial Hospital) Policy (reviewed 9/18/2018) reflected, "...A. ER to ER Transfer (EMTALA)
a. Transfer Center personnel will gather patient demographic information to include name, DOB, diagnosis, and transferring facility call back information including phone number and contact name.
b. Transfer Center personnel will notify the Emergency Department physician of the patient transfer and coordinate a physician to physician report.
c. The ED physician will determine if the transfer is emergent and tentatively accept or decline the transfer.
d. The ED will notify the Transfer Center of the bed type needed for the patient in case of admission.
e. Transfer Center personnel will notify a Clinical Operations designee or the House Supervisor to verify bed availability.
f. If beds are not available, the transfer center personnel will notify the ED physician, and the ED physician will make a final determination...."

During an interview on 7/10/19, in a staff office, Staff #12, Chief Nursing Officer confirmed the findings and when asked why the call center called the house supervisor instead of the ED physician Staff #12 stated, "... I think she wanted to make sure we had a bed.... that's not the policy."