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Based on observations, record reviews, interviews, review of the hospital's emergency department policies and procedures, review of the hospital's central log, review of the hospital's emergency department's on-call lists, review of the hospital's Governing Body and Medical Staff Bylaws, the hospital failed to provide Emergency Medical Treatment and Labor Act (EMTALA) signage, ensure on-call physicians presented to the Emergency Department (ED) to evaluate and treat Patient 1, and inappropriately transferred Patient 1 to Hospital 2. This deficient practice affected one (1) of 20 patient records reviewed (Patient 1).

The findings are:

Cross Reference to A 2402: The Hospital failed to provide adequate signage related to Emergency Medical Treatment and Labor Act (EMTALA).

Cross Reference to A 2404: The hospital failed to ensure on-call physician coverage to stabilize a patient identified as requiring a surgical consult and treatment after the patient's initial examination for one (1) of twenty (20) patients who required treatment for an emergency medical condition (Patient 1). The Emergency Department (ED) provider determined the patient required advance repair and an Ear, Nose and Throat (ENT) consultant was called. The on-call ENT failed to present to the ED to assess the patient.

Cross Reference to A 2409: The hospital failed to provide medical treatment within its capability to minimize the risks to the individuals' health for 1 (Patient #1) of 20 sampled patient charts that resulted in an inappropriate transfer of the patient. The hospital failed to ensure that its privileged Ear, Nose and Throat (ENT) medical doctor responded to request by the ED (Emergency Department) physician to assess a patient who presented with a facial injury caused by a dog bite and the ED physician deemed the patient required the expertise of either the specialty of plastics or ENT physicians. The hospital had the capability, including ancillary services routinely available, to treat Patient #1 but arranged for transfer to Hospital 2 after the on-call ENT did not present to the ED and this resulted in an inappropriate transfer.

Based on observations and interviews, the Hospital failed to provide adequate signage related to Emergency Medical Treatment and Labor Act (EMTALA) in that the hospital provided only signage by the ambulance bay and behind the registration desk. There was no signage in the emergency department waiting room, or in the emergency department treatment area, or in the obstetrical triage area. This had the potential to affect all patients.

The findings are:

On 08/13/2019 at 1:00 PM, observations of the hospital's Emergency Department (ED) revealed only one large EMTALA sign by the ambulance bay entrance and one small EMTALA sign behind the registration desk. The small sign behind the registration desk was not clearly visible from 20 feet away. There was no additional signage regarding EMTALA in the waiting room or in the treatment areas. Observations of Bay 4 and Exam room 9 showed no signage for EMTALA displayed. ED patients who are greater than sixteen weeks pregnant are taken directly to the obstetrics unit. On 08/13/2019 at 1:45 PM, observations of the triage area in the hospital's obstetrics unit revealed there was no signage regarding EMTALA.

During a face to face interview on 08/16/2019 at 11:00 AM with the Chief Medical Director, the Chief Medical Director relayed, "The signs have been ordered for the Obstetrics Unit. Since the unit is so new, currently there are no signs for EMTALA." The Director went on to say in an email communication on 08/21/2019 at 4:29 PM, "We do not have any policy that speaks to signage for EMTALA. Rather, we follow the guidelines in the EMTALA statute."

Based on record reviews, interviews, and review of the hospital's policies and procedures, the hospital failed to ensure on-call physician coverage to stabilize a patient identified as requiring a surgical consult and treatment after the patient's initial examination for one (1) of twenty (20) patients who required treatment for an emergency medical condition (Patient 1). The Emergency Department (ED) provider determined the patient required advance repair and an Ear, Nose and Throat (ENT) consultant was called. The on-call ENT failed to present to the ED to assess the patient.

The findings are:

On 08/14/2019 at 10:00 AM, review of Patient 1's emergency department chart revealed the patient presented to the emergency department on 07/19/2019 at 4:22 PM via a personal vehicle driven by a friend. The patient presented with a chief complaint of "facial laceration to lip and chin - dog known to pt. (patient). pt. is a vet tech."

Nursing
Review of a clinical note recorded by the Nurse Practitioner (NP) on 07/19/2019 at 4:32 PM revealed "I have evaluated this patient on arrival for the complaint of lip laceration, performing a problem focused assessment, reviewing nurse notes, vital signs, and initiating a medical screening examination. I have placed orders for diagnostic and therapeutic interventions as deemed medically necessary- explaining to the patient that the purpose of seeing a Provider - In- Triage is to expedite care while awaiting a full evaluation by one of our Emergency Department Physicians. In so far as this is the case, the patient's medical screening exam may be completed, and the patient disposition by another qualified medical provider. Orders that I have entered may be modified, added to, or deleted as judged appropriate by the physician responsible for a final disposition. Dog bite to the face with laceration of the upper lip and puncture marks to the chin." A note recorded by the Unit Secretary dated 07/19/2019 at 6:42 PM reads, "Called .....ENT (Ear, Nose, Throat) for consult @ (at) 6:28 PM- .....PA (Physician Assistant) Responded @ 6:35 PM." A note recorded by a unit secretary on 07/19/2019 at 6:44 PM revealed," Called Center of ..... Surgery for consult @ 6:20 PM- Not taking new patients or consulting." Review of a ED (Emergency Department) note recorded by a unit secretary on 07/19/2019 at 6:45 PM revealed "Called ..... Plastic Surgery @ 6:40 PM for consult." Review of a note dated 07/19/2019 at 6:00 PM by a registered nurse revealed" Pt AOX3 (Alert, Awake and Oriented times 3) skin warm and dry resp (respirations) even and unlabored. pt is vet tech while holding a boxer today for procedure boxer bit his upper lip. pt's top lip has a large skin flap + (plus) bleeding irregular shaped. new drsg (dressing) applied to lip." On 07/19/2019 at 7:10 PM, a Technician recorded, "Dr. (plastic surgeon) responded and he is currently not on call for the hospital. MD (Medical Doctor) notified." Review of the nurse note dated 07/19/2019 at 7:28 PM revealed, "PT AOX4 (Alert and Oriented times 4) holding a gauze to the upper lip. Chin also has a laceration-bleeding controlled both sites. .....will update pt accordingly Pt states dog was in vet's office and is up to date on shots." Review of a technician's note recorded on 07/19/2019 at 8:05 PM revealed "(Hospital 2) responded. Pt going to ED. Charge nurse ....., RN aware." Review of a nurse note dated 07/19/2019 at 8:37 PM revealed "Wounds irrigated with sterile saline and bandaged for transport."

ED Physician
History- Laceration facial laceration to lip and chin. dog known by pt. pt is a vet tech. 22 - year- old male presents to ED for evaluation of a dog bite. Bleeding was controlled with direct pressure. Tetanus is up- to- date. He denies any other injuries other than a complex laceration to the upper lip. Onset of occurrence: 1 hour....Associated symptoms: bleeding, no wound drainage, no fever and no vomiting."

Physical Exam- Complex laceration of the upper lip approximately 3 cm (centimeters) with poorly re-approached tissue. No involvement of the nasal cartilage. No dental trauma noted. Mild venous oozing noted."

The ED physician recorded "consults with other physician: yes Plastic surgery. Patient progress: Stable. Comments: The patient will be transferred to ....Hospital 2 for further management by plastic surgery. Wound was irrigated and he received IV (Intravenous) Unasyn. He remained NPO (nothing by mouth). The patient will be transported by his father. IV has been removed. Report has been given to ....Hospital 2 ED attending Dr.....".

ED Physician Note on 07/19/2019 at 6:38 PM revealed "I spoke with the NP with Dr. .... (ENT), who recommended contacting Dr. S (plastic surgeon) for consideration of repair. Dr. S was unavailable. Our secretary has called six other plastic surgeons listed at our facility but none are available."

Review of the ENT Call Schedule for 01/19/2019 showed the hospital had a ENT physician scheduled. Review of the patient's chart revealed the ED Physician recorded at 6:38 PM "I spoke with the NP with Dr. (ENT) physician, who recommended contacting Dr. (plastic surgeon) for consideration of repair. Dr. (plastic surgeon) was unavailable. Our secretary has called six other plastic surgeons listed at our facility but none are available. I consulted plastic surgery at ....(Hospital 2) for further assistance."

On 8/15/2019, review of the list of credentialed physicians practicing at the hospital showed seven (7) plastic surgeon groups who are deemed "Active Hospital Based", but there was no call list for plastic surgeons submitted by the hospital.

Interviews
ED Physician 1
On 08/15/2019 at 4:54 PM, a face to face interview with ED Physician 1 was conducted. Physician 1 stated, "I've been employed here for about a year out of residency. I did my residency at Hospital 2's ED, so I'm familiar with some of the physicians there. I saw the nurse note and went into the patient's room. The patient was there with his father. He had a rag over his face. The patient is a vet assistant and was bitten in the face. The dad brought the patient to the ED. He said he could get him there faster than the ambulance. The patient's vital signs were stable. On exam, this was a complex laceration with a flap of tissue hanging over his mouth. This is out of my skill set. We irrigated the wound, gave some IV antibiotics and pain medication. I said, I think he needs a plastic surgeon, and dad agreed with me. So I asked the secretary can we get in touch with the plastic surgeon. I spoke with the provider that was listed asked to reach out to ENT (Ear Nose and Throat) I spoke with the ENTs PA and they (ENT PA) replied they did not get involved unless there was nasal cartilage involvement. There were no plastic surgeons available. I believe the secretary called at least six offices. I had exhausted all resources, and this was late on Friday afternoon. No offices would be open on Saturday or Sunday. I called ....(Hospital 2) and explained the situation and that all resources have been exhausted. I talked to them twice. I talked to a physician that said they were on for facial trauma. They would call me back with a decision. I gave report to the ED physician who I'm familiar with.. I was just looking out for the best outcome for my patient. He was young and good-looking, and I thought he needed a timely repair for the best cosmetic outcome. I recognized my limits and did not think I could provide that outcome."

Unit Secretary 2
On 08/15/2019 at 2:19 PM, a face to face interview with Unit Secretary 2 was conducted. Unit Secretary 2 stated, "I've been employed here for 18-20 years. I'm the secretary for the clinical doctor and the nurses. If there is a consult, it can be put in the EPIC (electronic medical record) system. It can go to their beeper. They have to read the messages. If there is a consult for trauma, they need to call back in 30 minutes. If they happen to be in surgery, one of the associates or attending can generate a conference call to the doctor doing the surgery, and they can make a decision how fast the patient needs his attention. The on-call doctor can call his associate to see the patient if they can't wait."

Policies and Procedures
Medical Staff Rules and Regulations, dated 11/19/2018, reads," In section titled, Emergency Department, reads, 'Physician Consultation and Patient Referral', The department has the right to call, where deemed appropriate, consultant physicians and dentists who are members of the ....Medical Center Medical Staff. The Chief of each clinical specialty, as appropriate, will provide the Department with rosters of on-call physicians to whom patient referrals may be made. Outpatient referrals to private practitioners will be carried out in similar fashion where indicated. Patients having their own physicians will be referred to them. Private physicians will be consulted for specialty referral preferences subject to the agreement of the patient. The Department will obtain appropriate consultation in cases where admission is deemed necessary. When the consultant accepts the care of the patient, the patient becomes the responsibility of the consultant. The consultant is responsible for the patient whether or not the patient remains in the Department physically. Admission orders are solely the consultant's responsibility.

Review of the hospital's credentialing listing verified that plastic surgery is listed under the heading of general surgery. Review of the medical staff had no specific heading for plastic surgery but it did have a heading for general surgery, that reads, "General Surgery Department", Including General Surgery and sub- specialties of General Surgery, Pediatric Surgery, Plastic Surgery, and Podiatry.

Based on review of patient medical records, review of the hospital's policies and procedures, review of the hospital's on-call schedules, and staff interviews, it was determined the hospital failed to provide medical treatment within its capability to minimize the risks to the individuals' health for 1 (Patient #1) of 20 sampled patient charts that resulted in an inappropriate transfer of the patient. The hospital failed to ensure that its privileged Ear, Nose and Throat (ENT) medical doctor responded to request by the ED (Emergency Department) physician to assess a patient who presented with a facial injury caused by a dog bite and the ED physician deemed the patient required the expertise of either the specialty of plastics or ENT physicians. The hospital had the capability, including ancillary services routinely available, to treat Patient #1 but arranged for transfer to Hospital 2 after the on-call ENT did not present to the ED and this resulted in an inappropriate transfer.

The findings are:

On 08/14/2019 at 10:00 AM, review of Patient #1's emergency department chart revealed the patient presented to the emergency department on 07/19/2019 at 4:22 PM via a personal vehicle driven by a friend. The patient presented with a chief complaint of "facial laceration to lip and chin - dog known to pt. (patient). pt. is a vet tech."

Nursing
Review of a clinical note recorded by the Nurse Practitioner (NP) on 07/19/2019 at 4:32 PM revealed "Dog bite to the face with laceration of the upper lip and puncture marks to the chin." A note recorded by the Unit Secretary dated 07/19/2019 at 6:42 PM reads, "Called .....ENT for consult @ (at) 6:28- .....PA (Physician Assistant) Responded @ 6:35 PM." A note recorded by a unit secretary on 07/19/2019 at 6:44 PM revealed," Called Center of ..... Surgery for consult @ 6:20 PM- Not taking new patients or consulting." Review of a ED note recorded by a unit secretary on 07/19/2019 at 6:45 PM revealed "Called ..... Plastic Surgery @ 6:40 PM for consult." On 07/19/2019 at 7:10 PM, a Technician recorded, "Dr. (plastic surgeon) responded and he is currently not on call for the hospital. MD (Medical Doctor) notified." Review of the nurse note dated 07/19/2019 at 7:28 PM revealed, "PT AOX4 (Alert and Oriented times 4) holding a gauze to the upper lip. Chin also has a laceration-bleeding controlled both sites. .....will update pt accordingly Pt states dog was in vet's office and is up to date on shots." Review of a technician's note recorded on 07/19/2019 at 8:05 PM revealed "(Hospital 2) responded. Pt going to ED. Charge nurse ....., RN aware." Review of a nurse note dated 07/19/2019 at 8:37 PM revealed "Wounds irrigated with sterile saline and bandaged for transport."

ED Physician
History- Laceration facial laceration to lip and chin. dog known by pt. pt is a vet tech. 22 - year- old male presents to ED for evaluation of a dog bite. He denies any other injuries other than a complex laceration to the upper lip. Onset of occurrence: 1 hour....Associated symptoms:bleeding, no wound drainage, no fever and no vomiting."

Physical Exam- Complex laceration of the upper lip approximately 3 cm (centimeters) with poorly re-approached tissue. No involvement of the nasal cartilage. No dental trauma noted. Mild venous oozing noted."

Physician Orders: CBC (complete blood count) and differential. Prothrombin Time and activated Partial Thromboplastin Time. Basic Metabolic Panel. Diet/NPO (nothing by mouth) except medications. Insert peripheral IV (intravenous needle in the vein).. Unison IVPB (Intravenous) 3 g (grams), Morphine injection 4 mg (milligrams). Disposition: Transfer to Another Facility Condition: Stable.

The ED physician recorded "consults with other physician: yes Plastic surgery. Patient progress: Stable. Comments: The patient will be transferred to ....Hospital 2 for further management by plastic surgery. Wound was irrigated and he received IV Unasyn. He remained NPO. The patient will be transported by his father. IV has been removed. Report has been given to ....Hospital 2 ED attending Dr.....".

ED Physician Note on 07/19/2019 at 6:38 PM revealed "I spoke with the NP with Dr. .... (ENT), who recommended contacting Dr. ... (plastic surgeon) for consideration of repair. Dr. .... (plastic surgeon) was unavailable. Our secretary has called six other plastic surgeons listed at our facility but none are available. I consulted plastic surgery at (Hospital 2) for further assistance."

Review of the ENT Call Schedule for 07/19/2019 showed the hospital had a ENT physician scheduled. Review of the patient's chart revealed the ED Physician recorded at 6:38 PM "I spoke with the NP with Dr. (ENT) physician, who recommended contacting Dr. (plastic surgeon) for consideration of repair. Dr. (plastic surgeon) was unavailable. Our secretary has called six other plastic surgeons listed at our facility but none are available. I consulted plastic surgery at ....(Hospital 2) for further assistance."

On 08/15/2019, review of the list of credentialed physicians practicing at the hospital showed seven (7) plastic surgeon groups who are deemed "Active Hospital Based", but there was no call list for plastic surgeons submitted by the hospital.

Interviews

ED Physician 1

On 08/15/2019 at 4:54 PM, a face to face interview with ED Physician 1 was conducted. Physician 1 stated, "I've been employed here for about a year out of residency. I did my residency at Hospital 2's ED, so I'm familiar with some of the physicians there. I saw the nurse note and went into the patient's room. The patient was there with his father. He had a rag over his face. The patient is a vet assistant and was bitten in the face. The dad brought the patient to the ED. He said he could get him there faster than the ambulance. The patient's vital signs were stable. On exam, this was a complex laceration with a flap of tissue hanging over his mouth. This is out of my skill set. We irrigated the wound, gave some IV antibiotics and pain medication. I said, I think he needs a plastic surgeon, and dad agreed with me. So I asked the secretary can we get in touch with the plastic surgeon. I spoke with the provider that was listed asked to reach out to ENT (Ear Nose and Throat) I spoke with the ENT's PA and they (ENT PA) replied they did not get involved unless there was nasal cartilage involvement. There were no plastic surgeons available. I believe the secretary called at least six offices. I had exhausted all resources, and this was late on Friday afternoon. No offices would be open on Saturday or Sunday. I called ....(Hospital 2) and explained the situation and that all resources have been exhausted. I talked to them twice. I talked to a physician that said they were on for facial trauma. I gave report to the ED physician who I'm familiar with. I was just looking out for the best outcome for my patient. He was young and good-looking, and I thought he needed a timely repair for the best cosmetic outcome. I recognized my limits and did not think I could provide that outcome."

Unit Secretary 2
On 08/15/2019 at 2:19 p.m., a face to face interview with Unit Secretary 2 was conducted. Unit Secretary 2 stated, "I've been employed here for 18-20 years. I'm the secretary for the clinical doctor and the nurses. If there is a consult, it can be put in the EPIC (electronic medical record) system. It can go to their beeper. They have to read the messages. If there is a consult for trauma, they need to call back in 30 minutes. If they happen to be in surgery, one of the associates or attending can generate a conference call to the doctor doing the surgery, and they can make a decision how fast the patient needs his attention. The on-call doctor can call his associate to see the patient if they can't wait."

Policies and Procedures
Review of the Governing Body and Medical Staff Bylaws and ED policies and procedures revealed there was no hospital policy and procedure to guide ED physicians when the privileged specialist physicians fail to respond to a request by the ED physician to consult on a patient when the ED physician deems a patient to require a higher level of care from a specialist.