HospitalInspections.org

I. Based on document review and staff interview, the acute care hospital's administrative staff failed to ensure the hospital staff followed the hospital's policies when the on-call physician (Ear Nose and Throat) ENT Physician A failed to physically present to the Emergency Department (ED) for 1 of 2 patients (Patient #32), when requested by the ED physician, during the week of 1/2/17 to 1/8/17. The hospital's administrative staff identified an average of 1937 pediatric patients presented to the ED and requested emergency care per month.
Failure of ENT Physician A to physically present to the ED resulted in the ED Physician requesting ENT Physician B (who was not on-call) to present to the ED and remove a foreign body from Patient #32's lung.

Findings included:

1. Review of the "Medical staff bylaws of ... Iowa Methodist Medical Center, [and] Blank Children's Hospital (a department of Iowa Methodist Medical Center ...,"approved 9/29/2009, revealed in part, "Responsibilities: Active Staff members must: ... assume all the responsibilities of membership on the Active Staff, ... including ... emergency call, [and] care for unassigned patients ..."

2. Review of the "Medical Staff Roster w/Primary Office," generated 2/21/2017, revealed the Active medical staff included ENT Physician A.

3. Review of the document titled "On Call Schedule from 01/01/2017 to 01/31/2017," revealed ENT Physician A was scheduled to provide emergency ENT medical services to the hospital's ED for adult and pediatric patients from 8:00 AM on 1/2/2017 through 7:00 AM on 1/9/2017.

4. Review of Patient #32's medical record revealed he presented to the hospital's pediatric ED on 1/7/16 at 1:34 PM. Patient #32's mother incidentally stated Patient #32 possibly swallowed a thumb tack prior to the admission process. A radiology transcript dated 1/7/17 at 2:20 PM revealed the Radiologist (Physician specialized in review of X-Rays) identified a metallic foreign body in Patient #32's right lung. The ED Provider Notes filed by ED Physician C on 1/7/17 at 5:13 PM, revealed ED Physician C attempted to contact ENT Physician A to present to the ED and provide care to Patient #32. Initially, ENT Physician A failed to respond to ED Physician C's attempts to contact ENT Physician A. When ENT Physician A contacted ED Physician C, ENT Physician A instructed ED Physician C to contact an ENT physician not listed on the on-call schedule. ED Physician C contacted ENT Physician B, who agreed to present to the hospital and provide emergent medical care to Patient #32.

Please refer to A-2404 for additional information concerning the hospital's failure to ensure an on-call physician presented to the hospital and provided emergent care to Patient #32 when requested by ED Physician C.


II. Based on document review and staff interviews, the acute care hospital's administrative staff failed to develop and implement a policy addressing surgeons scheduling elective surgical procedures while the surgeon was responsible for providing emergent surgical care to patients that presented in the hospital's ED. The lack of a policy impacted 1 of 1 sampled patient who required emergent neurosugery (Patient #27) between 8/1/16 to 2/21/17. The hospital's administrative staff identified 12 patients from 1/1/16 to 12/31/16 who presented to the hospital with bleeding in the brain. The hospital's administrative staff identified an average of 3368 patients per month who requested emergency medical care in the ED.

Failure to develop and implement a policy addressing surgeons scheduling elective surgical procedures while they had responsibility to provide emergent surgical care to patients in the hospital's ED resulted in the ED staff transferring Patient #27 to a hospital located an hour away by helicopter due to the on-call neurosurgeon performing an elective surgical procedure while he was on-call.

Findings include:

1. Review of the "Medical staff bylaws of ... Iowa Methodist Medical Center, [and] Blank Children's Hospital (a department of Iowa Methodist Medical Center ...,"approved 9/29/2009, revealed the medical staff bylaws addressed the subject of surgeons performing elective surgical procedures while they had a responsibility to provide emergent surgical services to patients in the hospital's ED.

2. During an interview on 2/28/17 at 11:00 AM, the Vice President for Medical Affiars (VPMA) stated the hospital lacked a policy addressing the issue of surgeons performing elective surgical procedures while they had a responsibility to provide emergent surgical services to patients in the hospital's ED.

3. Review of Patient #27's medical record revealed Patient #27 arrived at the ED on 1/6/17 at 9:32 AM complaining of a headache lasting for several days and unrelieved with narcotic pain medication at home. A head CT scan (a detailed x-ray scan of the head) performed on 1/6/17 at 10:14 AM revealed bleeding that created pressure and swelling in Patient #27's brain. Radiologist I documented they contacted Physician's Assistant (PA) E at 11:03 AM on 1/6/17 to notify her about the bleeding in Patient #27's brain. PA E documented in the ED Provider Note at 12:34 PM on 1/6/17 that after Radiologist I informed her that Patient #27 had bleeding in the brain, Physician's Assistant E contacted on-call Neurosurgeon F (a surgeon specializing in surgery on the brain and spine) who was responsible for providing emergent care to patients in the ED. Neurosurgeon F's nurse spoke with Neurosurgeon F. Neurosurgeon F stated he and the other neurosurgeons could not provide care for Patient #27, as both neurosurgeons were performing long surgical procedures. Neurosurgeon F recommended the ED staff transfer Patient #27 to Outside Hospital A (approximately 1 hour away by helicopter flight). Registered Nurse (RN) G documented Patient #27 was transferred to Outside Hospital A by Iowa Methodist's helicopter ambulance at 12:35 PM on 1/6/17.

Please refer to A-2407 for additional information concerning the hospital's failure to provide Patient #27 with adequate stabilizing treatment.

Based on document review and staff interview, the Acute Care Hospital administrative staff failed to ensure the on-call physician came in to the hospital when requested in 1 of 2 patients (Patient #32) when the Emergency Department (ED) physician contacted Ear, Nose, and Throat (ENT) Physician A and requested ENT Physician A to physically present to the ED and provide care for a pediatric patient between 1/2/17 and 1/8/17 and the hospital staff provided stabilizing treatment within the hospital's capacity for 1 of 1 selected emergency department (ED) patient who required neurosurgery (Patient #27) from 8/1/16 to 2/21/17. The hospital administrative staff identified an average of 1937 pediatric ED patients and 3368 adult ED patients per month. The hospital's administrative staff identified 12 patients who presented to the hospital with bleeding in the brain between 1/1/16 to 12/31/16.

Failure of ENT Physician A to physically present to the ED resulted in the ED Physician requesting ENT Physician B (who was not on-call) to present to the ED and remove a foreign body from Patient #32's lung. Failure of on-call Neurosurgeon J to present to the ED resulted in the hospital staff transferring Patient #27 to an outside hospital approximately 1 hour away, by helicopter ambulance. The delay in treatment could have resulted in Patient #27 dying due to the delay.

Findings included:

1. Review of the "Medical staff bylaws of ... Iowa Methodist Medical Center, [and] Blank Children's Hospital (a department of Iowa Methodist Medical Center ...,"approved 9/29/2009, revealed in part, "Responsibilities: Active Staff members must: ... assume all the responsibilities of membership on the Active Staff, ... including ... emergency call, [and] care for unassigned patients ..."

2. Review of the "Medical Staff Roster w/Primary Office," generated 2/21/2017, revealed the Active medical staff included ENT Physician A.

3. Review of the document titled "On Call Schedule from 01/01/2017 to 01/31/2017," revealed ENT Physician A was scheduled to provide emergency ENT medical services to the hospital's ED for adult and pediatric patients from 8:00 AM on 1/2/2017 through 7:00 AM on 1/9/2017.

4. Review of Patient #32's medical record revealed the following:

a. He presented to the hospital's pediatric ED on 1/7/16 at 1:34 PM. Patient #32's mother incidentally stated Patient #32 possibly swallowed a thumb tack the night before admission.

b. A radiology transcript dated 1/7/17 at 2:28 PM revealed the Radiologist identified a metallic foreign body in Patient #32's right mainstem bronchus (right lung branch) resulting in collapse of the right middle and lower lobes of the right lung.

c. The ED Provider Notes filed by ED Physician C on 1/7/17 at 5:13 PM, revealed:

i. At 2:35 PM on 1/7/17, ED Physician C attempted to contact ENT Physician A to present to the ED and provide care to Patient #32 without response from ENT Physician A.

ii. At 2:45 PM on 1/7/17, ED Physician C again attempted to contact ENT Physician A without response from ENT Physician A.

iii. At 2:57 PM on 1/7/17, ED Physician C attempted a third call to ENT Physician A.

iv. At 3:03 PM on 1/7/17, ENT Physician A returned ED Physician C's phone call. ENT Physician A stated he was not on-call for pediatric patients. ENT Physician A instructed ED Physician C to call Pediatric ENT Physician D. ED Physician C verified ENT Physician A was on-call for the hospital. ENT Physician A stated he was not on-call for pediatric patients.

v. At 3:10 PM on 1/7/17, ED Physician C contacted Pediatric ENT Physician D's office. The office staff contacted their internal on-call physician, ENT Physician B (who was not on-call for the hospital). ENT Physician B called ED Physician C at 3:12 PM on 1/7/17. ENT Physician B agreed to come to the hospital and provide care to Patient #32.

vi. At 4:04 PM on 1/7/17, ENT Physician B arrived at the hospital and examined Patient #32. ENT Physician B transferred Patient #32 to the operating rooms to remove the foreign body at 4:32 PM on 1/7/17.

5. During an interview on 2/27/17 at 11:07 AM, ENT Physician B stated he was not on-call for the hospital on 1/7/17 and another unknown ENT Physician was responsible for providing emergency care to the patients at the hospital. ENT Physician B stated Patient #32's care was not complex and he felt comfortable removing the foreign body. ENT Physician B did not feel Patient #32 required Pediatric ENT Physician D's specialized skills.

6. Review of ENT Physician A's "Delineation of Privileges," approved 4/21/16, revealed the hospital approved ENT Physician A to perform surgical procedures such as those needed to treat Patient #32.

7. During an interview on 2/28/17 at 10:00 AM, ENT Physician A stated he was not on-call for pediatric ENT issues. He instructed ED Physician C to call Pediatric ENT Physician D regarding Patient #32. ENT Physician A acknowledged he could treat pediatric patients.

8. In a written email on 3/8/17 at 9:55 AM, the Manager of Clinical Decision Support stated ENT Physician A treated 136 pediatric patients between 1/1/16 and 12/31/26. ENT Physician A treated 1 patient where ENT Physician A removed a foreign body from a patient's airway from 1/1/16 to 12/31/16.

9. During an interview on 2/28/17 at 11:00 AM, the Vice President of Medical Affairs (VPMA) stated the hospital medical staff bylaws required the physicians to make themselves available to the ED for emergent specialty care if they are on-call. ENT Physician A decided on his own that Pediatric ENT Physician D was on-call for the pediatric ED instead of ENT Physician A providing emergent coverage for both pediatric and adult patients.

10. During an interview on 2/18/17 at 10:00 AM, ENT Physician A stated he was ultimately responsible to provide care for all of the patients in the ED when he was on-call because his name was on the schedule.

11. During an interview on 2/28/17 at 11:00 AM, the Vice President for Medical Affairs (VPMA) stated the hospital had achieved certification as a Level I Trauma Center, the highest level of certification for hospitals that specialized in the care of trauma patients.

12. An email statement from the Trauma Supervisor on 3/7/17 at 9:07 AM indicated the hospital followed the "Resources for Optimal Care of the Injured Patient 2014" as the criteria to obtain certification as a Level I Trauma Center.

13. Review of the hospital provided document, "Resources for Optimal Care of the Injured Patient 2014," revealed in part, "[Neurosurgery] must be continuously available for all [traumatic brain injury] and spinal cord injury patients and must be present and respond within 30 minutes... The intent is that neurosurgical care is promptly available for the acute care of the brain injured and spinal cord injured patient to include an in-person evaluation within 30 minutes [by a neurosurgeon]."

14. During an interview on 2/28/17 at 11:00 AM, the VPMA stated if a neurosurgeon was on-call to provide emergent trauma care to ED patients, the same neurosurgeon was available to provide medical/surgical care to other ED patients. The VPMA acknowledged the hospital lacked a policy addressing surgeons scheduling elective surgical procedures while the surgeon was on-call to provide emergent surgical care to patients in the hospital's ED. Specifically, the hospital lacked a policy instructing the hospital's staff on how to address the situation where an on-call neurosurgeon was performing elective surgical procedures, despite the hospital's designation as a Level I Trauma Center.

15. Review of the hospital's on-call schedule for neurosurgeons in January 2017 revealed that on 1/6/17, Neurosurgeon F was on-call to provide emergency medical/surgical care to the patients at Iowa Methodist Medical Center.

16. Review of Patient #27's medical record revealed:

a. Patient #27 arrived at the ED on 1/6/17 at 9:32 AM complaining of a headache lasting for several days and unrelieved with narcotic pain medication at home.

b. A head CT scan (a detailed x-ray scan of the head) performed on 1/6/17 at 10:14 AM revealed bleeding in the brain that created pressure and swelling in Patient #27's brain. Radiologist I (a physician specialized in reviewing x-rays) documented they contacted Physician's Assistant (PA) E at 11:03 AM on 1/6/17 to notify her about the bleeding in Patient #27's brain.

c. Physician's Assistant (PA-C) E documented in the ED Provider Note at 12:34 PM on 1/6/17 that after Radiologist I informed her that Patient #27 had bleeding in the brain, PA-C E contacted on-call Neurosurgeon F (a surgeon specializing in surgery on the brain and spine) who was responsible for providing emergent care to patients in the ED. on-call Neurosurgeon F's nurse spoke with on-call Neurosurgeon F. On-call Neurosurgeon F stated he and the other neurosurgeon could not provide care for Patient #27, as both neurosurgeons were performing long surgical procedures. On-call Neurosurgeon F recommended the ED staff transfer Patient #27 to Outside Hospital A (approximately 1 hour away by helicopter flight).

d. Registered Nurse (RN) G documented Patient #27 was transferred to Outside Hospital A by Iowa Methodist's helicopter ambulance at 12:35 PM on 1/6/17.

17. During interviews on 2/17/17 at 12:39 AM and 3/8/17 at 4:00 PM, on-call Neurosurgeon F stated he was on-call for medical and trauma patients at the hospital on 1/6/17. On-call Neurosurgeon F stated the hospital lacked a policy addressing surgeons performing elective surgery while on-call for emergent patients, so he scheduled Patient #33's surgical procedure while he was on-call to provide emergent medical care to patients in the ED.

18. Review of the "Master Daily Schedule" for the operating rooms on 1/6/17 revealed on-call Neurosurgeon F scheduled elective surgery on Patient #33 with Neurosurgeon H (who was not on-call) at 10:00 AM.

19. During interviews on 2/17/17 at 12:39 AM and 3/8/17 at 4:00 PM, on-call Neurosurgeon F stated he was performing an elective surgical procedure on Patient #33 with Neurosurgeon H (who was not on-call) when the ED staff contacted him about Patient #27. On-call Neurosurgeon F stated the surgical procedure would take several hours before he could provide care to Patient #27. On-call Neurosurgeon F stated he had the skills and the hospital had the capabilities to provide care for Patient #27, but due to Patient #33's long surgery, on-call Neurosurgeon F instructed the ED staff to transfer Patient #27 to Outside Hospital A.

Neurosurgeon J was not on-call for patients requiring emergency surgery at the hospital on 1/6/17, but the three neurosurgeons who are on the call schedule contact each other to see if they can provide emergent medical care if the on-call neurosurgeon performed an elective surgery while on-call. On-call Neurosurgeon F acknowledged all three neurosurgeons who accepted responsibility to provide emergency neurosurgery at the hospital (Neurosurgeons F, H, and J) were unavailable at the time Patient #27 presented to the hospital because they were in surgery and not available to any patients requiring emergent neurosurgery and could not respond within the 30 minute window required by the Level 1 Trauma Center criteria.

20. During an interview on 3/9/17 at 12:40 PM, Neurosurgeon J stated that approximately 3 or 4 times per year, a patient arrived at the hospital while the on-call neurosurgeon was performing elective surgery and the patient who arrived required neurosurgery. Approximately 2 times per year, the on-call neurosurgeon had to transfer a patient to another hospital for emergency neurosurgery because the on-call neurosurgeon was performing an elective surgical procedure.

I. Based on document review and staff interview, the Acute Care Hospital's administrative staff failed to ensure the hospital staff provided stabilizing treatment within the hospital's capacity for 1 of 1 selected emergency department (ED) patient who required neurosurgery (Patient #27) from 8/1/16 to 2/21/17. The hospital's administrative staff identified an average of 3368 adult ED patients per month. The hospital's administrative staff identified 12 patients who presented to the hospital with bleeding in the brain between 1/1/16 to 12/31/16.

Failure to provide all available stabilizing treatment, including neurosurgery (surgery on the brain or spine), resulted in the hospital staff transferring Patient #27 to an outside hospital approximately 1 hour away, by helicopter ambulance. The delay in treatment could have resulted in Patient #27 dying due to the delay.

Findings included:

1. Review of the "Transfer and Emergency Examination - EMTALA" policy, dated 10/2015, revealed in part, "If the individual has an emergency medical condition, further medical examination and treatment within the capabilities of the staff and facilities must be provided as required to stabilize the emergency medical condition..."

2. During an interview on 2/28/17 at 11:00 AM, the Vice President for Medical Affairs (VPMA) stated the hospital had achieved certification as a Level I Trauma Center, the highest level of certification for hospitals that specialized in the care of trauma patients.

3. An email statement from the Trauma Supervisor on 3/7/17 at 9:07 AM indicated the hospital followed the "Resources for Optimal Care of the Injured Patient 2014" as the criteria to obtain certification as a Level I Trauma Center.

4. Review of the hospital provided document "Resources for Optimal Care of the Injured Patient 2014," revealed in part, "[Neurosurgery] must be continuously available for all [traumatic brain injury] and spinal cord injury patients and must be present and respond within 30 minutes... The intent is that neurosurgical care is promptly available for the acute care of the brain injured and spinal cord injured patient to include an in-person evaluation within 30 minutes [by a neurosurgeon]."

5. During an interview on 2/28/17 at 11:00 AM, the Vice President of Medical Affairs (VPMA) stated if a neurosurgeon was on-call to provide emergent trauma care to ED patients, the same neurosurgeon was available to provide medical/surgical care to other ED patients. The VPMA stated the hospital medical staff bylaws required the physicians to make themselves available to the ED for emergent specialty care if they are on-call.

The VPMA acknowledged the hospital lacked a policy addressing surgeons scheduling elective surgical procedures while the surgeon was on-call to provide emergent surgical care to patients in the hospital's ED. Specifically, the hospital lacked a policy instructing the hospital's staff on how to address the situation where an on-call neurosurgeon was performing elective surgical procedures, despite the hospital's designation as a Level I Trauma Center.

6. Review of the hospital's on-call schedule for neurosurgeons in January 2017 revealed that on 1/6/17, Neurosurgeon F was on-call to provide emergency medical/surgical care to the patients at Iowa Methodist Medical Center.

7. Review of Patient #27's medical record revealed:

a. Patient #27 arrived at the ED on 1/6/17 at 9:32 AM complaining of a headache lasting for several days and unrelieved with narcotic pain medication at home.

b. A head CT scan (a detailed x-ray scan of the head) performed on 1/6/17 at 10:14 AM revealed bleeding in the brain that created pressure and swelling in Patient #27's brain. Radiologist I (a physician specialized in reviewing x-rays) documented they contacted Physician's Assistant (PA) E at 11:03 AM on 1/6/17 to notify her about the bleeding in Patient #27's brain.

c. Physician's Assistant (PA-C) E documented in the ED Provider Note at 12:34 PM on 1/6/17 that after Radiologist I informed her that Patient #27 had bleeding in the brain, PA-C E contacted on-call Neurosurgeon F (a surgeon specializing in surgery on the brain and spine) who was responsible for providing emergent care to patients in the ED. on-call Neurosurgeon F's nurse spoke with on-call Neurosurgeon F. On-call Neurosurgeon F stated he and the other neurosurgeon could not provide care for Patient #27, as both neurosurgeons were performing long surgical procedures. On-call Neurosurgeon F recommended the ED staff transfer Patient #27 to Outside Hospital A (approximately 1 hour away by helicopter flight).

d. Registered Nurse (RN) G documented Patient #27 was transferred to Outside Hospital A by Iowa Methodist's helicopter ambulance at 12:35 PM on 1/6/17.

8. During interviews on 2/17/17 at 12:39 AM and 3/8/17 at 4:00 PM, on-call Neurosurgeon F stated he was on-call for medical and trauma patients at the hospital on 1/6/17. On-call Neurosurgeon F stated the hospital lacked a policy addressing surgeons performing elective surgery while on-call for emergent patients, so he scheduled Patient #33's surgical procedure while he was on-call to provide emergent medical care to patients in the ED.

9. Review of the "Master Daily Schedule" for the operating rooms on 1/6/17 revealed on-call Neurosurgeon F scheduled elective surgery on Patient #33 with Neurosurgeon H (who was not on-call) at 10:00 AM.

10. During interviews on 2/17/17 at 12:39 AM and 3/8/17 at 4:00 PM, on-call Neurosurgeon F stated he was performing an elective surgical procedure on Patient #33 with Neurosurgeon H (who was not on-call) when the ED staff contacted him about Patient #27. On-call Neurosurgeon F stated the surgical procedure would take several hours before he could provide care to Patient #27. On-call Neurosurgeon F stated he had the skills and the hospital had the capabilities to provide care for Patient #27, but due to Patient #33's long surgery, on-call Neurosurgeon F instructed the ED staff to transfer Patient #27 to Outside Hospital A.

Neurosurgeon J was not on-call for patients requiring emergency surgery at the hospital on 1/6/17, but the three neurosurgeons who are on the call schedule contact each other to see if they can provide emergent medical care if the on-call neurosurgeon performed an elective surgery while on-call. On-call Neurosurgeon F acknowledged all three neurosurgeons who accepted responsibility to provide emergency neurosurgery at the hospital (Neurosurgeons F, H, and J) were unavailable at the time Patient #27 presented to the hospital because they were in surgery and not available to any patients requiring emergent neurosurgery and could not respond within the 30 minute window required by the Level 1 Trauma Center criteria.

11. During an interview on 3/9/17 at 12:40 PM, Neurosurgeon J stated that approximately 3 or 4 times per year, a patient arrived at the hospital while the on-call neurosurgeon was performing elective surgery and the patient who arrived required neurosurgery. Approximately 2 times per year, the on-call neurosurgeon had to transfer a patient to another hospital for emergency neurosurgery because the on-call neurosurgeon was performing an elective surgical procedure.



II. Based on document review and staff interview, the Acute Care Hospital administrative staff failed to ensure the on-call physician did not delay care for 1 of 2 patients (Patient #32) when the Emergency Department (ED) physician contacted Ear, Nose, and Throat (ENT) Physician A and requested ENT Physician A to physically present to the ED and provide care for a pediatric patient between 1/2/17 and 1/8/17.The hospital administrative staff identified an average of 1937 pediatric ED patients per month.

Failure of ENT Physician A to physically present to the ED resulted in the ED Physician requesting ENT Physician B (who was not on-call) to present to the ED and delayed the removal of a foreign body from Patient #32's lung.

Findings included:

1. Review of the "Medical staff bylaws of ... Iowa Methodist Medical Center, [and] Blank Children's Hospital (a department of Iowa Methodist Medical Center ...,"approved 9/29/2009, revealed in part, "Responsibilities: Active Staff members must: ... assume all the responsibilities of membership on the Active Staff, ... including ... emergency call, [and] care for unassigned patients ..."

2. Review of the "Medical Staff Roster w/Primary Office," generated 2/21/2017, revealed the Active medical staff included ENT Physician A.

3. Review of the document titled "On Call Schedule from 01/01/2017 to 01/31/2017," revealed ENT Physician A was scheduled to provide emergency ENT medical services to the hospital's ED for adult and pediatric patients from 8:00 AM on 1/2/2017 through 7:00 AM on 1/9/2017.

4. Review of Patient #32's medical record revealed the following:

a. He presented to the hospital's pediatric ED on 1/7/16 at 1:34 PM. Patient #32's mother incidentally stated Patient #32 possibly swallowed a thumb tack the night of 1/6/17.

b. A radiology transcript dated 1/7/17 at 2:28 PM revealed the radiologist identified a metallic foreign body in Patient #32's right mainstem bronchus (right lung branch) resulting in collapse of the right middle and lower lobes of the right lung.

c. The ED Provider Notes filed by ED Physician C on 1/7/17 at 5:13 PM, revealed:

i. At 2:35 PM on 1/7/17, ED Physician C attempted to contact ENT Physician A to present to the ED and provide care to Patient #32 without response from ENT Physician A.

ii. At 2:45 PM on 1/7/17, ED Physician C again attempted to contact ENT Physician A without response from ENT Physician A (10 minutes after the inital phone call from ED Physician C to ENT Physician A).

iii. At 2:57 PM on 1/7/17, ED Physician C attempted a third call to ENT Physician A (22 minutes after the inital phone call from ED Physician C to ENT Physician A).

iv. At 3:03 PM on 1/7/17, ENT Physician A returned ED Physician C's phone call (28 minutes after the initial phone call from ED physician C to ENT Physician A). ENT Physician A stated he was not on-call for pediatric patients. ENT Physician A instructed ED Physician C to call Pediatric ENT Physician D. ED Physician C verified ENT Physician A was on-call for the hospital. ENT Physician A stated he was not on-call for pediatric patients.

v. At 3:10 PM on 1/7/17, ED Physician C contacted Pediatric ENT Physician D's office (35 minutes after the initial phone call from ED Physician C to ENT Physician A). The office staff contacted their internal on-call physician, ENT Physician B (who was not on-call for the hospital). ENT Physician B called ED Physician C at 3:12 PM on 1/7/17. ENT Physician B agreed to come to the hospital and provide care to Patient #32.

vi. At 4:04 PM on 1/7/17, ENT Physician B arrived at the hospital and examined Patient #32 (89 minutes after the initial phone call from ED Physician C to ENT Physician A). ENT Physician B transferred Patient #32 to the operating rooms to remove the foreign body at 4:32 PM on 1/7/17 (117 minutes, almost 2 hours, after the initial phone call from ED Physician C to ENT Physician A).

5. During an interview on 2/27/17 at 11:07 AM, ENT Physician B stated he was not on-call for the hospital on 1/7/17 and another unknown ENT Physician was responsible for providing emergency care to the patients at the hospital. ENT Physician B stated Patient #32's care was not complex and he felt comfortable removing the foreign body. ENT Physician B did not feel Patient #32 required Pediatric ENT Physician D's specialized skills.

6. Review of ENT Physician A's "Delineation of Privileges," approved 4/21/16, revealed the hospital approved ENT Physician A to perform surgical procedures such as those needed to treat Patient #32.

7. During an interview on 2/28/17 at 10:00 AM, ENT Physician A stated he was not on-call for pediatric ENT issues. He instructed ED Physician C to call Pediatric ENT Physician D regarding Patient #32. ENT Physician A acknowledged he could treat pediatric patients.

8. In a written email on 3/8/17 at 9:55 AM, the Manager of Clinical Decision Support stated ENT Physician A treated 136 pediatric patients between 1/1/16 and 12/31/26. ENT Physician A treated 1 patient where ENT Physician A removed a foreign body from a patient's airway from 1/1/16 to 12/31/16.

9. During an interview on 2/28/17 at 11:00 AM, the Vice President of Medical Affairs (VPMA) stated the hospital medical staff bylaws required the physicians to make themselves available to the ED for emergent specialty care if they are on-call. ENT Physician A decided on his own that Pediatric ENT Physician D was on-call for the pediatric ED instead of ENT Physician A providing emergent coverage for both pediatric and adult patients.

10. During an interview on 2/18/17 at 10:00 AM, ENT Physician A stated he was ultimately responsible to provide care for all of the patients in the ED when he was on-call because his name was on the schedule.