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A. Based on review of one of 20 medical records (#9), staff interviews, and review of facility documentation, it was determined that the facility failed to ensure an individual physician is on-call for gastroenterology services to provide stabilizing treatment in the emergency department (ED).

Findings include:

On 2/9/23 at 12:00 PM, during review of Medical Record #9, the following was revealed:

On 12/30/22 at 13:16 (1:16 PM), Patient (P)9 arrived in the ED from a skilled nursing facility with a report of low hemoglobin. At 14:57 (2:57 PM), Staff #30, a Physician, documented in the ED Physician Documentation ED course, "The pt [patient] was reassessed at this time and [his/her] HBG (hemoglobin) is 6 grams. [He/she] has a GI [gastrointestinal] bleed. [He/she] will need to be transferred as there is no GI [gastroenterologist] available. Will initiate a transfer."

On 2/9/23 at 2:25 PM, a review of the "Gastroenterology December 2022 On-Call" list was conducted. For 12/30/22, when P9 arrived in the ED, the Gastroenterology on-call list indicated: "1st Call: *see below note." The "1st Call" note on the bottom of the page indicated: "*Switchboard to check who patient is assigned to (physician names). Once that is confirmed a call should be put out to the assigned provider. If the call is declined by the assigned provider, the 2nd call goes to (named physician) (unless it is [his/her] patient and [he/she] has declined to take the call.) The final call goes to Cooper Transfer Center."

The "Gastroenterology December 2022 On-Call" list did not clearly identify the individual physician on call for gastroenterology.

The medical record lacked documentation that the on-call gastroenterologist was contacted and available by the ED Physician in order to provide stabilizing treatment.

The above findings were confirmed by Staff #1 at 3:05 PM.



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B. Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition, as noted upon review of 14 dates in December 2022 corresponding with the critical care on call list.

Findings include:

At 12:00 PM, a review of the ED physician on-call list for the months of August 2022 through February 2023 was conducted. The Critical Care on-call list for the month of December 2022, specifically dates December 10, 11, 17, 18, 22-31st (14 days), did not indicate the physician on call. The space said "OPEN" where the assigned on-call physician names were to be documented.

During an interview with Staff #11 at 1:45 PM, when questioned how he/she would know who to contact using the on-call list when it states "OPEN," Staff #11 stated he/she "didn't know" and would just call the operator. Staff #15 confirmed the on-call process was for the staff to call the operators, who will then contact the physicians on call. At 2:32 PM, Staff #15 and Staff #6 (Charge Nurse) stated that registered nurses and unit clerks do not have access to the intranet to view the on-call list and confirmed the process is to contact the operator for the on-call physician.

At 3:08 PM, in the presence of Staff #1, Staff #2, and Staff #3, interviews were conducted with Staff #17 (Operator), Staff #18 (Operator), and Staff #19 (Operator), who confirmed that they are called by the ED staff to contact the on-call physicians. When asked who they contact when the on-call list states "OPEN," and there is no physician name, Staff #19 stated that the operators are updated either the night before or the morning of by the physician's office. Upon request, the operators were unable to provide documentation of the update for the dates listed as "OPEN". A request for an updated Critical Care on-call list for December 2022, including the names of physicians who were on-call for the dates documented as "OPEN", was made at that time to Staff #1, Staff #2, and Staff #3. At 3:48 PM, a list of physician names for the missing dates only was provided. When asked how this information was received, Staff #1 stated they "had to call the doctor" to receive the updated information. The facility failed to provide documentation that an on-call physican had been assigned and available for Critical Care for each day in December 2022.

The above findings were confirmed during the exit conference.

Based on the review of one (1) of 20 Medical Records (#1), staff interviews, and review of facility documents, it was determined that the facility failed to effectuate an appropriate transfer for a patient requiring further medical screening examination (MSE) by qualified medical personnel (QMP) to rule in or out an emergency medical condition (EMC). The facility failed to demonstrate that the patient's medical records related to the EMC were sent to the receiving facility. Additionally there is no evidence that the patient was educated on the risks of declining transfer via ambulance.

Findings include:

On 2/8/23 at 2:45 PM, a review of the ED medical record of Patient (P)1 was conducted in the presence of Staff (S)10. On 12/31/22 at 1:24 PM, P1 arrived in the Emergency Department (ED) with complaints of vaginal bleeding at 20 weeks pregnant. Staff (S)35 (physician) documented in the "ED Physician Documentation" the following: "Given [greater than] 20 wks (weeks) pregnant, recommend being seen at an L&D (labor and delivery) triage to evaluate. Deferred pelvic exam as some risk if [sic] placenta previa of making this worse and increasing bleeding. Requested closest hospital with L&D which would be [named facility], I called and spoke to the OB-GYN MD [obstetrics-gynecologist medical doctor] who is amenable to seeing her there today. Overall is well-appearing, in NAD [no acute distress], not having [a] significant amount of bleeding so feel stable to travel without ambulance transport - has significant other who will drive - still offered official ambulance transport which pt [patient] declined. Given address, directions, and phone number of facility. All questions answered, pt [patient] amenable to plan and agrees to go to be evaluated immediately.

A. At 2:44 PM, S35 documented in the Disposition Summary that P1 was discharged home in stable condition with the following reason: "Please go to a Labor and Delivery Triage. The closest option is [named facility and phone number]. Directions/address attached. Another option would be [named facility]." At 2:59, S36, a registered nurse (RN) documented in the Discharge Assessment that P1 was given discharge instructions, follow up, and referral plans. There is no documentation in the medical record that facility had provided the patient or the receiving facility with all medical records related to the patient's current EMC.

B. There was no documentation found in the medical record that the patient was notified of the risks and benefits of transfer, or of a patient signature confirming refusal of ambulance transportation.

On 2/9/23 at 3:20 PM, an interview was conducted S26, Interim VP of Quality and Patient Services. S26 stated that when the patient arrived at [named facility], the ED RN documented it in their incident reporting system. S26 stated that a medical record review was then conducted, and that the physician (S35) documented that the patient declined transfer, was given referrals to both [named facilities] but did not have the patient sign the facility's transfer form which included the risks and benefits of transfer and a refusal to consent to transfer. S26 stated that on 1/2/23, a formal report was sent to CMS disclosing this information, and the facility began their action plan. A document titled "Action Plan: Proactive Disclosure of Potential Salem Medical Center EMTALA Concern" was provided and reviewed. The first step of their action plan was to "reinforce EMTALA policy to ED Physicians through in-person and electronic education" within 3 months. The next phase was an audit of "5 ED records for pregnant patients to determine if any barriers to transfer exist" for December 2022, January 2023, and February 2023. S26 provided a copy of the facility's Action Plan which, beginning in January 2023, established a mechanism for the facility's Health Information Management Director to perform record reviews and report it to S1. Additionally, ongoing monitoring of the facility's network hospitals will be continued by network risk management departments. S26 provided documentation of the chart audits in place. The physician education documentation and ongoing audit of pregnant ED patients were verified during survey to support implementation of the facility's action plan.