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Based on interviews and review of medical records, Medical Staff rules and Regulations, Air Transport report, and on call schedules it was determined that the facility failed to ensure that that the on call physician on the call list was maintained in a manner that best meets the needs of the hospital's patients who are needing specialized treatment ( Orthopedic Hand Surgeons) for 1 patient ( # 26) of 26 patients medical records reviewed. The facility failed to call the second on call surgeon listed on the orthopedic on call schedule. The facility also failed to ensure names of the on- call physician who are on the on call list were consistently listed on the call schedules. Refer to findings in tag A-2404.

Based on review of medical records, polices and procedures, transfer logs, and on-call schedules, and staff interviews it was determined the hospital failure to provide medical treatment that was within its capacity, to minimize the risks to the individual's health ( patient # 26), and the hospitals inappropriately transferred an individual ( Patient # 26) by failing to provide definitive treatment for an identified emergency medical condition; and transferred this individual to a receiving hospital that had the same level of care that was within the capacity of the hospital for one ( patient # 26) of 26 patients sampled patient medical records reviewed. As this resulted in an appropriate transfer for Patient # 26. Refer to finding in Tag A-2409.

Based on interviews and review of medical records, medical staff rules and regulations, Air transport report, and on call schedules, it was determined that the facility failed to ensure that the on-call physician on the on call list was maintained in a manner that best meets the needs of the the hospital's patient who are needing specialized treatment ( orthopedic hand surgeon) for 1 (Patient #26) of 26 patients medical records reviewed. The facility failed to call the second on call orthopedic on-call surgeon listed on the the orthopedic on call schedule. The facility also failed to ensure the names of the on-call physicians who on-call were consistently listed on the call schedules.

Findings:

Medical Record Review-Patient # 26

Documentation by the Emergency Department Physician dated August 23, 2015 at 12:55 PM revealed in part, " History: Brought in by EMS( Emergency Medical Services) after patient # 26 chopped the metacarpal bone of his thumb in half with a machete while chopping branches off a tree. Patient # 26 wrapped the wound in a T-shirt and started driving to the hospital then decided to call EMS because of the heavy bleeding. Patient # 26 had no other complaints. Patient # 26 received 100 mg of Fentyl ( Fast acting pain medication and sedative) enroute to the the hospital. Patient # 26 stated he had no feeling in his thumb complaining of extreme pain at the site of the injury and burning sensation up his forearm.

Review of symptoms: Cardiovascular showed positive leg swelling. Musculoskeletal: Positive for arthralgia ( pain in joint), BP (Blood Pressure) 124/90, pulse 108, temperature 37C ( 98.6 F orally), respirations 20 and oxygen on room air 99 %.
Physical exam: Musculoskeletal: Patient has normal sensation and movement to right hand. Left hand shows tenderness to left forearm, decreased range of motion ( Left thumb with no motion), tenderness, decreased capillary refill, deformity and laceration. It was noted that there was decrease strength in the left hand. Patient # 26 exhibits thumb/finger opposition.
Left hand is noted to have exposed metacarpal bone( Any bone between wrist and fingers), thumb cool to touch, the other four fingers have normal sensation and capillary refill. Normal range of motion for fingers 2 thru 5 on the left hand. Skin: Laceration ( cut through the thumb tendons and metacarpal bone. Arterial bleeding noted at the site).
Differential diagnosis: Thumb amputation and radial artery injury with open fracture.
Is this an Emergent Medical Condition. Yes, Severe pain/Acute onset of symptoms, threat to the patient, impairment of bodily function and dysfunction of organ or part.
Medical decision making: Pictures of the wound on the medical chart. When the BP cuff was decreased it was noted that there was projectile arterial bleeding from the base of the metacarpal joint. Wound was dressed with direct pressure into the laceration site. Wound with bleeding problems intermittently as the dressing was taken down for the orthopedic residents and replaced several times. Preparation made for the operation by making patient NPO ( Nothing by Mouth).
Independent visualization of images , tracings or specimens shows x-ray of left hand that shows displaced fracture through metacarpal bone of the first finger with fracture of the second metacarpal from the machete blade.
ED( Emergency Department) Re-evaluation shows that orthopedic consulted to see the patient. The orthopedic residents were notified that the patient had partial amputation and needs urgent evaluation. Pre-operation labs, and x-rays ordered. Orthopedic junior at bedside and will have her senior to come and see patient and evaluate. The orthopedic resident states that the patient will be taken in tonight and possibly do a washout of the hand. Orthopedic stated that there is no micro vascular capabilities today for reattachment of the thumb so he will likely have the thumb washed out and pinned tonight with a possible salvage tomorrow.

Documentation by the ED physician( Staff J) at 6:53 PM states that it is the belief the patient # 26 needs an attempt at salvage with microvascular capabilities before tomorrow. Attempt made to transfer the patient to a center capable of performing this procedure sooner. Calls made by my attending and several others in the ED to an acute care hospital who agreed to take the patient for the procedure.

Documentation by the ED Registered Nurse( RN) on 08/23/2015 at 2:20 PM revealed in part, " BP tourniquet tightened on arm. Loosened for a few minutes and bleeding worsened. The emergency medicine physician notified and advised RN that BP cuff can stay on for a few more hours without damage. Will continue to monitor."

Documentation by the orthopedic Resident on 08/23/2015 at 3:45 PM,specified in part, CC ( Chief Complaint) shows right handed male who sustained a left hand injury while gardening. Injury occurred at 11:30 AM on 08/23/2015. Review of systems shows positive for hand injury. Physical exam shows laceration over palmar surface and dorsal surface of the first MCP joint active sanguineous drainage. Sensation absent over the radial surface of the thumb. Minimal sensation over the ulnar surface of the thumb. Patient # 26 is unable to move the thumb. Imaging of the left hand was reviewed by the Orthopedic Resident, which demonstrates complete amputation of the thumb through the metacarpal head. A second metacarpal neck fracture. Follow up included wound was washed out at bedside with 2 liters of normal saline. The wound was covered with xeroform( Wound dressing) and gauze and placed in thumb spica. Hand surgeon consulted and the patient will be admitted for possible replant in the morning. Patient consented to procedure."

Documentation by the Emergency Medicine resident on 08/23/2015 at 8:11 PM, revealed in part, the plan is to follow up with the transfer center regarding the patient # 26 transferring to an another facility for reattachment surgery.

Documentation by the Emergency Medicine RN on 08/23/2015 at 9:20 PM, revealed in part, " Patient complaining of increased pain at injury site ( Scale for pain 0 no pain to 10 the worst) stated it was an 8/10 with sharp aching sensation. Patient unable to feel first pointer finger on left hand. At 9:30 PM Anesthesiologist notified that patient is being transferred to another facility and not having procedure. At 10:20 PM Social worker at bedside. Documentation by the Case Manager revealed that " patient # 26 is to be transferred to another facility after our physician( Staff J) made decision not to perform surgery at this facility"

Patient # 26 " informed consent for Operative/invasive procedure dated 08/23/15 at 3:35 PM, reveled in part," the following operation and or procedure: left thumb on index finger replant and all other indicated procedures possible vascular graft, possible amputation to be performed by two orthopedic hand surgeon's who were named on the operative consent. The consent was obtained and signed both by the orthopedic resident and patient # 26.
Review of another consent titled informed Consent for multiple related Operative/Invasive procedures dated 08/23/2015 at 6:00 PM, specify in part " Consent to the following operational and/or procedure: Left thumb irrigation and debridement wound closure versus application of wound vac versus skin graft or flap coverage. Possible left thumb pinning " to be performed by the orthopedic surgeon. The consent was obtained by the orthopedic resident on 08/23/2015 at 6:00 PM and patient # 26 signed the consent. According to the Certification for Air Transport dated 08/23/2015 revealed that patient # 26 arrived at the hospital that accepted him on 08/23/2015 at 11:22 PM.
Further review of of patient # 26 medical record, shows that there was a problem with the on call physician for orthopedic hand surgeons on 08/23/2015. The informed consents for surgery were signed by patient # 26 at 3:25 PM and at 6:00 PM. There were two surgeons names on the surgical consent form for 08/23/2015 at 3:00 PM, and one surgeons name name listed on the second surgical consent form. There was no documentation in the medical record to indicate that either of these orthopedic surgeons were coming into to do the surgery. The interviews with staff validated the first on call physicians name listed on the 08/23/2015 at 3:35 PM surgical consent form was to come in and do the surgery but there was a problem and this surgeon could not come in.
There is also no documentation in the medical record to indicate that the second on-call orthopedic hand surgeon had been contacted. On 08/23/2015 patient # 26 was transferred to an acute care hospital for definitive treatment of his left hand injury after spending 10 hours in facility with an identified emergency medical condition.
There is no other documentation by the orthopedic resident who evaluated patient # 26 and who had consulted the on-call orthopedic surgeon physician, that the on-call hand surgeons were coming into the facility or if the surgery was to be rescheduled.

Medical record review receiving hospital for patient # 26.
Review of the medical record revealed that patient # 26 was in the receiving hospital ED on 08/23/2015 at 11:45 PM. Review of the consultants note indicated, that patient # 26 arrived to first facility at around noon. The first hospital stabilized patient # 26 and stated that they would get a doctor to fix patient # 26 hand. Patient # 26 waited until 10:30 PM at night. Review of the plan or care note dated 08/23/2015 at 11:55 PM the orthopedic surgeon documents " To Operating Room emergently with orthopedic surgeon for incision and drainage left hand, possible bone, artery, nerve, tendon repair, possible revision amputation and other indicated procedures.

Orthopedic On-Call Surgery Schedule for August 2015:
Review of the Orthopedics on-call schedule validated that on 08/23/2015 that an orthopedic hand surgeon was on call, when patient # 26 presented to the hospitals emergency department. The on-call schedule revealed that there was also a back up surgeon on call on 08/23/2015. Further review of the August 2015 on call schedule revealed " 1st resident TRAUMA" were listed 08/01/2015 thru 09/01/2015, but there were no names listed. The on call hand trauma for 08/01/2015 thru 08/03/2015 was listed as " Hand Trauma" and no physicians names listed. The on-call schedule for " Hand Plastics" revealed that on the following dates no physician names were listed: 08/04 thru 08/15/2015, 08/20 thru 08/21/2015 and 08/25 thru 08/31/2015.

Interviews:

During an interview on 02/04/16 at 10:40 AM, the Director of Quality Control (Staff B), was asked for on call physician list for 08/23/15. The on call list did not have have a name for the 1st trauma surgeon, only numbers to call. When asked who was called , Staff B stated the first name of the physician on the consent form was called, who was on call for orthopedics. The second physician on the consent sheet was not called.

During an interview on 02/03/16 at 12:10 PM and at 3:30 PM, the Manager of of the Adult Emergency room ( Staff A) and the Administrator of Quality, indicated that the orthopedic surgeon ( Staff I ) was in the operating room and was unable to speak with the surveyor.

During an interview on 02/03/16 at 12:48 PM, Staff J, ER( Emergency Room) Physician, states that there was a problem with attending orthopedic physician, who was contacted to do the surgery for patient # 26. There was no documentation of why this physician did not come in.

During an interview on 02/04/16 at 12:48 PM, with the Emergency Room Physician ( Staff J), when asked specifically about patient # 26, stated that he remembers the patient, because the patient was sent to another hospital, which is not done a lot. Further questioning included why was patient # 26 was scheduled for surgery and then was not done. Staff J stated that there was problem with the attending physician coming to the hospital. It was pointed out that the patient # 26 was triaged, and not considered a trauma alert. Staff J was asked why patient # 26 not considered a trauma patient who needed to be seen by the orthopedics, which the order to call the orthopedic specialist was done within 14 minutes. There was a plan for patient # 26 to go to the operating room( OR). It was decided that patient was not to go the OR. Anesthesia was canceled at 9:30 PM. Staff J stated did not know why there was no documentation by the Orthopedic resident, as to why surgery was canceled. Staff J was unable to state why there was no documentation after 3:30 PM. Around 6:53 PM, it was then decided to send patient to Tampa. No further notes in the medical records except that at 9:22 PM, the RN wrote patient # 26 was going to Tampa.

During an interview on 02/04/16 at 4:44 PM, the RN (Staff M), stated that the plan was for the first physician named on the consent sheet(Hand Orthopedic Surgeon ) Listed on the surgical consent( 08/23/2015) was to come in, and do the surgery but had car problems. The second surgeon named on the consent for surgery was not contacted.

Medical Staffing Rules and Regulations:

Review of policy titled "Medical Staffing Rules and Regulation" Chapter 3, states that the on call Attending, within 30 minutes. If the on call practitioner is requested by the Emergency department attending to appear in person must do as soon as possible to personally evaluate and or care for the patient. The on call medical staff member who will knowingly be unavailable to care for emergency patient must arrange for an appropriate alternate medical Staff to cover emergency call during the period of unavailability. This medical staff member making such an arrangement maintains the ultimate responsibility for the call.

There was no documented evidence to indicate that the first on-call hand orthopedic surgeon had made arrangements for an appropriate alternate medical staff member to cover emergency calls during his period of unavailability on 08/23/15 when patient # 23 presented to the hospital's emergency department.

Based on review of medical records, polices and procedures, transfer logs and on- call schedules, and staff interviews it was determined the hospital failed to provide medical treatment that was within its capability, to minimize the risks to the individuals health ( Patient # 26), and the hospital inappropriately transferred an individual ( Patient # 26) by failing to provide definitive treatment for an identified emergency medical condition; and transferred this individual to a receiving hospital that has the same level of care that was within the capacity of the hospital for one ( patient # 26) of 26 sampled patient medical record reviewed. As this resulted in an inappropriate transfer for patient # 26.

Finding:

Medical record review for patient # 26

Documentation by the Emergency Physician dated August 23, 2015 at 12:55 PM revealed in part, History: Brought in by EMS ( Emergency Medical Services) after patient # 26 chopped the metacarpal bone of his thumb in half with a machete while chopping branches off a tree. Patient # 26 wrapped the wound in a T-shirt and started driving to the hospital then decided to call EMS because of the heavy bleeding. Patient # 26 had no other complaints.

Patient # 26 " Informed Consent for Operative/Invasive Procedure dated 08/23/2015 at 3:35 PM, reveled in part, " the following operation(S) and/or procedure: Left thumb on index finger replant and all other indicated procedures possible vascular graft, possible amputation to be performed by ( Two orthopedic hand surgeons listed on the consent sheet). The consent was obtained and signed by an orthopedic surgeon. The consent was signed by patient # 26. The Informed consent for Blood Transfusion dated 08/23/2015 at 3:35 PM was reviewed. The consent indicates in part, " I have been informed that I need or may need a transfusion(S) of blood components before, during or after my operation(s) or during my care at the hospital."the blood transfusion consent was signed by a physician, patient # 26 and witnessed by an ED( Emergency Department) RN(Registered Nurse).

Review of a second consent titled Informed Consent for Multiple Related Operative/Invasive Procedures dated 08/23/2015 at 6:00 PM, specified in part, " consent to the following operational and/or procedures(s): Left thumb irrigation and debridement wound closure versus the application of wound vac versus skin graft or flap coverage. Possible left thumb pinning" to be performed by ( Name of Physician/Orthopedic surgeon). " The consent was obtained and signed by the orthopedic physician 08/23/2015 at 6:00 PM. The consent was signed by patient # 26. According to the certification for Air Transport dated 08/23/2015 revealed that patient # 26 arrived at the hospital that accepted him on 08/23/2015 at 11:22 PM EST( Eastern Standard Time). Further review of patient # 26 medical record, shows that there was a problem with the on-call physician for orthopedic hand surgeons on 08/23/2015. The informed consents for surgery were signed by the patient at 3:25 PM and another consent for surgery at 6:00 PM.

The department of Anesthesiology pre-operative Evaluation Record dated 08/23/2015 at 7:54 PM, documentation by the Anesthesiologist revealed in part," type of visit: in person...HPI ( History of present illness) ...Anesthetic complications: negative anesthetic complications ROS..Cardiac History includes hypertension... is well controlled..Physical Exam: Airway: mallampati( Test used to predict the ease of endotrachial intubation) Class III to IV associated with more difficulty. Class II..Pulmonary: breathe sounds clear to auscultation. Communications: Patient is not currently on a beta blocker. Informed consent obtained. Surgical consent obtained. The patient/family is aware of the they are having a surgical procedure. Anesthesia assessment/Plan: the patient will receive the following types of anesthesia: general...Procedure notes: no procedure notes written...All postoperative notes: none written. " The informed consent for Anesthesia/Sedation procedure dated 08/23/2015 at 9:15 PM, revealed the consent was signed by the patient #26, anesthesiologist, and witnessed by an ED RN.

The emergency Department transfer Certification form for patient # 26 was reviewed. The transfer certification, dated 08/23/2015 at 10:23 PM, specified in part, " reason for transfer: ( Check appropriate block) . X patient's need exceed facility capabilities and capacity, the on-call physician failed or refused to appear within a reasonable period of time. ( This section of the certification for transfer was left blank) ..Medical benefits of the transfer: higher level of care to re-attach digit/joint." The signatures listed on the consent form were that of a physician and patient # 26 on 08/23/2015 at 10:28 PM.

ED Admits-Transfers to hospital from ED:

The section of the hospital's ED log titled, : EMERGENCY MEDIC" dated 08/01/2015 through 12/07/2016 page 1 and 2 of 10 pages were reviewed. The transfer log revealed that on 08/23/2015 patient # 26 was transferred by the attending physician to a Non-Health Care point of Origin.

Policy and procedure review:

The hospital's policy titled " Emergency Patient's Acceptance of transfer", policy number CP 02.014. Digitally signed 02/20/2016, was reviewed. The section of the policy titled, " emergency Transfers for the facility: specified in part. "c. Requirements for an Appropriate Transfer...2. The transferring hospital provides medical treatment within its Service Capability and service Capacity to minimize the risks to the patients health."

Review of the orthopedic on-call schedule validated that on 08/23/2015 that an orthopedic hand surgeon was on call, when patient # 26 presented to the hospital's ED. The on-call schedule revealed that there was also a back up hand surgeon on call 08/23/2015.

Interviews:

During an interview on 02/03/16 at 12:48 PM, Staff J, ER( Emergency Room) Physician, stated that there was a problem with the attending orthopedic physician who was contacted to do the surgery for patient #26. There was no documentation of why this physician did not come in.

During an interview on 02/04/16 at 10:40 AM, Staff B was asked for on call physician list for 08/23/15. the on-call did not have a name for the 1st trauma physician, only numbers to call. When asked who was called, Staff B stated the first name of physician on the consent form was called, who was on call for orthopedics. The second physician on the consent sheet was not called.

During an interview on 02/04/16 at 12:48 PM with the Emergency Department physician ( Staff J) when asked specifically about patient #26, stated that he remembers the patient, because the patient was sent to another hospital, which is not done a lot. Further questioning included why was the patient scheduled for surgery and then not done. He stated that there was a problem with the attending physician coming into the hospital. Asked where was this documented. Stated it was not after looking at notes given to him. It was pointed out that the patient was triaged, and not considered a trauma alert. Asked why not and was told not considered a trauma alert but a patient who needed to be seen by orthopedics, which the order to call the specialist was done within 14 minutes. There was a plan to have the patient go to OR (Operating Room), then it was decided patient was not going to OR. Anesthesia was canceled at 9:30 PM, Staff J stated he did know why there was no documentation by the orthopedic physician, as to why the surgery was canceled. He was unable to state why there was no documentation after 3:30 PM, that is when the orthopedic surgeon was going to do surgery and then at around 6:53 PM, it was then decided to send patient to Tampa. No further notes except that at 9:22 PM, the RN wrote patient was going to Tampa.

During an interview on 02/04/16 at 4:44 PM, Staff M stated that the plan was for the first physician named on the consent sheet ( Hand orthopedic Surgeon) listed on the surgical consent ( 08/23/2015 at 3:35 PM consent) was to come in and do the surgery but had car problems. The second on-call hand surgeon was not contacted.

The hospital failed to ensure that their transfer policy and procedure was followed as evidenced by on 08/23/2015 the facility had the capability ( on call had surgeons of the facility by the availability of the coverage through the on call schedules) and capability of the hospitals( Physical space, equipment, supplies and specialized services( operating room, Ortho/hand surgery speciality, and Anesthesiology, the hospital provides, i.e surgery). Capacity( number of staff on duty, or the amount of equipment on the hospital's premises) to provided the needed services for patient # 26.