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Based on interview and record review the facility failed to ensure an on-call surgeon was available for one (Patient 1) of 20 patients that presented to the Emergency Department (ED).

This failure has the potential to impact and delay the care of patients needing emergent surgery.

Findings:

On October 4, 2023, at 9 a.m., an unannounced visit was conducted at the facility for an EMTALA survey.

On October 4, 2023, at 11 a.m., a review of the facility's ED log was conducted with the Director of Quality (DOQ). The ED log indicated Patient 1 arrived at the Emergency Department on July 14, 2023, at 9:53 p.m.

A review of the facility's document titled, "Emergency Room Specialty Call Roster," dated July 2023 was reviewed. This roster indicated Surgeon 1 was on call for surgery on July 14 and 15, 2023.

A review of the facility's undated document titled, "Information Sheet," indicated Patient 1 arrived at the Emergency Department on July 14, 2023, at 9:53 p.m., for complaints of left groin pain.

A review of the facility's document titled, "EDM Hemet Triage Report," dated July 14, 2023, at 10:06 p.m., indicated Patient 1 had left groin pain, swelling, tender and redness and rates pain on a scale of one to ten as a nine.

A review of the facility's untitled document, dated July 14, 2023, at 4:43 p.m., indicated, "...[Patient 1's name]...Computed tomography [CT] Scan...Abdomen/Pelvis...Impression...Left labial/perineal subcutaneous emphysema with extensive fat stranding extending to left lower abdomen. Findings are concerning for necrotizing fasciitis [a rare bacterial infection that spreads quickly in the body and can cause death]."

A review of the facility's document titled, "PHH Emergency Department Record," dated July 15, 2023, at 12:30 a.m., indicated ED physician 1 called Surgeon 1 (S1,on-call surgeon) multiple times with no response.

A review of the facility's document titled, "PHH Emergency Department Record," dated July 15, 2023, at 1 a.m., indicated ED Physician 1 called an outside hospital to discuss Patient 1's case, condition, work up results and plan of care. The outside hospital stated if the ED physician was unable to reach S1, they could accept Patient 1 as a lateral transfer.

A review of the facility's document titled, "PHH Emergency Department Record," dated July 15, 2023, at 3:50 a.m., indicated ED Physician 1 discussed Patient 1's case with the resident team, who agreed to admit Patient 1 to the Intensive Care Unit (ICU, unit that provides critical care and life support to acutely ill patients).

A review of the facility's document titled, "PHH Emergency Department Record," dated July 15, 2023, at 6:26 a.m., indicated ED Physician 1 was unable to get a hold of S1.

A review of the facility's document titled," IntraOperative Case Report," dated July 15, 2023, at 10:38 a.m., indicated Patient 1 underwent an Excisional Debridement of Left Mons Pubis Necrotizing Tissue (removal of flesh-eating soft tissue infection) on July 15, 2023, at 10:06 a.m. performed by S1.

An interview on October 5, 2023, at 10:30 a.m., with S1 was conducted. S1 stated he was the on-call surgeon on July 15, 2023, and was aware of the hospital policy on the need to respond to calls as soon as possible and to be at the emergency department within 30 minutes if needed. S1 stated he did not follow the facility's on-call policy. S1 stated, "I was asleep and I was very tired. I did not answer the calls since I had seven cases in the morning."

An interview on October 5, 2023, at 1 p.m., with the Chief Medical Officer (CMO) was conducted. The CMO stated S1 did not follow the hospitals ED physician's on-call policy on July 15, 2023, when S1 did not respond to the ED physicians' calls.

A review of the policy and procedure (P&P) titled, "EMTALA-Provision of On-Call Coverage Policy," dated April 2023 was conducted. The P&P indicated, " ...the hospital must maintain a list of physicians on its medical staff who have privileges at the hospital...Physicians on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with Emergency Medical Conditions (EMC)...The hospital has a process to ensure that when a physician is identified as being "on-call", it shall be that physician's duty and responsibility to assure the following ...Timely availability, at least by telephone, to the Emergency Department (ED), physician for his or her scheduled "on-call" period...Arrival or response to the ED within 30 minutes. The ED physician, in consultation with the on-call physician, shall determine whether the individual's condition requires the on-call physician to see the individual immediately ..."
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Based on interview and record review the facility failed to ensure a complete and accurate Emergency Department (ED) central log was maintained when two of 20 sample patients (Patient 11, Patient 12) were incorrectly entered in the central log.

This failure had the potential to cause a delay in treatment and/or deterioration of patients conditions.

Findings:

On October 4, 2023, an announced visit was conducted at the facility for an EMTALA survey.

A review of a facility document titled, "Central Log," for the month of April 2023, was conducted. The Central log indicated, "...status...ERROR..." for Patients 11 and 12.

A review of a facility document titled, "ED Summary Report," dated April 11, 2023, was conducted. The document indicated for Patient 11, "...Discharge Disposition: ERROR...Principal Complaint...Nausea/Vomiting/Diarrhea..."

A review of a facility document titled, "EDM Triage Report," dated April 9, 2023, at 2 a.m., was conducted. The document indicated for Patient 12, "...Chief Complaint...Abdominal pain...37 weeks pregnant c/o [complaint of] abdominal pain with on and off cramping x [for] 3 days, also c/o back pain, shortness of breath and high blood pressure at home, denies any vag [vaginal] discharge. GIP0 [one pregnancy, no births] under [physician name].

On October 5, 2023, at 2:02 p.m. a concurrent interview and record review was conducted with the Chief Quality and Patient Safety Officer (CQPSO). The CQPSO stated Patient 11's status was entered as an ERROR, the status should have been "left before being seen." The CQPSO further stated the status was entered incorrectly and a note should have been entered on why there was no triage, according to the facility policy.

On October 5, 2023, at 2:05 p.m., the CQPSO stated Patient 12 was sent to obstetric (O.B.) for the MSE (Medical Screening Examination) as per facility policy. The CQPSO further stated the status entered as an ERROR was incorrect, the correct status should have been "transferred to O.B."

A review of the policy and procedure (P&P) titled, "EMTALA - CENTRAL LOG POLICY," dated April 27, 2023, was conducted. The P&P indicated, "...The Central Log, including all additional logs incorporated into the Central Log by reference, shall be maintained in the same manner and with the same central core of information. The logs must contain at a minimum, the name of the individual, the date, time and means of the individual's arrival, the individual's age, the individual's sex, the individual's record number, the nature of the individual's complaint, the individual's disposition, the individual's time of departure, and whether the individual: refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged, or expired..."

Based on interview and record review the facility failed to ensure the transfer certification signed by the physician, contained a summary for risk and benefits for transfer for one of 20 sampled patients (Patient 14).

This failure resulted in Patient 14 being transferred without the risks and benefits being explained first.

Findings:

On October 4, 2023, an announced visit was conducted at the facility for an EMTALA survey.

A review of a facility document titled, "History and Physical," dated October 4, 2023, at 7:42 a.m., was conducted. This document indicated for Patient 14, "...Chief Complaint...Shortness of breath...In the ER [Emergency Room], patient was found to be having acute MI [Myocardial Infarction] [a blockage of blood flow to the heart muscle] ...Assessment/Plan...transfer to higher level of care for acute MI..."

A review of a facility document titled, "TRANSFER SUMMARY AND CERTIFICATION," dated October 4, 2023, at 6:57 p.m., was conducted. There is no documented evidence that the risk and benefits were discussed with Patient 14 or the responsible party. These two sections on the TRANSFER SUMMARY AND CERTIFICATION form were left blank by the physician, and the patient was transferred without completing the transfer form as indicated per facility's transfer policy and procedures.

A concurrent interview and record review was conducted on October 5, 2023, at 3:12 p.m. with the CQPSO. The CQPSO reviewed the medical records for Patient 14 and stated the physician should have completed the transfer form in its entirely and it was the facility's policy that the physician discuss the risks and benefits of the transfer with the patient or responsible party prior to the transfer. The CQPSO further stated there is no documented evidence that the physician discussed the risks and benefits.

A review of the policy and procedure (P&P) titled, "EMTALA - TRANSFER POLICY," dated April 27, 2023, was conducted. The P&P indicated, "...the hospital may transfer the individual only if the transfer is an appropriate transfer and meets the following conditions...A physician has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of the woman in labor, to the woman or the unborn child, from being transferred. The certificate must contain a written summary of the risks and benefits upon it is based..."