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Based on interview and record review, the hospital failed to comply with the requirements of 42 CFR 489.24 by failing to develop specific policies and procedure regarding unavailability of on-call physicians (refer to tag A2404), and planning for an appropriate hospital-to-hospital transfer (refer to tag A2409).

Based on interview and record review, the hospital failed to develop specific policies and procedures for emergency department on-call physician coverage for one of 30 sampled patients (1). Findings:

Patient 1 was admitted to Emergency Department A (ED A) on Sunday 6/16/13 at 1:08 p.m. with headache and neck pain following a lumbar puncture (LP, a diagnostic procedure where a needle is inserted into a fluid-filled space around the spinal cord of the lower back) done on 6/14/13 at another hospital (Hospital B).

Patient 1's record was reviewed on 12/2/13. The ED physician (EDP) documented Patient 1 required treatment by an Interventional Radiologist (IR, a specialist physician) who was unavailable at the hospital for the weekend. The EDP documented he recommended Patient 1 and a family member drive to another hospital for treatment. The record further indicated Patient 1's family member "was advised that the procedure needed for her condition is unavailable at this time. He (Patient 1's family member) was offered to have his wife wait in the ER and we would attempt transfer back to (Hospital B) for further care of her condition, but this process would take several more hours." The EDP documented Patient 1 and a family member elected to drive to the other hospital in a private vehicle. Prior to discharge from ED A, the record indicated Patient 1 received medications for pain, nausea, and anxiety and was discharged to the care of family on 6/16/13 at 2:11 p.m. Patient 1 reported at the time of discharge, she had a pain level of 8 on a 1-10 scale with 10 being the worst pain.

During an interview on 12/3/13 at 1:30 p.m. The EDP stated, Hospital B instructed Patient 1 to go to her nearest emergency department (emergency department A) for a "blood patch" (a procedure to correct leaking spinal fluid associated with a lumbar puncture) to relieve her headache. The EDP stated it was his practice to utilize an IR specialist to perform blood patches. The EDP stated at the time of Patient 1's visit he was under the impression there was no IR coverage. When asked regarding essential and non-essential on-call physician coverage, the EDP stated he was unaware there were two different categories for on-call physicians.

During an interview on 12/3/13 at 11 a.m., the ED medical director (EDMD) stated there was an interruption of IR coverage for nights and weekends from the end of May, 2013 to mid June, 2013. Although not sure, the EDMD stated he believed there was IR coverage during Patient 1's visit. The EDMD stated he informed the emergency department medical staff of restored IR coverage via an email, but was not sure if the EDP was aware of this. The EDMD further stated the emergency department had many on-call physicians, specialists, and sub-specialists. The EDMD categorized on-call physicians as either being essential (able to provide stabilizing treatment for individuals with emergency medical conditions) and non-essential (courtesy on-call).

During interviews with the chief executive officer (CEO) on 12/3/13 at 10:15 a.m., and 12/4/13 at 9 a.m., he explained the difference between contracted (essential) on-call coverage versus non-contracted (non-essential) on-call coverage. Contracted on-call coverage was always available to provide stabilization treatment to an individual with an emergent medical condition. Non-contracted on-call service was a courtesy service available to an ED patient if needed. The CEO stated IR coverage required for Patient 1's medical condition was a non-contracted service.

During an interview and record review on 12/3/13 at 9:30 a.m., the medical staff services consultant (MSSC) stated she was responsible for scheduling on call physician coverage for the ED. The MSSC provided a copy of the 6/2013 medical staff calendar coverage (form A) which indicated an IR would be available on-call for each day of the month, including the weekend of 6/15-6/16/13. The MSSC stated although form A indicated there would be IR ED coverage she had no way of validating if the ED had IR coverage for the said days.

Record review on 12/4/13 at 10:30 a.m. of the emergency department on-call schedule (form B) for 6/16/13 contained no information regarding IR on-call availability.

Record review on 12/4/13 at 10:20 a.m. of the Medical Staff General Rules and Regulation dated March 2013, indicated: "Each department/division of the Medical Staff,other than the Emergency Department, shall establish the criteria and maintain, by the procedure of its choice, a list of panel consultants that best meets the needs of the community and furnish the Emergency Department on at least a monthly basis a schedule of on-call panelists for consultation assumption of care, and/or referral of unassigned patients. The schedule must include the specific name of physician on-call (not the physician's group or practice name) and shall be available to the Emergency Department on on-call participants prior to it's implementation." The document further indicated "it is understood that occasionally a physician who practices within an under-represented specialty may be unavailable to respond to Emergency Department calls from this facility due to involvement in another case. In those instances it is the responsibility of that physician to ensure that (Hospital in question) emergency department is aware of his/her lack of availability so that the Hospital does not accept cases involving that specialty".

Record review on 12/4/13 at 10:45 a.m. of the hospital policy and procedure dated 2/10 regarding "Provision of On-Call Coverage" indicated "The hospital must maintain a list of physicians on its medical staff who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual receiving treatment for an emergency medical condition." Further review of the policy and procedure had no explanation regarding contracted versus non-contracted on-call services.

Based on interview and record review, the hospital failed to provide evidence the risk and benefits of a transfer were explained to a patient, and failed to provide evidence all reasonable steps were taken to obtain a written refusal by a patient for one of 30 sampled patients (1). Findings:

Patient 1 was admitted to Emergency Department A (ED A) on Sunday 6/16/13 at 1:08 p.m. with headache and neck pain following a lumbar puncture (LP, a diagnostic procedure where a needle is inserted into a fluid-filled space around the spinal cord of the lower back) done on 6/14/13 at another hospital (Hospital B).

Patient 1's record was reviewed on 12/2/13. The ED physician (EDP) documented Patient 1 required treatment by an Interventional Radiologist (IR, a specialist physician) who was unavailable at the hospital for the weekend. The EDP documented he recommended Patient 1 and a family member drive to another hospital for treatment. The record further indicated Patient 1's family member "was advised that the procedure needed for her (Patient 1) condition is unavailable at this time. He (Patient 1's family member) was offered to have his wife wait in the ER and we would attempt transfer back to (Hospital B) for further care of her condition, but this process would take several more hours." The EDP documented Patient 1 and a family member elected to drive to the other hospital in a private vehicle.

However, further review of the above note also indicated the following; Patient 1 was stable for discharge, but was instructed "to return to the (Hospital B) clinic, Physician, or emergency department where they may arrange for your procedure today". Follow-up instruction included for Patient 1 to "follow-up with your doctor (Hospital B) clinic, emergency room today even if well". Prior to discharge, Patient 1 received medications for pain, nausea, and anxiety and was discharged to the care of family on 6/16/13 at 2:11 p.m. Patient 1 reported at the time of discharge she had a pain level of 8 on a 1-10 scale with 10 being the worst pain.

During an interview on 11/15/13 at 10 a.m. Patient 1 stated she felt ill on 6/16/13 to the point where she could not walk. She stated after arriving at the ED, the physician told her the hospital could not provide the treatment she needed and advised her to go to a different hospital for treatment. Patient 1 stated the physician could arrange for an ambulance to transfer her to Hospital B, but it would take approximately six hours. Patient 1 stated she felt anxious at the prospect of making a trip to the other hospital, and her family member was frightened and angry at the prospect of driving her in a car when she was feeling so ill. Patient 1 stated she ended up going to the other hospital by private vehicle, where she was treated successfully without the use of an IR. Patient 1 stated she felt what happened prolonged the time it took her to get relief for her symptoms and was a bad experience for her and her family.

During an interview on 12/3/13 at 1:30 p.m. The EDP stated Hospital B instructed Patient 1 to go to her nearest emergency department (emergency department A) for a "blood patch" (a procedure to correct leaking spinal fluid associated with a lumbar puncture) to relieve her headache. The EDP stated he was unable to order treatment (blood patch) for Patient 1 due to the unavailability of IR coverage, and therefore suggested Patient 1 return to Hospital B.

During an interview on 12/3/13 at 11 a.m., the ED medical director (EDMD) stated there was an interruption of IR coverage for nights and weekends from the end of May, 2013 to mid June, 2013. Although not sure, the EDMD stated he believed there was IR coverage during Patient 1's visit. The EDMD stated he informed the emergency department medical staff of restored IR coverage via an email, but was not sure if the EDP was aware of this.

Review of the hospital's "EMTALA-California Transfer Policy" dated 2/13 indicated if an individual "refuses to consent to the hospital's offer to transfer" all reasonable steps would be taken to secure a written refusal... the medical record would contain the patient was informed of the risks and benefits and the reason for the individual's refusal to consent to the transfer.

Review of Patient 1's medical record on 12/4/13 at 2 p.m., had no indication Patient 1 was informed of the risks and benefits of the transfer, and the record lacked evidence the hospital took all reasonable steps to obtain a written refusal from the patient.