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Based on policy review, on-call physician schedule review, medical record review, and physician and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings included:

1. The hospital failed to ensure an on-call physician was available and responded to a call from the Dedicated Emergency Department requesting an on-call physician response to evaluate and treat a patient in the emergency department for 1 of 27 records reviewed (Patient #3)

~ Cross refer to On Call Physicians 489.20 (r)(2) and 489.24 (j)(1-2)- Tag A2404

2. The hospital failed to provide an appropriate transfer when an on-call physician failed to respond to the Emergency Department to evaluate a patient and the patient subsequently was transferred for 1 of 27 patients reviewed (Patient #3).

~ Cross refer to Appropriate Transfer 489.24 (e)(1)-(2) - Tag A2409

Based on policy review, on-call schedule review, medical record review and interviews, the hospital failed to ensure an on-call physician was available and responded to the Dedicated Emergency Department (DED) when the on-call physician was needed to evaluate a patient in the DED for 1 of 27 records reviewed (Patient #3)

The findings included:

Review of the policy "EMTALA Guidelines", date 09/2024, revealed "...(Name of Hospital) shall provide an on-call physician specialty list which includes all specialties privileged at the hospital.

Review of the "Rules and Regulations of the Bylaws", dated 08/2023, revealed "...Response time for on call physicians to provide emergency Medical Screening Exam or treatment will be a reasonable response time not to exceed 30 minutes. Response time is considered to be a telephone call or presenting to the department where the emergency is present. ..." An updated "Rules and Regulations of the Bylaws was effective 03/06/2025 and indicated the same "... Response time for on call physicians.... will be a reasonable response time not to exceed 30 minutes. ..."

Review of the on-call schedule for March 2025 showed MD #2 was on call 03/05/2025 when Patient #3 presented to the DED.

DED medical record review, on 06/11/2025, revealed Patient #3, a 66 year old, arrived to the DED 03/05/2025 at 2237 with a chief complaint of "Leg Injury." Review of the "Emergency Department Provider Note," date of service 03/05/2025 at 2326, revealed Patient #3 presented to the DED after a fall with left lower leg pain. The patient's past medical history included COPD (chronic obstructive pulmonary disease) and in DED was on 4 liters oxygen with oxygen saturations now in the "low 90s." Review revealed notable swelling and bruising to the "anterior tibial plateau" (flat top surface of tibia, bone in lower leg) with concern for a fracture. Further review of the Provider Note revealed "...ED Course Thu Mar 06, 2025 IMPRESSION: 1. Comminuted, angulated and impacted fracture (bone is broken in multiple pieces, at an angle, with one piece driven into another) of the proximal tibial diaphysis (shaft of tibia) 2. Comminuted, angulated and impacted fracture of the proximal fibular diaphysis (upper portion of shaft of fibula, bone in lower leg)... ." On 03/06/2025 at 0012 the Provider Note indicated "paging ortho" and at 0018 "Swelling progressive in LLE (left lower extremity).... now notable fullness. No pain out of proportion currently and NV (neurovascular) intact.... Potential developing compartment (emergency condition from pressure buildup caused by bleeding or swelling in the tissues). ..." At 0043, the documentation noted "repaging", at 0056 "Still awaiting call back from ortho", and at 0118 (1 hour, 6 minutes after the first page) "Will transfer given unable to reach ortho. Have attempted calling and paging. Supervisor aware and unable to reach as well...." Record review revealed the patient was accepted by a physician at Hospital B at 0138 with the note indicating "Dr. (Name) at (Hospital B) accepts. ..." The EMTALA Transfer Certification revealed the reason for transfer was "Qualified clinical personnel or service unavailable" and the certifying physician signed the certification 03/06/2025 at 0140. The transport team arrived at 0227 and Patient #3 departed Hospital A at 0228. No documentation was found to indicate the on-call physician ever responded.

Interview with the facility survey coordinator on 06/12/2025 at 1330 revealed MD #1, who did the MSE on Patient #3, was no longer on staff at this hospital.

Telephone interview with MD #2, an orthopedic surgeon, on 06/12/2025 at 1130, revealed MD #2 was on-call the night Patient #3 was in the ED (03/05-06/2025) but did not realize it at the time. Interview revealed "It was our mistake," stating an error was made on the office on-call schedule. Interview revealed that on the night in question, MD #2 was in clinic all day, left at the end of the day, went home feeling physically ill, took some medicine and went to sleep not realizing the physician was on call. Interview revealed the call schedule was completed 2-3 months in advance and added to the physicians' electronic calendars. Interview revealed the hospital on-call schedule was accurate to list MD #2, but MD #2 was not listed on the office on-call calendar which was used in creating the provider's calendars. Interview revealed the phone was not turned off but MD #2 went to sleep after taking the medicine and never heard the phone ring. MD #2 stated on-call had actually started at 0800 that morning but MD #2 got no calls during the day. If anyone had called earlier, the MD stated, the error would have been discovered while at work. Interview revealed "It was a perfect storm." There were no calls while in the office, then MD #2 went home, took medicine, went to sleep and did not hear the phone ring. MD #2 stated the orthopedic PA's (Physician Assistant) name and number had in the past also been on the call schedule, but at that time their names did not appear on it. Interview revealed "it was our fault." Interview revealed work was done afterwards and the calendar was changed where a PA phone number was now included. In addition, on-call schedules were now mounted on the wall and a new system was put in place where the schedule was double checked before it was posted to physicians calendars. A scheduler, a CMA (Certified Medical Assistant) and the Office Manager were all involved in ensuring that the on-call schedule posted to the physicians calendar was correct. Interview further revealed that MD #2 participated in the review after this incident occurred to determine how the error happened and prevent a future occurrence.

Interview with the ED Manager (Manager #3) on 06/12/2025 at 1340 revealed Manager #3 became aware of the issue when the incident ("Safe") report was completed. Interview further revealed the manager was not aware of any new incidents occurring after the RCA.

Telephone interview on 06/12/2025 at 1650 with Supervisor #4, the Patient Care Coordinator (PCC) who was on duty the night Pt #3 was in the ED, revealed the ED physician called Supervisor #4 to say the doctor could not get in contact with MD #2. Interview revealed Supervisor #4 called the Administrator-on-call to make them aware of the concern.

Interview with Administrator (Admin) #5 on 06/12/2025 at 1710 revealed Admin #5 was Administrator-on-call when this event occurred. Interview revealed the patient was safe, which was the most important issue at the time. In the morning, the follow-up began and a thorough review was done. Interview revealed Admin #5 was not aware of any reports of lack of on-call response since the incident in March involving Patient #3.

Based on review of Rules and Regulations, policy review, medical record review and staff and physician interviews, the hospital failed to provide an appropriate transfer when the on-call physician failed to respond to evaluate a patient and the patient subsequently was transferred for 1 of 27 patients reviewed (Patient #3).

The findings included:

Review of the "Rules and Regulations of the Bylaws", dated 08/2023, revealed "...Response time for on call physicians to provide emergency Medical Screening Exam or treatment will be a reasonable response time not to exceed 30 minutes. Response time is considered to be a telephone call or presenting to the department where the emergency is present. ..." An updated Rules and Regulations effective 03/06/2025 indicated the same, "...Response time for on call physicians....will be a reasonable response time not to exceed 30 minutes. ..."

Review of the "EMTALA Guidelines" policy, effective 09/2024, revealed "...(Hospital) may not transfer patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient. A transfer of a potentially unstable patient to another facility may only be for reason of medical necessity. ..."

Dedicated Emergency Department record review, on 06/11/2024, revealed Patient #3, a 66 year old, arrived to the DED 03/05/2025 at 2237 with a chief complaint of "Leg Injury." Review of the "Emergency Department Provider Note", date of service 03/05/2025 at 2326, revealed Patient #3 presented to the DED after a fall with left lower leg pain. Review revealed notable swelling and bruising to the "anterior tibial plateau" with concern for a fracture. Further review revealed tibia and fibula fractures. On 03/06/2025 at 0012, the Provider Note indicated "paging ortho" and at 0018 noted "Swelling progressive in LLE (left lower extremity).... now notable fullness. No pain out of proportion currently and NV (neurovascular) intact.... Potential developing compartment (emergency condition from pressure buildup caused by bleeding or swelling in the tissues). ..." The Provider Note revealed, at 0043, "repaging", at 0056 "Still awaiting call back from ortho", and at 0118 (1 hour, 6 minutes after the first page) "Will transfer given unable to reach ortho. Have attempted calling and paging. Supervisor aware and unable to reach as well. ..." At 0138, the Provider Note indicated "Dr. (Name) at (Hospital B) accepts. Clinical concern for developing compartment syndrome. Emergent transfer. ..." Further review revealed at 0151 the ED provider documented "Unable to get air (transport) given now weather conditions....reported snowing in (Location/city of Hospital B).... Patient leaving via ground (ambulance) given limited transport options. Understanding of plan and risk. ..." Review documented clinical impressions of "... Closed fracture of proximal end of left tibia....Closed fracture of proximal end of left fibula.... Traumatic compartment syndrome of left lower extremity... ." The EMTALA Transfer Certification revealed the reason for transfer was listed as "Qualified clinical personnel or service unavailable." The transport team arrived to the hospital at 0227 and Patient #3 departed Hospital A at 0228 for transfer to Hospital B.

Review of the Hospital B "ER Report" dated 03/06/2025 at 0506 revealed "...presents as a transfer.... secondary to left lower leg fractures and concern for swelling that could develop into compartment syndrome....Medical Decision Making.... Patient will be hospitalized at this time by Ortho team for further care.... Diagnosis/Disposition 1. Tibia Fracture 2. Fibula fracture 3. Fall 4. Generalized weakness... ." Review revealed Patient #3 was discharged from Hospital B on 03/12/2025.

Interview with the facility survey coordinator on 06/12/2025 at 1330 revealed MD #1, who performed the medical screening on Patient #3, was no longer on staff at Hospital A.

Telephone interview with MD #2, an orthopedic surgeon, revealed MD #2 was on-call the night Patient #3 was in the ED (03/05-06/2025) but did not realize it at the time. Interview revealed "It was our mistake," stating that an error was made on the office on-call schedule and MD #2's name did not appear on the MD's schedule that night. MD #2's name was on the hospital schedule, which was correct. Interview further revealed that on the night in question, MD #2 was in clinic all day, left at the end of the day, went home feeling physically ill, took some medicine and went to sleep, not knowing s/he was on call. Interview revealed MD #2 did not turn off the phone but went to sleep after taking medicine and never heard the phone ring.

Telephone interview on 06/12/2025 at 1650 with Supervisor #4, the Patient Care Coordinator (PCC) who was on duty the night Pt #3 was in the ED, revealed the ED physician called the supervisor to say the doctor could not get in contact with MD #2. Interview revealed Supervisor #4 called the Administrator-on-call to make them aware of the concern but did not recall what happened afterward.

Interview with Administrator (Admin) #5 on 06/12/2025 at 1710 revealed Admin #5 was the Administrator-on-call when this event occurred. Interview revealed the patient was safe which was the most important issue at the time. The next morning, interview revealed, follow-up began and a thorough review was done.

The medical record did not contain the name and address of the on-call physician who failed to appear to provide an evaluation and any necessary stabilizing treatment.