HospitalInspections.org

Walker Baptist Medical Center (Hospital # 1) was not in compliance with the Federal Requirements at 42 CFR 489.24 and related provisions of CFR 42 CFR 489.20 Responsibilities of Medicare Participating Hospitals in Emergency Cases on 2/13/13.


Based on interviews, record reviews, review of the Medical Staff Rules and Regulations, Walker Baptist "Scope of Care and Services" unattached Gynecology (GYN) On Call physicians' schedules, review of ED (Emergency Department) and EMTALA policies and procedures, Hospital 1 failed to:

A. Ensure that unattached GYN "On Call" physicians admitted patients who needed further evaluation and treatment to stabilize the patient's emergency medical condition (EMC) as determined by the emergency department (ED) Physician for one ED patient. Refer to Findings under A2404.

B. Provide stabilizing treatment for an EMC for an unattached GYN patient that was within the capability and capacity of the facility. Refer to Findings under A2407.

C. Prevent the inappropriate transfer of a patient requiring further evaluation and treatment to stabilize their EMC as determined by the ED Physician to another facility (Hospital # 2) while Hospital # 1 had the capacity and capability to provide the necessary services for Patient Identifier (PI) #7 on 2/13/13. Refer to Findings under A2409.


This deficient practice effected PI #7, one of twenty-one (21) ED sampled patients and had the potential of effecting other patients who presented to Hospital #1's emergency department.

Based on interviews, medical record reviews, review of the Rules and Regulations of the Medical Staff, and OB/GYN (Obstetrics and Gynecology) "On Call" physicians' and the Administrative On-Call schedules, it was determined Hospital #1 failed to ensure that their written Rules and Regulations of the Medical Staff policy related to unattached patients seen in the emergency department was followed to meet the needs of the hospital's patients who are receiving services as required, including the availability of on-call physicians, for 1 of 21 sampled patients (SP #7). It was also determined that the hospital failed to ensure that the GYN/OB on-call physician provided needed further evaluation and treatment to stabilize PI#&7 on 2/13/2013 emergency medical condition(EMC) as determined by the emergency department (ED) physician. This had the potential to affect other unattached OB/ GYN patients who needed OB/GYN services.


The findings include:

1. MEDICAL STAFF RULES & REGULATIONS
(Hospital # 1) Medical Staff Rules and Regulations 2012 included the following information.

A. Admission and Discharge of Patients
2. A patient may be admitted to the Hospital only by a member of the Medical Staff with Approved privileges...

E. Emergency Department Services
1. Responsibility for on call coverage for unattached patients seen in the Hospital Emergency Department and admitted to the Hospital will be assigned to Active Staff physicians on a rotating basis with the exception of physicians over 60 years of age... Members of the Active Staff will be responsible for on call coverage for each service in which they have privileges.

2. Specialty Physician On-Call and Administrative On-call Schedules (AOC)

February 2013

The hospital's on-call schedule for February 2013 was reviewed. Employee Identifier (EI) # 7, On Call OB/GYN Physician was listed as being "On Call" on February 7, 8, 9, 10, 11, 13, 14, 20, and 25th. Further review of the on-call schedule only listed physician's names, there was no distinction/difference as to whether the physicians were on call for attached or unattached patients.

Review of the AOC revealed EI # 4, the Director of Physician and Community Services, was the Administration "On Call" for 2/13/13.


3. REVIEW OF PI #7's ED RECORD & INTERVIEWS

PI# 7 presented to Hospital (H) # 1 on 2/13/13 at 12:08 PM, with Abdominal Pain.

The ED Physician, EI # 5, ordered a Computerized Tomography (CT - a method of examining body organs by scanning with x-rays using a computer) of the Abdomen and Pelvis without contrast at 12:14 PM. The CT was read at 2:27 PM.

The ED medical record (MR) contained documentation, "ED Interpretation- Large amount of hemorrhage (excessive discharge of blood from blood vessels; profuse bleeding) in pelvis, likely arising from a ruptured ovarian cyst, likely of the right."

EI # 6, ED Unit Secretary, documented a call to EI # 7, OB/GYN "On- Call" physician, at 2:28 PM.

EI # 5, ER Physician, documented, "I discussed ... radiographic results, as well as ED interventions and our preliminary working diagnosis with (EI # 7), who does not agree to accept the patient as they (EI# 7) are unattached 2:32 PM. Wants an ultrasound to be done. Ask to call (other GYN) ... discussed ... with (other GYN) nurse, who states doctor is out of town. House supervisor and AOC (Administrator on Call) notified at 2:52 PM ... The OB/GYN on call at (H # 2), who has agreed to accept the patient 3:41 PM. Patient requires transfer to another hospital, (H # 2), because of a higher level of care than we can accommodate at this hospital. This higher level of care includes OB/GYN readily available for possible operative intervention. At 4:38, (accepting physician), wants patient transferred by air instead of ground ... Patient transferred 17:17 (5:17 PM)."

PI # 7 presented to Hospital # 2 at 5:39 PM.

Hospital # 2's accepting physician progress notes dated 2/13/13 at 5:45 PM:

"Acute onset abdominal pain at 10 AM today. Pt started having some cramping at 6 AM, but extreme pain started at 9:45 (AM) when pt (patient) went to ER (emergency room - WBMC). Pt notes movement makes pain worse, rest makes better. Pain is burning. 10/10 before pain meds ... In ER at (hospital # 1 - WBMC), CT scan performed (with) hemoperitoneum (the presence of an accumulation of blood in the abdominal cavity due to internal bleeding) noted. Pt's vital signs stable there but asked to transfer pt due to large amount of blood in abdomen ...Discussed Diagnostic Lap (Laparoscopy - surgical procedure allows visual examination of the inside of the abdominal cavity) ... need to clean out abdomen to improve pt's pain ... Based on peritoneal signs s/p (status post) pain meds will need emergent OR (operating room). Discussed this with pt as well as risk/benefits.

Preoperative Diagnosis: Hemoperitoneum

Procedures Performed:
1. Diagnostic Laparoscopy.
2. Removal of blood.
3. Cautery of ovarian cyst on the right side.
Findings: Hemoperitoneum, right ovarian cyst rupture with acute bleeding."

PI # 7 was discharged on 2/14/13 at 9:31 AM.

INTERVIEWS
EI # 5 (ER Physician on 2/13/13 at Hospital # 1) was interviewed on 3/7/13 at 9:05 AM., and stated (EI# 7) was "On Call" on 2/13/13. When the patient (PI # 7) came to the ER on 2/13/13 with a "Ruptured Hemorrhagic cyst". (EI # 7) was called and when he responded he would not accept the patient because he was over age and he would not be taking unattached call. EI # 5 stated he called the Administrator "On Call" and was instructed to transfer the patient because no GYN coverage.

EI # 7 (On Call GYN for 2/13/13 at Hospital # 1) was interviewed on 3/7/13 at 8:00 AM., and stated he did not accept (PI # 7) because he had sent a Memo to the hospital administration on December 7, 2009, "As of 12/31/2009 I would appreciate my name being removed from the Drop-In Call Schedule. At my age I have the option to discontinue emergency room's calls." When asked what he had done to remove his name from the OB/GYN list and EI # 7 responded, "I told them multiple times when they called me. I tell them I don't take unattached (patients). EI # 7 was asked how his name continued to appear on the On Call schedule for ER he stated I put myself down to see the ER patients for my practice and the other 2 GYN's in town. When ask if he put himself on the unattached GYN ER schedule he stated he had never seen an unattached GYN ER schedule." Walker Baptist Medical Center (WBMC) failed to ensure that the on-call GYN physician listed on the OB/GYN call schedule came to the ED, when he/she was notified by the ED physician that PI #7 required further evaluation and/or treatment necessary to stabilize this patient's emergency medical condition on 2/13/2013.

EI # 4 (Administration On-Call on 2/13/13 at Hospital # 1) was interviewed on 3/7/13 at 9:40 AM. She stated she had received a call from EI # 5, the ED Physician, on 2/13/13 related to EI # 7 not taking a GYN patient. EI # 4 stated she instructed to transfer because the hospital was without GYN coverage. EI # 4 was asked how the person responsible for the ON Call schedule was made aware of any changes by physicians. EI # 4 stated the physicians are the people who fill out the schedules for their specialties. The physicians send the schedules to administration and the schedules are mark revised and dated and distributed to the ER and other departments. When asked why EI # 7 (GYN) continued to be placed on the On Call schedule after he had sent the memo back in 2009. EI # 4 stated EI #7 placed himself on the schedule. No one in Administration puts the physicians on the On Call schedules. This interview verified that the facility failed to ensure that their Rules and Regulations of the Medical Staff was followed as evidenced by failing to have an GYN on-call coverage for unattached patients seen in the ED be assigned to specialty physicians (GYN) on a rotating basis with Medical Staff with the exception of physicians over 60 years of age (EI#7) as stated in the Rules and Regulations of the Medical Staff.

Based on interviews, medical record reviews, review of the Medical Staff Rules and Regulations, Walker Baptist "Scope of Care and Services" and OB/GYN (Obstetrics and Gynecology) "On Call" physicians' schedules, it was determined Hospital #1 failed to provide stabilizing treatment for an unattached GYN patient, patient identifier (PI) #7 on 2/13/13. PI # 7 needed further evaluation and treatment to stabilize the patient's emergency medical condition (EMC), which was within the capability and capacity of the facility. This had the potential to affect other unattached GYN patients who needed GYN services.

The findings include:

1. Walker Baptist Scope of Care and Services 2011-2012

Emergency Center
Scope of Service: ...For individuals that visit Walker Baptist Department and it is determined that a medical emergency condition exists, the facility provide services within the capabilities of the Emergency Room Staff, Physicians and services available at the hospital. Walker Baptist provides stabilizing treatment within its capability and capacity. This includes space, equipment, supplies and on-call services as psychiatry, surgery, obstetrics, pediatrics, intensive care and orthopedics. This capacity and capability includes the measures Walker Baptist may take to meet the needs of the patient as addressing occupancy limits, disaster events resulting in ED capacity, or has exhausted all resources available for the patient's health status....

There will be a stabilization of a patient's condition prior to transfer from the Emergency Department in order that no decline of the patient's condition may occur. If Walker Baptist is unable to stabilize an individual within its capability and capacity, and has exhausted all efforts, an appropriate transfer will be implements at the determination of the treating physician...


2. SPECIALTY PHYSICIAN ON CALL SCHEDULE

February 2013

Employee Identifier (EI) # 7, On Call OB/GYN Physician was "On Call" February 13, 2013.



3. REVIEW OF PI #7's ED RECORD & INTERVIEWS

PI# 7 presented to Hospital (H) # 1 on 2/13/13 at 12:08 PM, with Abdominal Pain. The ED Physician, EI # 5, ordered a Computerized Tomography (CT) of the Abdomen and Pelvis without contrast at 12:14 PM. The CT was read at 2:27 PM. The ED medical record (MR) contained documentation, "ED Interpretation- Large amount of hemorrhage in pelvis, likely arising from a ruptured ovarian cyst, likely of the right."

EI # 5, ER Physician, documented, "I discussed ... radiographic results, as well as ED interventions and our preliminary working diagnosis with (EI # 7), who does not agree to accept the patient as they (EI# 7) are unattached 2:32 PM. Wants an ultrasound to be done. Ask to call (other GYN) ... discussed ... with (other GYN) nurse, who states doctor is out of town. .. The OB/GYN on call at (H # 2), who has agreed to accept the patient 3:41 PM. Patient requires transfer to another hospital, (H # 2), because of a higher level of care than we can accommodate at this hospital. This higher level of care includes OB/GYN readily available for possible operative intervention.

Review of PI # 7's medical record from Hospital # 2 revealed, PI # 7 presented to Hospital # 2 at 5:39 PM. ..Hospital # 2's accepting physician progress notes dated 2/13/13 at 5:45 PM;... Based on peritoneal signs s/p (status post) pain meds will need emergent OR (operating room). Preoperative Diagnosis: Hemoperitoneum: Procedures Performed: 1. Diagnostic Laparoscopy; 2. Removal of blood; 3. Cautery of ovarian cyst on the right side. Findings: Hemoperitoneum, right ovarian cyst rupture with Acute bleeding."


INTERVIEWS
EI # 5 (ER Physician on 2/13/13 at Hospital # 1) was interviewed on 3/7/13 at 9:05 AM., and stated (EI# 7) was "On Call" on 2/13/13. When the patient (PI # 7) came to the ER on 2/13/13 with a "Ruptured Hemorrhagic cyst". (EI # 7) was called and when he responded he would not accept the patient because he was over age and he would not be taking unattached call.

EI # 7 (On Call GYN for 2/13/13 at Hospital # 1) was interviewed on 3/7/13 at 8:00 AM., and stated he did not accept (PI # 7) because he had sent a Memo to the hospital administration on December 7, 2009, "As of 12/31/2009 I would appreciate my name being removed from the Drop-In Call Schedule. At my age I have the option to discontinue emergency room's calls." When asked what he had done to remove his name from the OB/GYN list and EI # 7 responded, "I told them multiple times when they called me. I tell them I don't take unattached (patients).
The facility failed to ensure that further medical examination and treatment that was within the capability and capacity available at the hospital was provided as required to stabilize an identified emergency medical condition (acute abdominal bleeding) for PI#7 on 2/13/2013.
The facility also failed to ensure that their Scope of Care and Services plan was followed for provision of patient care for PI # 7 as this resulted in delay of care for PI#7 on 2/13/2013, who required definitive treatment for an EMC.

Based on interviews, record reviews, review of the Physician Education review of ED (Emergency Department) and EMTALA policies and procedures, and interviews, Hospital #1 failed to prevent the inappropriate transfer of patients requiring further evaluation and treatment to stabilize their EMC (emergency medical condition) as determined by the ED Physician to another facility (Hospital # 2) while Hospital # 1 had the capacity and capability to provide the necessary services for Patient Identifier (PI) #7. This deficient practice affected PI #7 one of twenty-one (21) ED sampled patients and had the potential of affecting other patients who presented to Hospital # 1's emergency department with GYN emergencies.


The findings include:

1. ED EMTALA POLICIES AND PROCEDURES

Policies and procedures for the ED were presented. The "Transfer of Patient Policy number: WLK_ ED036" Revised October 29, 2012 states the following:
Procedure:
1. Transferring from (Hospital # 1) to another facility:
If a patient presents with an emergency medical condition that cannot be stabilized or definitive care cannot be given due to the resources of the facility, the transfer process is implemented...



2. MEDICAL RECORD REVIEWS FROM HOSPITAL #1 AND #2.

PI #7 presented to Hospital # 1's ED on 2/13/2013, with complaints of severe abdominal pain. The ED Physician, Employee Identifier (EI) #5 determined that PI # 7 needed to be admitted to Hospital # 1 for further evaluation and treatment to stabilize PI #7's EMC of Hemoperitoneum. EI # 5 presented PI #7 to EI #7 (On Call GYN) for admission to Hospital # 1. EI #7(GYN) stated he would not admit PI # 7 as he was over 60 and had informed administration he would not take unattached GYN cases. PI #7 was then transferred on 2/13/13 to Hospital # 2 to receive further evaluation and treatment necessary for stabilizing of the patient's EMC, and was taken emergently surgery. Walker Baptist Hospital failed to ensure that their transfer policy was followed as evidenced by' on 2/13/2013 the facility had the (resources) capability (there was physical space, equipment, supplies and specialized services (GYN), the hospital provides; and capability (level of care that he personnel of the hospital can provide within the training and scope of their professional licenses. This includes the coverage available through the hospital on-call roster), to stabilize and/or provide definitive care for PI #7.

INTERVIEWS
EI # 5 (ER Physician on 2/13/13 at Hospital # 1) was interviewed on 3/7/13 at 9:05 AM., and stated (EI# 7) was "On Call" on 2/13/13. When patient (PI # 7) came to the ER on 2/13/13 with a "Ruptured Hemorrhagic cyst", (EI # 7) was called and when he responded he would not accept the patient because he was over age and he would not be taking unattached call. EI # 5 stated he called the Administrator "On Call" and was instructed to transfer the patient because no GYN coverage.

EI # 7 (On Call GYN for 2/13/13 at Hospital # 1) was interviewed on 3/7/13 at 8:00 AM., and stated he did not accept (PI # 7) because he had sent a Memo to the hospital administration on December 7, 2009, "As of 12/31/2009 I would appreciate my name being removed from the Drop-In Call Schedule. At my age I have the option to discontinue emergency room's calls." When asked what he had done to remove his name from the OB/GYN list and EI # 7 responded, "I told them multiple times when they called me. I tell them I don't take unattached (patients)." EI # 7 was asked how his name continued to appear on the On Call schedule for ER he stated I put myself down to see the ER patients for my practice and the other 2 GYN's in town. When ask if he put himself on the unattached GYN ER schedule he stated he had never seen an unattached GYN ER schedule.

EI # 4 (Administration On-Call on 2/13/13 at Hospital # 1) was interviewed on 3/7/13 at 9:40 AM. She stated she had received a call from EI # 5, the ED Physician, on 2/13/13 related to EI # 7 not taking a GYN patient. EI # 4 stated she instructed to transfer because the hospital was without GYN coverage.

These citations were written as the result of the investigation of complaint/report AL00028563.