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NORTH SHORE MEDICAL CENTER 1100 NW 95TH ST MIAMI, FL 33150 Feb. 11, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on reviews of medical records, Medical Staff Rules and Regulations, policies and procedures, Urology on-call schedules, Medical staff roster, Delineation of Privileges, Hospital License and interviews the hospital failed to ensure that the on-call lists of physicians who are on the hospital medical staff who have privilege at the hospital are available to provide treatment necessary after the initial examination to stabilize individuals with an emergency medical condition for 1 of 11 patients. Refer to findings in Tag A-2404.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on reviews of medical records, Medical Staff Rules and Regulations, policies and procedures, Urology on-call schedules, Medical staff roster, Delineation of Privileges, Hospital License and interviews the hospital failed to ensure that the on-call lists of physicians who are on the hospital medical staff who have privilege at the hospital are available to provide treatment necessary after the initial examination to stabilize individuals with an emergency medical condition for 1 of 11 patients.
The findings are:
Review of the facility's hospital license showed that urology services were provided in the Emergency Department.

Review of the medical staff bylaws titled, "Rules and Regulation of the Medical Staff," approved 12/14, showed that when the call is placed from the ER (emergency room ) for consultation, the physician on call for the ER is the one responsible to come in. The physician immediately following the one on-call shall be considered second on-call. The physician on second call has a responsibility for response and coverage to that of the first. If the physician does not answer his call within 30 minutes, the physician on second call may be contacted. The bylaws also showed that ER on-call coverage is mandatory for urology physicians.

Review of the facility's policy titled," EMTALA," effective date 11/13/14, showed that the hospital will maintain a list of physicians from its medical staff who are on call for duty after the medical screening examination to provide further medical examination and treatment necessary to stabilize individuals who have been found to have an emergency medical condition. The policy also stated that if the physician on the on-call list is called by the emergency department to provide emergency screening or treatment, if the physician refuses or fails to arrive within the required response time the chain of command should be initiated in an effort to obtain treatment for the emergency patient.
Review of the hospital's Medical Staff Roster showed that there were seven urologists on staff.

Review of Urology ER on-call schedule showed that Urologist #1 was on call from January 12-18, 2015. The ER call schedule showed that Urologist #2 was on call for January 19-25, 2015. The Urology ER call schedule stated, the physician following the physician On-call will be considered second On-Call.

Review of Urologist #1 Delineation of Privileges (DOP) showed that he did not request privileges in [DIAGNOSES REDACTED] operation (corpora cavernosa and saphenous vein shunt) and was not approved by the Governing Body for this procedure.

Review of Urologist #2 thru #7 showed that all six urologists had approved privileges, at this facility, to perform [DIAGNOSES REDACTED] operation (corpora cavernosa and saphenous vein shunt).

Review of Sampled Patient (SP)#1 medical record showed that on 01/18/15, the patient walked into the Emergency Department (ED) complaining of penile pain. The ED physician ' s Physical examination was reviewed. The physical examination revealed in part, " male external genitalia positive erection ...10:07 medically screened ...10:50 diagnosis is [DIAGNOSES REDACTED]. " Review of physician orders on 01/18/15 at 10:16 AM showed a consult order for surgery- urological was written for Urologist #1. The ED Physician notes on 01/18/15 at 10:48 AM stated, the case was d/w (discussed with)[name of Urologist #1]-since pt (patient) has had symptoms x 3 ( times three) days-he will require surgical treatment which he doesn't perform-he recommends transfer to [name of Hospital #2] for higher level of care-he doesn't believe attempting aspiration will be of any benefit given the prolonged time of erection. The ED Physician notes on 01/18/15 at 12:43 PM stated, Spoke with [name of Urologist #3]-he is unable to treat pt in timely fashion. The notes further stated that the R.N. (Registered Nurse) Supervisor asked that we attempt to contact another GU MD (Genu-Urologist Medical Doctor) on staff to see if they will perform procedure before transferring patient -will contact another GU MD but will not wait longer than 30 minutes, otherwise will proceed with transfer for definitive treatment. The ED physician notes further stated- spoke with [Named physician] , he hasn't been on staff X 1 (times one) year. The notes at 1:06 PM then showed that Urologist #1 was out of town and unavailable to come to the ED. . (Per an Interview with the compliance officer on 01/27/15, she stated that this statement was an error as it was Urologist #4 who was out of town, per the facility ' s review). The record then showed that the patient was transferred to Hospital #2 on 01/18/15 at 2:24 PM.

Review of sampled patient #1 ED physician notes from Hospital #2 reported that the patient presented with [DIAGNOSES REDACTED]. Patient transferred from Hospital #1. The GU ( genu-urologist) consultation notes dated 01/18/2015 also reported that a irrigation and drainage of [DIAGNOSES REDACTED] was performed. The notes further stated that the plan is to monitor the patient in the emergency department for 2-4 hours and if resolved, patient may be discharged .

On 01/27/15 at 11:32 AM, Staff A, Registered Nurse (RN), stated that urology services are provided at this facility. On 01/27/15 at 1:46 PM, Staff A stated that she cared for SP#1. She stated that he (SP#1) had this condition lasting three days and was assessed by the ED physician. However, because of the three day window, the patient 's condition was determined by the physicians, to be difficult to treat and he was transferred because there was nothing the facility could do. She stated that the patient was transferred to Hospital #2.

On 01/27/15 at 1:56 PM, Urologist #1 stated that he was called for SP#1. He stated that from his experience, there was no way of draining it. He stated that the patient's condition needed surgical correction and that he was not trained in doing surgical procedures for [DIAGNOSES REDACTED]. Urologist #1 also stated that surgical correction of [DIAGNOSES REDACTED] would require draining areas to get the blood out. He stated that he does not know if other urologists were consulted to perform the procedure. He stated that the patient was sent to Hospital #2 because it is a university and they have a training program there. The urologist stated that he was available to come to the ED. However, he did not come because he knew that he could not perform the procedure the patient needed. He stated that if he had come to the ED, he would have had minimal chance of success with SP#1. The facility failed to ensure that the Medical staff Rules and Regulations were followed as evidenced by failing to ensure the on call Urologist came to the ED when requested by the ED physician ;to provide further evaluation and treatment after the initial examination for SP#1 on 1/18/2015 after it was determined the patient had an identified emergency medical condition.

On 01/27/15 at 2:20 PM, the ED physician (for SP#1) stated that he called four urologist and they were either unavailable or did not do the procedure. The ED physician then stated that SP#1 was transferred because the urologist (Urologist #1)recommended it.

On 01/27/15 at 2:34 PM, the Nursing Supervisor stated that if the on call physician is unable to perform care for a patient, normally all the physicians in the particular specialty would be called until someone answers. She stated that urology service is provided at this facility.

On 01/27/15 at 4:15 PM, the Compliance Officer stated that if the physician on call is not privileged in a particular care area, the second call would be to the on call physician for the following week.
In SP#1's case, the second call should have been made to Urologist #2.