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HOMESTEAD HOSPITAL 975 BAPTIST WAY HOMESTEAD, FL 33033 July 12, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of medical records, medical Staff Rules and Regulations, On-Call coverage agreement, On-Call Schedules, and interviews, the facility failed to ensure that the consulting on-call physician (Urologist) that was available came to the emergency department when requested by the emergency department physician, to provide treatment necessary after the initial examination to stabilize an individual with an identified emergency medical condition for one (1) out of 20 sampled patients (SP) #1. 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 review of medical records, medical Staff Rules and Regulations, On-Call coverage agreement, On-Call Schedules, and interviews, the facility failed to ensure that the consulting on-call physician (Urologist) that was available came to the emergency department when requested by the emergency department physician, to provide treatment necessary after the initial examination to stabilize an individual with an identified emergency medical condition for one (1) out of 20 sampled patients (SP) #1.

The findings:

The "Medical Staff Rules and Regulations" state under Emergency Services, On-Call Responsibility of Physician Specialist On-Call. a. The physician must be available to respond, by telephone and/or in person as medically necessary and as deemed appropriate to the Emergency Department in a timely, cooperative, and responsive manner.

The "Medical Staff Rules and Regulations", also state under the "Provision of Appropriate Medical Screening Examination and Screening" If any individual comes to the Emergency Department of the Hospital and a request is made on behalf of the individual for an examination to treatment for an emergency medical condition the Hospital must provide for an appropriate "medical screening examination" within the capability of the Hospital's Emergency Department to determine whether an emergency medical condition exists.


Review of the " On-Call Coverage Agreement" showed under the " Physician's Duties and Qualifications 3.2 At all times during On-Call Periods, the physician shall generally respond by telephone to a page or telephone call regarding a request for services at the ED or for an inpatient within thirty(30) minutes of receipt of such page to telephone call, and thereafter, if necessary, to be present at the ED or the inpatient unit, ready to provide On-Call Coverage Services to patients, within a medically reasonable time-frame as determined through consultation between the ED or attending physician and the physician.


The hospital's On-Call schedules for Urology for the Period of April 2016 and May 2016 were reviewed. Review of the on-call schedules for April 30, 2016 and May 1, 2016 revealed that as of April 30, 2016 at 7:00 AM to May 1, 2016 7:00 AM Urologist A was on call when SP #1 was in the hospital's emergency department.






Record review of sampled patient (SP) #1 showed he was uninsured. He presented himself to the emergency department on 04/30/2016 at 23:35 PM with chief complaints of vomiting and epigastric pain. SP#1 has no medical or surgical history. He was medically screened, examined and evaluated by (Emergency Department) ED Physician A. The results of the Computer Tomography (CT) without contrast of the abdomen showed: a large heterogeneous left renal mass measuring at least 8.5 x 6.8 x 8.8 centimeters (cm) likely representing a renal cell [DIAGNOSES REDACTED]; marked neo-vascularity throughout the perinephric space causing marked dilation and tortuosity of the left renal vein and dilation of the inferior vena cava (IVC) and bilateral adrenal masses. The results of the findings were discussed by phone with ED Physician B and the radiologist on 5/1/2016 at 5:47 AM.

The ED provider notes also showed on 05/1/2016 at 06:48 AM that the [Urologist A- named] urologist was called. at 8:20 AM. The ED notes then showed the transfer center was called, the case was discussed and (the transfer center) states case need to be discussed with [Urologist A-named] on call urologist prior to transfer. At 8:26 AM (1 hour and 38 minutes) the case was discussed with the urologist on-call and (he) states agree with transfer because patient needs interventional radiology for diagnosis. At 8:29 AM, the transfer center was recalled and they will contact an urologist at the main [named] hospital (facility #3) or facility # 4. At 10:27 AM the transfer center called the urologist on call who refused to accept the transfer and states patient needs to be transfer to interventional radiology. When case was presented to the interventional radiologist, he was willing to consult but state needs to be accepted by an urologist. At 11:48 AM the ED provider notes further showed spoke to another physician (facility #5) who is not accepting the case. At 12:10 PM spoke to [name person] from yet another physician who will discuss case with his attending. At 12: 40 PM another physician establishes patient should be transferred to the facility #7. At 1:25 PM the patient was finally accepted by a physician at facility #2. The facility failed to ensure that Urologist A followed the hospital's Medical Staff Rules and Regulations as evidenced by failing to respond by telephone within 30 minutes regarding a request from the emergency department physician on 05/01/2016 for further evaluation for SP #1.

Review of SP #1 ED provider's notes showed disposition: transfer. The reason for transfer: After extensive discussion with different urologist at the [named hospital] within the hospital system, none feel competent to manage the case at their institution.
Record review of the Transfer Center notes dated 05/1/2016 showed that extensive efforts towards transfer arrangements of SP #1 was done. The sequence of the transfer arrangements showed: Facility #3, Facility #4, and Facility #5 with in the hospital system
1. Facility #3 was overcapacity;
2. Facility #4 urologist did not accept the pt.
3. Facility #5 urologist refused to accept the pt. because of the complexity of the case;
4. Facility #5 IVR does not perform kidney biopsy;
5. Finally the case was presented to Facility #2 and was accepted for transfer.
The inherent complexity of the medical condition requiring physician expertise among the facilities with IVR services was found to be a challenge at the time of the transfer.


Facility #1, 2, 4 and 5 are all a part of the same hospital health care system.

Interview with Urologist A on 5/24/2016 at 5:00 PM revealed SP# 1 case was discussed with ED Physician B and after discussions Urologist A determined that IVR is needed. According to him, this facility does not have an IVR; No angiography. He said he has no problem removing the kidney but pt. will need percutaneous angiography with IVR for biopsy. Pt. has multiple kidney nodules. A biopsy is needed to be done first. Pt had nothing acute at that time so no additional procedures are needed. However, during that time, it is in the best interest of the pt. to go to Facility # 2. Based on the CT result, the patient has complex condition. Comprehensive assessment like doing more diagnostic procedures will not help in this situation. Cardio-thoracic surgeon was not needed; pulmonary nodule, the adrenal masses are not the priority; it is the kidney. There was no documentation in the medical record to indicate that Urologist -A came to the emergency department when requested to provide further evaluation on SP#1 on 05/01/2016 who had an identified emergency medical condition.

Interview with ED Physician B on 5/24/2016 at 5 PM revealed that the pt. is in a subacute condition, no unstable vital signs and no acute vessel obstruction. We are not compromising the patient's condition. We did everything we could; services he needed we don't have here; patient needed a multidisciplinary team. I tried our own system, none of them agreed. It is a difficult case. He also added the facility system could not handle this case. The pt. had cancer (Ca) combined with dilatation of 2 vessels.

Interview regarding SP #1 with Registered Nurse (RN B), the Charge Nurse at that time, revealed that there was back and forth telephone communications with the Transfer Center (TC). She recalls one physician said could not do the procedure here because we do not do IVR procedure. She remembers the ED Physician B called the Transfer Center upon receiving the result of the CT. Priority level 3 which was assigned to pt. would be able to wait. She remembers escalating this issue with the Nursing supervisor.

Phone interview with the Nursing Supervisor on 5/25/2016 at 10:00 AM re: SP #1 revealed he remembers talking to RN B about the transfer request for this pt. Several urologists were called; that they continue to call. On my end I remember calling the TC (Transfer Center) myself. This was an infrequent situation. However, they were able to resolve the issue on their own and found a Medical Doctor from a facility who accepted the case.

Interview with AVP (Assistant Vice President) of Nursing on 7/12/16 at 11:35 AM confirmed above findings that there was a late response from the on call urologist (A) and this was referred to Medical Staff Quality for review which is scheduled for this month.