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KENDALL REGIONAL MEDICAL CENTER 11750 BIRD RD MIAMI, FL 33175 July 22, 2016
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
Based on reviews of medical records, Medical Staff Rules and Regulations, policies and procedures, on-call schedules, and interviews, the facility failed to follow its policies and Medical Staff Rules and Regulations to have an on-call physician respond via telephone and in person for an initial consultation for further medical examination and treatment within it capabilities for one (SP#1) out of 20 sampled patients, who had an identified ophthalmology emergency medical condition (EMC).

The Findings:

Review of the "Medical Staff Rules and Regulations" under Emergency Services, page 15, D. show that telephone communication with ED must be established within 30 minutes of notification, ED personnel will contact the physician/practitioner twice during the 30-minute period. If unable to communicate with the physician/practitioner within the allotted period of time, the next physician on the call schedule in that specialty shall be contacted. The facility failed to adhere to their "Medical Staff Rules and Regulations".


The facility's policy and procedure titled, "EMTALA-Florida Provision of On- Call Coverage Policy, Original Date: 2/09, reviewed/revised date 02/16 was reviewed. The policy specified in part, "Purpose: To establish guidelines for the hospital, including a specialty hospital, and its personnel to be prospectively aware of which physicians, including specialists and sub-specialists are available to provide additional medical evaluation and treatment to individuals ...Policy: The hospital must maintain a list of physician on its medical staff who have privileges at the hospital ...Physicians on the list must be available after the initial examination to provide treatment to relieve or eliminate EMCs (emergency medical conditions) to individuals who are receiving services in accordance with the resources available to the hospital ...Physician Responsibility: The hospital has a process to ensure that when a physician is identified as being "on-call" to the ED for a given specialty, it shall be that physician's responsibility to assure the following: ...1. Immediate availability, at least by phone, to the DED physician for his or her scheduled "on-call" period ...3 Arrival or response time to the DED within 30 minutes ...4. The on-call physician has a responsibility to provide specialty care services as needed to any individual with an EMC who requests emergency services and case either as an initial presentation or upon transfer ...Physician Appearance Requirements: ...If a physician is listed as on-call and requested to make an in-person appearance to evaluate and treat an individual, that physician must respond in person within 30 minutes."

The hospital's On-Call Ophthalmology May 2016 on -call schedule was reviewed. The on-call schedule validated that MD-D was the ophthalmologist on call on 5/12/2016 when SP#1 presented to the ED with complaints of blurry vision to the right eye.


On 05/12/16 at 11:23 AM Sample Patient (SP) #1 presented to ED (Emergency Department) with chief complaints of sore throat for 2 days and blurry vision to the right eye the morning of coming to the ED.

Review of SP#1 the Emergency Provider Report: Consultation date 5/12/16 revealed:
At 11:58 AM -a requested call time for consultation with the ophthalmologist MD-D was made
At 1:24 PM (one hour and 22 minutes later) the call was returned by Ophthalmology MD-D regarding the consult and recommended that pt. should go to Facility #2 for a retinal specialist as he is not able to do anything related with the retina.
At 2:16 PM and again at 2:29 PM a requested call for Ophthalmologist MD-D was made for consultation
At 2:39 PM call was returned by the tech (technician) from the ophthalmologist MD-D to inform that the doctor will call in 10 minutes. After speaking with the Ophthalmologist MD-D , he again stated that the pt. needs to be transferred to another facility as he is not able to do surgery related to the retina.
At 7:31 PM called in [named ophthalmologist MD-D] who is coming into seeing the pt prior to transfer to receiving facility. I discussed the case with the incoming MD who is aware of the plan for the ophtho (ophthalmologist) consult and possible transfer if higher level of care is necessary.
At 7:59 PM other requested call time was made and was responded to at 7:59 PM by the ophthalmologist MD-D who stated that he will see the patient, the receiving facility will not want the transfer without our ophathos (ophthalmologist ) evaluation. Dr. [named] MD-D is coming in now to evaluate.

Review of the Consultation Report of Ophthalmologist MD-D dated 05/12/16 and dictated at 9:02 PM revealed that SP#1 came to ED due to painless right eye loss of vision that occurred the morning pt. presented to ED. Physical Examination revealed that SP#1 with counting fingers was found to have a visual acuity of 20/30 to the right eye. Pupils were dilated and evaluation of the retina demonstrated areas of bleeding in the peripheral retina of the right eye. The left eye had areas of bleeding but did not affect the patient's center vision. Recommendations and plan include transferring the pt. to another facility for evaluation of a retinal specialist that could determine whether surgery or observation is needed. The facility failed to ensure that their policy and procedure were followed as evidenced by failing to ensure that the on-call ophthalmologist responded telephonically within 30 minutes as stated in the policy and the Medical Staff Rules and Regulations.

Review of the Emergency Patient Records: Patient Notes dated 5/12/16 authored by nurse, showed that SP #1 was transported at 11:37 PM via ambulance in a stable condition to the receiving facility.

Phone interview on 7/8/16 at 8:48 AM with Vice President of Quality and the Ophthalmologist MD-D was conducted and the Ophthalmologist stated as an on-call physician, I try to call back as quickly as I can. If I am with a patient, I call back as quickly as I can. I don't have a time frame to get there, but I respond as quickly as I can and possibly and when traffic permits. The hospital also failed to ensure that the on call ophthalmologist came to the hospital in person within 30 minutes, as per the hospital's policy and procedure after a request was made by the ED physician to come and evaluate SP#1 on 5/12/2016 prior to transfer. The delay in examining SP #1 on 5/12/2016 was inappropriate, the patient waited up to 9 hours for an examination by the on-call ophthalmologist.


Interview with the Medical Director of ED on 07/7/16 at 11:00 am revealed Consultation is done at the ED by an ED physician if he/she cannot handle this type of the pt. condition. The on-call physician is called, and both the ED physician discuss the case and plans together and the care of the patient. Depending on the discussion between the ED physician and the on-call, it may or may not require the on-call physician to come in and evaluate the pt. The two plan collaboratively and come to a decision together. The on-call can give direction on the phone. If it is a life and limb or eye threatening emergency, time is of essence. It is based on the decision together by the 2 practitioners and depending on the case, may demand for the on-call to come in and evaluate the pt. and provide appropriate management; or it can be done over the phone. For a case that requires stabilization, the ED care could start the correction so the likelihood of deterioration of transfer may not occur. It is a case by case basis, based on the clinical decision and judgment of the physician, and of the patient presentation. On-call physicians are expected to call back within 30 minutes, otherwise, the nursing supervisor is called and the administrator to intervene.
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record review and interview, the facility failed to have an on-call physician available within 30 minutes through a medical staff call roster for initial consultation for further medical examination and treatment within it capabilities for 1 (SP#1) out of 20 sampled patients.
(Refer to 2404)