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FAWCETT MEMORIAL HOSPITAL 21298 OLEAN BLVD PORT CHARLOTTE, FL 33952 Jan. 24, 2013
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on reviews of medical records, policies and procedures, Medical Staff By-Laws and Rules, emergency services agreements, emergency room (ER) physician schedules and staff and physician interviews, the facility failed to comply with 42 Code of Federal Regulations (CFR) 489.24, special responsibilities of Medicare hospitals in emergency cases. The facility's on-call surgeon refused to provide necessary stabilizing treatment requested by the ER physician in preparation for an appropriate transfer.

The findings include:

Fawcett Memorial Hospital has been certified to accept Medicare patients. As a Medicare provider the facility has agreed to comply with 42 CFR 489.24. As part of the agreement the facility must have on-call services available to provide treatment necessary after the initial examination to stabilize individuals with emergency medical conditions.
Review of the medical record for Patient #2 shows the patient (MDS) dated [DATE] at 10:45 p.m. The patient had a gunshot wound to the abdomen and was determined to be a Priority 1 - in urgent need of care. A bedside ultrasound was done and fluid was seen in the right and left upper quadrant (upper areas) of the abdomen. The ER physician documented that he immediately called the on-call surgeon. The on-call surgeon refused to come to the hospital and treat the patient. After the on-call surgeon repeatedly refused to come in to the hospital, the treating emergency physician transferred the patient to a trauma center (see A-2404) without the requested surgical attendance. The repeated requests for and refusal of the on-call surgeon resulted in a delayed stabilizing decisions prior to transferring the patient for necessary treatment.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
Based on reviews of medical records, policies and procedures, Medical Staff By-Laws and Rules, Emergency Services agreements, emergency room Physician schedules and staff and physician interviews, the facility failed to ensure that one (Patient #2) of 30 patients was provided a physical evaluation for surgical intervention at the request of the treating emergency physician.

The findings include:

Review of the medical record for Patient #2 shows the patient presented to the emergency room (ER) on 12/31/12 at 10:45 p.m. The patient had a gunshot wound to the abdomen and was determined to be a Priority 1 - in urgent need of care. A bedside ultrasound was done and fluid was seen in the right and left upper quadrant (upper areas) of the abdomen. The ER physician documented that he immediately called the on-call surgeon. The on-call surgeon refused to come to the hospital and treat the patient. When the ER physician explained this was a potentially unstable patient that needed to be taken to the operating room (OR) immediately, the on-call surgeon again refused to come in to the hospital and said the patient needed to be transferred to a trauma hospital. The ER physician called a hospital in Tampa which had a trauma unit and he spoke to a physician there. The ER physician documented his conversation with the physician in Tampa as "Pt continued stable vital signs, no tachycardia, and no hypotension. Results discussed. Given that blood identified on bedside ultrasound, he did not feel that the patient was stable to fly."

The ER physician placed another call to the on-call surgeon who continued to refuse to come to the ED and see the patient. After the patient had a CT scan, which showed bullet fragments in the rear left flank (side) of the abdomen, the ER physician called a trauma surgeon at a designated trauma unit in Fort Myers, Florida. This trauma unit is approximately 30 miles from the hospital. After the ER physician spoke to the trauma surgeon in Fort Myers, the patient was accepted for transfer. The patient was transferred, at 11:55 p.m., by ambulance and arrived at the Fort Myers trauma unit at 12:29 a.m. The patient was taken to the OR for emergency surgery and required multiple bowel repairs and a right colon resection.

In an interview on 1/30/13 at approximately 4:10 p.m., the receiving trauma physician confirmed that the doctor from Fawcett Memorial called him and they accepted the patient for transfer. He said they had to do a "damage control laparotomy (opening of the abdomen to explore);" he said the patient had multiple holes inside the abdomen and in the colon. He did the repairs during the first surgery. Because the patient was losing blood, they needed to do a temporary closure at that time. The patient was placed in the Intensive Care Unit (ICU). When the patient was hemodynamically stabilized, they did a "second look laparotomy" and gave the patient a temporary right colostomy.

Review of the facility transfer agreements shows Fawcett Memorial has agreements in place with the hospital in Fort Myers, Florida and with a hospital in Sarasota, Florida.

Review of the facility on-call schedule for the ER revealed the name of the on-call surgeon for 12/31/12. The name of this physician does not appear on the January, 2013 on-call schedule.

Review of the facility's Medical Staff Policy & Procedures (MS Rules) revealed section 700 Department of Emergency Medicine #725, "All on-call practitioners are required to respond when called from the Emergency Care Center at least by telephone within 30 minutes." Although the surgeon spoke with the ER physician twice he continued to refuse to come in and see the patient at the request of the ER physician.

During an interview with the Chief Operating Officer and the Chief Medical Officer on 1/24/13 at 4:00 p.m., it was revealed that the facility has not concluded their investigation regarding the surgeon's refusal to provide services to Patient #2.

The on-call surgeon refused to see Patient #2 at the request of the emergency room physician as required. He did not adhere to the facility's Medical Staff Rules and honor his obligation to report to the hospital and evaluate Patient #2 for emergency surgical intervention causing the patient to be transferred to another hospital, 30 miles away, for emergency surgery.