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GOOD SAMARITAN MEDICAL CENTER 1309 N FLAGLER DR WEST PALM BEACH, FL 33401 March 3, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of medical records, policies and procedures, Medical Staff Rules and Regulations, Emergency Department Logs, Transfer Logs, emergency room call schedules, and credential files and interview, the facility failed to follow their policies and procedures and the Medical Staff Rules and Regulations as evidenced by failing to ensure that specialty on-call ophthalmology physicians were available to best meet the needs of hospital patients and to examine the patients as required when requested by the emergency department attending physician for 2 of 20 sampled patients who required the specialty services of the opthomologist. This affected Patient #3, and #20 who were not examined in the ED by the ophthalmologist on-call when requested by the emergency department attending physician. Refer to findings in Tag A 2404.

Based on review of medical records, policies and procedures, On-call Schedules and credentialing files it was determined the facility failed to follow their policy and procedure by failing to appropriately transfer an individual to another medical facility for 1 (#20) of 20 sampled patients medical records reviewed. Refer to findings in Tag A-2409.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, policies and procedures, Medical Staff Rules and Regulations, Emergency Department Logs, Transfer Logs, emergency room call schedules, and credential files and interview, the facility failed to follow their policies and procedures and the Medical Staff Rules and Regulations as evidenced by failing to ensure that specialty on-call ophthalmology physicians were available to best meet the needs of hospital patients and to examine the patients as required when requested by the emergency department attending physician for 2 of 20 sampled patients who required the specialty services of the opthomologist. This affected Patient #3, and #20 who were not examined in the ED by the ophthalmologist on-call when requested by the emergency department attending physician.

The findings included:

Review of the facility's policy titled EMTALA (Emergency medical Treatment and Labor Act) revealed: 'If an individual comes to the Emergency Department...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 as necessary to stabilize individual who have been found to have an emergency medical condition.'
Under E. Individuals Who Have An Emergency Medical Condition: 'the hospital must... a. Within the capability and capacity of the staff and facilities available (including coverage available through the on-call roster, provide treatment necessary to stabilize the individual, at which time the individual may be discharged .'
Under G. Physician On-Call: 'If a physician on the on-call list is called by the Emergency Department physician to provide emergency screening or treatment, the physician must respond within a reasonable time in accordance with the time established with the Medical Staff By-laws. 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. If the physician's failure to appear, the hospital is required under EMTALA to document in the medical record the name and address of the physician who failed to appear...'

Review of the Medical Staff Rules and Regulations revealed: 'When requested by the ED staff, the on-call practitioner shall be present in the ED within 60 minutes. When the practitioner is unavailable, s/he should have an alternate active medical staff practitioner be available. If this cannot be arranged and when circumstances justify action, the Division Director, Section Chief or the Chief of Staff shall be notified.'

1. Review of the Emergency Department (ED) central log and transfer log revealed Patient #3 (MDS) dated [DATE] 10:52 PM with chief complaint of Pressure behind eye. The patient was triaged by the nurse at 11:05 PM and was coded as a priority level (ESI) 4 (stable, present with minor or chronic problems and require one resource during the valuation process).

A Medial Screening Examination (MSE) was completed for Patient #3 on 01/23/2016 at 11:33 PM by the Nurse Practitioner. The Nurse Practitioner documented, discussed with the medical physician at 11:55 PM who ordered an ophthalmology consult with Physician-F and with ophthalmologist Physician-C (chief of ophthalmology).
On 01/24/16 at 00:02 AM, the ED nurse documented a call was placed to Physician-F, the ophthalmologist on call; and a second call was placed to Physician-F at 00:32 AM. At 00:56 AM, Physician-I (ophthalmologist) returned the call and the call was transferred to the Nurse Practitioner. The nursing supervisor was notified, who called the Chief of Ophthalmology.

On 01/24/16, at 01:36 AM, the ED physician documented: 'spoke finally with Physician-I ophthalmology who said Physician-F was not on call and will not discuss any patient unless it is established patient of Physician-F'. The ED-physician then arranged for transfer of the patient to another acute care hospital for the services of Ophthalmology.
At 01:36 AM, the ED physician documented an order for the transfer of Patient #3 to another acute care hospital for specialty of Ophthalmology for Increased Intraocular Pressure of the eye.
At 1:49 AM, the physician documented the patient required specialty care. The physician documented at 01:54 AM on 01/24/16, a diagnosis of Increased Intraocular Pressure left eye with a Differential diagnosis of Acute Glaucoma left eye. The transfer of Patient #3 was initiated to another acute care hospital for services. The ED physician documented the patient was stable, the transfer forms were completed, and the patient left the ED 2:35 AM.

Review of " Good Samaritan Medical Center (GSMC) ER (emergency room ) Call schedule -call report for 1/23/2016 was reviewed. The ER call scheduled dated 1/23/2016 verified that Physician F was the ophthalmologist on call when Patient #3 (MDS) dated [DATE]. The facility failed to ensure that Patient #3 was provided further evaluation and treatment by the on-call ophthalmologist on 1/23/2016 when the request was made by the ED attending physician.

Interview on 03/03/16 with the risk manager and the director of ED revealed that Physician-I was not on their medical roster list so was most likely a partner of Physician-F, and since Physician-F was on vacation, Physician-I was covering.


2. Review of the ED record for Patient #20 revealed the patient presented as a walk-in to the ED on 01/27/2016 (Wednesday) at 4:37 PM with a chief complaint of ' last night strained to use toilet and since then I see blood inside my right eye and I can't see anything clear, everything is blurred from the right eye.'

The patient was triaged by the ED triage nurse at 4:37 PM and coded as a priority level of ESI 3 (stable, present with normal vital signs and require utilization of at least 2 or more resources during the evaluation process).

The ED physician MSE was completed at 4:41 PM with a documented diagnosis of Vitreous Hemorrhage (leakage of blood into the areas in and around the vitreous humor of the eye) right eye. Review of the physician notes of 7:23 PM revealed the ED-physician consulted the ophthalmologist and documented ' discussed with the ophthalmologist (Physician F), retinal detachment verses vitreous hemorrhage; Physician F is not a retinal specialist but agrees to see the patient on Friday; Physician-F is not on call. Recommend the patient go to (Name of Eye Institute) eye emergency in Miami. Patient understands the importance of this and will have son drive patient. Patient provided with driving instructions, address and phone number of both (Name of Eye Institute) and Physician-F'. The patient was discharged from the ED at 6:18 PM.

Review of the ophthalmology on-call list for 01/27/16 revealed Physician-F was listed as being on call for ophthalmology. Review of Physician-F ophthalmologist credential file revealed Physician-F had privileges for Retinal Detachments. Patient #20 was not seen by the on-call ophthalmologist on 1/27/2016. The facility failed to ensure that patient #20 was provided further evaluation and treatment by the on -call ophthalmologist on 1/27/2016, when the request was made by the ED attending physician.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on review of medical records, policies and procedures, On-call Schedules and credentialing files it was determined the facility failed to follow their policy and procedure by failing to appropriately transfer an individual to another medical facility for 1 (#20) of 20 sampled patients medical records reviewed.
The Findings included:


The facility ' s Policy and Procedure titled " EMTALA (Emergency Medical Treatment and Labor Act) Policy, Policy Number .1.45 Origination Date: 1/8/10; Revision Date: 8/14. The policy specified in part, " H. Transfer of Unstable Individuals ...b. With Certification. The Individual may be transferred if a physician or, should a physician not physically be present at the time of the transfer, another qualified medical person in consultation, with a physician has certified that the medical benefits expected from transfer outweigh the risks. The date and time of the certification should be close in time of the actual transfer ...2. When GSMC transfers an individual with an unstabilized emergency medical condition to another facility, the transfer shall be carried out in accordance with the following procedures.
a. GSMC shall, within its capability, provide medical treatment that minimizes the risks to the individuals health and; ...
b. A representative of the receiving facility must confirm that: (1) The receiving facility has available space and qualified personnel to treat the individual; and (2) The receiving facility agrees to accept transfer of the individual and to provide appropriate treatment.
c. GSMC must send to the receiving facility copies of all pertinent medical records available at the time of transfer, including: (1) history; (2)records related to the individual ' s emergency medical condition; (3) observations of signs and symptoms; (4) preliminary diagnoses; (5) results of diagnostic studies or telephone reports of the studies; (6) treatment provided; (7) results of any tests; (8) the written patient consent or physician certification to transfer; and the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. GSMC must forward relevant records, pending lab work and test results to the receiving facility that was not available at the time of the transfer. "

Patient #20 ' s medical record was reviewed. The ED physician MSE was completed at 4:41 PM with a documented diagnosis of Vitreous Hemorrhage (leakage of blood into the areas in and around the vitreous humor of the eye) right eye. Review of the physician notes of 7:23 PM revealed the ED-physician consulted the ophthalmologist and documented ' discussed with the ophthalmologist (Physician F), retinal detachment verses vitreous hemorrhage; Physician F is not a retinal specialist but agrees to see the patient on Friday; Physician-F is not on call. Recommend the patient go to (Name of Eye Institute) eye emergency in Miami. Patient understands the importance of this and will have son drive patient. Patient provided with driving instructions, address and phone number of both (Name of Eye Institute) and Physician-F'. The facility failed to ensure that their transfer Policy and procedure was followed as evidenced by failing to ensure the Eye Institute had available space and qualified personnel for the treatment patient #3 on 1/27/2016; failing to ensure the Eye Institute had agreed to accept the patient and provide appropriate treatment; failing to ensure that GSMC sent the Eye Institute copies of all pertinent medical records available at the time of the patients transfer; and failing to ensure that a copy of the written certification for transfer was completed by the ED physician, and the name of the on-call physician (Physician F) that failed to appear.

Review of the ophthalmology on-call list for 01/27/16 revealed Physician-F was listed as being on call for ophthalmology. Review of Physician-F ophthalmologist credential file revealed Physician-F had privileges for Retinal Detachments.