The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST MARY'S MEDICAL CENTER 901 45TH ST WEST PALM BEACH, FL 33407 Jan. 28, 2015
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, administrative and clinical record review, the facility failed to ensure that 1 of 10 sampled patients' (Patient # 1) received timely medical care and treatment for their emergency medical condition to insure that the patient's emergency medical condition did not deteriorate from the facility's medical staff failure to provide the necessary treatment.

The findings include:

The By laws of the Medical staff and the Rules and Regulations for the Medical Staff discloses, " Members of the Consulting Staff shall serve on the Hospital On-Call service as directed. Patients who require consultations with specialist physicians following admission shall be assigned the specialist physician on call at the time the patient requires the consult. Members of the Consulting Staff who have admitting privileges and/or who participate in any "on-call activities must live or practice within in a sixty (60) minute drive time of the Hospital in order to provide continuous care to and supervision of their patients. Medical staff responsibility discloses that such responsibility shall be exercised in good faith and in a reasonable, timely and responsible manner, reflecting the interests of providing patient care of the generally recognized professional level of quality and efficiency and of maintaining harmony of purpose and effort with the governing body and with the community. Progress Notes: Pertinent progress notes, sufficient to permit continuity of care, shall be recorded on all patients at the time of the observation and not less than daily. Reports: Consultations Reports shall contain the opinion of the consultant and, when appropriate, an actual examination of the patient and the patient's medical record (s)."

Review of the clinical record for Patient # 1 failed to provide evidence that the above rules and bylaws were implemented as related to the neurosurgeon consultation. Patient # 1 is a seven year old patient who was transferred to the facility's emergency department on 12/21/2014 at 3:58 PM from another acute care hospital requesting follow up specialty care with the Pediatric Neurosurgeon. The patient's history includes a 2 week history of the child complaining of headaches every day, mostly in the mornings with occasional vomiting associated and occasionally waking her up at night. The transferring facility performed a CT Scan (computed tomography) of the Brain which revealed a "5 centimeter (cm) right mixed density right side posterior fossa mass compressing and displacing the fourth ventricle" (a large mass in the back of her head on the right which compressed and displaced the fourth fluid filled cavity in the brain). The emergency room physician noted that he had discussed the case with the on call neurosurgeon (MD # B who is a general neurosurgeon who does not have fell owship training in pediatric neurosurgery). MD # B reviewed the imaging study done at the transferring facility and recommended that the patient receive a MRI (magnetic resonance imaging) of the brain and complete spine on tomorrow morning,12/22/2014 and starting the patient on Decadron (steroid medication treating brain inflammation). The emergency room physician wrote the order to transfer to the Pediatric Intensive Care Unit at 5:53 PM for close cardiorespiratory (heart/breathing) and neurological monitoring and treatment.
An interview was conducted on 1/27/2015 at 11:58 AM with the Chief Medical Office (CMO), who reported that the facility has 4 neurosurgeons who provide the on call coverage for Neurosurgery. The four neurosurgeons includes the one pediatric neurosurgeon, MD # A. When the neurosurgeon covers and a child is involved and they are not the pediatric neurosurgeon, the on-call physician stabilizes the patient, informs the pediatric neurosurgeon and the pediatric neurosurgeon will see the patient the following morning and assumes responsibility for the patient and the patient becomes his patient. He further stated that a tumor in itself is not emergent because it takes time to grow but when it start bleeding it then requires surgery. He further stated that consultant physicians are to see patients within 24 hours and dictate the consultant report. This did not occur with Patient # 1. The patient was not seen by the pediatric neurosurgeon until 12/23/2014, two days after admission to the facility. Additionally, the physician did not dictate the neurosurgeon consultation report until 12/30/2014 and the CMO stated that some information in the report was incorrect regarding the physician noting that he was on vacation. He also stated the report was dictated after Patient # 1 had expired. When MD # A saw the patient on 12/23/2014 the physician felt the patient was stable and scheduled the patient for surgery on 12/26. On 12/24 the patient became agitated, having increased pain and MD # B was notified because he was the on call physician. He saw the patient and felt that the patient needed to go to surgery. Though MD # A was not officially on a noted vacation or out of town, he said he was not available until 12/26/2014. The PICU was also trying to contact MD # A on 12/24 and they had also informed the CMO and he was about to send the police to MD#A when another physician was able to contact the physician's wife. They spoke with MD # A at approximately 10:00 PM and he told them that he had had a few drinks and could not do surgery. The PICU MD then discussed the case with MD # B who was on his way to perform surgery on another patient and MD # B said to transfer the patient.
An interview was conducted on 1/27/2015 at 3:18 PM with MD # B who confirmed that he was the Neurosurgeon on call on 12/21/2014. He stated that the pediatric emergency physician discussed the patient's findings with him but he confirmed that he didn't see the patient because the patient's current presentation was not considered an emergency. The patient was alert and awake and he reviewed the CT Scan and determined that the [DIAGNOSES REDACTED] did not need immediate emergency surgery and could receive further evaluation and follow up care from the pediatric neurosurgeon. He considered that the patient was stable and their protocol could be followed for pediatric neurosurgery consults. The protocol intimates that if the patient is stable, the Pediatric neurosurgeon could see the patient the following day. He stated he text MD # A, the pediatric neurosurgeon, to inform him of the patient and MD # A stated he would see the patient in the morning (Monday).
However, MD # A - the pediatric neurosurgeon did not see the patient on 12/22/2014 nor did the on-call neurosurgeon. There is no documented progress note for 12/22/2014. Though the patient was admitted on [DATE] for pediatric neurosurgery, the patient was not seen by neurosurgery for her "critical" [DIAGNOSES REDACTED] until 12/23/2014. The clinical record contains a neurosurgery consult dictated on 12/30/2014 and neurosurgery progress notes are dated 12/23/2014 and 12/24/2014.
The 12/22/2014 MRI of the brain and spine with and without contrast revealed a "5.2 cm in length on its long axis which is from the anteromedial to the posterior lateral. It measures 4.2 cm transversely and 3. 3 cm cephalcaudal (between the head and the base of the spine). The mass is heterogeneous internally with high signal posteriorly on all sequences, likely indicating some hemorrhage." The impression documented there is a "right cerebellar region mass. It is not entirely certain that it is arising within the cerebellar (in the lower back of the brain near the middle of the back of the head. It controls movement, balance and posture) substance, but that it is still statistically more likely than an extra-axial origin. It could be a [DIAGNOSES REDACTED]. Secondary effects include displacement and compression of the fourth ventricle, supratentorial [DIAGNOSES REDACTED] with early transependymal fluid migration and downward displacement of the cerebellar tonsils. He also noted that the "above critical results were called by me to MD # A at 1:55 PM."
An interview was conducted on 1/28/2015 at 10:40 AM with the Radiologist who performed the MRI on 12/22/2014. He stated he discussed the results of the MRI with MD # A and informed him of the presence of the tumor that displaced the foramen magnum; there was noted [DIAGNOSES REDACTED] (fluid on the brain) and the presence of an abnormal vein located on the dura sinus underneath the cerebellar (underneath the tumor). The tumor was smooth and had round borders. He also stated that the mass of 5 cm did not grow overnight. He suspected a slow-growing tumor depending on the symptoms the patient was experiencing which would determine how quickly there is a need for surgery. The Radiologist then stated that the determination of the necessity of surgery is a clinical decision. He also stated that on the 22nd MRI there was not any acute hemorrhaging (bleeding) but confirmed all tumors will have some blood in them. However, even with enhancement, it did not look like the tumor was bleeding. He further confirmed that hemorrhaging was definitely not present at the time on the 22nd. Acute hemorrhage is an unexpected occurrence.
A 12/23/2014 11:49 AM (Tuesday, two days after the patient was admitted to the facility) handwritten Neurosurgery progress note is documented by MD # A. This is also the first note by neurosurgery since the patient's admission on 12/21/2014. The 12/23/2014 progress note records the patient's vital signs, "patient complains of nausea and vomiting, bit better after Decadron increased. Patient with [DIAGNOSES REDACTED] (eyes making repetitive, uncontrolled movements); right upper extremity dysmetria (disturbance of the power to control the range of movement in muscular action); good hearing on bilateral exam. MRI reveals right cerebellar mass likely [DIAGNOSES REDACTED] (tumor that arise from astrocytes-star shaped cells that make up tissue of the brain) with 4th ventricle compression and [DIAGNOSES REDACTED]. Impression and plan, right cerebellar tumor; plan surgery on Friday. Use Precedex (Intravenous sedative usually used with intubated or mechanically ventilated patients) to keep relaxed and help with nausea and vomiting (N/V). Check labs!!! Nothing by mouth after midnight Thursday Night. May need EVD ( External Ventricular Drain) Shunt." (The EVD is a device used in neurosurgery that relieves elevated intracranial pressure and [DIAGNOSES REDACTED] when the normal flow of cerebrospinal fluid around the brain is obstructed. This is a plastic tube placed by neurosurgeons to drain fluid from the ventricles of the brain and thus keep them decompressed, as well as to monitor intracranial pressure.)
Additionally on 12/23/2014 the PICU MD documented "that since yesterday patient has had multiple episodes of excruciating headache, nausea and vomiting with no by mouth (po) tolerance. MD # A is aware of this. We got in touch with him because of the patient persistent symptoms and he came and evaluated patient and talked with family today but his opinion is that this is not an emergency and the plan continues to be to go to surgery on Friday, 12/26/2014 despite understanding all of the symptoms that patient is presenting and all radiological studies."
Review of the 12/ 4 progress note confirmed that MD #B saw the patient on 12/24/2014 at 9:54 AM and documented that the patient is "having nausea and vomiting this morning. Following commands. Will increase Decadron dose and add Diamox. Plan for surgery on 12/26/2014." There was nothing in the progress note to indicate that MD # B spoke with MD # A or that the patient is declining and his recommendation that the patient required surgery immediately, prior to 12/26/2014. There was no indication that additional imaging was prescribed at this time to evaluate if there were possible changes in the brain secondary to the patient increased symptoms of [DIAGNOSES REDACTED]
A telephone interview was conducted on 1/27/2015 beginning at 2:30 PM with MD # A, Pediatric Neurosurgeon. He stated that he is the only Pediatric Neurosurgeon for the facility. He also stated he told the team he would be on Christmas vacation Tuesday, Wednesday and Thursday. He said that the PICU MD and MD # C the Neurosurgery Section Chief were aware that he was going to be off. He admits that he did not send the usual emails alerting everyone of his vacation but said he verbally informed them. MD # A relayed this accounting of occurrences with Patient # 1. He stated that the patient came in on Sunday, 12/21/2014 and MD # B was on call. According to Med # A when a patient comes in and requires neurosurgical service, the patient is added to the list and the on-call neurosurgeon is responsible for the patient that day. He stated that MD # B didn't see the pediatric patient but MD # B text him to see the patient. He came to see the patient on 12/22/2014 but the patient was not in the room and he found out the patient was away having the MRI. He left the facility and went to his local office to see patients and he assumed that MD # C would see the patient because he was on call on 12/22/2014. He did not return to the facility after completing his office hours in his local office. He confirmed he saw the patient the next day on 12/23/2014 and he looked at the CT scan and MRI and felt the patient had a benign [DIAGNOSES REDACTED] or [DIAGNOSES REDACTED] (a tumor that arises from the meninges, the membranes that surround the brain and spinal cord). He stated he came in on Tuesday, 12/23/2014 despite the fact that he was supposed to be off. When he finally saw the patient on 12/23/2014, the patient appeared stable. She was watching television. She did have some nausea. He did a full neurological exam and only found that the patient had [DIAGNOSES REDACTED] and he didn't find anything else with her neurologically and felt she was relatively stable and scheduled her for surgery on Friday, 12/26/2014, three days later and 5 days after her admission to the hospital. He felt she had a low-grade tumor and she would be stable until Friday. The next two days was going to be Christmas Eve and Christmas and stated the operating room would have a skeleton crew. For neurological surgery he needs some specialty items, the surgery would take 5-8 hours and would require a pediatric anesthesiologist. He stated when he saw the patient on 12/23/2014 he showed the films to the grandmother and said the MRI and CT scan looked the same and the patient should be okay unto Friday. He informed her he would not be available for the next two days but other neurosurgeons would be available. He also stated he called MD #C on Tuesday and MD #C informed him he had not seen the patient. Apparently MD # B never told him about the patient. MD # A stated he updated MD # C about the patient because MD # C was on call that day. He stated that MD # C and MD # B were to watch the patient Wednesday and Thursday. He said he informed MD # C that he could transfer the patient to MD # B the next morning. He (MD # A) would be celebrating Christmas. MD # B saw the patient in the morning on 12/24/2015 and changed her meds around preparing the patient for surgery. MD # B text MD # A updating him about the patient and MD # A told MD # B that he would do surgery on Friday. He also thought MD # B visited the patient later and felt she was okay on Wednesday. The PICU MD on call was concerned and was calling MD # B, and MD # B was calling him (MD # A).
A telephone interview was conducted on 1/27/2015 at 3:18 PM with MD #B. He confirmed he was the Neurosurgeon on call when Patient # 1 was admitted on [DATE]. He stated the pediatric ER physician discussed with him concerning the patient. He also confirmed that he did not physically see the patient because it was not considered an emergency. The patient was alert and awake and the [DIAGNOSES REDACTED], from his review of the CT scan, did not require immediate emergency surgery. He felt that the patient was stable and MD # A would see the patient the following day. He text MD # A to inform him of the patient's condition and he would see the patient in the morning. He also stated that regarding the on-call for neurosurgery, the Neurosurgeon on call is responsible for the neurosurgical patients that day. For children non-trauma urgent or emergent we notify the pediatric neurosurgeon, provided that he hasn't notified us he is not available. If the pediatric neurosurgeon is unavailable, 100% of the time we would transfer the patient out. MD # A was available as far as he knew. He had not officially informed anyone he was off. It is an understanding for his job, as the pediatric neurosurgeon, to be available at all times unless otherwise declared. As far as he knew, after MD # A saw the patient, MD #A was going to perform surgery on Friday, 12/26/2015, when he (MD#A) was on call. MD#B stated his next involvement with Patient #1 was on Wednesday, 12/ 24 when he was on call. Patient # 1 was "doing badly, having vomiting, pain from headaches. The patient was getting worse and felt that she potentially needed to go to surgery. He stated he text MD #A to tell him the patient was doing badly and he needed to do something. According to MD #B both he and MD #C, the Section Chief of Neurosurgery advised MD #A to operate on the patient. At this point MD #B said he had only saw the initial study done on 12/22. According to MD #B, the MRI showed some streaking of bleeding yet MD# A put the patient on the surgery schedule for Friday, 3 days after he saw her. According to MD# B, this is the "Worse case of patient abandonment!" and told the surveyor "you can quote me on that." He again stated he would cover MD #A pediatric patients only when he is in town. When he (MD#A) is unavailable we would send them out.
Additionally on 12/24/2014 at 6:12 PM the PICU MD documented that the patient continues to have complaints of severe head pain. We have been in discussion with neurosurgery as far as medications to be given for pain control and at this time, we will provide Tylenol only. The patient continues to complain of severe pain and does have crying. She is hard to console at this time. We have been in constant discussion with neurosurgery throughout the day in regards to pain control. At this time, neurosurgery is comfortable with her having Tylenol only, although MD # B will be speaking with MD # A in regards to any further pain control methods. The patient does have some complaints of nausea, although no vomiting today. The patient heart rate in the last 24 hours has been 56-87, blood pressure 122-139 over 59-83. Her heart rate today have ranged more in the mid to high 40's and low 50's. Assessment and Plan- currently nothing by mouth with IV fluids. This morning MD #B did asses patient and discontinued her morphine, Toradol and Motrin. We have spoken with him multiple times throughout the day in regards to her pain control. She does continue to have severe headaches and is inconsolable at times."
The nursing staff interviewed also confirmed that initially the patient was stable but began to have increased pain and vomiting. The staff made multiple attempts to contact MD#A and MD#B during these times.
An interview was conducted on 1/28/2015 at 12:15 PM with the Pediatric Intensive Care Unit (PICU) Nurse ( RN # A) who cared for the patient on the day of admission and on 12/22/2014. She stated that the patient was alert, walking, talking and happy on admission to the PICU. The Radiologist had called her and informed her of the midline shift and partial effacement at the fourth ventricle and it was critical. He also spoke to the attending pediatric PICU physician. She also took care of the patient on 12/22/2014. She stated that later that day, Monday, the patient began vomiting and complaining of excruciating pain from a headache (HA). She stated she tried calling MD # A about six times and left messages. The patient began screaming in pain and though she was NPO (nothing by mouth) she was vomiting. When she was able to speak with MD # A she stated that he prescribed Toradol for pain. She stated that the MD is supposed to put in the orders but MD # A stated he was in his office and did not have access to the computer system. She stated that when she attempted to put in the order MD # A prescribed, she noticed it was not the normal dose and when she tried to put in the prescribed dose she kept getting an overdose alert. (review of the Physician orders discloses a 12/22/2014 entry for Toradol ( ketorolac) 165 mg 11 ml injection on 12/22/2014 at 6:15 PM and a physician stop date for the same time). She stated she had to call him back several times and he finally told her to do whatever the PICU physician says to do. She also stated they were questioning the physician ordering the Toradol secondary to the hemorrhaging side effect. She stated she was also calling the physician because the patient had a change in condition. The patient woke up with bad HA and she tried to calm her down. She further stated that the afternoon headache she had continued. The child eyes were dark red and she had been crying. She stated she received several orders from the physician via telephone. She also reports that she overheard MD # A telling the child's grandmother and great aunt that he did not know what his spouse's plans were for Christmas eve (Wednesday) and Christmas (Thursday) but he would do the surgery on Friday and it was not an emergency. Additionally on 12/24/2014, when the patient was experiencing excruciating pain, though she was not Patient # 1 assigned nurse, she was assigned a patient across the hall from Patient # 1 and "she could hear Patient # 1 screaming all day long." She stated she asked what are we going to do?"

An interview was conducted on 1/28/2015 at 1:25 PM with RN # B, a Pediatric Oncology nurse who floated to PICU on 12/24/2014, 7:00 AM to 7:00 PM and cared for Patient # 1. She stated that the patient was photophobic (having an abnormal sensitivity or intolerance to light), complained of pain and vomited at least once during her shift. She stated she really didn't know how the on call worked on PICU because on her unit she usually just speaks to their oncologist, but when she floats she will use the on call list and call who is on call. She stated on 12/24 she was in touch with MD # B, who was the covering on-call physician. The patient was originally on Morphine and Toradol and she was content but MD # B discontinued the Morphine and Toradol and she was giving the patient Tylenol only and that was not sufficient. She further stated that the patient was "in agony" and expressed that her head was hurting. She was NPO and she was hungry but also had vomiting. She had an IV in place. She stated she did not try to call MD # A, the pediatric neurosurgeon. She only contacted MD # B. She stated she was informed by MD # B that he had had conversation with MD # A. She further said that MD # B told her that the Morphine and Toradol "could be deadly to the patient if she went to surgery". She stated she informed the PICU MD. She said she was also told that the PICU MD had spoken with MD # A. The PICU MD informed MD # A that the patient was only on Tylenol, but he (MD #A) was not going to operate any sooner than scheduled. She again stated that the patient was in a lot of pain. The patient was "crying" when she gave report.
An interview was conducted on 1/28/2015 at 4:25 PM with MD # C, General Neurosurgeon who also serves as the Section Chief of Neurosurgery. The Chief Medical Officer (CMO) was also present during the interview. He explained the Neurosurgery service make up of having four (4) neurosurgeon on call; three (3) are general neurosurgeons with no pediatric fell owship training though they all had a rotation in pediatric in their residency; one (1) physician who serves as their Pediatric neurosurgeon and he handles all the non-trauma pediatric patients. In an emergency they all will handle pediatric and adult neurosurgery trauma and non trauma. When a pediatric patient requires neurosurgical consult, the pediatric neurosurgeon is contacted by the covering neurosurgeon. The covering on-call physician will accept the patient into the service and when the child arrives the pediatric neurosurgeon is to assume care on the child. Because he covers for Neonatal / PICU/ Ped Oncology he is responsible 365/7 days a week and we realize that is impossible so we try to help out to cover for him when he is off. But he is to assume the care of the child as soon as possible. He states he checks with MD # A in advance to determine when he definitely wants off. We know if he is out of town and if we are contacted about a pediatric neurosurgical patient we will suggest they transfer to another facility and tell them the specialist is not available. If he is in town they will call him. If he cannot assume care he always has the option of transferring out. MD # C reaffirmed the scenario of the patient presenting to the facility as relayed earlier regarding MD # B accepting the patient on service and MD # A agreeing to see the patient the following morning. However he was unable to see the patient on 12/22/2014 and did not see the patient until 12/23/2014. MD # C provided additional information that on 12/23 he (MD #C) came into the PICU to see another patient when the staff informed him about Patient # 1 and gave him details about the case. He stated he spoke with MD # A at 9:00 AM and told him he needed to see the patient today and have surgery as soon as possible (ASAP). The patient was better but still had the HA and was nauseated. He looked at the MRI done on 12/22 at the facility and the CT scan from the transferring facility. The patient had a 5 cm mass, a large slow growing tumor located on the right cerebellar hemisphere mass; significant compression on the fourth (4th) ventricle. He also saw an area of small hemorrhage. He said it was not bad. It looked like an old hemorrhage it did not appear as active bleeding. It appeared like a speckling of blood. He stated he suggested to MD # A that surgery needed to be done 12/23 or 12/24 and the patient needed to be seen immediately. He said MD # A was also contacted by Radiology and informed of the results. The patient was seen by MD # A later that morning as indicated above. MD # A did not perform surgery on the patient on 12/23 or 12/24 as the Section Chief said he suggested but instead scheduled the surgery on 12/26 (3 days later).
MD # C denied that MD # A informed him that he would not be available on the 23-25th. He stated that MD # A only informed him that he would not be available and wanted off the 1st week in December. When time off is requested there are numerous people who have to be informed.
MD# C stated MD # A told him he planned to do the surgery on Friday 26th. MD # C stated he expressed his concern for the delay. He signed off service on Tuesday (23rd) at 9:00 PM with MD # B. He told MD # B that MD#A decided to operate on Friday and that he had advised MD# A should do surgery on the 23rd or the 24th.
The changing symptoms noted on the 24th were indicating increasing intracranial pressure, increasing neurological compromise,and an increase in brain swelling.
MD #B increased the Decadron and discontinued Nsaids and Toradol. These medications are not a good idea for surgical patients, gives Platelets dysfunction. MD # A also prescribed Precedex and the PICU MD was not comfortable with that order and did not give. The medication is a hypnotic calming sedative when used can possibly increase brain swelling. They made multiple attempts to reach MD#A. MD#B also tried to reach MD # A and had text communications. The CMO stated he read the exchanges and one in particular he reported to the surveyor that MD# B wrote that the patient looks like sh__ and MD # A responded OK. MD # A was 5 miles away and would not come. According to the CMO, MD # A kept telling them "I got this."
According to the clinical record, the patient continued to decline and decompensate having excruciating pain, decreased heart rate, and elevated blood pressure. The patient was intubated and placed on mechanical ventilation after 8:00 PM and 10:00 PM performed a repeat CT Scan which showed "Internal development of hemorrhage in the right posterior fossa measuring 3.1 x 5.2 cm in the largest axial plane with surrounding edema. This is in the region of the previously described posterior fossa mass. The 4th ventricle is completely effaced. On the study of 12/24/2014 there was a small area of fourth ventricle visualized. Interval worsening of obstructive [DIAGNOSES REDACTED] causing increased dilatation of the visualized ventricle with mild transependymal resorption of CSF(cerebrospinal fluid). Impression: Development of acute hemorrhagic conversion of the large right posterior fossa mass with complete effacement of the fourth ventricle and increasing obstructive [DIAGNOSES REDACTED] and edema. The critical findings were discussed with the treating physician at 11:08 PM on 12/24/2014."
The facility again attempted to contact MD # A and finally was able to speak with the physician who informed them he could not come in. He had consumed some alcohol and to transfer the patient.
The facility transferred the patient on 12/25/2015 to another acute care hospital to receive the pediatric neurosurgical follow up requested on 12/21/2014.
Further interview on 1/27/2015 at 2:30 PM with MD # A, who was informed the PICU MD spoke with MD # B stating that patient's heart rate was declining and the patient was in and out of consciousness. The patient was intubated around 8 or 9 PM. He stated he told them to transfer the patient immediately because he was with his family and he had had a drink. He was not drunk but he was not going to jeopardized his license because he had had a drink. He told them to transfer when the CT scan showed a large bleed suggestive of a malignant tumor now. When he initially spoke with Radiology it was felt the tumor was a low grade [DIAGNOSES REDACTED]. He did not mention hemorrhaging and he didn't see any hemorrhaging on the 22nd MRI. He felt it was okay to put off surgery until Friday because from Sunday to Tuesday (though the nurses reported increased pain and vomiting) the patient remained stable and when he reviewed the CT scan and MRI, he did not see hemorrhaging and felt it was a slow growing tumor based on how long the symptoms had been going on (2 weeks). He later found out the patient expired on [DATE]. The surgery was performed at the other acute care hospital and the patient was diagnosed with [DIAGNOSES REDACTED]