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.

COVENANT MEDICAL CENTER 3421 WEST NINTH STREET WATERLOO, IA 50702 July 21, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of documents, policies, medical records, and staff interviews, the hospital failed to enforce its EMTALA policies to ensure staff provided a proper medical screening exam for 1 of 30 sampled patients who presented in the Emergency Department (ED) of the hospital on July 9, 2016 with an emergency medical condition (Patient #14).

Failure to ensure the ED staff provided an appropriate medical screening exam for each patient requesting emergency medical care in the ED in accordance with the hospital's EMTALA policy could potentially result in delay in patient treatment, harm and/or poor outcomes for patients.

Findings include:

1. Review of the hospital policy titled, "EMTALA Medical Screening and Stabilizing Treatment" revised date 6/16, revealed the following in part, "...any patient who comes to the the Hospital's dedicated emergency department and requests...emergency examination and treatment...will be provided an appropriate medical screening examination within the capabilities of the dedicated emergency department, including ancillary services routinely available to the emergency department to determine whether an emergency medical condition exists...where the medical screening examination reveals that the person has an emergency medical condition, the hospital will provide further medical examination and stabilizing treatment as required...stabilizing treatment consists of providing medically appropriate treatments within the capabilities of the hospital necessary to ensure that, with reasonable medical probability, no material deterioration of the patient's condition is likely to occur during the inpatient care, transfer or discharge of the patient....an emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain)...such that the absence of immediate medical attention could reasonably be expected to result in...placing the health of the individual...in serious jeopardy."

2. Review of the hospital policy titled, "EMTALA: On Call Physicians" revised date 6/16, included the following in part, "...It is the policy of Wheaton Franciscan Healthcare-Iowa to provide guidance for on-call physician coverage...the hospital will maintain a list of physicians who are on-call for duty after the initial examination to provide examination and/or treatment necessary to stabilize an individual with an emergency medical condition...the physician on-call roster will be utilized to ensure that Hospital staff are aware of those physicians available, if necessary, to provide medical screening examinations to individuals requiring a specialty consult to determine if an emergency medical condition exits and/or stabilizing treatment to patients who, on the basis of the medical screening examination, are believed to have emergency medical conditions.

3. A hospital document titled "Medical Staff Rules and Regulations" dated 6/2/16, included in part, "...Medical and Surgical Consultation...qualifications: a consultant must be qualified on his/her individual training...and competency, in the field in which the opinion is sought...a consultation includes examination of the patient and the patient's medical record. A documented opinion signed by the consultant must be included in the medical record."

Refer to A 2407 for additional information concerning the medical screening examination of Patient #14.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of hospital documents, medical records, and staff interviews, the hospital failed to ensure Patient #14 received further examination and stabilizing treatment for his emergency medical condition prior to transfer. The investigation involved review of the Emergency Department (ED) medical records for 25 sampled patients who presented to the ED for an emergency medical condition from June 9, 2016 to July 18, 2016.

Failure to ensure Patient #14 recieved further examination and stabilizing treatment within the scope of services available at the hospital placed the patient at risk for harm and/or death.

Findings include:

1. A hospital policy titled, "STEMI ALERT" (ST Elevation MI) dated 11/14, included in part, ..."A STEMI (ST elevation myocardial infarction) is characterized by ST - segment elevation (refers to a finding on an electrocardiogram wherein the trace in the ST segment is abnormally high above the baseline and may or may not be indicative of a heart attack) ....recognition and treatment of a STEMI is an emergent process. Patients with STEMI usually have complete occlusion of an...coronary artery. Direct catheter-based reperfusion reduces mortality and saves heart muscle; the shorter the time to reperfusion, the greater the benefit

2. A hospital document titled, "Programs and Services Provided at Wheaton Franciscan Healthcare" included in part, "...Covenant Cardiology is dedicated to the most forward-thinking methods in the prevention, intervention, and treatment of heart disease...each of our cardiologists specialize in a particular area of cardiology, providing expert, personalized care with a passion to make a difference in every life they touch...the goal of Covenant Cardiology is to provide patients...access to multiple cardiac specialties...conditions we treat, services we provide and procedures we perform...arrythmias, heart failure...services we provide...cardiology services including diagnostic and interventional procedures...pacemakers."

A hospital document titled, "Bylaws of Covenant Medical Center, Inc." undated, included in part, "...Medical staff membership is comprised of physicians...who are privileged to admit or to attend patients. The privilege of attending physicians shall be extended by the board of directors to practitioners who meet the professional...and personal qualifications, standards and requirements of these bylaws...the medical staff has the responsibility and authority to assure quality of care...each medical staff member is authorized to attend patients by reason of appointment to the medical staff by the board of directors."

A hospital document titled, "Covenant Medical Center Medical Staff Rules and Regulations" dated 6/2/16, included in part, "...The consultant is the physician called by the Attending of Record to provide a professional opinion and/or treatment for a specified clinical concern...all members of the Medical Staff are expected to abide by the requirements of...EMTALA...when the medical screening examination reveals that the person has an emergency medical condition, the hospital will provide further medical examination and stabilizing treatment as required to stabilize the medical condition...the hospital will maintain a list of on-call physicians who can provide further evaluation and/or treatment to stabilize an individual with an emergency medical condition."

A hospital document titled, "Covenant Medical Center - Critical Care Census Report" dated 7/9/16, included in part, "...Total beds: 12...occupied beds: 2...beds available: 10."

3. Review of Patient #14's medical record revealed the following:

a. On 7/9/16 at 2:40 AM, the patient presented to the ED by ambulanance with a complaint of shortness of breath and substernal chest pain (pain scale = 7 out of 10), and diaphoresis (sweating).

- At 2:43 AM, An Electrocardiogram (EKG) machine report revealed the following:
arrhythmia, right bundle branch block, anterior infarct, Acute Myocardial Infarction MI/STEMI (a MI/STEMI is a full-blown heart attack caused by the complete blockage of a heart artery, taken very seriously, and is a medical emergency that needs immediate attention.

- At 2:49 AM, ED Physician A documentation on the EKG report revealed the following: "Not a STEMI". The patient's blood pressure was 101/67, heart rate was 130 beats per minute (BPM) and respiratory rate was 28 breaths per minute. He was alert and oriented and x 3 (alert to person, place and time) opening his eyes spontaneously, and talking.

- At 2:56 AM, ED Physician A documented the following: The patient admitted to smoking crack 3 hours ago and had shortness of breath and chest pain.

- At 3:00 AM, Physician A documented the following: Discussed the case with Cardiologist B and faxed the EKG to him. The medical record lacked additional documentation of orders or instruction from the cardiologist.

- At 3:18 AM, laboratory results showed Patient #14's Troponin T test level (a test that measures the levels of certain proteins called Troponin T in the blood. These proteins are released when the heart muscle has been damaged, such as a heart attack) was critically elevated and the PRO BNP test level (a test that measures B type natriuretic peptides used along with other cardiac biomarker tests to detect heart stress and damage) was elevated.

- At 3:35 AM, an EKG machine report revealed the following: arrhythmia, right bundle branch block, inferior infarct, Acute MI/STEMI. The EKG lacked documentation by ED Physician A at the time the test was completed that confirmed the computerized results.

- At 3:43 AM, ED Physician A documented the following: Reviewed the second EKG with Cardiologist B who does not think this is an acute STEMI. ED Physician A documented the patient was going to be intubated because a chest x-ray showed an extremely enlarged heart, the patient appeared to be in heart failure because his pressure was low and heart erratic. May need to start dopamine/atropine.

- At 3:57 AM, ED Physician A documented the following The patient was successfully intubated, will start Atropine for bradycardia and Dopamine for low blood pressure.

- At 4:07 AM, an EKG machine report reveled the following: chest pain, right bundle branch block, inferior infarct, possibly acute, ACUTE MI/STEMI, consider right ventricular involvement. Physician A documented 3rd degree block, now intubated (third-degree heart block limits the heart's ability to pump blood to the rest of the body. Third-degree heart block requires prompt treatment because it can be fatal).

- At 4:31 AM, Physician A documented discussed case with [Hospitalist, Physician C] and [Critical Care Physician/Pulmonologist, Physician H].

- At 4:32 AM, Physician A documented the following: Will start transcutaneous pacing. Dopamine and Atropine do not seem to be significantly helping the patient much.

- At 4:58 AM, Physician A documented the following: Spoke with [Cardiologist E] at the accepting hospital about transferring patient for a temporary pacer.

b. A document titled, "Nurse to Nurse Report" dated 7/9/16 at 5:02 AM for Patient #14, included in part, "...Reason for transfer: transcutaneous pacer...SOB (shortness of breath)...smoked crack...no heart history...BP: 91/50...60/30...heart rate: less than 30...rhythm: third degree...O2 (oxygen): 86% on vent...other info: [Cardiologist B] said "NO STEMI"...manual bagging."

- A document titled, "Patient Transfer Form" dated 7/9/16 and untimed, included in part, "...Diagnosis: Complete Heart Block, Congestive Heart Failure, Acute respiratory distress, Crack Cocaine Abuse, Hypotensive, Bradycardia...Risks/Benefits: Obtain a higher level of care...no internal pacing available..." ED Physician A completed the document.

- A document titled, "Transfer Acceptance/Direct Admission" dated 7/9/16 at 4:57 AM, included in part, "...transferring physician [ED Physician A]...BP: 81/50...heart rate 70 paced...clinical situation: Heart block, ? STEMI...intubated, heart failure...past medical history: Coronary Artery Disease (CAD)...transcutaneous pacing."

- A document from the Waterloo Fire and Rescue EMS dated 7/9/16 at 6:37 AM included in part, "...primary impression: Cardiac Rhythm Disturbance...3rd degree heart block...BP at 5:06 AM: 76/58...5:15 AM: 98/60...5:22 AM: 115/55...Narrative...Dispatched for an emergent transfer from Covenant ER to [accepting hospital ER] for a [AGE] year old male that needs a pacemaker placed...patient was brought to the ER with shortness of breath and thought to be in heart failure. Patient's condition deteriorated was was found to be in 3rd degree heart block. Patient is currently being externally paced at 70 BPM and 40 milliamps. Patient is sedated and intubated...patient is being transferred to the accepting hospital's ER for internal pacemaker placement...call received 4:58 AM...transported to [Accepting Hospital ER] 4:59 AM...at destination 5:00 AM."

c. The medical record did not contain evidence of the patient's past medical history of diabetes or heart irregularities. The medical record did not contain evidence that the on call cardiologist came to the ED to provide further examination or treatment to stabilize Patient #14 or the the hospital lacked the necessary capabilities to stabilized the patient's cardiac emergency.

d. Total time Patient #14 was in the ED from presentation to transfer 3 hours.

4. Review of Patient #14's closed medical record from the accepting hospital showed Patient #14 (MDS) dated [DATE] at 5:31 AM for Atrivoventricular block, complete (a type of heart block in which the conduction between the atria and ventricles of the heart is impaired).

5. Review of document titled, "Phone logs" revealed on 7/9/16 Cardiologist B received 2 telephone calls from ED Physician A. One call at 2:54 AM and one call at 4:37 AM. On 7/9/16 at 4:49 AM, ED Physician A placed 1 telephone call to Cardiologist E at the accepting hospital.

6. Review of Cardiologist B's credential file revealed on 6/2/16 the Medical Staff and Governing Board privileged him for the following procedures including but not limited to: transvenous pacemaker placement.

7. Review of documents titled "Transvenous Pacemaker Procedures" revealed Cardiologist B performed 8 transvenous pacemakers from 6/26/16 to 7/20/16 for patient's with medical conditions including but not limited to: elevated ST, complete heart block, V tach, 3rd degree heart block and STEMI.

8. During an interview on 7/19/16 at 9:40 AM, Cardiologist B confirmed he was the on-call cardiologist on 7/9/16. Cardiologist B stated he was contacted by ED Physician A at 2:55 AM to look at "abnormal" EKG results for Patient #14 and reported the patient had taken cocaine approximately 3 hours earlier and was complaining of shortness of breath and chest pain. Cardiologist B stated he observed the EKG and the computer registered it as a STEMI with a wide QRS rhythm. When asked what a wide QRS rhythm meant, Cardiologist B stated it may indicate a bundle branch block which is an electrical abnormality of the heart that may be old or new. He said if it is a left bundle branch block and it is new that it could indicate a STEMI. Cardiologist B stated the EKG findings at 2:55 AM in his opinion indicated a right bundle branch block and he told Physician A to repeat an EKG. He said although there was an AV disassociation which meant there is no communication between the atrium and ventricle of the heart there was no indication of a STEMI and the patient's heart rate was 58. Cardiologist B stated there was a lot of artifact and this could be a heart block and that patient could need a permanent pacemaker.

Cardiologist B said when he received the repeat EKG result at 4:07 AM he observed a right bundle branch block he discussed the findings with ED Physician A and told him to place a transcutaneous pacemaker on the patient and transfer him to Iowa City. Cardiologist B said he told ED Physician A if there were any problems to contact him but he never received a call from ED Physician A.

Cardiologist B stated he reviewed 2 EKG's from ED Physician A. Cardiologist B stated, the plan was to stabilize the patient's heart rate and blood pressure and transfer him to Iowa City for a permanent pacemaker. When asked if he observed a ST elevation he said "There was not an ST elevation on either EKG's that night so it did not meet the criteria of a STEMI." When asked if he examined the patient he stated, "No" he did not go to the hospital and physically examine the patient because ED Physician A called him for an opinion of the EKG. When asked if he was aware if ED Physician A completed another EKG after 4:07 AM he stated, "No" because he never received another call back from [ED Physician A].

During an interview on 7/19/16 at 3:00 PM, Paramedic E said on 7/9/16 at approximately 4:00 AM the ER called his office and said they were getting ready to intubate a patient. He stated he went to the ER and by the time he arrived [ED Physician A] was leaving the room and Patient #14 was intubated. Paramedic E reported respiratory therapy staff was "bagging" the patient because his oxygen saturation was "low". He said he noticed a lot of artifacts (as electrical interference that is recorded from sources other than the electronic signals of the heart. Artifact is a distortion of the signal being recorded) on the heart monitor so he changed the patches. He stated after changing the patches in his opinion tracing improved, the patient's oxygen saturations increased, but his blood pressure remained low. When asked what the patient's condition was, Paramedic E said the patient was deteriorating, he was in sinus bradycardia (A condition that can be some forms of heart block, sinus refers to the sinus node, the heart's natural pacemaker which creates the normal regular heartbeat. Bradycardia means that the heart rate is slower than normal), his pulse rate is 48 and at that point he felt the patient could be a potential air transfer to Iowa City. Paramedic E said when the third EKG showed third degree heart block ED Physician A ordered a transcutaneous pacer (external pacemaker). He reported after the external pacemaker was placed the patient's blood pressure improved and he was doing "a little' better. ED Physician A said the patient needed to be transferred because [Cardiologist B] didn't do transvenous pacemakers. Paramedic E said when the patient left their ED, in his opinion, he was more stable but still "very sick".

During an interview on 7/19/16 at 4:10 PM, ED Registered Nurse (RN) A said she was Patient #14's primary nurse on 7/9/16. She said when the patient presented to the ED at 2:56 AM he was complaining of chest pain, shortness of breath, and was "really" diaphoretic (perspiring profusely). Nurse A stated the patient was awake, talking and responded to questions. She said per protocol she administered Nitroglycerin ( a medication used used to treat angina symptoms, such as chest pain or pressure), four 81 milligrams (mg) of Baby Aspirin, placed the patient on 4 liters of oxygen, and obtained an immediate EKG. She said ED Physician A first examined the patient at approximately 3:00 AM, by that time the results of the EKG were available for review and she asked Physician A if a STEMI needed to be called because the EKG report documented a STEMI and there was an ST elevation (a finding on an electrocardiogram wherein the trace in the ST segment is abnormally high above the baseline. It can be associated with heart attacks). Nurse A reported when a ST elevation is present on the EKG results, a STEMI, is activated to alert the STEMI team (a team of specialists including the CATH lab staff, cardiologists, radiologists, laboratory staff and the CODE team). ED Physician A said "no" and instructed Nurse A to complete a second EKG in 20 minutes. Nurse A reported Patient #14 still complained of chest pain, he was holding the center of his chest and was "dripping" wet with sweat. After approximately 20 minutes the second EKG was completed, she gave ED Physician A the results. Nurse A stated, I again asked ED Physician A if I should call a STEMI. ED Physician A said "no" he was going to consult with a cardiologist. Nurse A stated, I returned to the patient's room and the patients status was "critical" at that point. Nurse A stated, the patient was on a heart monitor and an alarm sounded indicating the patient was in V tack momentarily. (A fast but regular heart rhythm, it can lead to ventricular fibrillation, which is fast and irregular. With ventricular fibrillation, the heartbeats are so fast and irregular that the heart stops pumping blood. Ventricular fibrillation is a leading cause of sudden cardiac death). Nurse A said at this point the patient's condition had declined, he was unresponsive and "very" diaphoretic and there was no response to a sternal rub (is a test for unconsciousness where painful or noxious stimuli is used to illicit a response from a semi-conscious person). Nurse A stated, ED Physician A said we needed to intubate the patient. The cardiac monitor alarm sounded again and she briefly saw V tack and then it went into a "crazy" rhythm and but you could still see an ST elevation. Nurse A reported the air care staff, ED Physician A, and the respiratory team was in the patient's room. Nurse A reported within a matter of 10-15 minutes the patient was moved to the trauma room, intubated, and another EKG was completed. Nurse A reported, ED Physician A left the patient's room briefly and when he returned he ordered staff to place an external pacemaker (A temporary means of pacing a patient's heart during a medical emergency, accomplished by delivering pulses of electric current through the patient's chest, which stimulates the heart to contract) on the patient and set the rate at 70 because the patient's blood pressure and pulse was low. Nurse A said she thought by that time ED Physician A said he was going to transfer the patient because [Cardiologist B] couldn't do a pacemaker and then [Air Paramedic E] suggested air care transfer to Iowa City. ED Physician A said "no" the patient was going to the accepting hospital. Nurse A reported she accompanied the patient in the ambulance to the accepting hospital because of the patient's critical state and the external pacemaker. She said Patient #14 never regained consciousness. When asked what time the ambulance arrived at the accepting hospital, Nurse A stated 6:00 AM. Prior to conclusion of the interview, Nurse A said she felt a STEMI should have been called when the first EKG was completed. When asked why she felt a STEMI should have been called she stated, "Because the team would have been there even if they weren't needed."

During an interview on 7/19/16 at 6:15 PM, ED Physician A said he was Patient #14's primary physician on 7/9/16. He said when the patient arrived by ambulance he was complaining of chest pain and shortness of breath. ED Physician A stated the patient admitted to a serious drug abuse history and to smoking crack a few hours before he came to the ED. He said the patient had a history of diabetes and heart problems when he reviewed his computer electronic medical record when entering orders. ED Physician A said the patient was in moderate distress. He said when the first EKG came back is showed a "couple" of "strange" things, complete AV block and significant ST elevation. ED Physician A stated he contacted [Cardiologist B] and told him the EKG looked "funny" there was an ST elevation and the computer was calling it an acute MI/STEMI. He said he didn't agree with that necessarily, that it was a "gray" area and that's why they have cardiology consultants. He said when he contacted the on-call cardiologist he was instructed to send him the EKG strip results. Cardiologist B called him back and said he didn't think it was a STEMI, he thought it was 3rd degree heart block and to repeat the EKG. ED Physician A reported he told the cardiologist he thought he needed to intubate the patient and he was " a little" bradycardic. When asked why the patient needed to be intubated, ED Physician A stated the patient's ABG's (arterial blood gases - a lab test that measures the levels of oxygen and carbon dioxide in the blood from an artery) was abnormal, his oxygen saturations decreased, he was in AV block, obtunded (altered level of consciousness, typically as a result of a medical condition or trauma), his heart was enlarged and there were no compensatory mechanisms left. ED Physician A stated when the patient first arrived he was able to answer simple questions however his condition declined and all the tests they were taking supported that. He said the patient was in complete heart failure and 3rd degree heart block and needed a pacer so he instructed staff to put a transcutaneous pacer on the patient approximately 45 minutes after he arrived to the ED. Physician A stated when he contacted the on-call cardiologist the second time, Cardiologist B told him to "ship" the patient to Iowa City but his staff were hesitant. He said at that point they were still "fighting" the idea the patient was having an MI and should be in the Cath lab. He reported the flight crew suggested sending the patient to the accepting hospital and he agreed so he contacted the on-call Cardiologist at accepting hospital [Cardiologist E]. ED Physician A said he reviewed the patient's condition and the cardiologist said it sounded like the patient needed a transvenous pacemaker and accepted the patient. Prior to conclusion of the interview, ED Physician A stated, "This guy would have died no matter what we did even if we'd done a temporary pacemaker."

During an interview on 7/20/16 at 7:30 AM, ED Physician G (accepting hospital) stated, Cardiologist E (accepting hospital) contacted him on 7/9/16 regarding a patient transfer to their ED for an emergency transvenous pacemaker. He said Cardiologist E told him Patient #14 needed a temporary pacemaker and after the conversation occurred the CATH team was alerted because this type of procedure was normally performed in the CATH lab. ED Physician G stated the patient arrived at approximately 5:20 AM to (accepting hospital) ED. When asked what the patient's condition was at the time of presentation he stated the patient was in critical condition, unresponsive, intubated and ventilated with an ambu bag (a hand held device used to provide pressure ventilation to patients who are not breathing) and he had an external pacemaker. ED Physician G stated the patient's pulse was "dangerously" low and his systolic blood pressure was in the 60's (The highest pressure when your heart beats and pushes the blood round your body, ideally should vary from 120 to 90.). ED Physician G said the patient was sent to their hospital because he had a dangerous heart rhythm called complete heart block although there were concerns for a STEMI based on the initial EKG from Covenant. ED Physician G reiterated, the patient's condition was critical on arrival and remained critical until the transvenous pacemaker procedure was performed. ED Physician G said Cardiologist E (accepting hospital) arrived at approximately 5:45 AM and assumed control of the patient. He said by that time the CATH team was there and he continued to chart after the patient left the ED, called ICU for a bed, and entered disposition orders in the patient's electronic medical record. ED Physician G confirmed his last entry was at 6:08 AM.

During an interview on 7/20/16 at 8:00 AM, Cardiologist Physician E (accepting hospital) stated he was contacted by ED Physician A, on 7/9/16 at 5:00 AM regarding a patient in their ED who had presented with chest pain and shortness of breath after smoking crack three hours prior to arrival to their ED. Cardiologist E stated ED Physician A reported the patient was in now in Congestive Heart Failure, they had to intubate him, he was hypotensive, desaturating, his blood pressure and heart rate was low and they had determined he was in complete heart block. When asked what complete heart block meant, he said it was the most severe heart block and was life threatening. Cardiologist E stated ED Physician A reported after application of a transcutaneous pacemaker (also called external pacing, is a temporary means of pacing a patient's heart during a medical emergency, accomplished by delivering pulses of electric current through the patient's chest, which stimulates the heart to contract), administration of Atropine injections ( a medication used in cardiac emergencies that acts on the conduction system of the heart and accelerates the transmission of electrical impulses through cardiac tissue. In cardiac arrest it is given to reverse asystole and severe bradycardia) and Dopamine infusions ( a medication is used to treat certain conditions, such as low blood pressure which may be caused by heart attack), for the past 2 hours and they had been unable to bring the patient's blood pressure up and he was "very unstable". Cardiologist E said when Physician A said the patient needed a pacemaker and he told him "OK" do a temporary pacemaker (transvenous pacemaker) if that's what he thought the patient needed. Cardiologist E said ED Physician A reported that Patient #14 had to be transferred because the hospital didn't have the capabilities to perform a transvenous pacemaker. When asked how he responded to ED Physician A when he told him they didn't have the capabilities to perform a transvenous pacemaker, Cardiologist E said, "Are your sure, have you spoken with your cardiologist?" He said ED Physician A said yes he had been speaking with their cardiologist (Physician B) for the past 2 hours and he'd suggested transferring the patient. ED Physician A told Cardiologist E if he didn't accept the patient they would have to send him to Iowa City. Cardiologist E stated he told ED Physician A, "OK, if you want me to do a temporary pacemaker then I can do that. I agreed to accept [Patient #14] for transfer." He said instructed ED Physician A to call the ER physician at their hospital. Cardiologist E stressed at no time throughout the conversation with ED Physician A was the word "permanent pacemaker used." Cardiologist E said when he arrived to their ED, at 5:36 AM, an EKG for Patient #14 showed a complete heart block. Cardiologist E reported, the patient was unresponsive, a blood pressure of 76/52, the patient's heart rate was "extremely" low and the patient's condition was unstable on arrival. Cardiologist E reported, the patient was taken to the cardiac catheter lab for a transvenous catheter within 10 minutes after arrival to the ED. When asked if ED Physician A reported if the patient had a history of previous cardiac conditions, Cardiologist E stated, "No, when I spoke with [ED Physician A] earlier, he told me he did not know if the patient had previous medical or cardiac conditions." Cardiologist E said they took Patient #14 to the cardiac catheter lab, performed the transvenous catheterization without difficulty. The patient tolerated the procedure well and he was transferred to the ICU. Cardiologist E stated, "[ED Physician A] was adamant they did not do transvenous pacemaker insertions at Covenant."

During an interview on 7/20/16 at 9:10 AM, Associate Registered Nurse Practitioner F(ARNP) (the ED physician accepting the transfer for the receiving hospital) stated he was contacted by [ED Physician A] on 7/9/16 regarding transferring Patient #14 to their hospital. Physician A told him the patient needed some type of pacemaker placement that their cardiologist was unable to do. ARNP F said ED Physician A reported he'd spoken with [Cardiologist E] and was instructed to transfer the patient to the ED (accepting hospital). ARNP F reported he signed the transfer form and talked [ED Physician G].

During an interview on 7/20/16 at 11:55 AM, the RN/Director of Cardio-Pulmonary Services reported transvenous catheter procedures are common and performed regularly at Covenant Medical Center.

During a follow up interview on 7/21/16 at 8:25 AM, the surveyor asked Cardiologist B if he reviewed Patient #14's medical record, Cardiologist B stated, "No, I can not review it at all because we don't have any portals to review." When asked if he documented anything in Patient #14's medical record, Cardiologist B stated, "No, because what happens when they call me, they're asking for my opinion, they ask me to look at an EKG to see what the EKG is because they don't understand."

During an interview on 7/21/16 at 2:20 PM, Hospitalist, Physician C confirmed he was the hospitalist on 7/9/16. He said ED Physician A contacted him that morning to inform him the patient may possibly be admitted to their hospital. Physician C stated within a half an hour later, after approximately 4:30 AM, ED Physician A contacted him again and told him the patient's blood pressure and pulse had decreased, he was not stable, and he was going to be transferred to the accepting hospital.

During an interview on 7/21/16 at 2:25 PM, the Vice President of Medical Affairs, acknowledged Cardiologist B had privileges for transvenous pacemaker placement and acknowledged their hospital had the capacity and capability to perform a transvenous pacemaker for Patient #14.

During an interview on 7/21/16 at 3:05 PM, Critical Care Physician/Pulmonologist, Physician H confirmed he was the Critical Care Physician/Pulmonologist on 7/9/16. When asked if he evaluated Patient #14 in the ED, Physician H stated he did not. He said Physician A contacted him between 4:00 - 5:00 AM and told him the patient was bradycardic and he'd spoken with Cardiologist B. When asked if he reviewed what services Patient #14 needed with Physician A, he stated, "I told him I thought the patient needed a pacemaker because the patient was having a heart attack and because of the complete heart block despite medications, and he needed to talk with cardiology." When asked what the standard protocol at their hospital would be if a patient presented with an acute cardiac event, Physician H stated, "If we think it's heart related the patient goes from the ED to the Cath Lab and then to ICU." Prior to conclusion of the interview Physician H said he felt he was contacted to give him a "heads up" if the patient was sent to the CATH lab or admitted to the hospital.