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FAXTON-ST LUKE'S HEALTHCARE 1656 CHAMPLIN AVENUE UTICA, NY 13503 July 31, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on findings from document review, medical record review and interview, the hospital failed to comply with the requirements at 489.24 and related requirements at 489.20.

See Tag A2404.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
Based on medical record (MR) review, document review, and interview, the facility did not ensure the following: 1) in 1 of 12 MRs reviewed (for patients requiring on call physician services), the on-call provider refused to make an in-person appearance to evaluate and treat an unstable individual. 2) In 4 of 12 MRs reviewed (for patients requiring on-call physician services), the on-call provider did not respond timely to emergency department (ED) physician's calls. 3) The hospital on-call list for surgeons does not consistently identify the individual physician who is responsible for call. 4) The hospital policy and procedure (P&P) for on-call physicians did not clearly outline the duties and responsibilities of the physician on-call and did not address all regulatory requirements. These lapses could lead to untoward patient outcomes.

Findings regarding (1) above include:

-- Review of Patient #1's MR, the Patient was brought to the ED (via ambulance) on 6/5/17 at 10:45 pm after a motor vehicle accident with loss of consciousness. He was triaged as a level 1 (on 1-5 scale, 1= requires immediate life-saving intervention). At 11:51 pm, the on-call surgeon, Staff B was called. Staff were unable to reach him/her. However, at 12:07 am (on 6/6/17), documentation reveals Staff A (ED Physician) spoke to an on-call surgeon, Staff C (from Staff B's surgical group.) Staff C refused to come to the ED to evaluate the patient. He/she instructed Staff C to transfer Patient #1 to the local trauma center (Hospital A).

-- Per review of the hospital's P&P titled "EMTALA: Emergency Medical Treatment and Active Labor Act- Screening, Stabilization, Management of Transfers and Recordkeeping; Reporting Suspected EMTALA Violations," dated 3/16/17, "When a physician is on call ... it is not acceptable to refer or transfer unstable cases ... the physician must come to the hospital to examine the individual."

-- Per interview of Staff A on 7/28/17 at 1:00 pm, Patient #1 had severe back pain, hypotension (low blood pressure), and positive loss of consciousness. When he/she asked the on call surgeon (Staff C) to come in to examine Patient #1, he/she refused and told Staff A the patient needed to be sent to a trauma center.

-- Per interview of Staff C on 7/28/17 at 2:15 pm, regarding Patient #1, he/she was paged and responded. After Staff A explained the patient case he/she recommended to "resuscitate the patient and transfer to the trauma center." The patient needed critical care. He/she stated he did not refuse to see the patient but "wanted the patient resuscitated and transferred." He did not come in to see the patient.

Findings regarding (2) above include:

-- Per review of the facility's P&P titled "EMTALA: Emergency Medical Treatment and Active Labor Act- Screening, Stabilization, Management of Transfers and Recordkeeping; Reporting Suspected EMTALA Violations," dated 3/16/17, it indicated the on-call physicians' responsibility to respond, examine and treat emergency patients is set forth in the facility's Medical Staff Rules and Regulations.

-- Review of the facility's "Medical Staff Policies (Rules and Regulations)" last revised 6/2017, revealed that the member on call is to respond to the ED when requested by the ED practitioner by telephone call within 20 minutes. In addition, response time in emergency situations surgeons, anesthetists and obstetrician must be in the physical presence of the patient within 30 minutes.

-- Per review of Patient #2's MR, on 6/5/17 at 8:13 am, she presented to the ED (via ambulance) with abdominal pain and hypotension. She was triaged as a level 2 (condition has potential to threaten life, limb, visual function, requires rapid medical intervention, should not wait to be seen). At 8:15 am, Staff D evaluated the patient. At 11:13 am, Staff D (ED Physician) discussed the patient with on-call surgeon (Staff C) and he agreed to see the patient. At 12:43 pm (1 hour and 30 minutes later), Staff C arrived at the ED to evaluate Patient #2.

-- Per review of Patient #3's MR, on 5/8/17 at 3:07 pm, he presented to the ED with a right thumb traumatic amputation. He was triaged as a level 2. At 3:34 pm, Staff E (ED Physician) called the on-call provider (Staff F) and left a message. At 3:51 pm, another message was left. At 4:40 pm (59 minutes later), Staff F, the on-call provider called back. (Contact was made with another facility at 4:05 pm. That facility called back at 4:15 pm and after discussion indicated Patient #3's thumb could not be reattached so patient should stay there.)

-- Per review of Patient #5's MR, on 3/23/17 at 1:50 am, she presented to the ED with abdominal and groin pain. She was triaged as a level 3 (require two or more resources, but less urgent). At 5:28 am, Staff G called the on-call surgeon (Staff C). Staff C responded and stated he/she understood the patient needed surgery and he/she would make a few phone calls. At 5:40 am (12 minutes later), Staff C telephoned and stated he/she would see the patient in the hospital and agreed to admit the patient. At 8:46 am (3 hours and 6 minutes later), the patient was taken to surgery by Staff H (Surgeon). Consultation documentation revealed the on-call surgeon (Staff C) did not present to the hospital ED but indicated he would meet Staff H in the operating room.

-- Per review of Patient #4's MR, on 7/3/17 at 9:29 am, he presented to the ED (via ambulance) with left shoulder pain and swelling after being thrown from a bicycle. He was triaged as a level 2. At 11:11 am, the on-call surgeon (Staff B) was called, and a message was left. At 11:35 am, and 11:58 am, additional messages were left for Staff B. At 12:01 pm, Staff I (ED Physician) consulted with Staff J (Cardiothoracic Surgeon) who provided treatment orders. At 12:08 pm, a trauma surgeon from another hospital (Staff K) was contacted and he/she accepted the patient for transfer. The MR lacks documentation of any return call from Staff B, the on-call surgeon.

-- During interview of Staff L (Director of Quality Management) on 7/31/17 at 2:00 pm, he/she acknowledged the above findings.

Findings regarding (3) above include:

-- Review of the facility's surgery on-call list for June and July of 2017, identified the following: on June 1, 5 (date of the index case), 9, 17, 21, 25, 29, 2017 and July 3, 7, 19, 27, 31, 2017, Staff B is listed as the on-call surgeon. However, per interview of Staff M (ED Medical Director) on 7/28/17 at 10:40 am, he/she confirmed that Staff B's name indicated his/her surgical group is on call. It may be one of the three surgeons in the group, not specifically Staff B.

-- Per interview of Staff N (Chief Medical Officer) on 7/28/17 at 11:00 am, he/she stated there is no formal communication with this surgical group to indicate which specific physician is on call.

-- Per interview of Staff L on 7/28/17 at 12:50 pm, he/she stated the head of the surgical group is listed on the on-call list and the group decides who is on call. He/she was not sure who exactly was on call on 6/5/17.

Findings regarding (4) above include:

-- Per review of the hospital's P&P titled "EMTALA: Emergency Medical Treatment and Active Labor Act- Screening, Stabilization, Management of Transfers and Recordkeeping; Reporting Suspected EMTALA Violations," dated 3/2017, and the hospital's "Medical Staff Rules and Regulations," last revised 6/2017, these documents did not address simultaneous call or contain a back up procedure when the on-call physician is not available to respond.

-- During interview of Staff N (Chief Medical Officer) on 7/28/17 at 11:15 am, he/she acknowledged the above findings.