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.

Based on Medical Record review, document review and interview, in one (1) out of four (4) patients that left Against Medical Advice (AMA), the facility failed to ensure that a Medical Consultation was conducted in accordance with the facility's Policy.

This failure puts all patients at risk for not receiving appropriate Consultations to meet their medical needs.


On the afternoon of 12/07/15, during Medical Record review, it was noted that Patient #8 presented to the Emergency Department (ED) on 11/22/15 at 1:17PM with complaints of Palpitations. The patient's Heart Rate was documented at 140 and her Troponin Level of 0.02 at 2:01PM was within the normal range of 0.00-0.03.

At 2:32 PM the ED Physician ordered a Cardiology Consult and the On-Call Cardiologist was paged.

Two (2) hours later, at 4:34PM, the ED Physician documented that "Patient states she has developed an "ache" in her chest" and "Cardiology On-Call paged again" and Labs were reordered.

At 5:12PM the patient's Troponin Level was documented as elevated to 0.18.

At 5:55PM the Physician documented "Unable to reach Cardiology On-Call."

At 6:47PM the patient signed out AMA because "the patient is upset that a Cardiologist has not come to see her in the ED yet" and she wanted to go to another hospital.

Review of the facility's Policy titled "On-Call Process and Responsibilities - Emergency Department" dated 06/14 revealed, under "Procedure" #3 "Response time for On-Call Physicians", that "In accordance with the Hospital's Medical Staff Rules and Regulations, On-Call Physicians must respond by phone or in person within twenty (20) minutes of being paged, beeped or otherwise contacted, and the Medical Staff Member must be present in the Emergency Department within approximately thirty (30) minutes for critical (emergent) patients as determined by the ED Physician and within two (2) hours for all others".

The On-Call Cardiologist failed to respond to the page within the facility's required twenty (20) minutes, and failed to present to the patient within the facility's required two (2) hours.

In an interview with Staff A (ED Physician) on 12/08/15 at 9:30AM, when asked what the facility Policy was regarding return calls from On-Call Physicians, replied "I don't know the exact time frame" and was unable to verbalize the Policy.