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 JOSEPH MEDICAL CENTER 1717 SOUTH J STREET TACOMA, WA 98405 July 9, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interviews, document review and medical record review, it was determined that the hospital failed to meet the requirements to comply with 42 CFR 489.24. Failure to do so places patients at risk for not receiving appropriate treatment according to the EMTALA requirements.

Findings include:

A) On June 8, 2014, Patient #1 was transferred via ambulance to the Emergency Department at Hospital #1.

After the MSE of the patient, the ED physician contacted the ENT on-call physician who refused to see the patient.

The ED physician made several phone calls to find an accepting ENT specialist to stabilize the patient and the patient was transferred to another local hospital via ambulance.

In Hospital #1's Medical Staff Bylaws, Article II: General Rules, Section 10, the requirements for active medical staff performing on-call functions is outlined. This was not followed by Physician #1. This was corroborated through interview with Physician #1 on July 9, 2014 at 1045.



B) Based on interview and document review, the facility did not define in hospital medical staff bylaws or rules and regulations the individuals qualified to perform a medical screening exam. Failure to do so does not meet the EMTALA requirements.

Findings include:

In Hospital #1's policy #345.00 EMTALA: How to Comply with the Law, under section (F)(3), the policy states that the medical screening exam should be performed by a physician or other qualified medical personnel. The investigator could not find documentation designating who is determined qualified by the medical staff in their bylaws or rules and regulations, to perform the medical screening exam, except for licensed allied health professionals & Women's Care Center Regional Structure Standards (IV)(B)(iv)(14) state " Delivery Nurses who have demonstrated competency can perform medical screening exams to differentiate true and false labor". This was corroborated with the Medical Staff Coordinator and the Risk Manager in an interview on July 7, 2014.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
Based on interview and medical record review, the on-call ENT physician failed to respond to stabilize Patient #1's emergency condition. Failure to respond required the patient to be transferred to another hospital for stabilizing care.

Findings include:

On receipt of the patient at Hospital #1, the ED physician contacted the ENT on-call physician who refused to see the patient for the following reasons:
1) The on-call ENT physician did not accept the transfer from the other facility and,
2) The communication the ENT physician received was that another physician accepted the patient and therefore should care for the patient.

The ED physician made several phone calls to find an accepting ENT specialist to stabilize the patient and the patient was transferred to a local hospital via ambulance.


Specific to 42 CFR 489.24 and Hospital #1's policy #345: EMTALA-How to Comply with the Law, the hospital failed to provide necessary stabilizing treatment within the capabilities of the staff and facility. This was corroborated through interview with Physician #1 on July 9, 2014 at 1045.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interview and document review, the facility did not define in hospital medical staff bylaws or rules and regulations the individuals qualified to perform a medical screening exam. Failure to do so does not meet the EMTALA requirements.

Findings include:

In Hospital #1's policy #345.00 EMTALA: How to Comply with the Law, under section (F)(3), the policy states that the medical screening exam should be performed by a physician or other qualified medical personnel. The investigator could not find documentation designating who is determined qualified by the medical staff in their bylaws or rules and regulations, to perform the medical screening exam except for licensed allied health professionals.

This was corroborated with the Medical Staff Coordinator and the Risk Manager in an interview on July 7, 2014.


The Women's Care Center Regional Structure Standards (IV)(B)(iv)(14) state " Delivery Nurses who have demonstrated competency can perform medical screening exams to differentiate true and false labor".

This designation was not found in the medical staff bylaws or rules and regulations as outlined in the EMTALA regulations 42 CFR 489.24(a)(1)(i).
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on interview and medical record review, the on-call physician failed to respond to stabilize Patient #1's emergency condition. Failure to respond required the patient to be transferred to a different facility for stabilizing care.

Findings include:

Hospital #1 ED physician performed a Physical Exam with presenting signs and symptoms & past medical history, Laboratory testing & radiologic studies including: Rapid Strep Screen, Basic Metabolic Panel, Hemogram, Differential, GFR-Male, Mononucleosis Screen and CT-soft tissue neck. See patient records for results.

Medication given (Hydromorphone/Dilaudid-1mg Intravenous).

Hospital #1, ED physician contacted the ENT on-call physician to stabilize the medical condition. On-call ENT physician refused to see the patient for the following reasons:
1) The on-call physician did not accept the transfer from the other facility and,
2) The communication the physician received was that another physician accepted the patient and therefore should care for the patient.
The ED physician made several phone calls to find an accepting ENT specialist to stabilize the patient and the patient was transferred to another hospital via ambulance.

In an interview with Physician #1 on July 9, 2014 at 1045, the physician stated the s/he was aware of the responsibility of being on-call to the emergency department and agreed that s/he was on-call on the day of question.