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FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVE NORFOLK, NE 68701 Sept. 24, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
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Based on record review of hospital policies, Medical Staff Rules and Regulations, on-call physician lists and staff interviews; the Ear, Nose and Throat (ENT) specialist physician on call failed to be available as required resulting in a delay of treatment for Patient 21. The facility also failed to immediately accept Patient 21 when called by the Crititcal Access Hospital requesting ENT services.The total sample size was 21. See also A 2404 and 2411. Findings are:

A. Record review of Medical Staff Rules and Regulations (last revised 1/2018) states that "when a request is made to accept the transfer of a patient from another facility, the house nursing supervisor, requesting physician, accepting physician shall be contacted to determine whether there is adequate capability and capacity to treat the patient". The policy further states that " The Hospital (including the Emergency Department physician and staff physicians) shall not refuse to accept requests for transfers if the patient is in need of the specialized, capabilities or facilities available at the Hospital"... "If an on-call physician receives a request for a transfer and is unwilling or unable to accept the transfer, the physician should refer the request to the administrator on call to determine whether to accept the transfer based on available capacity and capabilities."

Record review of facility policy titled" Emergency Medical Treatment and Labor Act (EMTALA) Policy last revised 8/18 states that the hospital "with respect to rural areas [CAH's are located in rural areas], regional referral centers may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who such specialized capabilities if the recieving hospital has the capacity to treat the individual."


Record review of facility policy titled "City Call Policy" (last revised 6/2016) states "The on-call physician, once consulted by the emergency room physician and notified of the need for his services in the emergency department will have 30 minutes (per Trauma Guidelines, Cardiology) in which to report to the emergency department, This period of 30 minutes cannot be extended by making telephone requests for further diagnostic studies to be done".

B. Record review of facility internal document titled "Incident Abstract Report" noted on 9/13/19, the House Supervisor, Registered Nurse (RN) A was unable to contact MD (Medical Doctor) A who was the ENT physician on call. A Critical Access Hospital (hospital providing a lower level of care) Physician , ED (Emergency Department) MD C, had spoken with the ENT around 4:00 PM in a conference call with RN A and ED MD C had a patient (Patient 21) in the Emergency Department with a nosebleed. The ENT MD A gave the critical access hospital physician, ED MD C, suggestions and agreed that ED MD C could call ENT MD A back in an hour if the bleeding continued. MD C called back again and RN A tried to reach ENT MD A at 7:40 PM using the cell phone number previously answered, received a message "no voice mail set up", pager and SPOKE (a secure text message system for the hospital) with no response. Patient 21, actively bleeding and becoming unstable was transferred to Hospital 3 as the ENT MD was unable to be reached.

C. Phone interview with ENT MD A (on 9/24/19 at 10:30 AM) confirmed being on call on 9/13/19 and recalled being called about Patient 21, a nosebleed patient. Hospital 1 physician had tried packing Patient 21's nose and suggested other things to try and "anything else needed to do & necessary to transfer". ENT MD A stated "initially, felt no Emergency Medical Condition (EMC), trickling blood, dripping." [The patient] was hemodynamically (vital signs stable) stable. The first call came on cell phone, second call ENT MD A was in a different part of house, where sometimes cell and pager will not work. ENT MD A lives outside of town with no land line available. ENT MD A was aware of issues in with contacting and had installed 2 cell boosters and wifi. This is the first time ENT MD A has not been able to be contacted since the boosters were installed. Later that night ENT MD A was reached and came in to take a patient to surgery. Once called it takes 6 -7 minutes or 10 minutes if traffic to get to the hospital.

D. ENT MD A is the sole active staff provider for ENT services and is available for call on some days and other days there is no ENT on call coverage. On call records for September 2019 show ENT MD A was on call 19 times in September including on 9/13/19 from 7 AM until 7 AM on 9/17/19.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on a review of facility policy, facility internal investigation report, and physician and staff interviews; Medical Doctor (MD) A, an Ear, Nose and Throat (ENT) on call specialty physician (at Hospital 2) failed to respond to multiple attempts of contact by hospital staff on 9/13/19 resulting in a delay of treatment for a patient (Patient 21) with an EMC (Emergency Medical Condition) needing transfer acceptance to the hospital from a critical access hospital, Hospital 1's, Emergency Department (ED) and the services of the specialty physician. The total sample included 21 patients. Facilty data provided for the past 6 months shows the facility ED treats on average 1,289 patients per month, The Facility Data Base with information provided by the facility identifies that they are a Regional Referral Center. Findings are:

A. Record review of facility internal document titled Incident Abstract Report noted on 9/13/19, the House Supervisor, Registered Nurse (RN) A was unable to contact ENT MD A who was the ENT physician on call. A Critical Access Hospital (CAH - a facility providing a lower level of care) Physician , ED MD C, had spoken with the ENT around 4:00 PM in a conference call with RN A and ED MD C had a patient (Patient 21) in the Emergency Department with a nosebleed. ENT MD A gave the critical access physician, ED MD C, suggestions and agreed that ED MD C could call ENT MD A back in an hour if the bleeding continued. ED MD C called back again and RN A tried to reach ENT MD A at 7:40 PM using the cell phone number ENT MD A previously answered, received a message "no voice mail set up", and paged and SPOKE (a secure text message system for the hospital) with no response.

B. Staff interview with House Supervisor, RN A, (on 9/24/19 at 9:00 AM) revealed that the process for CAH is to call a direct number to them for transfer or to talk with a specialist on call. The House Supervisor then stays on the line and creates a conference call with the specialist and the CAH physician. If the patient is to be transferred, the House Supervisor arranges bed placement once accepted by the physician.

RN A recalled that ED MD C from CAH (Hospital 1) called on 9/13/19 regarding Patient 21 asking if an ENT specialist was available. ENT MD A was on call and RN A connected the call. RN A recalled ED MD C asking questions regarding air for rhino rockets ( a nasal balloon inflated with air to stop nosebleeds). ENT MD A responded telling MD C to put more air in the rockets and that the patient will need antibiotics to decrease risk of infection. ENT MD A also related that the rockets can be left in for 3 -4 days if needed. RN A recalled there was no request for transfer to their hospital (Hospital 2) by ED MD C. ED MD C asked "when should ED MD C be worried" and was told by ENT MD A to "keep an eye on him, if questions call back." ED MD C called back to speak with ENT MD C again. RN A tried the same number that was called prior and got no answer with message "no voice mail set up". RN A then asked CAH ED MD C if CAH ED MD C would like to talk with the hospitals ED MD and responded with "No." RN A continued to try to reach ENT MD A by all methods available. 20 minutes passed and no response to calls. At 6:45 PM, RN A and the on coming House Supervisor tried SPOKE also with no return call. RN A then called the CAH ED MD C and reported unable to reach the ENT and had transferred the patient to Hospital 3. RN A said they were never able to reach ENT MD A who was on call for both ENT and Plastic Surgery at their Hospital. RN A confirmed ENT MD A was not doing surgery at this time. RN A said the incident report was done on ENT MD A being unable to reach when on call.

RN A stated that since the incident there has not been any new phone numbers to reach ENT MD A, only the cell number, pager and SPOKE. RN A stated "the expectation - should reach immediately or call back if in surgery." If in surgery the staff return the call to let us know. RN A stated they always offer to transfer direct to ED (done through call for advance acceptance to ED MD). The cah ED MD C was asked if wanted to talk to the ED MD and refused.

C. Record review of Hospital 1's Medical Record (dated 9/13/19) for Patient 21 notes the patient was seen by ED MD C at 2:59 PM for an unresolving nosebleed. At the time of arrival the patient was applying pressure to the outside of the nose with a blood soaked paper towel. Vital signs on arrival were Blood Pressure (BP) 138/59, Temperature 99.5 F (Fahrenheit), Pulse elevated at 136, Respirations of 18 per minute and pulse oximetry of 99 %. Patient stated the nosebleed started around 4:00 AM and had been progressively worsening throughout the day. The patient had 3 episodes of vomiting during the day with associated nausea and denied any recent trauma or nosebleeds requiring ED visits. Laboratory testing showed the patient was anemic with Hemoglobin of 7.8 (normal 12.4 to 14) and[DIAGNOSES REDACTED] ( a low platelet count) with platelets at 60 ( platelets help to form blood clots, normal range is 150 to 400). ED MD C documented the patient soaked through packing two times. A bilateral balloon catheter (rapid rhino rocket) was placed in the nose and inflated. Normal Saline l liter was given IV. 45 minutes later the physician noted the patient continued to have post nasal oozing. The notes state "Decision made at that patient would need transfer to ENT." ED MD called and spoke to ENT at Hospital 3 who agreed transfer was needed given the length of time bleeding had been present and continued bleeding despite packing. The patient was accepted for transfer at Hospital 3 however the patient then stated [the patient] preferred to be transferred either to Hospital 2 or Hospital 4. Hospital 2 and 3 were approximately an hour away. Hospital 4 was approximately 3 hours away.

ED MD C (per the record) then contacted the ENT on call at Hospital 2, ENT A. The record notes that ENT A suggested continued inflation of balloons every 10 -15 minutes for the next hour to help try to stop the bleeding "before he would accept transfer." IV antibiotics were given and the balloons were inflated further every 15 minutes with continued post nasal bleeding. ED MD C noted "Attempted to contact [Name of ENT A]. After spending greater than 1 hour attempting to get back in contact with [Name of ENT A], decision was made to get in contact with ENT at Hospital 4". It took 45 minutes longer to reach the ENT at hospital 4 during which time the patient had a large bloody emesis which prompted the Hospital 4 ENT to recommend transfer to a closer facility. Hospital 3 was then contacted again and agreed to the transfer.

Record review of the receiving hospital, Hospital 3's medical record and ambulance notes the patient left Hospital 1 at 8:48 PM, more than 5 hours after arrival at Hospital 1. Vital signs at the time of transfer were BP 125/74, Temperature 99.2 F. Pulse elevated at 107 and respirations normal at 18 per minute. He was awake alert and conversant. The patient arrived at 9:44 PM and was a direct admit to the floor. The ENT saw the patient and put in more specialized packing. The patient required surgery to control the source of the bleeding as well as blood transfusions and platelet transfusions during the hospital stay.

C. Phone interview with ED MD C (on 9/23/19 at 4:30 PM) confirmed the patient refused transfer to Hospital 3 after [the patient] was accepted. The patient lived near Omaha and wanted to go to Hospital 2 or Hospital 4. ED MD C recalled reaching ENT MD A who was on call from Hospital 2. The call was facilitated through someone else (the House Supervisor ) who stayed on the line. ENT MD A told ED MD C to increase the air in the Rhino Rockets and let ENT MD A know in an hour if not improved or needed something more. ED MD C called back an hour later and asked to talk with ENT MD A again. ENT MD A did not answer so they took my cell and said they would page ENT MD A. 20 minutes later I called back and they said ENT MD A had not responded. They said they would repage. 15 minutes later no response. I asked Hospital 2 "Is ENT MD A supposed to be on call, they responded "yes" until Saturday (the next day) AM. ED MD C recalled the patient had been stable, still oozing, blood pressures were ok, slightly tachy (elevated Heart Rate) 101 - 105 but overall ok. ED MD C also recalled then trying to reach the ENT on call at Hospital 4 and again having delays in contacting. During this time the patient became more tachy and bleeding more profusely,. Hospital 4 suggested to send [the patient] to the nearest ED. Hospital 2 was accepting and we transferred [the patient] there. Patient 21 had the nosebleed for 16 hrs and a low hemoglobin of 7.3. We did type and crossmatch for blood transfusion here so blood could be ready to give on arrival. Hospital 2 is affiliated with us so medical records and lab results work together. Plan was to give [the patient] 2 units of blood on arrival. I think [the ptaient] "had an Emergency Medical Condition by the time [the patient] transferred."

D. Phone interview with ENT MD A (on 9/24/19 at 10:30 AM) confirmed END MD A being on call on 9/13/19 and recalled being called about Patient 21, a nosebleed patient. Hospital 1 physician had tried packing nose and ENT MD A suggested other things to try and "anything else needed to do & necessary to transfer". ENT MD A stated "initially, felt no EMC, trickling blood, dripping." [The patient] was hemodynamically (vital signs stable) stable. The first call came on ENT MD A's cell phone, second call ENT MD A was in a different part of the house, sometimes cell and pager will not work. ENT MD A lives outside of town with no land line available. ENT MD A was aware of issues in contacting and had installed 2 cell boosters and wifi. This is the first time ENT MD A has not been able to be contacted since the boosters were installed. Later that night ENT MD A was reached and came in to take a patient to surgery. Once called it takes 6 -7 minutes or 10 minutes if traffic to get to the hospital.

E. ENT MD A is the sole active staff provider for ENT services and is available for call on some days and other days there is no ENT on call coverage. On call records for September 2019 show ENT MD A was on call 19 times in September and was on call 9/13/19 from 7 AM until 7 AM on 9/17/19.

F. Phone interview conductd with ENT E, the receiving hospital ENT for Hospital 3 on 9/13/19 at 1:30 PM. ENT E recalled getting the initial call from ED MD C. ENT E felt the patient had an EMC and voiced our willingness to accept the patient for transfer. ENT E recalled receiving "in EMC,[with] ongoing bleeding from a noncompressable site and unfavorable coagulation (clotting) status".The patient went to surgery twice to control sources of bleeding and was discharged on [DATE]".

G. Record review of the "Medical Staff Rules and Regulations"( last revised 1/2018) states: "when a request is made to accept the transfer of a patient from another facility, the house nursing supervisor, requesting physician, accepting physician shall be contacted to determine whether there is adequate capability and capacity to treat the patient". The policy further states that " The Hospital (including the Emergency Department physician and staff physicians) shall not refuse to accept requests for transfers if the patient is in need of the specialized, capabilities or facilities available at the Hospital", "If an on-call physician receives a request for a transfer and is unwilling or unable to accept the transfer, the physician should refer the request to the administrator on call to determine whether to accept the transfer based on available capacity and capabilities.

Record review of the facility policy "City Call Policy" (last revised 6/2016) states: "The on-call physician, once consulted by the emergency room physician and notified of the need for his services in the emergency department will have 30 minutes (per Trauma Guidelines, Cardiology) in which to report to the emergency department, This period of 30 minutes cannot be extended by making telephone requests for further diagnostic studies to be done".
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review of 20 Emergency Department (ED) records, facility policy review and staff /provider interviews the facility failed to accept 1 sampled patient (Patient 21) for transfer from a Critical Access Hospital (CAH) "1". CAH hospitals provide a lower level of care and transfer patients needing more complex care to Regional Referral Centers. The Facility Data Base completed by the facility identifies Faith Regional Health Services (Hospital "2") as a Regional Referral Center. Failure to accept the patient for transfer can cause a delay in treatment leading to harm and or death. Findings are:

A. Record review of Hospital 1's Medical Record (dated 9/13/19) for Patient 21 notes the patient was seen by ED MD C at 2:59 PM for an unresolving nosebleed. At the time of arrival the patient was applying pressure to the outside of the nose with a blood soaked paper towel. Vital signs on arrival were Blood Pressure (BP) 138/59, Temperature 99.5 F (Fahrenheit), Pulse elevated at 136, Respirations of 18 per minute and pulse oximetry of 99 %. Patient stated the nosebleed started around 4:00 AM and had been progressively worsening throughout the day. The patient had 3 episodes of vomiting during the day with associated nausea and denied any recent trauma or nosebleeds requiring ED visits. Laboratory testing showed the patient was anemic with Hemoglobin of 7.8 (normal 12.4 to 14) and[DIAGNOSES REDACTED] ( a low platelet count) with platelets at 60 ( platelets help to form blood clots, normal range is 150 to 400). ED MD C documented the patient soaked through packing two times. A bilateral balloon catheter (rapid rhino rocket) was placed in the nose and inflated. Normal Saline l liter was given IV. 45 minutes later the physician noted the patient continued to have post nasal oozing. The notes state "Decision made at that patient would need transfer to ENT." ED MD called and spoke to ENT at Hospital 3 (in another state) who "agreed transfer was needed given the length of time bleeding had been present and continued bleeding despite packing." The patient was accepted for transfer at Hospital 3 however the patient then stated he preferred to be transferred either to Hospital 2 or Hospital 4 located in Nebraska. Hospital 2 and 3 were approximately an hour away. Hospital 4 was approximately 3 hours away.

B. Documentation from CAH Hospital 1 showed ED MD C contacted ENT(Ear Nose and Throat specialist) MD A who was the on-call ENT for Faith Regional Center (Hospital 2). The notes showed on-call ENT A, "suggested continued inflation of balloons every 10-15 minutes for the next hour to help to try to stop bleeding before he wounded accept transfer."
ED MD C's documentation stated "Catheters inflated further every 15 minutes with continued postnasal bloody drainage". He attempted to call ENT A but after spending greater than 1 hour trying to reach ENT A at Faith Regional (Hospital 2), the decision was made at 7:00 PM to start work on transfer to Hospital 4, the patients other choice. Documentation by ED MD C states that while attempting to contact an ENT at Hospital 4 for transfer the patient "had a large bloody emesis which prompted the ENT at Hospital 4 to recommend transfer to a closer facility, therefore ED MD C then contacted the first hospital (Hospital 3) out of state. The patient was transferred by ground ambulance. ED MD C documented deciding to transfer the patient at 5:00 PM and "it was not until 7:45 PM that we were able to get acceptance."

C. Staff interview with House Supervisor, RN A, (on 9/24/19 at 9:00 AM) revealed that the process for CAH is to call a direct number to them for transfer or to talk with a specialist on call. The House Supervisor then stays on the line and creates a conference call with the specialist and the CAH physician. If the patient is to be transferred, the House Supervisor arranges bed placement once accepted by the physician. RN A recalled that ED MD C from CAH (Hospital 1) called on 9/13/19 regarding Patient 21 asking if an ENT specialist was available. ENT MD A was on call and RN A connected the call. RN A recalled ED MD C asking questions regarding air for rhino rockets ( a nasal balloon inflated with air to stop nosebleeds). ENT MD A responded telling MD C to put more air in the rockets and that the patient will need antibiotics to decrease risk of infection. ENT MD A also related that the rockets can be left in for 3 -4 days if needed. RN A recalled there was no request for transfer to their hospital (Hospital 2) by ED MD C. ED MD C asked "when should ED MD C be worried" and was told by ENT MD A to "keep an eye on him, if questions call back." ED MD C called back to speak with ENT MD C again. RN A tried the same number that was called prior and got no answer with message "no voice mail set up". RN A then asked CAH ED MD C if CAH ED MD C would like to talk with the hospitals ED MD and responded with "No." RN A continued to try to reach ENT MD A by all methods available. 20 minutes passed and no response to calls. At 6:45 PM, RN A and the on coming House Supervisor tried SPOKE (a messaging system) also with no return call. RN A then called the CAH ED MD C and reported unable to reach the ENT. The patient had to be transferred to Hospital 3. RN A said they were never able to reach ENT MD A who was on call for both ENT and Plastic Surgery at their Hospital.

D. Phone interview with ED MD C (on 9/23/19 at 4:30 PM) confirmed the patient refused transfer to Hospital 3 after [the patient] was accepted. The patient lived near Omaha and wanted to go to Hospital 2 or Hospital 4. ED MD C recalled reaching ENT MD A who was on call from Hospital 2. The call was facilitated through someone else (the House Supervisor ) who stayed on the line. ENT MD A told ED MD C to increase the air in the Rhino Rockets and let ENT MD A know in an hour if not improved or needed something more. ED MD C called back an hour later and asked to talk with ENT MD A again. ENT MD A did not answer so they took my cell and said they would page ENT MD A. 20 minutes later I called back and they said ENT MD A had not responded. They said they would repage. 15 minutes later no response. I asked Hospital 2 "Is ENT MD A supposed to be on call, they responded "yes" until Saturday (the next day) AM. ED MD C recalled the patient had been stable, still oozing, blood pressures were ok, slightly tachy (elevated Heart Rate) 101 - 105 but overall ok. ED MD C also recalled then trying to reach the ENT on call at Hospital 4 and again having delays in contacting. During this time the patient became more tachy and bleeding more profusely,. Hospital 4 suggested to send [the patient] to the nearest ED. Hospital 2 was accepting and we transferred [the patient] there. Patient 21 had the nosebleed for 16 hrs and a low hemoglobin of 7.3. We did type and crossmatch for blood transfusion here so blood could be ready to give on arrival. Hospital 2 is affiliated with us so medical records and lab results work together. Plan was to give [the patient] 2 units of blood on arrival. I think [the patient] "had an Emergency Medical Condition by the time [the patient] transferred."

E. Record review of facility policy titled" Emergency Medical Treatment and Labor Act (EMTALA) Policy last revised 8/18 states that the hospital "with respect to rural areas [CAH's are located in rural areas], regional referral centers may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who such specialized capabilities if the receiving hospital has the capacity to treat the individual."
Record review of Medical Staff Rules and Regulations (last revised 1/2018) states that "when a request is made to accept the transfer of a patient from another facility, the house nursing supervisor, requesting physician, accepting physician shall be contacted to determine whether there is adequate capability and capacity to treat the patient". The policy further states that " The Hospital (including the Emergency Department physician and staff physicians) shall not refuse to accept requests for transfers if the patient is in need of the specialized, capabilities or facilities available at the Hospital"... "If an on-call physician receives a request for a transfer and is unwilling or unable to accept the transfer, the physician should refer the request to the administrator on call to determine whether to accept the transfer based on available capacity and capabilities."

F. The evidence in the Medical Record at the CAH indicated Patient 21 had an unstabilized Emergency Medical Condition (EMC) that required the services of an ENT physician that was not available at the CAH, necessitating transfer of the patient to a higher level of care. ENT A was on- call for Faith Regional Medical Center, a Regional Referral Center, and delayed the care of a bleeding patient with an unstabilized medical condition when he conditioned acceptance of an appropriate transfer request on additional treatment at the CAH. The on-call ENT MD A failed his oncall obligations when recontacted by the CAH and the transferring hospital had to arrange transfer to another hospital.