HospitalInspections.org

.
Based on observation, record review, and staff interviews, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. Facility A failed to provide stabilizing treatment for one (1) or twenty-one (21) patients (Patient #1) experiencing an emergency medical condition. Patient #1 arrived at Facility A on 03/03/2025 at 8:58 P.M., for right-sided facial swelling and an increase in both the swelling and pain. Facility A failed to provide stabilizing treatment. Patient #1 deteriorated after a diagnosis of Parotitis and discharge home. Patient #1 sought treatment the same day at 5:06 P.M., at Facility B, with the same complaint of increased swelling and pain of the face. Patient #1 was hospitalized for airway monitoring and intravenous antibiotic treatment.
.
See Tag 2407

.
Based on observation, record review, and staff interviews, Facility A failed to provide adequate physician on-call coverage consistent with the services provided at the hospital and the resources the hospital has available, including the availability of specialists, subjecting patients seeking emergent treatment to probable harm.
.
Findings:
.
1. Record review of the on-call physicians' schedule at Facility A:
.
A. October 2024- 1 of 30 days did not have a diagnostic radiology on-call.
B. December 2024- 1 of 31 days did not have a diagnostic radiology on-call.
C. January 2025- 1 of 31 days did not have a diagnostic radiology on-call.
D. September 2024- 8 of 30 days did not have a gastroenterology on-call.
E. January 2025- 2 of 31 days did not have a gastroenterology on-call.
F. March 2025- 2 of 31 days did not have a gastroenterology on-call.
G. November 2024- 3 of 30 days did not have a hospitalist on-call.
H. December 2024- 1 of 31 days did not have a hospitalist on-call.
I. March 2025- 2 of 31 days did not have an interventional radiology on-call.
J. September 2024- 5 of 30 days did not have maxillofacial trauma on-call.
K. November 2024- 3 of 30 days did not have maxillofacial trauma on-call.
L. December 2024- 4 of 31 days did not have maxillofacial trauma on-call.
M. January 2025- 4 of 31 days did not have maxillofacial trauma on-call.
N. March 2025- 1 of 31 days did not have OR anesthesia on-call.
O .December 2025- 5 of 31 days did not have spine on-call.
P. March 2025 1 or 31 days did not have spine on-call.
.
2. Interview:
.
During an interview with the Director of Medical Staff Services, Staff M was provided with a copy of the on-call physician schedule. Staff M was asked to identify the notations on the schedule. When asked if the days selected in red and labelled "no coverage" meant there was not a physician available, Staff M responded, "That's correct." When asked if the days selected in purple with no physician listed meant there was not a physician available, Staff M responded, "That's correct."
.
3. Policies:
.
Review of Facility A's Rules and Regulations: Revision Approved June 2024,
A-6: Response Time: Page 7 of 35:
"ED - If the patient's clinical situation warrants the presence of the attending physician, designee, or on- call physician, as determined by the ED physician, such physician is expected to arrive at the hospital within 30 minutes after responding to the call or page. Physicians must respond within 30 minutes of being paged.
.
In the event, a particular specialty is not available or the on-call physician cannot respond due to circumstances beyond the physician's control, the emergency department physician should attempt to make one (1) additional contact to a physician in the same specialty on the medical staff. If this attempt is unsuccessful and/or the response takes longer than 30 minutes, the chain-of-command must be invoked and immediate arrangements should be secured for patient transfer to an appropriate facility."
.
B-16: Call responsibility: Page 11 of 35:
"All Active Medical Staff members may be required to take emergency room call for emergency room patients if there is a designated call rotation schedule for their specialty.
The physician's responsibility while on call to the ED includes evaluating and treating a patient when the patient is referred from the Emergency Department to the on-call physician for office follow-up and/or further care.
If the on-call physician is unable or unwilling to provide patient care, the on-call physician shall arrange coverage by a back-up or alternate physician; the back-up or alternate physician must contact the Emergency Department within thirty (30) minutes of the original request for consult by the ED to discuss a resolution to the patient care need.
If the on-call physician is unable to be contacted or unwilling to arrange alternate coverage, the back-up physician listed on the call schedule or covering the physician's practice must assume those responsibilities.
.
In the event that both the on-call physician and back-up/covering physician are unable to be contacted or are unwilling to provide patient care, the Department Chief shall be immediately contacted and will attempt to arrange with another appropriate physician to care for the patient, if there is such a physician available. If no such physician is available, the Department Chief will contact the administrator on-call and the administrator on-call may contact the Chief of Staff, and together, all three will determine the next course of action. In all circumstances, the safety and well-being of the patient will be of primary concern. As such, at any point, a physician may initiate a transfer of the patient if he/she deems it necessary after having considered the potential impact on the patient of the prevailing circumstances and delays in securing the needed specialists or other physicians."

.
Based on observation, record review, and staff interviews, Patient #1 arrived at Facility A on 03/03/2025 at 8:58 P.M., for right-sided facial swelling and an increase in both the swelling and pain. Facility A failed to provide stabilizing treatment. Patient #1 deteriorated after a diagnosis of Parotitis and discharge home. Patient #1 sought treatment the same day at 5:06 P.M., at Facility B, with the same complaint of increased swelling and pain of the face. Patient #1 was hospitalized for airway monitoring and intravenous antibiotic treatment.
.
Findings
.
1.Medical Record
Review of Patient #1's medical record from Facility A:
On 03/03/2025 at 8:58 A.M., Patient #1 arrived at Facility A's emergency department with complaints of right-sided facial swelling. During triage Patient #1's vital signs included a blood pressure of 147/95, a heart rate of 99, and a temperature of 99.0 Fahrenheit.
At 9:02 A.M., Patient #1's medical screening examination was completed by Staff N. Staff N's note states that Patient #1 claims that the facial swelling "has rapidly increased in size and become more painful," and that Patient #1 "reports pain with swallowing but is able to tolerate fluids without difficulties." At this time, Staff N reports "no acute distress" and "airway patent."
At 9:11 A., Patient #1 was worked up for sepsis. Patient #1 was administered intravenous antibiotics (Clindamycin) and a 2,300 mL (milliliter) bolus of normal saline. The patient received a chest x-ray, blood cultures, labs, pain medications, and a CT (computed tomography) scan.
Per the testing results, there was no evidence of sepsis, however, the CT scan findings did indicate right sided parotitis.
At 11:45 A.M., per the provider's note, "the patient's (Patient #1) condition is stable and appropriate for discharge." "Follow up information for ENT (ear, nose, nose, and throat physician) provided in the discharge paperwork."
Patient #1 was diagnosed with parotitis, discharged charged home 03/03/2025 at 11:45 A.M., and was not admitted for further observation of the swelling that could restrict the airway.
.
Review of Patient #1's medical record from Facility B:
On 03/03/2025 at 4:32 P.M Patient #1 arrived at Facility B's emergency department with complaints of previous salivary gland infection with large amount of facial swelling."
At 5:06 P.M, Patient #1 was administered steroids, pain medication, antibiotics, labs, blood cultures, a 2,500 mL (milliliter) electrolyte-a bolus, and a CT (computed tomography) scan.
CT scan findings indicated "extensive nonspecific inflammatory changes of the right face and neck with mass effect and moderate narrowing of the airway. Additional nonspecific prevertebral soft tissue edema."
At 7:55 P.M., The provider noted that Patient #1's "swelling has progressed; patient (Patient #1) reports some difficulty speaking and breathing as well as managing secretions." Vital signs at this time were within normal limits. Facility B's provider consulted ICU (intensive care unit) providers for admission of Patient #1 for "airway watch." Provider noted Patient #1's "acute distress," "ill-appearing," and "Massive R (right) sided swelling from upper cheek to upper neck," and "breathing with mild stridor."
At 8:04 P.M., ENT (ear, nose, and throat physician) was consulted.
At 8:14 P.M., Patient #1 was admitted to the ICU (intensive care unit).
Patient #1 was diagnosed with facial swelling and admitted to the ICU (intensive care unit) for airway monitoring due to the narrowing of the airway, per the CT (computed tomography) scan. Patient remained in the ICU (intensive care unit) at Facility B for three (3) days, per the complainant.
.
2.Policies
Review of Facility A's document EMTALA- Medical Screening Examination and Stabilizing Policy EC.EM.002
Page 12 of 15:
7. Stabilizing Treatment Within Hospital Capability
"An individual has been provided sufficient stabilizing treatment when the physician treating the individual in the DED (dedicated emergency department) has determined, within reasonable clinical confidence, that no material deterioration of the condition is likely ..."
.
3.Interviews
On 03/25/2025 at 12:15 P.M. an in-person interview with Medical Director Staff F was conducted.
Staff F stated, "a medical screening exam under law by a qualified professional, advanced practice provider, or MD, to make sure there isn't a medical emergency or to meet the needs of an emergency. There are additional parts to EMTALA, but that is the main one I focus on."
Staff F explains, "We did start with the sepsis protocol just to make sure. Vitals were within normal range, labs were unremarkable, and the CT scan showed no signs of abscess. A CT scan would provide me with big evidence. I was not concerned for any airway compromise, if I were, I would have admitted him." "His speech was fine, the airway was patent, he only had unilateral external swelling around the mandible." "There was no abscess to drain with this patient, so it was just symptomatic management. 99% of the time, salivary gland infections resolve themselves."