HospitalInspections.org

Based on Medical Staff bylaws, rules and regulations review, policy and procedure review, closed medical record reviews, On-call physicians' schedule review, and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 42 CFR 489.24 by failing to ensure a physician who was on-call for Orthopedic services was available to provide services upon the request of the dedicated emergency department (DED) physician for 1 of 11 patients that were transferred with an emergency medical condition (#20).

The findings include:

The hospital failed to ensure a physician who was on-call for Orthopedic services was available to provide services upon the request of the dedicated emergency department (DED) physician for 1 of 11 patients that were transferred with an emergency medical condition (#20).

~ cross refer to 489.20(r)(2) and 489.24(j)(1-2), On Call Physicians - Tag A2404.

Based on Medical Staff bylaws, rules and regulations review, policy and procedure review, closed medical record reviews, on-call physicians' schedule review, and physician interviews, the hospital failed to ensure the physician who was on-call for Orthopedic services was available to provide services upon the request of the dedicated emergency department (DED) physician for 1 of 11 patients that were transferred with an emergency medical condition (#20).

The findings include:

Review on 07/16/2014 of the 2014 Medical Staff Bylaws, Rules and Regulations revealed "PART FIVE: RULES AND REGULATIONS ...A. Medical Staff Coverage: ...c. All members of the Active Medical Staff shall be responsible for posting each month of the calendar year the names of physician(s) available for emergency care for each individual and group practice. A covering member shall respond, examine and treat patients with emergency medical conditions when requested by the Emergency Physician. (1) The covering member may either assume the care of the patient or refer the patient to another Medial Staff member or, when patient need(s) exceeds the scope of this Hospital's available services, to another practitioner at a facility which provides service(s) consistent with patient need(s). ..."

Review on 07/16/2014 of current hospital policy "Emergency Medical Treatment and Active Labor Act (EMTALA)", Policy Number: 1RI.ADM.0003, effective 02/24/2014 revealed "...D. ...On-call physicians have an obligation to be immediately available by phone and respond within 30 minutes. He/she must be present in the Emergency Department as soon as possible, within a timeframe not to exceed one hour of the request or as otherwise specified by the Emergency Physician to provide stabilizing treatment for an EMC. ..."

Review on 07/16/2014 of the On-call physicians' schedule revealed Physician B was on-call for the DED starting 12/30/2013 at 0700 until 01/06/2014 at 0700 for Orthopedic services.

Hospital A, closed DED record review on 07/16/2014 for Patient #20 revealed a 51 year old male who presented via ambulance to the DED on 01/01/2014 at 1416. Review revealed the patient was triaged by a Registered Nurse (RN) at 1417. Review of triage nurse documentation at 1417 revealed "Stated Reason for Visit: Pt (Patient) states he stepped back and heard a pop in his right ankle, he was in the woods and had to crawl out for an hour. The ankle is swollen and he says his pain is now 10/10. Pulse palpated, foot is cool and mottled." Further review revealed "Chief Complaint: PAIN-LOWER EXTREMITY." Review revealed "Associated Symptoms-Objective: Pink, Warm, and Dry, Unlabored Respirations. Review revealed vital signs (VS) were assessed as: temperature (T) 97.9 degrees Fahrenheit, oral; heart rate (HR) 89; blood pressure (BP) 146/74; respiratory rate (RR) 18; oxygen saturation (O2 Sat) 97% on room air (RA). Review revealed a pain assessment was performed using a numerical pain scale of 0-10 (0 pain free, 10 worst pain) with a reported pain rating of 10. Review revealed a Glasgow/Trauma Score (GCS) [a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment] assessment of Motor Response Glasgow: Obeys Commands; Verbal Response: Oriented and Converses; Eye Opening Response: Spontaneously. Review revealed a total GCS score of 15 (3 [in a coma] -15 [normal score]). Review revealed the patient was assigned as Acuity 3-Urgent. Review of nursing assessment documentation by an RN revealed at 1426 Musculoskeletal - Musculoskeletal Symptom: Joint swelling; Current Functional Status: Worsening; Moves All Extremities Well: Yes except Below; Joint Assessment Grid: Anatomical Location: Ankle, Foot; Position: Right; Range of Motion: Limited; Function Signs/Symptoms: Swollen Distal Neurovascular: Intact; Comment: "Pt right foot is swollen and cool to touch. Pt has normal, regular pedal pulse. Pt has swelling near ankle joint nearest to the leg." At 1459 peripheral line initiated by EMS (prior to arrival at DED), 20 gauge over the needle to left antecubital.
At 1606 VS reassessed as: HR 94; BP 134/79; RR 17; O2 Sat 96% on RA. At 1608 Sodium Chloride 0.45% IV at 80 milliliters per hour continuous infusion initiated. At 1609 revealed Notified Provider Name: (Physician A); Notification Method: On Unit; Notification Reason: Change in Patient Status; Notified Orders Received: Yes; Provider Notification Note: "ER MD made aware of pt right pedal pulse weaker than when pt arrived in ER. Call made to Dr. (Physician B). Left message to call ER ASAP." At 1641 revealed Notified Provider Name: (Physician B); Notification Method: Paged; Notification Reason: Change in Patient Status; Notified Orders Received: No; Provider Notification Note: "left message x2 on voicemail." At 1647 Ancef (antibiotic) 2 Grams IV piggyback administered. At 1647 Percocet (narcotic for pain control) 325mg - 5 mg, 2 tablets orally administered for a pain assessment rating of 7/10. At 1648 VS were reassessed as: HR 93; BP 134/96; RR 18; O2 Sat 96% on RA. At 1654 revealed Notified Provider Name: (Physician B); Notification Method: Paged; Notification Reason: Change in Patient Status; Notified Orders Received: No; Provider Notification Note: "Paged MD (Physician B) on phone. Left third message." At 1704 Ace Wrap and Posterior OCL applied. At 1744 revealed Notified Provider Name: (Physician A); Notification Method: On Unit; Notification Reason: Condition Update; Notified Orders Received: Yes; Provider Notification Note: "Pt NPO (nothing by mouth) as of now. Pt made aware by RN per ER MD." At 1752 VS were reassessed as: HR 101; BP 128/97; RR 17; O2 Sat 96% on RA and PRN Intervention Response was assessed as "Partially Relieved." At 1813 revealed Notified Provider Name: (Physician A); Notification Method: On Unit; Notification Reason: Condition Update; Notified Orders Received: Yes; Provider Notification Note: "ER MD stated pt okay to leave IV (intravenous) in for ride to (Hospital B), IV wrapped with kerlex and tubular bandage. Pt verbalizes he will not unwrap bandage and will leave in place for ride to (Hospital B)." At 1815 Ace Wrap and Sugar-Tong OCL applied. At 1818 Discharge Report Given to Another Facility: (Hospital B) ER (staff RN name); Summary of Care Provided to Facility: Yes; Discharge Comments: "RN called report to (Hospital B). Pt verbalizes he will go straight to (Hospital B) without stopping directly to ER for treatment." Discharge Mode: Wheelchair; Belongings Given to: Patient. Record review revealed the patient's wife was present.

Review of MSE documentation by Physician A at 1530 revealed HPI (History of Present Illness), chief complaint of injury to right ankle, onset/duration just prior to arrival, 2 hours. Review revealed "Patient was chopping wood + (and) stepped in a hole he felt a pop had to crawl out of a hole." Associated symptoms of unable to bear weight and popping sensation. Review of Systems (ROS) negative. PAST HISTORY - alcoholism. PHYSICAL EXAM - General Appearance: no acute distress, alert, smells of alcohol. EXTREMITIES FOOT: Skin intact, erythema, "color is abnormal cool, blueish [sic]/purple." ANKLE: negative tenderness, swelling, erythema bilateral, deformity. LEG: normal inspection, non-tender. KNEE: normal inspection, non-tender, normal ROM. No joint swelling. GAIT: normal. NEURO/VASC/TENDON: cool skin/abnormal cap refill; Pulse deficit: present but decreased. HEAD/ENT (Ears, Nose, Throat): normal inspection, pharynx normal; NECK/BACK: normal inspection, non-tender; RESPIRATORY: chest non-tender, breath sounds normal; CVS (cardiovascular system): heart sounds normal; ABDOMEN/GU (Genitourinary): non-tender, pelvis stable. PROCEDURES: Reduction/Splinting/Other: splint posterior OCL, applied by Nurse. Examined post splint application, NV (neurovascular) intact. Other: Right splint posterior/sugartong. PROGRESS: "Discussed discoloration/decreased pulse c (with) Dr. (Physician B). @ 3:45 PM, color appeared worse attempted Dr. (Physician B) X [times] 4 (waited 1 hr) will transfer to (Hospital B) concern for vascular compromise. Spoke to Dr. [Physician D] (ED) accepted pt. Does not appear ischemic but does appear limited. Will allow for POV (Privately owned vehicle) to ED." Further review revealed "See computer notes for addendum." Review revealed CLINICAL IMPRESSION: closed fracture of the distal tibia and distal fibula and vascular insufficiency. Review revealed "DISPO (disposition) TIME" of "1530" with an "X" marked in a box adjacent to "Admit." Review revealed "CONDITION" with an "X" in a box adjacent to "unchanged." Review revealed "Care transferred to Dr. (Physician B)/(Physician C) at "1530." Further revealed the "X" marked in the box adjacent to "Admit" was striked over. Further review revealed "DISPOSITION DECISION TIME" as "1750" with an "X" marked in a box adjacent to "Transfer."

Review of an ER Report "Reason for transfer-addendum" by Physician A, dated 01/01/2014 at 2031 revealed "Patient's foot appeared cool and blue/purple upon arrival. He does have a palpable DP (dorsalis pedias) pulses. Dr. (Physician B) consulted initially, discussion about concern for vascular compromise and distal tib/fib fracture. He (Physician B) accepted the patient and wrote admission orders. Throughout the stay in the ED, his foot became more painful and the color became deeper blue. Pulse continues to be palpable but it is thready and seemingly worse. I attempted to contact out orthopedic on call (Physician B) to come and evaluate the patient regarding the changes that we were observing. Unfortunately, I was unable to reach him after 4 separate occasions. I waited one hour and then made the decision to transfer him (Patient #20) to (Hospital B), as definitive care would probably be necessary tonight, due to concern of vascular compromise. He was transferred via POV as this appeared to be in need of urgent evaluation as compromised pulse was still present and did not think that he needed to be transferred by lights and sirens. Patient had family arrive quickly and was instructed to go straight to the ED with the transfer papers."

Review of the Certification of Transfer (COT) form dated 01/01/2014 revealed a diagnosis of distal tibia/fibula fracture with vascular insufficiency. Review revealed "Patient Unstable - The patient has been examined an EMC has been identified and patient is not stable, but the transfer is medically indicated and in the best interest of the patient." Review revealed "unable to get ortho @ (Hospital A)." Review revealed the reason for transfer is "medially indicated." Review revealed medical benefits were to receive Ortho/Vascular services (handwritten), obtain level of care/service not available at this facility and benefits outweigh risks of transfer (preprinted). Review revealed medical risks were deterioration of condition enroute and worsening of condition or death if you stay here (preprinted). Review revealed mode of transport as determined by physician - private car. Review revealed the handwritten signature of Patient #20 witnessed by a RN, consenting to the transfer at 1807. Review of the Physician Transfer Order & Request Form dated 01/01/2014 at 1800 revealed Physician A's handwritten signature adjacent to "I hereby certify that based on the risks and benefits to the patient and based on the information available at this time the medical benefits expected from the transfer outweigh the increased risk if any to the patient's medical condition."

Interview on 07/16/2014 at 1147 with Physician A revealed she was the ED Medical Director for Hospital A. Interview revealed she was the attending ED physician on-duty who performed the MSE on Patient #20 when he presented to the ED on 01/01/2014. Interview revealed "I am very familiar with the patient." Interview revealed the patient presented with a broken leg. Interview revealed the foot had a pulse, felt cool and was discolored. Interview revealed the foot was perfusing, but had vascular insufficiency. Interview revealed she initially spoke via telephone with Physician B the Orthopedic Physician on-call for the ED. Interview revealed she discussed the case with him. Interview revealed Physician B asked "can he (Patient #20) just come to my office tomorrow." Interview revealed she stated "no" he needed to see the patient, because the patient had a decreased pulse in the foot. Interview revealed "he (Physician B) did not refuse to come in and see the patient." Interview revealed Physician B asked her to give the telephone to a nurse and he would give admission orders. Interview revealed Physician B realized the patient was an alcoholic so he wanted the primary care physician to admit the patient for medical management and he would be the consultant. Interview revealed she called the primary care physician (Physician C) and told her Physician B wanted her to admit the patient and then he would consult for Orthopedics. Interview revealed Physician C was "concerned" and wanted to know when Physician B would see the patient because she "did not want a dead foot to be sitting on the floor." Interview revealed she attempted to call Physician B back. Interview revealed "I went to reevaluate the patient and there was a slight change in the foot condition which was concerning and I wanted him to come in and see the patient now." Interview revealed she was unable to get up with Physician B. Interview revealed she called Physician C back and told her that she would give Physician B one hour to call back, and if he did not return the call she would transfer the patient to Hospital B. Interview revealed the patient's foot "was not in imminent or emergent danger" of turning blue. It was "urgent" and needed evaluation within the next couple of hours. Interview revealed Physician B did not respond to multiple pages. Interview revealed "I was worried about the foot." Interview revealed she called the ED physician at Hospital B who accepted the patient for transfer. Interview revealed the patient's family was present and wanted to take the patient by private vehicle (POV). Interview revealed at the time the hospital's two ambulances were not available. Interview revealed the foot had been splinted with a sugar-tong and anterior/posterior splint. Interview revealed the family members present were responsible and concerned about the patient. Interview revealed the family members were not intoxicated. Interview revealed "the patient did not need lights and sirens." Interview revealed "there would not have been anything the ambulance staff could have done for the patient. He needed Orthopedics." Interview revealed she thought there would be no change in condition enroute to Hospital B, but there could be deterioration overnight. Interview revealed "the limb was unstable, not the patient." Interview revealed she marked unstable on the transfer form for the foot. Interview revealed she should have marked the "stable" box. Interview revealed the patient was alert and oriented, able to function normally, his vital signs were stable. Interview revealed the patient did have a history of alcoholism, but he was "clinically sober." Interview revealed "the patient was stable from a cardiovascular standpoint." Interview revealed she felt the transfer was "more urgent, than imminent or emergent." Interview revealed she felt the patient was medically stable to go by POV. Interview revealed POV was "an acceptable mode of transfer." Interview revealed the patient would arrive at the hospital approximately 45 minutes after discharge. Interview revealed she verbally explained the risk and benefits of transfer to the patient and family. Interview revealed the patient was instructed to leave the ED and go straight to the ED at Hospital B. Interview revealed an EMC existed for Patient #20 but he was stable at the time of transfer. Interview revealed Physician B did call back to the ED approximately 2 hours after the second attempt. Interview revealed the patient was already being placed into the wheelchair for transfer. Interview revealed she told Physician B that she had been trying to reach him. Interview revealed she informed Physician B that the patient was being transferred to Hospital B. Interview revealed she informed Physician B that if he was at the hospital, she would hold the patient and he could see the patient. Interview revealed she asked Physician B if he was "immediately available" and he stated "no, he was about 45 minutes away." Interview revealed she does not recall the exact reason given by Physician B for not responding to repeated pages but it was "not an acceptable reason for not responding." Interview revealed "I thought he was going to admit the patient and come in and see him. I thought the patient needed surgery that day." Interview revealed "he did not verbally refuse to come see the patient or to come in." Interview revealed "I thought it was clear he needed to see the patient now, when I told him no the patient could not be seen in the office the next day." Interview revealed when Physician B did not respond the hospital's Administrator On-Call was notified and the (contracted DED physician group) risk management was notified. Interview revealed the incident went up the chain of command to peer review. Interview revealed she has not had any other issues with on-call physicians' response since the incident on January 1, 2014. Interview revealed on-call physicians have 30 minutes to respond to the ED. Interview revealed issues with failure of on-call physicians to respond is addressed by the hospital's medical staff.

Follow-up telephone interview on 07/17/2014 at 1119 with Physician A confirmed she did not specifically request for Physician B to immediately present in-person to the emergency department on 01/01/2014 when she made first contact. Interview revealed "I thought it was implied he needed to come in and see the patient and that is why he requested me to give the phone to a nurse to write admission orders." Interview confirmed "he (Physician B) did not refuse to come into see the patient."

Interview on 07/16/2014 at 1600 with Physician B revealed he has been on Hospital A's medical staff for 3 years. Interview revealed he is an Orthopedic physician. Interview confirmed he was the on-call Orthopedic physician on January 1, 2014 when Patient #20 presented to the ED. Interview revealed he "does not recall all the details, but remembers some." Interview revealed the patient broke an extremity in a field and dragged himself out. Interview revealed he initially talked to the ED physician (Physician A). Interview revealed a "typical" tibia fracture. Interview revealed the ED physician "did not" request for him to come in immediately to evaluate the patient. Interview revealed the patient had been splinted in the ED. Interview revealed he gave admission orders to the nurse. Interview revealed his plan was to come into the hospital later that day or night to evaluate and schedule the patient for surgery the next day. Interview revealed the hospital's system does not allow for the type of surgery needed to be performed immediately. Interview revealed for the type of surgery needed, he would have to arrange for specialized surgical equipment to be delivered by courier from Hospital B. Interview revealed if there had been vascular damage the patient would have needed to been transferred to Hospital B because vascular services are not available at the hospital (Hospital A). Interview revealed at the time the ED was unable to get in touch with him on January 1, 2014, his cell phone battery was dead and he placed the phone on a charger in a different room. Interview revealed when he went to retrieve his cell phone from the charger he realized he had missed several phone calls. Interview revealed he returned the call to the ED and spoke with the ED physician. The ED physician told him the patient's foot had become more dusky and was concerned that the foot had vascular compromise. Interview revealed he was told the ED had been trying to contact him for about an hour and a half. Interview revealed he told the ED physician he would have to get ready and could be in to the ED in half an hour. Interview revealed it is about a 20 minute drive from his residence to the hospital. Interview revealed the ED physician had already decided to transfer the patient to Hospital B. Interview revealed "I did not refuse to come in." Interview revealed he went to the hospital and when he arrived the patient was already out in the parking lot leaving for Hospital B. Interview revealed he does not have a telephone land line. Interview revealed he only has a cell phone.

Interview on 07/16/2014 at 1515 with Physician C revealed she has been on the medical staff of Hospital A since 1985. Interview revealed she is a Family Medicine physician. Interview revealed the patient (Patient #20) had an orthopedic injury. Interview revealed on the day Patient #20 presented to the ED (01/01/2014) she was notified by the ED physician (Physician A) that she had been requested by Ortho (Physician B) to admit the patient to the hospital for medical management and that Ortho would be a consult. Interview revealed she told the ED physician "that would be wonderful, however if the patient had an orthopedic problem and required surgery that night, Ortho needed to come in and see the patient." Interview revealed she would have admitted the patient if the ED physician would ensure Ortho would come in to see the patient and do the surgery. Interview revealed she was not willing to take care of the patient if Ortho was not going to come in and see the patient. Interview revealed "if the patient deteriorated neurovascularly from the break, I am not able to manage the patient." Interview revealed it was in the best interest to transfer the patient if he needed to be operated on that day or night. Interview confirmed she did not admit the patient to her service. Interview revealed she had no contact with the patient or Physician B.

Hospital B, closed record review on 07/16/2014, revealed Patient #20 presented to the DED of Hospital B on 01/01/2014 at 2000 via private transportation. Review revealed a MSE was performed by a QMP. The patient was subsequently admitted to an inpatient unit and underwent a surgical procedure for application of uniplanar external fixator with closed treatment of the tibia with manipulation and closed treatment of the fibula with manipulation on 01/02/2014. The patient was discharged from the hospital on 01/03/2014 with a diagnosis of right tibial pilon fracture.

NC00098864