HospitalInspections.org

Based on a review of emergency room medical records, policies and procedures, call logs, on- call schedules, and Medical Staff Rules and Regulations and hospital staff interviews, the hospital failed to ensure that the on-call physician listed on the on-call list responded when called by the Emergency Department (ED) Physician to meet the needs of the hospital's patients who are receiving services required with resources available to the hospital to include the availability of on-call physicians for 1 (Patient #3) of 20 sampled patients. The facility failed to follow their own policies and procedures to meet the patient's needs when an on-call physician did not respond to calls. Refer to findings in tag 2404.

Based on a medical record review, policy and procedure review, Medical Staff Rules and Regulations, and staff interview, the hospital failed to ensure an appropriate transfer for an individual to an acute care hospital which had the capability to manage 1 (Patient #3) of 20 patients sampled with an emergency medical condition because the on-call physician failed to respond when called by the ED Physician. Refer to findings in tag 2409.

Corrective Action taken by the hospital prior to the EMTALA investigation:
* The ER physician C was suspended (4/21/16) pending peer review which the hospital anticipated would be in 2-3 weeks.
* The hospital sent an e-mail (4/27/16) out to all ER staff to be read and signed for about what to do if a physician does not respond to the call about admission decision.
* The on-call physician B received a letter (4/28/16) including a quote from the Medical Staff Bylaws which states the physician must respond within 30 minutes of being called by the Emergency Room.

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Based on a review of emergency room medical records, policies and procedures, call logs, on-call schedules, and Medical Staff Rules and Regulations and hospital staff interviews, the hospital failed to ensure that the on-call physician listed on the on-call list responded when called by the Emergency Department (ED) Physician to meet the needs of the hospital ' s patients who are receiving services required with resources available to the hospital to include the availability of on-call physicians for 1 (Patient #3) of 20 sampled patients. The facility failed to follow their own policies and procedures to meet the patient needs when an on-call physician did not respond to calls.

The findings included:

1. Patient #3 came into the emergency room on 4/6/16 at 10:44 p.m., for chest pain and shortness of breath. The patient was examined; a chest X-ray and blood work was done. The chart stated at 2:10 a.m., the physician on call, internal medicine Physician B, was called and messages were left on both the physician's home and cell phones. At 2:20 a.m., Physician B was again called with no answer. At 3:15 a.m., the patient was transferred to the medical-surgical unit at the hospital under the on-call doctor's service.

The documentation in the nursing note at 3:15 a.m., said the patient became unresponsive while being assisted into bed. The patient was very short of breath and sweaty. A Code Blue was called, sternal rub was done, and the patient again became aroused. The documentation reflected the Nursing Supervisor and the Emergency Room Physician C were both at the bedside. The patient again became unresponsive and lost his pulse at 5:10 a.m. The Code Blue Team worked on this patient for approximately 40 minutes with no response from the patient. The patient expired at 5:50 a.m. There was a physician's note from C stating he contacted the physician on call regarding the patient. The time was not documented, but review of the call log for the hospital said the phone call was made at 5:57 a.m.

The hospital's Medicine Call Schedule for April 2016 was reviewed. The on-call schedule verified that Physician B was on call on 4/6/2016 when the ED physician (Physician C) called Physician B regarding Patient #3's emergency medical condition that required further evaluation and treatment after the initial examination to meet the needs of the patient.

The hospital's Medical Staff Rules and Regulations adopted and amended August 2007 was reviewed. The Medical Staff Rules and Regulations revealed in part, "1.1.5 Emergency Admission ... 1.1.5.2... The Emergency Room Physician may call any physician, dentist ...on call to care for the patient. The physician ... called must respond within 30 minutes and assume the care of that patient himself or otherwise arrange disposition."

The hospital's Policy and Procedure entitled EMTALA/Medical Screening/Transfer revised 2/2015, said if there was a refusal or an unreasonable delay in providing necessary treatment by the on-call physician, there was a chain of command that should be contacted about the issue including the Chief of Service, Chief of Staff, the Administrator on call, or the Corporate Compliance Officer. None of these specified staff were notified regarding this issue. The Nursing Supervisor was also not notified of the failure of the on call doctor to respond.

The hospital failed to ensure that their Medical Staff Rules and Regulations were followed as evidenced by the on-call physician failing to respond when called by the ED physician for further evaluation and treatment for Patient #3 after the initial examination by the ED physician.

On 4/27/16 at 2:30 p.m., the Risk Manager, the Chief Nursing Officer, the Compliance Officer, and the Clinical Director of the Emergency Room, all indicated the on call physician was also called at 4:03 a.m. with no response. There was no documentation regarding this call in the record.

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Based on a medical record review, policy and procedure review, Medical Staff Rules and Regulations, and staff interview, the hospital failed to ensure an appropriate transfer for an individual to an acute care hospital which had the capability to manage 1 (Patient #3) of 20 patients sampled with an emergency medical condition because the on-call physician failed to respond when called by the Emergency Department (ED) physician.

The findings included:

1. Patient #3 was presented to the emergency room on 4/6/16 at 9:54 p.m. The patient was complaining of chest pain with an onset of 1 day prior to admission. The patient had blood work and a chest X-ray in the emergency room. The chest X-ray revealed infiltrates (fluid in the lungs). The patient also had an elevated D-dimer blood test which showed potential thrombolytic occurrence (blood clot). This hospital does not have computerized tomography (three-dimensional imaging) which would be the definitive test for pulmonary emboli. The internal medicine specialist was not available. With no intensive care unit at the hospital, transfer would be a consideration for definitive diagnosis.

Patient #3's record revealed the emergency room doctor was made aware of the elevated D-dimer (a blood test indicating blood clotting) at 12:30 a.m. as documented by the nurse.
At 2:45 a.m. the nurse documentation contains information regarding the Heparin (a drug that prevents clotting) 5000 units. The nurse documented "Spoke with [ER physician] about starting the Heparin 5000 units SQ [subcutaneous] earlier that at 0600 [6 a.m.] as scheduled by Cardinal pharmacy". The ER physician advised the Heparin could be started at 6:00 a.m.
Physician notes included: "Called to floor because the patient became unstable. Was diaphoretic [sweaty] and tachypneic [rapid pulse]. Became hypotensive [low blood pressure]. Called Dr. [name] at [a larger hospital] at 0430 to arrange transfer and he recommended intubation and tPa ["clot buster" drug] at dose 0.9 mg/kg with 10% over 1 minute and the rest over an hour. Patient was difficult intubation with secretions and had to be intubated by anesthesiologist. Had blood in airway at that time. Patient coded and was in PEA [pulseless electrical activity] and asystole [cardiac standstill] and never regained spontaneous circulation. Probable diagnosis is massive PE [pulmonary embolism]..." During the patient's decline, attempts were made to transfer this patient, but all air transports were not flying due to the weather and ground transportation did not arrive until after the patient had arrested and expired at 5:50 a.m. on 4/7/2016.

Review of the Death Record date 4/7/2015 revealed that Patient #3's cause of death was, "Cardiopulmonary Arrest, Pulmonary Embolism."

The hospital's policy EMTALA /Medical Screening Transfer (revised 02/15) was reviewed. On page 4, "Stabilization" included section 4.C. "If there is any refusal or unreasonable delay in providing necessary treatment by on-call physician(s), the Emergency Department physician shall contact any or all of the following for additional assistance in providing stabilizing treatment, and similarly document these attempts:
1. Chief of Service
2. Chief of Staff
3. Administrator On-call
4. Corporate Compliance Officer".
On page 6, "Transfer of Unstabilized Patients" included section 1.B.(2) "If the transfer becomes necessary because the on-call physician(s) refused or failed to provide necessary stabilizing treatment within a reasonable period of time as outlined above in STABILIZATION (4), thereby causing the benefits of transfer to outweigh the risks of transfer, the patient records shall include documentation of the name of the on-call physician who refused or failed to appear and what attempts were made to contact the physician or request patient care assistance, and the Risk Manager shall be notified promptly."

Medical record review revealed the emergency room staff attempted to contact the on call physician 2 times with no response. When the on-call physician failed to respond, the emergency room physician did not follow policy for contacts to: the Chief of Service, the Chief of Staff, the Administrator On-call, or the Corporate Compliance Officer for assistance.

In an interview on 4/27/16 at 4:04 p.m., the Corporate Compliance Officer said she was unaware of the incident of 4/6/16 until 4/20/16.

Emergency Room Physician C made the decision to admit the patient to the medical-surgical unit. Once there, the patient deteriorated. At 4:20 a.m., there was an attempt to transfer the patient to a larger hospital with the appropriate capability. Due to weather, no flights were available to transfer this patient. The emergency room physician had a consultation with a physician at the larger hospital and the transfer was accepted. Treatment was initiated upon this physician's recommendation. Prior to the transfer taking place, the patient arrested and expired.

The hospital's Medical Staff Rules and Regulations adopted and amended 2007 were reviewed. The Medical Staff Rules and Regulation specified, in part, "1.6.9 Emergency Services ...1.6.9.2.b... All patients requiring hospital admission through the Emergency Department shall have admitting orders specifying the patient's initial care, treatment and/or further diagnostic work-up. These initial admission orders may be written by the attending Physician, the On-call, or by a nurse qualified to receive and transcribe verbal orders. Initial admitting orders (only) may also be written by the Emergency Department, after consultation with the admitting physician."

On 4/28/16 at 12:18 p.m., the Clinical Director of the Emergency Room, said the emergency room physician has the authority to transfer the patient without the attending (on-call) physician's authorization.