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Based on interview and record review, the hospital failed to maintain a physician On Call Schedule to meet the needs of patients presenting to the Emergency Department (ED). The facility also failed to have policies and procedures in place to address changes in the physician On Call provider response and/or availability to meet patient needs in the ED. These failures increased the risk of harm to all patients presenting to the Emergency Department (ED) with an emergency medical condition (EMC).

Findings included:

1. Review of the ED provider on duty schedule, dated 12/03/18 through 02/23/18 showed Qualified Medical Personnel (QMP), Nurse Practitioner and Physician Assistant working in the ED without a physician present in the ED.

Even though requested from the facility's administrative personnel, the hospital failed to show an appropriate written OC schedule of ED physicians that were available to provide treatment if necessary after the initial examination to stabilize an individual with an EMC. The facility instead provided an ED staffing schedule. The facility later also provided a one page typed document with two days of OC staff and a staffing schedule.

During an interview on 01/03/19 at 9:20 AM, Staff G, Nurse Practitioner, stated that Staff K, ED Medical Director was on call twenty four hours a day seven days a week. If she needed a physician to come in and examine a patient she would not call Staff K because he lived in another state, and it would take him an hour to get to the ED. During Business hours, if she needed a physician to examine a patient in the ED after the initial examination, she would get a physician from the outpatient clinic to assist her.

2. Review of the hospital's Medical Staff By-Laws, dated 02/22/17, showed no directives that clearly delineate the responsibilities of the OC physician to respond, examine or treat patients and address the steps to follow if an OC physician cannot respond.

Review of the hospital's undated Medical Staff Rules and Regulations, showed no directives that clearly delineate the responsibilities of the OC physician to respond, examine or treat patients and address the steps to follow if an OC physician cannot respond.

During an interview on 01/03/19 at 1:01 PM, Staff I, Chief Executive Officer, stated that the hospital did not have an OC schedule. Staff I stated that Staff K, ED Medical Director, was on call twenty four hours per day, seven days a week. Staff I also stated that there was no policy and procedure pertaining to the ED OC Physician Schedule that addressed the steps to follow if an OC physician cannot respond. Staff K, in the physician employment agreement, should be able to respond within 30 minutes to provide stabilizing treatment if requested. If the Qualified Medical Personnel (QMP) needed a physician, they would request Staff H, Chief of Staff to assist them in the ED.

Review of the Physician Emergency Department Coverage and Collaborative Practice Service Employment Agreement, dated 03/01/16, signed by Staff K, ED Medical Director, showed that the ED coverage service required a physician on call at all times, unless prevented by circumstances beyond his control. He shall be within thirty minutes driving time of the ED, respond telephonically or via text within five minutes of any call or page from ED personnel, and present to the ED within thirty minutes of having received a request to do so from ED personnel or having been notified, if, in his professional judgement, a patient's condition requires such a response.

During a telephone interview on 01/03/19 at 3:00 PM, Staff K, ED Medical Director, stated that he was on call twenty four hours per day, seven days a week. He was on vacation from 12/15/18 through 1/12/19 and was not able to respond within 30 minutes to the ED. Staff H, Chief of Staff, was not expected to cover for him. He felt that he did not need to respond within 30 minutes to the ED, he could take care of the call via telephone or text messaging.

Review of the Physician Emergency Department Coverage and Collaborative Practice Service Employment Agreement, dated 09/01/17, signed by Staff H, Chief of Staff, showed no agreement for overseeing the ED. The agreement did not clearly delineate the responsibilities of the OC physician with the understanding of response time, examination, or treatment. The agreement also did not address steps, with her understanding, if she could not respond.

During an interview on 01/03/19 at 11:45 AM, Staff H, Chief of Staff, stated that the hospital did not have a written OC schedule. Staff K, ED Medical Director, was on call all the time. She did not take call, or have any oversight of the ED department. Staff H also stated that she was not on call for the ED in Staff K's absence.

Based on interview and document review, the Critical Access Hospital (CAH) failed to stabilize within its capabilities prior to transfer, three patients (#11, #22, and #23) of 23 patients' medical records reviewed who presented to the hospital's Emergency Department (ED) seeking care.

Findings included:
1. Review of the hospital's policy, titled, "EMTALA - Medical Screening Exam and Stabilization", revised 12/07/18, showed that when an individual presents to or is brought to I-70 Community Hospital for examination and treatment of a nonscheduled medical condition, a physician, physician's assistant, advance nurse practitioner or an Emergency Department Registered Nurse (RN) will provide a medical screening examination within the capability of the facility, including ancillary services routinely available for the purposes of determining the presence or absence of an Emergency Medical Condition (EMC).

Further record review showed there was no requirement for a physical examination or consultation with an available physician prior to Advanced Practice Nurses and Physician Assistants initiating the transfer of an unstable or stable patient to another facility when stabilizing treatment was not available.

Although requested from Administrative staff, the facility failed to provide a policy that addressed collaboration with a supervising physician for care and treatment of patients who were seen by Advanced Practice Nurses and Physician Assistants.

2. Patient #11:
Review of Patient #11's Emergency Medical Services (EMS) record showed that on 01/01/19 at 8:21 AM treatment in route to the hospital consisted of oxygen at four liters per nasal cannula, an intravenous catheter (small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) insertion and delivery of Normal Saline (solution used to aid transfusion), a breathing treatment that included a bronchodilator (medication used to relax muscles in the airways and increase airflow to the lungs) and an Electrocardiogram (ECG, test that checks for problems with the electrical activity of the heart). EMS arrived at I-70 Community Hospital at 9:07 AM.

Review of the ED Medical Record progress note by Staff G, Nurse Practitioner (NP) dated 01/03/19 at 00:22 AM, late entry, showed that Patient #11 presented to the ED via EMS for shortness of breath that became much worse this am, as reported by the patient's wife. Home glucose reading: HIGH. On arrival the patient was tachycardic (abnormally rapid heartbeat) and tachypneic (abnormally rapid breathing). Physical exam showed that patient was in moderate distress related to shortness of breath and answered simple questions with one-two word responses.
Cardiovascular exam showed tachycardia. Pulmonary exam showed respirations were labored with increased work of breathing, tachypnea, oxygen saturation initially was in the mid 80's, gradually increased to low 90's. Lungs with crackles and wheezes bilaterally. Extremities exam showed pedal edema (swelling) bilateral lower extremity edema.
The impression showed in part:
- Diabetic ketoacidosis (DKA, buildup of acids in the blood) with glucose greater than 700 mg/dL (milligrams per deciliter, unit of measure);
- Myocardial Infarction (MI, heart attack); and
- Cardiopulmonary arrest.
The treatment plan showed in part:
- LAB/CXR/EKG ordered.
- While Staff G was doing a re-examination and more in-depth history with patient/family, patient was noted to have decreasing oxygen saturation and decreasing heart rate. Although patient was in normal sinus rhythm, the patient was moved to ER room one in preparation for impending intubation. Patient was still spontaneously breathing, but with decreased effort.
- Patient became unresponsive while gathering supplies in preparation for intubation. Orally intubated with 7.0 endo tracheal tube (ETT) using a scope for visualization.
- Patient lost a pulse during intubation and Cardiopulmonary Resuscitation (CPR) was initiated immediately. Advanced cardiac life support (ACLS) protocol initiated.
- Patient achieved return of spontaneous circulation (ROSC), although he was hypotensive (abnormally low blood pressure). Dopamine (medication used to raise blood pressure) drip was initiated at 10 mcg (microgram, unit of measure). A nearby hospital was called by Staff G to emergently transfer the patient and helicopter transport was called.
- Staff G initially spoke with Internal Medicine at a nearby hospital who accepted the patient, but requested an ED to ED transfer. Then spoke with the ED doctor at CenterPoint, who suggested blood administration as well as other means of lowering the Potassium level.
- A unit of O negative blood was administered while continuing to administer medications to lower the potassium, as well as Epinephrine every 3-5 minutes.
- Resuscitation efforts terminated at 11:15 AM, after over an hour of intermittent CPR and ACLS intervention.

Review of the CPR Flow Sheet dated 01/01/19 at 9:50 AM showed that the following EMS staff were present; Staff D, Paramedic; Staff E, Emergency Medical Technician (EMT); and Staff F, EMT.

There was no evidence in the medical record that Staff K, Director of ED, physician on call, was notified by Staff G or provided further examination or certified in the medical record the benefits of transfer outweighed the risks prior to the attempt to transfer the patient.

During an interview on 01/03/19 at 9:20 AM, Staff G, NP stated that:
- EMS left and then came back to the hospital; because the ED needed more hands;
- At night, on weekends, and holidays, if a patient were to code, they call EMS;
- There were only a few staff at the hospital on night, weekends and holidays;
- Patient #11 was in room two and she saw his heart rate drop and he was experiencing symptomatic bradycardia;
- She did not treat the bradycardia, she just thought that she needed to intubate and left the patient to go get supplies;
- The dietary technician made calls to the helicopter companies and they were not flying due to the weather;
- Epinephrine was to be given every three to five minutes. The code documentation does not show everything that happened;
- She collaborated with a nearby hospital's Internal Medicine physician and an ED physician about 15 minutes after intubation, discussing treatment options;
- The nearby hospital's internal medicine physician helped her with treatment options;
- The nearby hospital's ED physician told her that she could not do a transfer to intensive care unit because the patient was not stable, she would have to do an ED to ED transfer;
- She did not contact Staff K to collaborate with treatment or come in to assist because he lived in another state, and it would take him an hour to arrive at the ED; and
- She collaborated with Staff K after the patient expired.

During an interview on 01/03/19 at 1:32 PM, Staff J, RN ED stated that:
- If a patient were to code, they moved the patient to the trauma room, room one, because they would have to move the crash cart to the other rooms, and it was easier to move the patient and it only takes 30 seconds;
- With Patient #11, EMS came in to help them with the code, because the only other staff in the building was a "cook";
- If necessary, EMS comes back to the hospital to help out, when they need extra hands; and
- Staff K, ED Physician was not notified.

During an interview on 01/02/19 at 4:15 PM, Staff B, Chief Nursing Officer (CNO) stated that:
- Epinephrine was not given every three to five minutes;
- ACLS protocol was not followed properly;
- Patient was moved to ER room one out of convenience;
- There was a delay in treatment by moving rooms;
- EMS was called back after they left the hospital because the ED staff needed help;
- EMS personnel were not employees of the hospital;
- EMTs helped with CPR, if a paramedic came they could give medications, and could intubate patients; and
- There was no contract between the hospital and EMS for providing help.

During a telephone interview on 01/03/19 at 2:00 PM, Staff D, Paramedic stated that:
- He was called on 01/01/19 directly by the hospital, bypassing 911 dispatch, and was told it was an emergency;
-The EMS crew arrived to the hospital with the thought that they were transferring a patient, and ended up helping with a code blue;
- He performed CPR on Patient #11;
- He also stated that he and other EMS staff help with compressions during a code at the hospital and can intubate if they needed help;
- None of the EMS staff were employed at the hospital; and
- While they were treating Patient #11, it took them out of service of the community for an hour and a half; that caused two other communities EMS crews to cover their service.

During an interview on 01/03/19 at 3:45 PM, Staff O, Radiology Technician stated that:
- She was on call on 01/01/19 and was called in to do a chest x-ray;
- Anyone in the hospital can help with a code;
- EMS was called in to help with the code;
- She helped in recording the code events by writing times on a paper towel;
- There was confusion on some of the times during the code between the clock and the paper; and
- There was no formal review of events after a Code Blue.

During an interview on 01/03/19 at 11:45 AM, Staff H, MD, Chief of Staff stated that:
- It was okay to use EMS for help because they were adequately trained;
- The Director of the ED was responsible for the ED providers;
- She had a collaborative agreement with Staff L, NP for clinic activities;
- She was not on call for the ED; and
- All staff should follow ACLS guidelines.

During an interview on 01/03/19 at 1:00 PM, Staff I, Chief Operating Officer (CEO) stated that:
- She expected staff to follow ACLS protocol;
- She was not aware that transfers were not being discussed with the collaborating physician prior to the transfer;
- She expected Physicians, Nurse Practitioners, and Physician Assistants to follow EMTALA regulations; and
- EMS should not be performing services in the hospital.

Patient #22
Review of Patient #22's ED Progress Note showed:
- Patient was a 73 year old male traveling from Florida to Montana to meet family and while in the hotel he developed severe abdominal pain on 12/19/18 after having a meal of barbeque the evening before;
- Arrived by EMS on 12/19/18 at 7:01 AM with a history of gallstones and a pain score of 10/10. He received pain medication while in route to the hospital;
- Impression showed acute cholecystitis (inflammation of the gallbladder) and pancreatitis (inflammation in the pancreas);
- Staff L, NP transferred the patient to a nearby hospital for further evaluation and surgical consult at 9:40 AM; and
- There was no evidence in the medical record that Staff K, Director of ED, physician on call, provided further examination or certified in the medical record the benefits of transfer outweighed the risks prior to the transfer of the patient.

3. Patient #23
Review of Patient #23's ED medical record showed that the patient had developed garbled speech and right sided weakness while sitting across from his wife, and was brought to the hospital by personal vehicle on 12/19/18 at 5:00 PM. Impression was cerebral vascular accident (CVA-stroke) and Staff L, NP consulted a nearby hospital for correct dosing of stroke medications prior to transfer. The patient was transferred by EMS to a nearby hospital on 12/19/18 at 6:40 PM.

There was no evidence in the medical record that Staff K, Director of ED, physician on call, provided further examination or certified in the medical record the benefits of transfer outweighed the risks prior to the attempt to transfer the patient.

During a telephone interview on 01/04/19 at 12:10 PM, Staff L, NP stated that she collaborated with Staff H, Chief of Staff, prior to all transfers but sometimes failed to document in her note. If Staff H, was not available, she collaborated with Staff K, ED Medical Director.



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