HospitalInspections.org

Based on review of medical records (MR), review of credential files (CF), review of policies and procedures, review of facility documents and interviews with staff (EMP), it was determined the facility failed to maintain a list of on-call physicians, failed to provide on-call Otolaryngology services in accordance with facility by-laws, and failed to have a specific policy and procedure in place to respond to situations in which a specific specialty medical service was not available for 13 of 26 medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR11, MR12, MR13 and MR14).

Findings include:

1) Review on February 4, 2016, of policy "On-Call, Physicians Specialists," dated January 2016, revealed this policy outlined the procedure for referring specialty services to patients presenting to the Emergency Department. This policy did not address the requirement of having individual physician names listed on the on call schedule.

Review on February 5, 2016, of facility document "Sacred Heart Hospital On Call Schedule" for the months of May, June, July, August, September, October, November and December 2015, revealed no documented evidence that the Otolaryngology (medical specialty involving the ear, nose and throat otherwise known as "ENT") service and/or physicians were on call for duty. Otolaryngology was not listed on the on call schedule.

Review on February 5, 2016, of facility document "Sacred Heart Hospital On Call Schedule" for the months of May, June, July, August, September, October, November and December 2015, revealed "Orthopedics Call [phone number listed]." Individual physicians were not listed on the on call schedule for Orthopedics.

Review on February 5, 2016, of facility document "Sacred Heart Hospital On Call Schedule" for the months of May, June, July, August, September, October, November and December 2015, revealed "Cardiac Surgery Call Service [phone number listed]." Individual physicians were not listed on the on call schedule for Cardiac Surgery.

Review on February 5, 2016, of facility document "Sacred Heart Hospital On Call Schedule" for the months of May, June, July, August, September, October and November 2015, revealed no documented evidence that the Nephrology service and/or physicians were on call for duty. Nephrology was not listed on these on call lists.

Review on February 5, 2016, of facility document "Sacred Heart Hospital On Call Schedule" for the month of December 2015, revealed "Nephrology [name of nephrology physician group and phone number listed]." Individual physicians were not listed on the on call schedule for Nephrology.

Review on February 5, 2016, of facility document "Sacred Heart Hospital On Call Schedule" for the months of May, June, July, August, September, October, November and December 2015, revealed "Urology." There was no additional information listed for this service. Individual physicians were not listed on the on call schedule for Urology.

Interview on February 5, 2016, at 11:15 AM, with EMP4 confirmed that the facility did not have a policy related to the requirement of having the individual names of physicians listed on the hospital's on-call list for duty in the Emergency Department. EMP4 confirmed individual physician names were not listed on the on call schedules for Orthopedics, Cardiac Surgery, Nephrology and Urology specialty services. EMP4 confirmed that Otolaryngology was not listed as an on-call specialty service.

2) Review on February 4, 2016, of facility document "Bylaws of the Medical Staff," dated June 2014, revealed "Section 6 - Medical Staff Categories ... The Medical Staff shall be divided into the following categories: Active, Courtesy, Consulting, Affiliate, and Honorary ... A) The Active Medical Staff shall consist of practitioners who regularly admit or otherwise provide service to patients in the Hospital, who are located closely enough to the Hospital to provide continuous care to their patients ... C) In order to remain on the Active Staff, an individual must be willing to assume reasonable service assignments ... 3) Acceptance of emergency call responsibilities and care of service patient as designated by department chairpersons and specified in the Medical Staff Rules and Regulations ...."

Review on February 4, 2016, of "Medical Staff Rules and Regulations," dated June 2014, revealed "... Article XIV-Surgery ... B) Subdivisions of the Surgical Department shall be: ... Otolaryngology and Head and Neck [ENT] ... D) On Call Responsibilities-Members of the Active Medical Staff are required to be listed on the On Call Schedule in their respective subdivision. The subdivision chief will assign the on call schedule. The physician on call is responsible to see patients in the Emergency Care unit as well as unreferred consults." There was nothing in this facility document, or in any other documents provided, that exempted ENT physicians from providing on call services to Emergency department patients.

Review on February 4, 2016, of CF1, CF2, CF3, CF4, CF5, CF6 and CF7 revealed these ENT physicians were currently credentialed as medical staff "Active" category.

Interview with EMP5 on February 4, 2016, confirmed CF1, CF2, CF3, CF4, CF5, CF6 and CF7 were ENT physicians credentialed as "Active" medical staff.

On February 4, 2016, surveyor requested any documentation available for the Department Chairperson exempting ENT physicians from providing on call services. None was provided.

On February 4, 2016, surveyor requested EMP4 to provide a policy and procedure to address how to respond to situations in which a specific specialty medical service was not available. None was provided.

Review on February 4, 2016, of MR1 revealed the patient was transferred from the ED to another facility on February 3, 2016, for "ENT emergency" services.

Review on February 4, 2016, of MR2 revealed the patient was transferred from the ED to another facility on May 17, 2015, for "lack of ENT services."

Review on February 4, 2016, of MR3 revealed the patient was transferred from the ED to another facility on March 16, 2015, for "Peritonsillar abscess."

Review on February 4, 2016, of MR4 revealed the patient was transferred from the ED to another facility on May 2, 2015, for "Tonsillitis."

Review on February 5, 2016, of MR5 revealed the patient was transferred from the ED to another facility on January 12, 2015, for "tonsillar abscess."

Review on February 5, 2016, of MR6 revealed the patient was transferred from the ED to another facility on May 18, 2015, for "Peritonsillar abscess."

Review on February 5, 2016, of MR7 revealed the patient was transferred from the ED to another facility on November 22, 2105, for "Possible peritonsillar abscess."

Review on February 5, 2016, of MR8 revealed the patient was transferred from the ED to another facility on December 14, 2015, for "Peritonsillar Abscess."

Review on February 5, 2016, of MR9 revealed the patient was transferred from the ED to another facility on December 28, 2015, for "Peritonsillar Abscess."

Review on February 4, 2016, of MR11 revealed the patient was transferred from the ED to another facility on May 9, 2015, for "acute tonsillitis, tonsillar cellulitis."

Review on February 5, 2016, of MR12 revealed the patient was transferred from the ED to another facility on July 6, 2015, for "Pharyngitis, Peritonsillar abscess (left)."

Review on February 5, 2016, of MR13 revealed the patient was transferred from the ED to another facility on March 16, 2015, for "Peritonsillar abscess."

Review on February 5, 2016, of MR14 revealed the patient was transferred from the ED to another facility on May 24, 2015, for acute anterior epistaxis (recurrent), remote nasal carcinoma."

Interview on February 5, 2016, at 9:45 AM, with EMP3 confirmed the facility does not offer on call ENT services in the ED and that the patients in MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR11, MR12, MR13, and MR14, who presented to the ED, were transferred to another facility who provided ENT services. EMP3 confirmed that the physicians in CF1, CF2, CF3, CF4, CF5, CF6 and CF7 were listed as " Active " medical staff but do not provide on call ENT services for this facility.

Interview on February 5, 2016, at 1:00 PM, with EMP4 confirmed the facility did not have a formal policy and procedure in place to respond to situations in which a specific specialty medical service was not available; specifically Otolaryngology; nor was there a policy in place to provide guidance on how to treat emergency Otolaryngology patients that required diagnostic and treatment beyond the scope of the Emergency department physician's expertise.

Based on review of medical records (MR), review of facility policies and procedures, review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure that a "Certification and Consent to Transfer" form was completed for seven of 26 Emergency Department (ED) transfer medical records reviewed (MR2, MR3, MR4, MR8, MR10, MR13 and MR14).

Findings include:

Review on February 4, 2016, of facility policy "Transfer - Interhospital," revised January 2016 revealed " ... V. Methods A. The following are acceptable reasons to transport patients from the Emergency Department: 1. Level of care or treatment needed not available at this facility ... F. 4. Completion of the following documents: a. Certification and Consent to Transfer ... "

Review on February 4, 2016, of facility document "Certification and Consent to Transfer" form, revealed " ... 2. Physician Component A medical screening examination was performed on the above patient, and I certify, that based on the examination (check one only):

The patient does not have an emergency medical condition and is not a pregnant woman having contractions

The patient does have an emergency medical condition, specifically: ___________

An emergency transfer is being made prior to stabilization of patient's condition.

Non-emergent transfer is being made prior to stabilization of patient's condition.

The patient is a pregnant woman having contractions ... "

Review on February 4, 2016, of MR2 revealed the patient was transferred on May 15, 2015, to another facility for level of care not available at Sacred Heart Hospital. Further review of the "Certification and Consent to Transfer" for MR2 revealed no documentation that Section 2 - Physician Component was checked by the the physician as required by facility policy and procedures.

Review on February 4, 2016, of MR3 revealed the patient was transferred on March 15, 2015, to another facility for level of care not available at Sacred Heart Hospital. Further review of the "Certification and Consent to Transfer" for MR3 revealed no documentation that Section 2 - Physician Component was checked by the the physician as required by facility policy and procedures.

Review on February 4, 2016, of MR4 revealed the patient was transferred on May 2, 2015, to another facility for level of care not available at Sacred Heart Hospital. Further review of the "Certification and Consent to Transfer" for MR4 revealed no documentation that Section 2 - Physician Component was checked by the the physician as required by facility policy and procedures.

Review on February 5, 2016, of MR8 revealed the patient was transferred on December 14, 2015, to another facility for level of care not available at Sacred Heart Hospital. Further review of the "Certification and Consent to Transfer" for MR8 revealed no documentation that Section 2 - Physician Component was checked by the the physician as required by facility policy and procedures.

Review on February 5, 2016, of MR10 revealed the patient was transferred on May 5, 2015, to another facility for level of care not available at Sacred Heart Hospital. Further review of the "Certification and Consent to Transfer" for MR10 revealed no documentation that Section 2 - Physician Component was checked by the the physician as required by facility policy and procedures.

Review on February 5, 2016, of MR13 revealed the patient was transferred on May 16, 2015, to another facility for level of care not available at Sacred Heart Hospital. Further review of the "Certification and Consent to Transfer" for MR13 revealed no documentation that Section 2 - Physician Component was checked by the the physician as required by facility policy and procedures.

Review on February 5, 2016, of MR14 revealed the patient was transferred on May 24, 2015, to another facility for level of care not available at Sacred Heart Hospital. Further review of the "Certification and Consent to Transfer" for MR14 revealed no documentation that Section 2 - Physician Component was checked by the the physician as required by facility policy and procedures.

Interview on February 5, 2016, at 11:00 AM, with EMP4 confirmed there was no documentation of a check for the physician component in Section 2 of the "Certification and Consent to Transfer" in MR2, MR3, MR4, MR8, MR10, MR13, and MR14.