HospitalInspections.org

Based on medical record review, review of the Emergency Department (ED) physician coverage schedules, review of the Medical Staff Rules and Regulations, review of facility policies, review of the facility census, review of the on-call physician's credentials, review of the Ear Nose and Throat (ENT) answering service logs, and interview, the facility failed to ensure the availability of the on-call physician for consultation and/or treatment for one patient (#20) with an Emergency Medical Condition (EMC) despite the facility's capability and capacity to treat the EMC.

Refer to findings under A-2404

Based on medical record review, review of the Emergency Department (ED) physician coverage schedules, review of the Medical Staff Rules and Regulations, review of facility policies, review of the facility census, review of the on-call physician's credentials, review of the Ear Nose and Throat (ENT) answering service logs, and interview, the facility failed to ensure the availability of the on-call physician for consultation and/or treatment for one patient (#20) with an Emergency Medical Condition (EMC) despite the facility's capability and capacity to treat the EMC.

The findings included:

Medical record review revealed patient #20, the identified patient, presented to the ED on August 7, 2012, at 8:43 p.m. The patient was accompanied by the grandmother as the patient was an 8 year old minor.

Medical record review of the Triage (Registered Nurse's assessment) note, dated August 7, 2012, at 8:48 p.m., revealed the patient was seen in triage at 8:48 p.m. The patient'S vital signs were as follows: temperature 99.0 degrees Fahrenheit, pulse 109 regular, blood pressure 97/60, respiration 24 unlabored, and oxygen saturation (O2 sat) 99% (percent). The patient pain score was 0 on a scale of 1-10 with 10 highest. The Chief Complaint for presentation was post operative (post-op) times two weeks for a Tonsillectomy and Adenoidectomy (T&A) with current and newly started bleeding for five minutes with bright red blood and no clots.

Medical record review of the Emergency Department (ED) Physician's note, dated August 7, 2012, at 8:59 p.m., revealed the "...onset of symptoms was immediately prior to arrival...present now...severe...bleeding from Tonsillectomy site on left...Physical Exam:...left tonsil bleeding noted...all labs reviewed (Complete Blood Count, Basic Metabolic Panel, Protime, and Partial Thromboplastin Time)...no clinically significant abnormalities...Consultation and Critical Thinking:...9:49 p.m...case discussed with (named) Ear Nose Throat (ENT) doctor (#1) (who had performed the surgery on the patient 2 weeks prior; was not the on call ENT physician; and was no longer obliged to be on call for the ED due exemption for Senior Physician status). I discussed the case with (doctor #1) after (named doctor #2 - physician listed on-call schedule for August 7, 2012 for ENT) informed us that he was not unavailable and that the unassigned Dr. (doctor) for ENT would be responsible for this. Time of consult 10:02 p.m. Case discussed with doctor. I called the answering service to let them know that I again needed to discuss the case with the ENT on call. Time of consult 10:11 p.m. Case discussed with doctor Answering service for ENT, (named person of answering service) informed me that (named) Dr. (#2) not available to cover (named) Dr's (#1) patient and that he would not be available to discuss the case with me. Clinical Impression: Post operative pharyngeal bleeding. Disposition: Patient will be transferred to (named) Hospital. Condition: Stable. Certified Medical Emergency: Patient's condition represents a certified medical emergency. Disposition date/time August 7, 2012, at 11:00 p.m.

Review of the Emergency Medical Services Medical Necessity Certification, dated August 7, 2012, no time noted, revealed "...means of transportation based on patient health and safety:...Cardiac Monitoring and Watch for Bleeding..."

Review of the Patient Transfer Form, completed by the ED physician and nurse completing transfer documents, dated August 7, 2012, at 10:23 p.m., revealed "...Appropriate medical records: lab tests, face sheets, ED records, Nurse's Notes...Receiving facility (named) hospital...monitor, IV (intravenous fluids), O2, EMT...ambulance with Paramedic (Advanced Life Support)...accepting physician (named)...acknowledgement/risks/benefits signed by guardian...expected benefits Higher level of ENT...Risks MVA (motor vehicle accident) worsening condition..."

Continued medical record review of the nursing documentation, dated August 7, 2012, at 11:15 p.m., revealed "Transfer:...Transfer was initiated for: Specialized Care - Pediatrics. (named) Dr (#3) arranged transfer. Dr (named of physician at accepting hospital) accepted patient...Transferred by ground EMS (Emergency Medical Services)...medical record given to transfer service for delivery to receiving hospital. Vital signs taken at 11:00 p.m., were (temperature 98.7 degrees, (pulse) 115 and is regular, (respirations) 20 and unlabored, (blood pressure) 105/55, O2 sat 97 (on room air), pain 0 on 1-10 scale, patient left department August 7, 2012, at 11:17 p.m."

Review of the ED Physician staffing schedule for August 2012, revealed Dr #3 was the ED on duty Physician from August 7, 2021 from 7:00 p.m., through August 8, 2012, at 7:00 a.m.

Review of the Hospital's "Physician On Call Schedule", dated August 2012, revealed Dr #2 was the ENT physician listed under the specialty ENT for August 7, 2012.

Interview in the conference room with the Chief Executive Officer on August 27, 2012, at 8:45 a.m., confirmed the facility admitted pediatric patients to the 63 bed medical surgical unit. Review of the Hospital Census, dated August 7, 2012, revealed a total census of 45 patients with a capacity of 135. Continued review of the census revealed the beds were occupied as follows: Obstetrics - 4; Rehabilitation - 6; Intensive Care Unit - 5; Swing bed - 3; Nursery - 4; Semi-private - 17; Private - 1; Obstetrics other - 1; and medical surgical - with telemetry - 4.

Review of the Credential File of Physician #2 revealed the physician was re-appointed November 23, 2010 to an ENT Physician position as active staff. Continued review revealed the Physician had lifetime Board Certification in Otolaryngology. Continued review revealed requested and approved delineated privileges included Tonsillectomy, Adenoidectomy, and use of Laser for Pharynx.

Review of facility report of Dr #2's patient encounter counts from July 31, 2011 through August 1, 2012 revealed the Physician had no inpatients encounters and 890 outpatient encounters (outpatient surgeries).

Review of the facility policy "EMTALA (Emergency Medical Treatment And Active Labor", policy number 40, reviewed May 2010, revealed "...purpose:...to maintain compliance with EMTALA requirements for emergency department patient care and administration...emergency department will follow corporate policy on compliance with EMTALA regulations..."

Review of the facility policy "Medical Staff Responsibility for Care in the Emergency Department", policy number 21, reviewed May 2010, revealed "...purpose...to define medical responsibility for care of patients presenting to the emergency department...Policy: The private physician may come in and see his/her private patient in the emergency department at their discretion...Procedure: The emergency physician provider or designee retains the right and responsibility to perform a medical screening exam on every patient presenting to the emergency services to determine if a life or limb threatening situation exists unless the private physician is in attendance at the time the patient presents...Physicians on the on-call specialist list for emergency coverage or responsible for consultations to the emergency physician providers in their area of specialty. If a staff physician is on call or will not be available he/she is responsible to assure backup coverage for the specialty call according to the hospital staff bylaws...physicians are required to follow up medical staff rules and regulations outlining emergency department responsibilities..."


Review of the facility policy "Procedures/Treatments Not Allowed in the Emergency Department", policy number 30, reviewed May 2010, revealed "...Purpose: To identify those procedures not to be performed in the emergency department. Policy:...any procedure requiring general anesthesia ...any procedure for which the individual performing the procedure is not privileged or credentialed to do..."


Review of the facility policy "Transfer of Patient to Another Facility: Emergent or Non-emergent" policy number 2014, effective January 1989, revealed "...to prevent any patients from being arbitrarily transferred to another facility...patients are transferred according to the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA)...Procedure for Emergency Transfers...If the patient has an emergency medical condition emergency...treatment will be initiated and patient stabilized prior to transfer...The physician will thoroughly assess and obtain appropriate consultation to determine need for transfer...the decision for transfer will be based on the following pre-established criteria: when beds, medical care or facilities appropriate the patient's care or not available..."


Review of the Medical Staff By-laws, dated August 2011, article VI, revealed "...Screening, Treatment and Transfer...Screening an individual who presents to the emergency department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition. Generally, an "emergency medical condition" is defined as active labor or condition manifesting set symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment of bodily organs or functions or serious jeopardy to the health of the individual or unborn child...Stabilization:...A patient stable for transfer if the treating physician has determined, within reasonable clinical confidence, that the patient is expected to leave the hospital and to be received at a second facility with no material foreseeable deterioration in his or her condition; and the treating physician reasonably believes the receiving facility has the capability to manage the patient's medical condition and any reasonable foreseeable complications of that condition...Consultations, Referrals and Emergency Department Call: When the emergency department physician determines that a consultation or specialize treatment beyond the capability of the emergency department physician is needed, the patient shall be permitted to request the services of a specific private physicians. This request shall be documented in the patient's medical record...An appropriate attempt to contact the physician will be considered to have been made when the emergency department physician or the emergency department designee has attempted to reach the physician in the hospital, called the physician's home, called the physician at his or her office, and called once on the physician's pager. Twenty minutes will be considered a reasonable time to carry out this procedure ...The rotation call list, containing the names and phone numbers of the on-call physician's shall be posted in the emergency department. In the event the patient does not have a private physician, the private physician refuses the patient's request to come to the emergency department, or the physician cannot be contacted within 20 minutes of the initial request, the rotation call list shall be used to select a private physician to provide the necessary consultation or treatment for the patient...For patients requiring a specialist consultation, the applicable rotation call schedule shall be used. A physician who has been called from the rotation list may not refuse to respond the emergency department. The Emergency Department physician's determination shall control whether the on-call physician is required to come in to personally assess the patient. Any such refusal shall it be reported to the CEO for further action and may constitute grounds for revocations of the physician's medical staff appointment and clinical privileges...Physicians called are required to respond to the emergency department call by telephone within 10 minutes. If requested to come in, they are required to do so within 20 minutes after responding by telephone..."

Interview in the conference room with the Chief Executive Officer and Director of Quality Management and Regulatory Compliance on August 27, 2012, at 3:40 p.m., revealed "...Dr #1 and Dr #2 are in practice together...Became aware of the issue the following morning (August 8, 2012) from the Risk Manager...The incident was discussed in the morning meeting...The facility developed a plan to re-educate the staff on on-call issues and how they are to be handled...The actions of Dr #2 were to be discussed during the Medical Executive Meeting scheduled for August 27, 2012, but, due to EMTALA survey investigation, the meeting was rescheduled...The facility had beds available and an ENT Physician on-call and available who refused to return the call the the ED Physician regarding a patient the ED Physician considered to have an Emergency Medical Condition and had called the ENT without response...The patient had to be transferred to another hospital..."

Interview in the conference room with the Risk Manager, the Chief Executive Officer and the Director of Quality Management and Regulatory Compliance on August 27, 2012, at 4:00 p.m., revealed "...became aware of incident in ED the following morning (August 8, 2012)...Dr. #1 was discussing with the Medical Director of the ED (Dr #4) the events related to Dr #2 not answering call as required...the information was brought to the morning meeting (August 8, 2012)...an investigation is ongoing...did not feel an EMTALA violation had occurred..."

Interview by phone with the Medical Director of the ED (Dr. #4) on August 28, 2012, at 10:10 a.m., revealed "...became aware the next morning (August 8, 2012)...Report from (ED Physician - Dr. #3) of happenings...read over the medical record...case was handled fine...Discussed with (ENT Physician's who performed surgery - Dr. #1) and was informed that (Dr. #1) was unavailable...Have not spoken with (ENT on call Physician - Dr. #2)...Discussed with Chief Executive Officer and informed Chief of Staff...see an issue with the call schedule...main concern was care of the patient and feel the patient was referred timely and suffered no harm...Disappointed with occurrence and (Dr. #2's) lack of response...On-call Doctor (Dr. #2) did not respond as required..."

Interview by phone on August 28, 2012, at 10:30 a.m., with the ED Physician on Duty (Dr. #3) on August 7, 2012, for patient #20's care, revealed "...Never spoke with (on-call for ENT - Dr.#2)...Initially the answering service had been contacted and informed the staff (Dr. #2) did not cover (Dr. #1's) patients...I spoke with (Dr. #1) and was informed (Dr. #1) was not the on-call and ENT on call would have to handle it...I personally called the answering service for and was told (Dr. #2) was not available to consult because it (patient #20) WAS (Dr. #1's) patient...I had a bleeding patient and I spoke with the (hospital where patient was transferred) ENT on call and the ED Physician (at the hospital where patient was transferred...who accepted the patient in transfer...and was informed that was an issue as an ENT was available on-call here...I again tried the answering service and to speak with (Dr. #2) and the answering service informed me (Dr.#2) would not speak with me...After the child was transferred (Dr. #1) called to see what occurred and told me I would need to report...I spoke with Risk Management and the ED Medical Director...I see an EMTALA violation as the EMT doctor was available and the means to care for the patient were available..."

Interview in the conference room with (the on-call ENT - Dr. #2) on August 28, 2012, at 11:55 a.m., revealed "...three ENT's in town...all in same group...two of us have issues with (Dr. #1)...provided Administration in writing 7 - 8 years ago that we did not want association with or care of (Dr. #1's) patients...I knew nothing of the incident of August 7, 2012 until 7- 10 days ago when a colleague told me...Answering service has been directed to not take (Dr. #1's) call for coverage for the other two ENTs...ED has home, cell, and pager number...No ED doctor called me...Aware I was ENT on-call ...Per EMTALA, if ED Physician called I would see the patient (if it's a child bleeding)...I knew nothing of the ED case (of patient #20)...Answering service called that night to tell me a patient of (Dr. #1)...and the conversation ends at that point...This has been a problem of getting calls from the answering service for (Dr. #1's) patients...The answering service takes call for the three of us (Dr #1, Dr. #2 and another ENT in the group) ...(Dr. #1) is to be called on his patients...I think it could have been handled differently as the child was bleeding...I feel I should have been called at home, pager or cell phone...I know now it was the ED but I didn't know then..."

Review of the answering service call forms submitted for review revealed on August 7, 2012, at 9:38 p.m., (Dr. #1) was called by the ED related to a 2 week post operative Tonsillectomy and Adenoidectomy patient bleeding,,,(Dr #1) said he is unavailable and to call (Dr. #2)...said no...(Dr. #1) called back finally took the call..." Continued review revealed on August 7, 2012, at 9:56 p.m., (Dr. #2) was called by (Dr. #3) from the ED ...regarding child bleeding post operatively 2 weeks Tonsillectomy and Adenoidectomy...(named person)(answering supervisor)told me not to call him (Dr. #3) back..."