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I. Based on document review and staff interview, the acute care hospital's administrative staff failed to ensure medical staff followed the hospital's policies when requesting a change affecting the on-call schedule resulting in the inability of hospital staff to identify (Ears Nose and Throat specialized training) ENT physician on-call coverage on 9/11/2018 when requested by the ED physician B for 1 of 1 patients (Patient #16) who presented to the (Emergency Department) ED in respiratory arrest (stopped breathing). Failure of ENT Physician A to follow the hospital process to make a change in the call schedule resulted in hospital staff not contacting ENT Physician G who had agreed to take call coverage for Physician A in his absence and led to a delay in Patient #16's medical care leaving the Patient #16 in a permanent vegetative state. The hospital's administrative staff identified an average of 2392 patients presented to the ED and requested emergency care per month.

Findings included:

1. Review of the Medical Staff Policy "EMTALA CALL", revised 4/17, revealed in part, "The UPH-DM (Unity Point Health-Des Moines) Answering Service is the contact for calls requiring EMTALA coverage. Schedule changes: i. The physician requesting a change affecting his/her call schedule is responsible for communicating the information to the answering service. ii. The UPH-DM Answering Service will communicate and document the change."

2. Review of the document titled "On-Call Schedule from 9/01/2018 to 9/20/2018" revealed the schedule listed ENT Physician A to provide ENT on-call coverage (available to the ED if a patient required ENT Physician A's specialized care) from 07:00 AM on 9/01/18 through 07:00 AM on 9/20/18.

3. Review of the document "Unity Point Health Des Moines, DM Roster of Practicing Staff" identified ENT Physician G as an "active" member (able to admit and care for patients and take emergency call) of the medical staff at Iowa Lutheran Hospital (ILH).

4. Review of the document "UNITYPOINT HEALTH- DES MOINES, BLANK CHILDREN'S HOSPITAL, IOWA LUTHERAN HOSPITAL, IOWA METHODIST MEDICAL CENTER, METHODIST WEST HOSPITAL, Delineation of Privileges", approved by the Board of Directors 4-19-2018, revealed in part, ENT Physician G requested otolaryngology privileges which included admission, work up, diagnosis, and provision of non-surgical and surgical care... "Please choose your primary campus below. Your...EMTALA coverage...is determined by your selection. If a campus is not selected, the default section will be "both." ____ ILH ___Hospital B ____Both The form revealed no blanks had been marked. ENT Physician G failed to choose a primary campus resulting in EMTALA responsibility at both ILH and Hospital B.

5. An interview on 9/26/2018 at 9:03 AM with ENT Physician A revealed ENT Physician A had contacted ENT Physician G to provide back-up coverage for ENT Physician A while he was out of town and that ENT Physician G agreed to cover for ENT Physician A. ENT Physician A was not aware of the hospital policy and procedure for requesting a change in the on-call schedule and had never followed it. ENT Physician A stated he had never been asked by anyone at the hospital to follow the designated procedure for requesting a change in the on-call schedule. ENT Physician A stated he emailed the VPMA (Vice President of Medical Affairs) with the dates Physician A was going to be gone, called the Emergency Department and told them the dates he was going to be gone, and called ENT Physician G to arrange for back-up.

6. An interview on 9/25/2018 with Unit Secretary J revealed Unit secretary J knew ENT Physician A was out of town as ENT Physician A had called the ED and Unit Secretary J had placed a note on the computer the Unit Secretary used to identify on-call providers. The note listed the dates ENT Physician A was out of town and to utilize Hospital B's on-call list. Unit Secretary J revealed she did not try to call ENT Physician G as it said on Hospital B's call schedule that ENT Physician G does not come to ILH. Unit Secretary J called an ENT Provider not on call and took approximately 30 minutes for ENT Physician H to arrive after being summoned.

7. An interview on 9/25/2018 at 3:10 PM with RN (Registered Nurse) ED Nurse Manager revealed she was aware that ENT Physician A is on-call unless ENT Physician A notifies the ED by phone or email that he will be gone and that the Unit Secretary then placed a note on the computer screen. RN ED Nurse Manager verbalized that changes take place with the on-call provider that do not make it to the on-call schedule.

8. Review of Patient #16's medical record revealed:

a.. Patient #16 presented to the hospital's ED on 9/11/2018 at 4:00 PM in respiratory arrest, and within a few minutes of arrival, went into cardiac arrest (heart stopped beating). ED staff initiated CPR (cardio pulmonary resuscitation), administered emergency medications, and Patient #16's pulse returned approximately 10 minutes later.

b. ED Physician B attempted to intubate (put a breathing tube through the patient's mouth and into the trachea) Patient #16 but was not successful. Hospital staff requested an anesthesia physician and ENT physician come to the ED to help establish an adequate airway for Patient #16.

c. Anesthesiologist C (a physician with specialized training in putting patients to sleep for surgery) arrived at 4:13 PM. ED Physician B and Anesthesiologist C made multiple attempts to establish an adequate airway utilizing specialized equipment could not intubate Patient #16 due to significant swelling in their throat. In between attempts to intubate, ED staff ventilated (caused air to enter the lungs) with a BVM (bag valve mask, a hand held device commonly used to ventilate patients who are not breathing) connected to oxygen.

d. ED Physician B, assisted by anesthesiologist C, performed a cricothyroidotomy (an incision made through the skin in the neck to establish an airway during life-threatening situations) at 4:34 PM and established a temporary adequate airway. The hospital staff continued to provide treatment to Patient #16 for an emergency medical condition.

e. ED Physician B consulted with ENT Physician H at 4:55 PM and requested placement of a tracheostomy (surgical procedure which consists of making an incision in the front of the neck and opening a direct airway through the trachea or windpipe) for airway stabilization. ENT physician H stated he was not on-call but agreed to come in due to the extreme emergency.

f. ENT physician H arrived and Patient #16 entered the surgical suite at 6:19 PM. The surgical procedure finished at 7:40 PM.

Please refer to A- 2404 for additional information concerning the hospital's failure of the on-call schedule to clearly identify the hospital lacked ENT coverage on 9/11/18.


Please refer to A-2407 for additional information concerning the hospital's failure to provide timely emergency surgical care on 9/11/18.

Based on document review and staff interview, the acute care hospital's administrative staff failed to ensure the hospital ED (Emergency Department) staff had an accurate, up to date on-call schedule, resulting in the inability of hospital staff to identify (Ears Nose and Throat specialized training) ENT physician on-call coverage on 9/11/2018 when requested by ED Physician B for 1 of 1 patients (Patient #16) who presented to the ED in respiratory arrest (stopped breathing). The hospital had one ENT Physician who took call 24/7 unless he was out of town. Failure of the hospital to maintain an accurate on-call schedule resulted in the delay of ENT care and the placement of a stabilizing tracheostomy (surgical procedure which consists of making an incision in the front of the neck and opening a direct airway through the trachea or windpipe) for Patient #16. The hospital's administrative staff identified an average of 2392 patients presented to the ED and requested emergency care per month.


Findings included:

1. Review of the Medical Staff Policy "EMTALA CALL", revised 4/17, revealed in part, "The UPH-DM (Unity Point Health-Des Moines) Answering Service is the contact for calls requiring EMTALA coverage. Schedule changes: i. The physician requesting a change affecting his/her call schedule is responsible for communicating the information to the answering service. ii. The UPH-DM Answering Service will communicate and document the change." "Unavailability of On-Call Coverage: During periods when a.... subspecialty medical service is not available...the patient will be stabilized within the capabilities of the hospital and may be transferred to another facility with capabilities appropriate to the medical condition."

2. Review of the document titled "On-Call Schedule from 9/01/2018 to 9/20/2018" revealed the schedule listed ENT Physician A to provide ENT on-call coverage (available to the ED if a patient required ENT Physician A's specialized care) from 07:00 AM on 9/01/18 through 07:00 AM on 9/20/18.

3. Review of the document "Unity Point Health Des Moines, [Des Moines] Roster of Practicing Staff" identified 10 ENT Physician as an "active" member (able to admit and care for patients and take emergency call) or "associate" member (able to admit and care for patients and take emergency call) of the medical staff at Iowa Lutheran Hospital (ILH).

4. An interview on 9/26/2018 at 9:03 AM with ENT Physician A revealed ENT Physician A had contacted ENT Physician G to provide back-up coverage for ENT Physician A while he was out of town and that ENT Physician G agreed to cover for ENT Physician A. ENT Physician A was not aware of the hospital policy and procedure for requesting a change in the on-call schedule. ENT Physician A stated he emailed the VPMA (Vice President of Medical Affairs) with the dates Physician A was going to be gone, called the Emergency Department and told them the dates he was going to be gone, and called ENT Physician G to arrange for back-up.

5. An interview on 9/25/2018 with Unit Secretary J revealed Unit secretary J knew that ENT Physician A was out of town as ENT Physician A had called the ED and Unit Secretary J had placed a note on the computer the Unit Secretary used to identify on-call providers. The note listed the dates ENT Physician A was out of town and to utilize Hospital B's on-call list. Unit Secretary J revealed she did not try to call ENT Physician G as it said on Hospital B's call schedule that ENT Physician G does not come to ILH. Unit Secretary J called an ENT Provider not on call and took approximately 30 minutes for ENT Physician H to arrive after being summoned. ENT Physician G's office is located within approximately minutes of ILH.

6. Review of Patient # 16's medical record revealed the following:

a. Patient #16 presented to the hospital's ED on 9/11/2018 at 4:00 PM in respiratory arrest (not breathing), and within a few minutes of arrival, went into cardiac arrest (heart stopped beating). ED staff initiated CPR (cardio pulmonary resuscitation), administered emergency medications, and Patient #16's pulse returned approximately 10 minutes later.

b. ED Physician B attempted to intubate (put a breathing tube through the patient's mouth and into the trachea) Patient #16 but was not successful. Hospital staff requested an anesthesia physician and ENT physician come to the ED to help establish an adequate airway for Patient #16.

c. Anesthesiologist C (a physician with specialized training in putting patients to sleep for surgery) arrived at 4:13 PM. ED Physician B and Anesthesiologist C made multiple attempts to establish an adequate airway utilizing specialized equipment could not intubate Patient #16 due to significant swelling in their throat. In between attempts to intubate, ED staff ventilated (caused air to enter the lungs) with a BVM (bag valve mask, a hand held device commonly used to ventilate patients who are not breathing) connected to oxygen.

d. ED Physician B, assisted by anesthesiologist C, performed a cricothyroidotomy (an incision made through the skin in the neck to establish an airway during life-threatening situations) at 4:34 PM and established a temporary adequate airway. The hospital staff continued to provide treatment to Patient #16 for an emergency medical condition.

e. ED Physician B consulted with ENT Physician H at 4:55 PM and requested placement of a tracheotomy for airway stabilization. ENT physician H stated he was not on-call but agreed to come in due to the extreme emergency.

f. ENT physician H arrived and Patient #16 entered the surgical suite at 6:19 PM. The surgical procedure finished at 7:40 PM, and the hospital staff transferred Patient #16 by ambulance to Hospital #2 from the OR.

4. An interview on 9/25/2018 at 8:15 AM with Charge Nurse I revealed:

a. Attempts to call in an ENT physician started about the time we called in anesthesia, which was around 4:00 PM on 9/11/2018.

b. Charge Nurse I believed the ENT on Call refused to come in when Unit Secretary J informed Charge Nurse I that Hospital #2's ENT Physician does not come to ILH (Iowa Lutheran Hospital) and Hospital #2's ENT Physician was only on call for Hospital #2.

c. Unit secretary J called Hospital 2's On-Call Trauma Surgery Team; the team was involved in surgery at Hospital 2 and not available.

d. Unit secretary J handed Charge Nurse I the telephone after reaching ENT physician H. ENT physician H verbalized he was very angry that he was paged. Charge RN I explained this was a life or death situation. ENT Physician H agreed to come in.

5. An interview on 9/25/2018 at 4:30 PM with ED Physician B revealed:

a. The hospital staff experienced difficulty understanding the procedures when ENT Physician A was not available to provide on-call availability to the ED. ENT Physician A always provided on-call availability to the ED, unless ENT Physician A notified the hospital in advance that he could not provide ENT on-call availability.

b. ED Physician B reported to the ED Medical Director that ENT Physician H was called to ILH to care for Patient #16 when he was not on-call and did not practice normally at IHL.

6. An interview with Anesthesiologist C on 9/25/2018 at 2:00 PM revealed the hospital lacked consistent ENT coverage and had difficulty obtaining back-up ENT coverage. The hospital staff had to transfer patients to another hospital if ENT Physician A was not available to provide emergency ENT coverage.

7. An interview on 9/25/2018 at 11:00 AM with Unit Secretary J revealed:

a. Unit Secretary J received a request to call Anesthesia, and Anesthesiologist C arrived quickly after Unit Secretary J called him. After Anesthesiologist C could not intubate Patient #16, Unit Secretary J received a request to contact the on-call ENT physician.

b. ENT Physician A called Unit Secretary J on 9/7/18 and stated that ENT Physician A would be out of town from 9/10/18 to 9/21/18. ENT Physician A instructed Unit Secretary J to contact Hospital #2's on-call ENT physician, ENT Physician G. Unit Secretary J wrote the information on a sticky note and placed the sticky note on a computer at the Unit Secretary's work station, so other staff would know ENT Physician A was unavailable and they needed to call Hospital #2's on-call ENT physician.

c. Unit Secretary J did not call ENT Physician G when Patient #16 presented to the hospital on 9/11/2018 and required emergency ENT care despite Physician G's name being listed on Hospital #2's ENT call schedule for 9/11/18. Unit secretary J noted that ENT Physician G's call listing contained a note that stated he did not provide ENT call coverage at Iowa Lutheran Hospital. Unit Secretary J tried to contact Hospital #2's trauma surgeons, but the trauma surgeons were already performing emergency surgery and could not assist Patient #16. Unit Secretary J tried to contact the on-call surgeon at Iowa Lutheran Hospital and was informed that Surgeon K was unavailable, as he was already performing surgery. Unit Secretary J resorted to searching the internet for ENT Physician H's phone number. Unit Secretary J reached ENT Physician H by telephone and had Charge Nurse I speak with ENT Physician H.

d. Unit Secretary J verbalized she did not know the process used to generate the on-call schedule or have any access to make a change to the on-call schedule, such as when ENT Physician A called the ED and notified the ED staff ENT Physician A was unavailable to provide emergency ENT care.

8. An interview on 9/25/2018 at 11:00 AM with ENT Physician H revealed the following:

a. ENT Physician A provided emergency on-call coverage to the ED at Iowa Lutheran Hospital all the time. ENT Physician H expected the ILH ED physician to transfer any patients requiring emergency ENT medical care to Hospital #2 when ENT Physician A was unavailable, since Hospital #2 has on-call ENT physicians.

b. ENT Physician H received a phone call from Iowa Lutheran Hospital's ED around 5:00 PM on 9/11/18. The caller stated they knew ENT Physician H was not on-call, but asked if ENT Physician H could respond to Patient #16's ENT emergency. ENT Physician H instructed the staff at Iowa Lutheran Hospital to transfer Patient #16 to Hospital #2, since Hospital #2 had an on-call ENT physician. The Iowa Lutheran Hospital staff member informed ENT Physician H that they could not safely transfer Patient #16, due to Patient #16's medical condition and that Patient #16 was dying. ENT Physician H agreed to provide emergency ENT care to Patient #16, despite ENT Physician H not providing medical care at Iowa Lutheran Hospital for at least 10 years and did not know the hospital's staff.

9. An interview on 9/26/2018 at 4:30 PM with ENT Physician G revealed that ENT Physician A had talked with ENT Physician G about ENT Physician G providing on-call coverage for ENT Physician A's private practice when ENT Physician A was out of town from 9/10/2018 to 9/21/2018. ENT Physician G stated that ENT Physician A did not discuss ENT Physician G providing emergency ENT care to the patients that presented at ILH. The common practice was that if ENT Physician A was not available, the ED at ILH did not have access to an ENT physician, and would need to transfer all patient's requiring ENT care to Hospital #2 (approximately 2.5 miles sway.).

10. An interview on 9/26/2018 at 9:03 AM with ENT Physician A revealed he only took EMTALA call at ILH, and was the only ENT doctor that comes to ILH. When ENT Physician A was going to be out of town, ENT Physician A emailed the VPMA the dates he would be gone, called the ILH ED and let them know the dates he would be gone, and called a provider for back up. ENT Physician A disclosed he was not familiar with the Medical Staff EMTALA On-Call policy and had not read it. ENT Physician A verified ENT Physician G covered all ENT Physician A's patient phone calls and office practice.

11. An interview on 9/25/2018 at 3:10 PM with the ED Nurse Manager verified the ED Nurse Manager was aware that ENT Physician A would call the ED unit secretary about once a month, instead of hospital approved on-call change procedure, when he was going to be out of town and ENT Physician A was unavailable to provide emergency ENT services.

ED Nurse Manager revealed the hospital lacked a back-up plan for providing emergency ENT services to patients when ENT Physician A was not available. ED Nurse Manager divulged if ENT Provider A was unavailable and a patient required emergent ENT services, the ED staff would call ENT physicians with privileges to practice at Iowa Lutheran Hospital instead of following the hospital's established policy to transfer patients to Hospital #2.

12. During an interview on 9/26/2018 at 2:30 PM, the VPMA acknowledged ENT Physician A sent him an email stating ENT Physician A would be out of town, and not be available to provide emergency ENT services at the hospital. The VPMA was unaware that ENT Physician A failed to notify the designated answering service that ENT Physician A would be out of town and thus, unavailable for emergency ENT care.

13. An interview on 9/25/2018 at 11:00 revealed Unit Secretary J talked with the ED Medical Director about ENT on-call on 9/12/18. Unit secretary J reported the ED Medical Director got back to her later that day and informed Unit Secretary J that he talked with the VPMA (Vice President of Medical Affairs). ED Medical Director clarified to Unit Secretary J that when ENT Physician A was not available to provide emergency care, and a patient required emergency ENT care presented to ILH, the hospital staff would need to transfer the patient to Hospital #2 for emergency ENT care.

14. An interview on 9/25/2018 at 2:44 PM with ED Medical Director E confirmed Medical Director E talked with VPMA on 9/12/2018 and verified Hospital 2's On-Call Physicians are not on-call for ILH and will accept transfer of patients with emergent ENT needs at Hospital 2 (approximately 2.5 miles away).

The VPMA stated ENT Physician A is the only ENT physician that provided on-call emergent ENT services at ILH. When ENT Physician A was unavailable, a patient that presented to the ED with an emergent ENT need, the hospital staff would stabilize the patient within the hospital's capabilities, and then transfer the patient to Hospital #2, which had an ENT physician available on-call.

15. An interview on 9/25/2018 at 3:10 PM with ED Nurse Manager disclosed that the daily listing of individual specialist providers on the EMTALA on-call schedule frequently contained incorrect information for multiple specialist services. The ED Nurse Manager stated the ED staff often learned the name of the actual physician providing specialist coverage to the ED when the ED staff called the phone number listed on the schedule and the discovered another physician was providing emergency specialist coverage to the ED.

I. Based on document review and staff interview, the Acute Care Hospital's administrative staff failed to ensure the hospital staff did not delay providing stabilizing treatment within the hospital's capability for 1 of 1 selected emergency department (ED) patient who required an emergency tracheotomy (Patient #16) and presented to the hospital between 3/1/18 and 9/20/18. Failure to provide all available stabilizing treatment within its capabilities and capacity placed patient # 16 at significant risk for bleeding, shock and further delays in receiving appropriate treatment. The hospital's administrative staff identified an average of 2392 patients per month who presented to the hospital and requested emergency medical care.


Findings include:

1. Review of Patient # 16's medical record revealed the following:

a. Patient #16 presented to the hospital's ED on 9/11/2018 at 4:00 PM in respiratory arrest (stopped breathing), and within a few minutes of arrival, went into cardiac arrest (heart stopped beating). ED staff initiated CPR (cardio pulmonary resuscitation), administered emergency medications, and Patient #16's pulse returned approximately 10 minutes later.

b. ED Physician B attempted to insert a breathing tube through patient # 16's mouth and into his trachea without success. After multiple failed attempts, ED physician B and Anesthesiologist C (a physician with specialized training in putting patients to sleep for surgery) performed a cricothyroidotomy (an incision made through the skin in the neck to establish an airway during life-threatening situations) at 4:34 PM and established a temporary adequate airway. The hospital staff continued to provide treatment to Patient #16 for an emergency medical condition.

c. ED Physician B consulted with an Ears, Nose and Throat (ENT) Physician H at 4:55 PM and requested placement of a tracheostomy (opening the trachea through a surgical incision). Though not on-call, ENT physician H agreed to come to the hospital and perform the procedure in the operating room due to the patient's extreme emergent condition.

d. Following the procedure in the operating room, ED Physician B arranged to transfer Patient #16 to Hospital #2.

e. ED Physician B documented in the medical record at 5:35 PM that the reason for transfer was intensive care, and the risk of transfer included "bleeding/shock; additional delay in receiving appropriate treatment." The benefits of transfer did not outweigh the risks.

2. Iowa Lutheran's capabilities included a 206 bed staffed hospital with an average inpatient census of 117 patients, a dedicated emergency department, a cardiac intensive care unit, a medical/surgical intensive care unit, respiratory care services, surgical services, diagnostic and therapeutic radiological services, an on-call surgeon with the capabilities to perform tracheotomies and an on-call intensivist (a board-certified physician who provides special care for critically ill patients).

3. An interview with General Surgeon K on 10/04/2018 at 2:22 PM revealed General Surgeon K received a page from his office to call the Iowa Lutheran Hospital (ILH) ED on the afternoon of 9/11/18. General Surgeon K stated he called the ILH ED and spoke with Anesthesiologist C. Anesthesiologist C informed General Surgeon K that Patient #16 had an established airway with a cricothyroidotomy and required a tracheotomy. General Surgeon K advised Anesthesiologist C to call an ENT physician or Trauma Surgeon to perform the tracheotomy. General Surgeon K revealed that the governing body at ILH had approved General Surgeon K to perform tracheotomies at ILH.

4. In an interview on 9/26/18 at 8:30 AM, Pulmonary Intensivist D confirmed his group of physicians managed the care of patients at Iowa Lutheran Hospital. "We are able to go to Lutheran for pulmonary/critical care." "We cover 4-8 patients in the ICU at Lutheran on a daily basis as well as on the medical floor."

5. After arrival at Hospital # 2 on 9/11/18, physicians determined that patient # 16 suffered from irreversable brain damage due to a lack of oxygen and remains in a persistent vegetative state.