Based on interview and record review, the facility did not ensure that: 1. The facility's written procedure was followed when the on-call specialist was unavailable to consult with the emergency department (ED) physician. 2. An on-call specialist was available to meet the needs of a patient who requested a transfer for specialized services available at the facility. 3. The facility staff was aware of all available physicians on-call who could have provided needed specialized treatment. This practice resulted in the failed transfer of a patient who needed specialized care. Findings: A patient with a severe limb injury (Patient 22) presented to the ED of Hospital A for treatment on November 27, 2014. Hospital A lacked the specialized services to treat the patient's injury and requested to transfer the patient to Hospital B, where the specialized services were available. Hospital B denied the transfer request because there were no Operating Rooms (O.R.'s) available. Later that evening Hospital A made a second transfer request. Hospital B denied the request because there was no on-call specialist available to treat the patient. During an interview with MD 1, on February 19, 2014, at 4:20 PM, he stated that the facility transfer center (patient transfer communication center) for Hospital B called him about a patient transfer request from a nearby hospital (Hospital A) on November 27, 2014. Because the O.R.'s were full, MD 1 could not accept the patient for transfer. He relayed this information to the transfer center (Hospital B) and they passed the information on to Hospital A. MD 1 stated that he did not recall receiving any further pages regarding the patient or telling anyone he didn't want to accept the patient. During a telephone interview with Staff 1, on February 19, 2015, at 4:50 PM, she stated that she always worked the 6:00 PM to 6:30 AM shift in the transfer center and that MD 1 was paged that evening regarding transfer of a limb injury patient from Hospital A. When MD 1 answered the page from Staff 1, he was familiar with the limb injury patient requesting transfer and replied that he had already declined that case. According to Staff 1, MD 1 said "No, I already declined, so don't call me again." She relayed the information to the ED physician (MD 2), and he asked her to page MD 1 back. Staff 1 paged MD1 again, but he didn't respond. She then called her supervisor, Staff 2, for advice since MD 1 did not respond to his page. She said she was told to "page him." Finally the facility (Hospital B) notified Hospital A that they would "have to try somewhere else" because they did not have an available specialty surgeon to treat the patient. During an interview with Staff 2, on February 20, 2015, at 12:50 PM, she stated she received a page from the transfer center staff on the evening of November 27, 2014, and she was told that the on-call hand surgeon (MD 1) did not answer his pages. Staff 1 wanted to know what to do since MD 1 didn't call back. During the interview Staff 2 was asked if there was a written policy for staff to follow when an on-call specialist didn't call back. She answered, "Everyone knows what to do." Staff 2 was shown the "On-Call Assignments" sheet for "Hand Replant-Attending Backup," dated November 27, 2014, which indicated there was another physician (MD 3) available on backup call. Staff 2 stated she didn't know there was a backup on-call physician available and she was "not sure why we didn't know about the back up." During a review of the facility "On-Call Assignments" sheet for "Hand Replant- Attending Backup" (a surgeon who specializes in hand surgery and is available if the first surgeon is unavailable), dated November 27, 2014, indicated MD 3 (another hand surgeon) was available as a backup surgeon. During a review of the transfer center communication log entries, dated November 27, 2014, indicated: 4:38 PM-Hospital A requested to transfer Patient 1 to Hospital B. 4:41 PM-Hospital B paged the hand surgeon on-call (MD 1). 4:55 PM-Hospital B called operator and confirmed that MD 1 was the specialist on-call. 4:59 PM-MD 1 spoke with the ED Physician (MD 4) (regarding the transfer). 5:20 PM-MD 1 spoke with MD 4 (O.R.'s are unavailable). 5:24 PM-Hospital A was notified that Hospital B was unable to accept the transfer. 6:17 PM-Hospital A called back and made a second transfer request. 6:23 PM-Hospital A notified cannot accept patient (O.R.'s are unavailable). 8:25 PM-Hospital A hand surgeon requested to speak with Hospital B hand surgeon (MD 1). 8:30 PM-MD 2 asked to have MD 1 paged, an O.R. was available. MD 1 was paged. 9:13 PM-Hospital B paged MD 1 a second time. 9:20 PM- MD 1 did not want to accept the patient. MD2 requested MD 1 paged again to discuss. 9:47 PM-Hospital B paged MD 1 again. 10:02 PM-MD 1 did not answer page. Transfer center Staff 1 paged House Supervisor. 10:04 PM-Hospital B paged MD 1 again. No response. 10:13 PM- MD 1 did not answer page. Transfer center Staff 1 paged Supervisor (Staff 2). 10:33 PM-Staff 2 asked Staff 1 to inform the ED they did not have an accepting physician. 10:33 PM-Hospital B transfer center notified the ED -unable to contact on-call physician. 10:40 PM-Hospital A was informed there was no hand surgeon available to take the patient. The facility Administrative Procedure titled "Chain of Command for Differences in Professional Opinion," effective 04/2014, indicated, "A formalized, prescribed chain of command, beginning at the level of concern, shall be used when a physician's order, care, or response to a concern is interpreted as unsafe, conflicting with (facility name) policy, or conflicting with another physician's order...If conflict/difference remains unresolved (undecided): Proceeds to the next level in the chain of command, in this order, as necessary. Attending Physician, Medical director, if applicable, Chief of Clinical Service, President of the Medical Staff, Chief of Staff/designee." The facility "Medical Staff Bylaws 2013-2014," dated May 21, 2013, indicated "Basic Responsibilities of Medical Staff Membership. The ongoing responsibilities of each member of the Medical Staff shall include ...Participating in such emergency service coverage (being on-call) or consultation panels as may be determined by the Medical Staff ... " Behavioral Expectations of Medical Staff Members and Code of Conduct ...Specifically, physicians will: Respond to patient, staff and colleague (other medical professionals) calls and requests in an appropriate, respectful, and timely manner." The facility "2013-2014 Medical Staff Rules and Regulations," dated March 25, 2014, indicated, "Consultations are required under the following circumstances ...Whenever a patient or a patient representative requests a consultation by a specific practitioner or for a specific problem, consultation by the specified practitioner with the knowledge and/ or skill necessary to address the specific problem shall be obtained."

Based on interview and record review, the hospital failed to ensure that their emergency department (ED) log entries were accurate for 2 of 20 sampled patients. This failure had the potential to adversely affect the care of ED patients. Findings: During a review of the hospital's ED patient log on February 20, 2015, there were two patient entries that had the incorrect disposition of the patients. 1. Patient 2 was admitted to the ED on November 30, 2014. The ED log entry showed that the patient expired. A review of Patient 2's ED record showed that the patient was admitted . 2. Patient 3 was admitted to the ED on November 28, 2014. The ED log entry showed that the patient eloped. A review of Patient 3's ED record showed that the patient was discharged . In an interview with the ED Clinical Educator on February 20, 2015 at 9:20 AM, she acknowledged that the entries were in error and stated that the ED log should be accurate.

Based on interview and record review, the facility failed to accept a patient from a referring hospital that requested specialized services. This practice led to the facility failing to meet the needs of the community in accordance with resources available. Findings: A patient with a severe limb injury (Patient 22) presented to the ED of Hospital A for treatment on November 27, 2014. Hospital A lacked the specialized services to treat the patient's injury and requested to transfer the patient to Hospital B, where the specialized services were available. Hospital B denied the transfer request because there were no Operating Rooms (O.R's) available. Later that evening Hospital A made a second transfer request. Hospital B denied the request because there was no on-call specialist available to treat the patient. During an interview with MD 1, on February 19, 2014, at 4:20 PM, he stated that the facility transfer center (patient transfer communication center) for Hospital B called him about a patient transfer request from a nearby hospital (Hospital A) on November 27, 2014. Because the O.R.'s were full, MD 1 could not accept the patient for transfer. He relayed this information to the transfer center (Hospital B) and they passed the information on to Hospital A. MD 1 stated that he did not recall receiving any further pages regarding the patient or telling anyone he didn't want to accept the patient. During a telephone interview with Staff 1, on February 19, 2015, at 4:50 PM, she stated that she always worked the 6:00 PM to 6:30 AM shift in the transfer center and that MD 1 was paged that evening regarding transfer of a limb injury patient from Hospital A. When MD 1 answered the page from Staff 1, he was familiar with the limb injury patient requesting transfer and replied that he had already declined that case. According to Staff 1, MD 1 said "No, I already declined, so don't call me again." She relayed the information to the ED physician (MD 2), and he asked her to page MD 1 back. Staff 1 paged MD1 again, but he didn't respond. She then called her supervisor, Staff 2, for advice since MD 1 did not respond to his page. She said she was told to "page him." Finally the facility (Hospital B) notified Hospital A that they would "have to try somewhere else" because they did not have an available specialty surgeon to treat the patient. During a review of the transfer center communication log entries, dated November 27, 2014, indicated: 4:38 PM-Hospital A requested to transfer Patient 1 to Hospital B. 4:41 PM-Hospital B paged the hand surgeon on-call (MD 1). 4:55 PM-Hospital B called operator and confirmed that MD 1 was the specialist on-call. 4:59 PM-MD 1 spoke with the ED Physician (MD 4) (regarding the transfer). 5:20 PM-MD 1 spoke with MD 4 (O.R.'s are unavailable). 5:24 PM-Hospital A was notified that Hospital B was unable to accept the transfer. 6:17 PM-Hospital A called back and made a second transfer request. 6:23 PM-Hospital A notified cannot accept patient (O.R.'s are unavailable). 8:25 PM-Hospital A hand surgeon requested to speak with Hospital B hand surgeon (MD 1). 8:30 PM-MD 2 asked to have MD 1 paged, an O.R. was available. MD 1 was paged. 9:13 PM-Hospital B paged MD 1 a second time. 9:20 PM- MD 1 did not want to accept the patient. MD2 requested MD1 paged again to discuss. 9:47 PM-Hospital B paged MD 1 again. 10:02 PM-MD 1 did not answer page. Transfer center Staff 1 paged House Supervisor. 10:04 PM-Hospital B paged MD 1 again. No response. 10:13 PM- MD 1 did not answer page. Transfer center Staff 1 paged Supervisor (Staff 2). 10:33 PM-Staff 2 asked Staff 1 to inform the ED they did not have an accepting physician. 10:33 PM-Hospital B transfer center notified the ED -unable to contact on-call physician. 10:40 PM-Hospital A was informed there was no hand surgeon available to take the patient. The facility "Medical Staff Bylaws 2013-2014," dated May 21, 2013, indicated "Basic Responsibilities of Medical Staff Membership. The ongoing responsibilities of each member of the Medical Staff shall include...Participating in such emergency service coverage (being on-call) or consultation panels as may be determined by the Medical Staff." Also, "Behavioral Expectations of Medical Staff Members and Code of Conduct ...Specifically, physicians will: Respond to patient, staff and colleague (other medical professionals) calls and requests in an appropriate, respectful, and timely manner." The facility "2013-2014 Medical Staff Rules and Regulations," dated March 25, 2014, indicated, "Consultations are required under the following circumstances ...Whenever a patient or a patient representative requests a consultation by a specific practitioner or for a specific problem, consultation by the specified practitioner with the knowledge and/ or skill necessary to address the specific problem shall be obtained."