Based on record review and interviews, the facility failed to ensure that 2 of 55 emergency room Physician's maintained current board certification (#11, # 39) and that 3 of 55 emergency room Physician's maintained current certification in Advanced Cardiovascular Life Support (ACLS) or Pediatric Advanced Life Support (PALS) (#15, #21, #48). Findings include: 1) A review of the delineation of Medical Staff Privileges, Emergency Medicine dated 2014 reveals, applicants can be Type 1, Board eligibility by the American Board of Emergency Medicine; Type 2, Successful completion of an accredited residency in Emergency Medicine or Type 3 Training and experience in Emergency Medicine or a related specialty sufficient to evaluate and initially manage and treat patients who seek emergency care. General privileges include Cardiopulmonary Resuscitation ( Current ACLS required). Review of the Bylaws of the Medical Staff dated 2014 revealed, the following requirements for appointment to the Medical Staff: Initial appointment to the Medical staff shall be on a provisional basis for not less than a period of one (1) year. Members desiring reappointment must be able to provide evidence of current clinical competency at the time of requesting reappointment to the medical staff. Categories of the Medical Staff including Active, Consultant, Courtesy, Affiliate, Teaching Faculty and Honorary. Review of the Delineation of Privileges for the Pediatric Emergency Department include the following: Category I: routine general pediatric care of children with complex or severe illness result in skills acquired in pediatric training sufficient for Board Eligibility/certifications. Category 2 Illness or problem requiring expertise or techniques acquired during pediatric subspecialty training. (Requires completion of an approved fell owship program and attestation regarding current clinical competency, Pediatric emergency medicine, Pediatrics (emergency room Physician). Pediatric Emergency Department Requirements: Type 1 Board eligibility or certification by the American Board of Pediatric Emergency Medicine. Type 2 Successful completion of an accredited residence in Pediatric Emergency Medicine Type 3 Training and experience in Pediatric Emergency Medicine or the Pediatric emergency room sufficient to evaluate and initially manage and treat patients who seek emergency care. Documentation of certification for Cardiopulmonary resuscitation child/ adolescent PALS and /or ACLS. The sample of active status emergency room Physician credential files revealed the following discrepancies; 1) Physician # 15 ACLS Certification expired on [DATE]. 2) Physician # 21 no evidence of ACLS or PALS certification. 3) Physician # 11's Board Certification in Emergency Medicine expired on [DATE]. 4) Physician #39 Pediatric Board Certification expired on [DATE]. 5) Physician #48 did not have evidence of PALS certification. An interview was conducted with the Medical Director of Quality Organizational Effectiveness (Medical Staff Director), the Vice President of Medical Affairs, the Credentialing Coordinator and the Vice President of Quality on 7/6/16 at 1:00 PM. The Credentialing coordinator was asked to describe the credentials required of a physician to practice in the Ermegency Department. She stated, "have to be either Board Certified in Emergency Medicine at the time of appointment, or if Board Eligible must be Board Certtified within 5 years. The Pediatricians have to be Board Certified or Board Eligible at the time of appointment as well. The Pediatricians must maintain current PALS certification. Currently we do not require recertification as this is under review by the medical staff. It has not been officially changed in the requirements for privileges yet. The electronic system shows us the type of document that is going to expire within 30 days such as their ACLS, license, PALS and the list goes to the Physician by email. Our new Physician tracking system will go live on 7/15/16. We used to have a paper system and we have uploaded it to the new electronic system." The Medical Staff Director stated, "all Emergency Physician's must have current ACLS cetifications and the Pediatricians must be PALS certified. The Director reviewed the Credential file for Physician # 15 and confirmed that her ACLS certification expired in 4/2016 although she was still listed as an Active Provisional physician. The Director then placed a Text message to Physician # 21, who responded, " He did not have to maintain current ACLS certification in New Jersey and didn't know he had to maintain it in Florida." The Medical Director could not say why this physician was granted Emergency Medicine privileges without the required evidence of either ACLS or PALS certification. The Medical Staff Director was unaware that 3 of the Emergency Physicians with active privileges had expired ACLS certification and that the Board Certification of # 11 had expired in 2015. The Medical Director confirmed that the five identified physicians did not meet facility criteria as Qualified Medical Staff for the Emergency Department and that the facility failed to ensure that the credentials requirements were met.

1. Based on the review of the clinical records, Medical Staff Policy, on-call schedules, Facility license, Physician Privileges, and Physician interviews, the facility failed to ensure that the Plastic Surgeon and the Oral Maxillofacial Surgeon on the on-call list were available to provide treatment necessary after the initial examination to stabilize an individual with an identified emergency medical condition, but refused to come to the emergency department to evaluate the individual (Patient #2) after a request was by the Emergency Department Physician for 1 of 20 samples patients. Refer to the finding in Tag A-2404. 2. Based on staff interview and the review of clinical records, policy and procedures, on-call schedules, the facility failed to ensure that their Medical Staff policy was followed as evidenced by failing to ensure the on-call physicians provided stabilizing treatment that was within its capability and capacity as required when it was determined that an emergency medical condition existed for 1 of 20 sampled patients (Patient #2). Refer to findings in Tag A-2407. 3. Based on staff interview, reviews of clinical records, Physician on call schedules, and delineation of Privileges, the facility inappropriately transferred an individual as evidenced by the transferring facility, Hospital A, failing to provide the necessary medical treatment for an identified emergency medical condition which was within its capability (Plastic Surgeon & Oral Maxillofacial Surgeon) and capacity (facilities and equipment) for 1 of 20 sample patients (Patient # 2) before facilitating a transfer to Hospital B, thus increasing the risk to the patient and delaying treatment. The transferring hospital failed to provide medical treatment that was within its capacity to minimize the risks to the individual's health. Refer to findings in Tag A-2409.

Based on observations, review of policy and procedures, and staff interviews, the facility failed to post signs clearly noticeable and visible to "all" individuals entering the emergency department and to those awaiting emergency care/services specifying the right to be examined and receive treatment, for a woman in labor, and an individual with an emergency medical condition.The findings include:During the observational tour of the Emergency Department (ED) on 10/05/2015 beginning at 10:25 AM while accompanied by the Director of the ED, it was observed that the facility failed to provide evidence of posted signs delineating patient's right to emergency services and care. The facility's Policy and procedure titled, " Emergency Medical Treatment and Active Labor Act (EMTALA), Operations Regulation 1106, Origin June 25, 2002, Last Reviewed: May 22, 2015, was reviewed. The policy specified in part, " D. Signage. The Department shall post conspicuously in all patient waiting areas signs that specify the rights of individuals under the law ...The sign shall be in other languages prevalent in the community. " An interview was conducted with the Director at the time of the observation, beginning at 10:25 AM, who confirmed the signs concerning patient rights were not posted in the emergency department. An interview was conducted with the Supervisor of Registration on 10/05/2015 at 10:45 AM, who also confirmed that the signs concerning patient rights were not posted in the emergency department. She stated, the staff provided the patients with a copy of the bill of rights when they are registered.

Based on the review of clinical records, Medical Staff Policy, on-call schedules, Facility license, Physician Privileges, and Physician interviews, the facility failed to ensure the Plastic Surgeon and the Oral Maxillofacial Surgeon on the on-call list were available to provide treatment necessary after the initial examination to stabilize an individual with an identified emergency medical condition, but refused to come to the emergency department to evaluate the individual (Patient #2) after a request from the Emergency Department (ED) Physician for 1 of 20 samples patients. Findings Include: Review of the clinical record for Patient # 2 reveals that the patient presented to Hospital A on 08/13/2015 at 8:48 PM as a walk-in patient with a gunshot wound to the face. The triage nurse documented the patient ' s initial triage (medical assignment for urgency to illness to decide the order of treatment) was a level 2 (emergent). The patients vital signs were listed as Pulse 154 (normal 60-100); Blood pressure: 145/79 H (High); Respiratory rate- 24; Pulse Oxygen Saturation was 98% on Room Air. The patient ' s pain level was assessed as a level 10 (numeric pain scale - 0 pain free to 10 -worst pain). The physician notes revealed, a Medical Screening Examination was initiated at 8:50 PM to include the patient's vascular and airway were stable; clinical impression was documented as Acute Penetrating Trauma (gunshot wound) and severe facial trauma/laceration. A CT (computerized axial tomography) of the head and neck was completed. The report documented, "negative CAT of neck." A CT of the maxillofacial revealed, "Gunshot wound in left face with comminuted displaced fracture of left lateral maxillary wall and non-displaced fracture of left zygomatic arch"; and the CT of head revealed, "No intracranial hemorrhage." The ED physician identified the patient had an emergency medical condition and required further medical treatment. The ER physician contacted the Plastic Surgeon and the Oral Maxillo-Facial surgeon on-call and noted that it was "beyond the scope of their practice." The ER physician then contacted Hospital B to transfer the patient. The patient ' s Medical Record from Hospital B was reviewed. Patient #2 arrived via Emergency Medical Services (EMS) on 8/13/2015 at 11:22 p.m. The triage nurse documented at 11:39 p.m., the patients ' presenting complaint was " EMS states: Transfer from Bethesda East gunshot wound to the face. " Patient # 2 was evaluated at Hospital B and it was determined that the patient's injuries were soft tissue injury with two isolated fractures and did not meet trauma services criteria, therefore the patient was evaluated in Hospital B's Emergency Department by the On-call Plastic Surgeon and Oral Maxillo-Facial Surgeon. The patient was discharged home on 8/14/2015 at 3:33 a.m. The hospital policy entitled, "Medical Staff Policy" documents: "At the request of the E.R. (emergency room ) Physician, the on-call physician from the appropriate specialty must come in to evaluate and stabilize the patient's condition." Hospital A's facility license has an expiration date of 10/30/2016 and documents, the facility has a dedicated Emergency Department and is licensed to offer services which include Emergency Services, General Surgery, Ophthalmology, Oral/Maxillo-facial Surgery and Plastic Surgery. Hospital A's August 2015 emergency room Call Schedule was reviewed. The schedule verified that Hospital A did have the service capability of the Plastic Surgeon and Oral-Maxillo-facial Surgeon On-Call when Patient # 2 presented to the hospital's ER on 08/13/2015. Review of the Plastic Surgeon's, Physician # 1, delineation of privileges revealed, Physician # 1 has appointment to Hospital A 10/28/2009 to 06/30/2017 with privilege status of Plastic Surgery. The physician has been granted Plastic Surgery Consultation Privileges; General Privileges in Plastic Surgery which encompasses operations in aesthetic surgery of the face; general reconstructive surgery employing various flaps and grafts; maxillofacial surgery and soft tissue. Review of the Oral-Maxillofacial Surgeon's, Physician # 2, delineation of privileges revealed, Physician # 2 has an appointment to Hospital A 05/25/2011 to 12/31/2016 with privilege status of Oral and Maxillofacial Surgery. The physician has been granted General Privileges which encompasses privileges for Incision and Removal of foreign bodies of jaw and face; Repair of facial lacerations around oral cavity and all related oral structures, including lacerations associated with maxillofacial injuries; open reduction of the Maxilla, Zygoma and Mandible; Closed Reduction of the Maxilla, Zygoma and Mandible; Repair of Alveolar Fractures of the Maxilla and Mandible; Special Procedures; Surgical Excision of the Mandible or Maxilla with Bone Graft; Osteotomy of the Maxilla, Mandible, or Zygoma; Open Reduction of the Zygoma, Orbit and Nasal Bones (Cranial-Facial Complex Fractures); Closed Reduction of the Zygoma, Orbit, and Nasal Bones (Cranial-Facial Complex Fractures). Interview with the Oral Maxillofacial Surgeon, Physician #2, was conducted on 10/06/2015 at 10:15 AM. According to Physician # 2, he has been performing Oral Maxillofacial surgery for 10 years. Physician # 2 admitted that he never saw the patient and could not speak to the extent of the tissue damage which Patient # 2 had. He stated, he was called by the ER physician and was informed the patient was an acute GSW (gunshot wound) with multiple fractures and tissue involvement. He felt, based on what he was told that the patient needed Level 1 -Trauma. He further stated, all GSW require multidisciplinary care. The surveyor then read the results of the CT scan and questioned the physician regarding the results being within his scope of practice to manage. He stated, it was a GSW and that he could no longer speak with the surveyor because he had to catch a flight. Interview was conducted with the Plastic Surgeon, Physician #1, on 10/06/2015 at 10:20 AM. According to Physician # 1, he has been a Plastic Surgeon for 10 years. He stated, he was contacted by the ER Physician regarding the patient's injury. He stated, he did not come into the ER to evaluate the patient but was sent pictures from the ER physician. He stated he immediately requested an ophthalmology consult to follow up with the patient after surgery, if ophthalmology follow-up was needed. He confirmed, he was capable of performing the surgery for the patient's emergency medical condition "without a problem." Interview with the ER Physician, Physician # 3, was conducted on 10/06/2015 at 1:00 PM, who stated that the patient presented to the ER with a GSW to the face, under his eye. She stated, the facility performed lab work and several CT scans (face, head and neck). She stated, she contacted both Plastics and Oral Maxillofacial surgeons on 8/13/2015 and described what she saw and they gave their recommendations. She also confirmed that physicians #1 and #2 did not come in to evaluate Patient #2 on 8/13/2015. She stated, the physicians have the capability to view radiology from home and sometimes the ER physicians will forward pictures. She stated, she forwarded pictures of Patient # 2's injuries to the Plastic Surgeon. She stated, the Plastic Surgeon informed her he wanted ophthalmologist available to help manage. The facility does not have ophthalmology on call and have not had the service available for 6-12 months and before that it was 1-2 days per month. She stated, she called Hospital B and they recommended that the Plastic Surgeon evaluate and obtain results of the CT scans. When the Specialists tell her their recommendation that's what she followed because they are the Specialists. The Hospital failed to ensure that their Medical Staff policy was followed as evidenced by a failure of the Plastic Surgeon, and the Oral Maxillofacial Surgeon, both of whom have privileges at the hospital, were available and on call on August 13, 2015 when patient #2 presented to the ED with an emergency medical condition and failed to come to the ED when called by the ED physician to provide treatment after the initial examination.

Based on staff interview and review of clinical records, policy and procedures, on-call schedules, the facility failed to ensure that their Medical Staff policy was followed as evidenced by failing to ensure that the on-call physicians provided stabilizing treatment that were within its capability and capacity as required when it was determined that an emergency medical condition existed for 1 of 20 sampled patients (Patient #2). The findings include: The facility's Policy and procedure titled, " Emergency Medical Treatment and Active Labor Act (EMTALA), Operations Regulation 1106, Origin June 25, 2002, Last Reviewed: May 22, 2015, was reviewed. The policy revealed in part, " III Procedure A. Screening and Stabilization ... b. A Qualified Medical Person or Physician ...must provide any necessary stabilizing treatment with such persons capabilities. " Hospital A August 2015 emergency room Call Schedule was reviewed. The schedule verified that Hospital A indeed had the service capability of a Plastic Surgeon and Oral-Maxillo-Facial Surgeon On-Call when Patient # 2 presented to the hospital's ER on 08/13/2015. Review of the clinical record for Patient # 2 reveals that the patient presented to Hospital A on 08/13/2015 at 8:48 PM as a walk-in patient with a gunshot wound to the face. The physician notes revealed, a Medical Screening Examination was initiated at 8:50 PM to include the patient's vascular and airway were stable; clinical impression was documented as Acute Penetrating Trauma (gunshot wound) and severe facial trauma/laceration. A CT (computerized axial tomography) of the head and neck was completed. The report documented, "negative CAT of neck." A CT of the maxillofacial revealed, "Gunshot wound in left face with comminuted displaced fracture of left lateral maxillary wall and non-displaced fracture of left zygomatic arch"; and the CT of head revealed, "No intracranial hemorrhage." The ED physician identified the patient had an emergency medical condition and required further medical treatment. The ER physician contacted the Plastic Surgeon and the Oral Maxillo-Facial surgeon on-call and noted that it was "beyond the scope of their practice." The ER physician then contacted Hospital B to transfer the patient. Patient # 2 was evaluated at Hospital B and it was determined that the patient's injuries were soft tissue injury with two isolated fractures and did not meet trauma services criteria, therefore the patient was evaluated in Hospital B's Emergency Department by the On-call Plastic Surgeon and Oral Maxillo-Facial Surgeon. The patient was discharged home on 8/14/2015 at 3:33 a.m. Hospital A August 2015 emergency room Call Schedule was reviewed. The schedule verified that Hospital A did have service capability of a Plastic Surgeon and Oral-Maxillo-Facial Surgeon On-Call to provide stabilizing treatment that was needed for Patient # 2 whom presented to the hospital's ER on 08/13/2015. An interview with the Oral Maxillofacial Surgeon, Physician #2, was conducted on 10/06/2015 at 10:15 AM. He stated, he was called by the ER physician and was informed the patient was an acute GSW (gunshot wound) with multiple fractures and tissue involvement. He felt, based on what he was told that the patient needed Level 1 -Trauma. He further stated, all GSW require multidisciplinary care. An Interview was conducted with the Plastic Surgeon, Physician #1, on 10/06/2015 at 10:20 AM. According to Physician # 1, he has been a Plastic Surgeon for 10 years. He stated, he was contacted by the ER Physician regarding the patient's injury. He confirmed, he was capable of performing the surgery for the patient's emergency medical condition "without a problem." The facility failed to ensure that their policy and procedure was followed as evidenced by failing to provide necessary stabilizing treatment that was with such persons capabilities of the Plastic Surgeon and Oral Maxillofacial Surgeon that were available to provide the needed services for patient #2 on 8/13/2015.

Based on staff interview, review of clinical records, Physician on-call schedules, and delineation of Privileges, the facility inappropriately transferred an individual as evidenced by the transferring facility, Hospital A, failing to provide the necessary medical treatment for an identified emergency medical condition which was within its capability (Plastic Surgeon & Oral Maxillofacial Surgeon) and capacity (facilities and equipment) for 1 of 20 sample patients (Patient # 2) before facilitating a transfer to Hospital B, thus increasing the risk to the patient and delaying treatment. The transferring hospital failed to provide medical treatment that was within its capacity to minimize the risks to the individual's health. The findings include: Review of the clinical record for Patient # 2 documents that the patient presented to Hospital A on 08/13/2015 at 8:48 PM as a walk-in patient with a gunshot wound to the face. The physician notes revealed a Medical Screening Examination was initiated at 8:50 PM and upon evaluation the ER (emergency room ) physician's clinical impression of the patient was that the patient had an Acute Penetrating Trauma (gunshot wound) and severe facial trauma/laceration. Further review revealed, the ER physician contacted the Plastic Surgeon and the Oral Maxillo-facial surgeon on-call for evaluation and treatment however it was noted that it was "beyond the scope of their practice." The hospital's "Transfer Out Record" for Patient #2 dated 8/13/2015 was reviewed. The transfer form revealed, in part, " ...Patient Stable: This patient has been examined, an EMC has been identified and stabilized such that, within reasonable clinical confidence, no material deterioration of this patient ' s condition is likely to occur during the transfer. II. Reason for Transfer. Medically indicated ... On-Call Physician refused or failed to respond within a reasonable period of time Physician Name ________Address________ " were all left blank. " Hospital A's August 2015 emergency room Call Schedule was reviewed. The schedule verified that Hospital A indeed had the service capability of a Plastic Surgeon and Oral-Maxillo-Facial Surgeon On-Call when Patient # 2 presented to the hospital's ER on 08/13/2015. Review of the Plastic Surgeon, Physician # 1, delineation of privileges documents, Physician # 1 has appointment to Hospital A 10/28/2009 to 06/30/2017 with privilege status of Plastic Surgery. The physician has been granted Plastic Surgery Consultation Privileges; General Privileges in Plastic Surgery which encompasses operations in aesthetic surgery of the face; general reconstructive surgery employing various flaps and grafts; maxillofacial surgery and soft tissue. Review of the Oral-Maxillofacial Surgeon, Physician # 2, delineation of privileges documents, Physician # 2 has appointment to Hospital A 05/25/2011 to 12/31/2016 with privilege status of Oral and Maxillofacial Surgery. The physician has been granted General Privileges which encompasses privileges for Incision and Removal of foreign bodies of jaw and face; Repair of facial lacerations around oral cavity and all related oral structures, including lacerations associated with maxillofacial injuries; open reduction of the Maxilla, Zygoma and Mandible; Closed Reduction of the Maxilla, Zygoma and Mandible; Repair of Alveolar Fractures of the Maxilla and Mandible; Special Procedures; Surgical Excision of the Mandible or Maxilla with Bone Graft; Osteotomy of the Maxilla, Mandible, or Zygoma; Open Reduction of the Zygoma, Orbit and Nasal Bones (Cranial-Facial Complex Fractures); Closed Reduction of the Zygoma, Orbit, and Nasal Bones (Cranial-Facial Complex Fractures). Interview with the Oral Maxillofacial Surgeon Physician #2 was conducted on 10/06/2015 at 10:15 AM., revealed he was called by the ER physician and was informed the patient was an acute GSW (gunshot wound) with multiple fractures and tissue involvement. Interview with the Plastic Surgeon, on 10/06/2015 at 10:20 AM. According to Physician # 1, he has been a Plastic Surgeon for 10 years. He stated, he was contacted by the ER Physician regarding the patient's injury. He stated, he did not come into the ER to evaluate the patient but was sent pictures from the ER physician. He confirmed, he was capable of performing the surgery for the patient's emergency medical condition "without a problem." This interview confirmed that patient #2 was inappropriately transferred to Hospital B on 8/13/2015. The facility failed to have an effective policy that addresses transfers of individuals when the facility can provide medical treatment that is within its capacity that minimizes the risk of the individual's health.