1. Based on medical record reviews, policy and procedure review, Medical Staff Rules and Regulations review, facility hospital license review, Medical Staff By Laws review, Physician Credentialing files review, and on-call staff rosters, and interviews the facility failed to ensure that on-call Pulmonologists listed on the On-Call Roster and who are on the hospital's medical staff and available to provide necessary treatment after the initial examination to stabilize individuals with emergency medical conditions for five (5) #2, #3 ,#4 , 5, & #6 of twenty (20) sampled patients. Refer to findings in Tag A-2404. 2. Based on review of medical records, on-call rosters, policies and procedures, Physician Credentialing Files/Delineation of privileges, and interviews, the facility failed to ensure that medical treatment was provided that was within the capacity that minimizes the risk of the individual's health, as evidenced by the refusal of the on-call Pulmonologist physician to consult on 5 (#2, #3, #4, #5, & #6) of 20 sampled patients who were intubated and on the ventilator. As this resulted in inappropriate transfers for Patient #2, Patient #3, Patient #4, patient #5 and Patient #6. Refer to findings in Tag 2409.

Based on medical record reviews, policy and procedure review, Medical Staff Rules, Policies, and Rules and Regulations review, facility hospital license review, Policy and Procedure review, Physician Credentialing files review, on-call staff rosters, and interviews, the facility failed to ensure that on-call Pulmonologists listed on the On-Call Roster and who are on the hospital's medical staff and available to provide necessary treatment after the initial examination to stabilize individuals with Emergency Medical Conditions for five (5) #2, #3,#4, #5, & #6 of twenty (20) sampled patients. Findings: I. A review of documentation which the facility had filed with the State of Florida regarding the services it provides under its license revealed that Pulmonary Medicine was "provided on site 24 hours per day, 7 days per week." II. A review of the document, "Medical Staff Bylaws, Policies, and Rules & Regulations" revealed the following: "Appointees to the Consulting category must: Care for unassigned patients and participate in the on-call coverage in the event of a coverage crisis as specified in the rules and regulations of each campus." Therefore, participation in the on-call process as defined by the hospital is expected. This expectation also means that if there was a lack of coverage available for a specialty that was sought by the Emergency Department physician for consultation, a non-scheduled physician would be expected to fill in. This understanding was confirmed during an interview with the Chief Executive Officer (CEO) on 10/4/17 at 10:04 AM. III. A review of the document, "Rules & Regulations" for the Emergency Department revealed the following: "Each member of the Active and Provisional Active staff agree that, when he/she is the designated practitioner on call, he will accept responsibility during the time specified by the published schedule and provide care to any patient requested by the Emergency Department physician. ... If there is a desire to change the published on call schedule, it is the scheduled medical staff member's responsibility to notify the Medical Staff Office by letter or memorandum at least twenty-four (24) hours prior to the scheduled rotation as to whom they have arranged to cover their ER call. The Medical Staff Office will verify coverage with both the scheduled physician and the covering physician." Thus, per facility expectations, if an emergency room Physician requests inpatient care be accepted by an On-Call Physician to a patient planned for admission, and the admission is completely dependent on the on-call physician's acceptance, the On-Call physician must comply. This requirement does not specify that the desired care be provided solely in the emergency room . Furthermore, acceptance of an in-patient assignment would be necessary to finalize treatment in the emergency room . During an interview of the C.E.O. on 10/4/17 at approximately 10:04 AM, he confirmed this understanding. Regarding the published schedule, this entry in the "Rules & Regulations" requires that it be followed and that any changes follow certain steps. A review of the "Rules & Regulations" revealed the following: "A physician must be credentialed to manage a ventilator patient or a Pulmonologist consult must be generated upon intubation." Thus, if a ventilator patient were to be admitted from the emergency room while on a ventilator, unless an Admitting Physician had ventilator management credentials, a Pulmonologist would need to be consulted immediately. This was confirmed during an interview with the Risk Manager on 10/6/17 at 12:53 PM. IV. The "Medical Staff Bylaws, Policies, and Rules & Regulations" read: "All unassigned patients are assigned to the service concerned with the treatment of the problems or disease which necessitated admission. In order to expedite the emergency care of a patient, the Emergency Department Physician on duty may, at his/her discretion, assign the appropriate specialist on call." This requirement further supports the right of the Emergency Department physician to call upon the services of an on-call physician. V. The facility's Policy titled, "EMTALA Emergency Transfers Policy" Approval date 6/8/2018, Review Date 6/12/2017 was reviewed. The policy stated in part, "PROCEDURE ...2. If a patient comes to the Hospital and is determined to have an Emergency Medical Condition following a Medical Screening Examination, the Hospital must provide further medical examination and treatment, including hospitalization if necessary, as required to stabilize the Emergency medical condition within the capabilities of the staff and facilities available at the hospital." VI. A review of the medical record of Patient #2 revealed the following. The patient arrived in the Emergency Department on 9/17/17 at 10:23 PM. A nurse's note on 9/17/17 at 10:23 PM read: "Presenting complaint: EMS (Emergency Medical Services) states: Pt c/o (complains of) SOB (shortness of breath) since 2:00 PM today." A nurse's note at 10:29 PM on 9/17/17 read: "(I, MD) is Attending Physician." An Emergency Department physician note of 10:29 PM on 9/17/17 by I, MD read: "This ... presents to ER (emergency room ) via EMS (Emergency Medical Services) ground with complaints of shortness of breath." An Emergency Department Physician note of 9/17/17 at 10:32 AM by I, MD read: "He c/o (complains of) sob (shortness of breath), vomiting that began this afternoon. States he was weak and unable to get out of bed. Was able to make it to his mother's bedroom later and fell in her room. ..." The Discharge Summary, authored by I, MD indicated the following diagnoses[DIAGNOSES REDACTED]" An emergency room physician note of 9/18/17 at 12:10 AM by I, MD read: "ED course: Case was discussed with the on-call (H, MD) of pulmonology. The pulmonology group here currently is not seeing patients without insurance. This patient has Medicaid and the group will see the patient in consultation." At this point the on-call pulmonologist (H, MD) had agreed to consult with the patient because he had an understanding that Patient #2 had insurance. The record continued. An Emergency Department physician note at 12:20 AM on 9/18/17 by I, MD read: "ED (Emergency Department) course: Registration informed me that this patient does not have Medicaid or any other form of insurance. I informed the on-call Pulmonologist (H, MD) of this fact and he asks that the patient be transferred to another facility." Per, medical record documentation, the On-Call Physician (H, MD) had originally agreed to consult regarding the patient, but this changed when the On-Call Physician (H, MD) learned that Patient #2 did not have the previously mentioned Medicaid or any other type of insurance. During an interview of I, MD on 10/4/17 at 1:17 PM, he stated that his plan was to admit the patient and that he had been preparing an admission order and was waiting for an Admitting Physician to call back, but before he could send the order, registration had called back with their news of Patient #2 not having insurance coverage. He stated that he felt compelled to tell H, MD of such, due to problems the facility had with prior admissions in which Pulmonology would not cover and provide treatment to an eventual admitted patient upon learning that an admitted patient had a lack of insurance. He stated that during the conversations he had not asked H, MD for any emergency room guidance regarding their management of the patient. A review of the facility's On-Call Roster dated 9/18/2017 verified that the on-call Pulmonologist (H, MD) was on call, while Patient #2 was in the ED. A review of the Physician call log for Patient #2 revealed that the on -Call Pulmonologist was called on 9/18/2018 at 0010 and returned call at 0010; called at 0015 and returned call at 0015; and called at 0025 and returned call at 0025. A review of the facility's credentialing file titled "Request for Clinical Privileges and Record of Privileges Granted" dated 10/15/01 for the on-call pulmonologist (H, MD) was reviewed. The clinical privileges revealed the "Areas of Practice" checked off were, "Internal Medicine and Pulmonary and Critical Medicine." The refusal of the On-Call Pulmonologist (H, MD) to consult regarding Patient #2 was a violation of Medical Staff expectations. This understanding was confirmed during an interview of the C.E.O. on 10/4/17 at approximately 1:45 PM. The Pulmonologist (H, MD) who was On-Call and consulted refused to come and see Patient #2 on 9/18/2017 to provide treatment necessary after the initial examination to stabilize the patient's identified emergency medical condition, when requested by the ED physician. VII. A review of the medical record of Patient #3 was performed. The patient was admitted on [DATE] at 4:54 AM. A nursing note on 9/9/17 at 4:58 AM read: "Presenting complaint: Patient states: difficulty breathing starting at 12:00 AM. A nurse's note on 9/9/17 at 4:58 AM read: "(I, MD) is Attending Physician." A nurse's note on 9/9/17 at 5:04 AM read: "Complains of pain in chest. ... Respiratory: Reports shortness of breath. Onset: The symptoms/episode began/occurred today, the patient has moderate difficulty breathing and speaking full sentences." A nurse's note on 9/9/17 at 6:30 AM read: "Assist provider with intubation via oral route. Intubated by (I, D)." A nurse's note on 9/9/17 at 6:39 AM addressed ventilator settings. A nurse's note on 9/9/17 at 8:02 AM read: "Attending physician role handed off by (I, MD)." An Emergency Department Physician note of 9/9/17 at 8:22 AM by L, MD read: "Physician consultation: "(J, MD) was called at 8:22 AM, was contacted at 8:24 AM, regarding admission, to the ICU (intensive care unit), patient's condition, would like consultation with the on-call pulmonologist (E, MD) discussed with (M, MD) ... who agreed but wanted pulmonary called and confirm that they will consult and follow pt (patient) #3 prior to accepting pt. (#3) for admission." A nurse's note on 9/9/17 at 8:02 AM read: (L, MD) is attending physician." An emergency room Physician note of 9/9/17 at 8:23 AM by L, MD read: Physician consultation: Pulmonologist on-call (E, MD) was called at 8:24 AM, was contacted at 8:28 AM, regarding consult, patient's condition, (E, MD) refused the pt consult." An Emergency Department physician note of 9/9/17 at 8:50 AM by I, MD read: "... Spring Hill Regional Hospital does not immediately have the required specialist, the on-call Pulmonologist (E, MD) refused to consult on patient" A review of the hospital's On-call Roster dated 9/9/2017 verified that the On- Call Pulmonologist (E, MD) was on call for Pulmonology services when Patient #3 presented to the ED. A review of the hospital's credentials file "delineation of Privileges for the On-Call Pulmonologist (E, MD) was reviewed. The Delineation of Privileges for (E, MD) was "Pulmonology" and the effective dates were 3/1/2016 to 2/28/2018, and Board approval on 2/21/2016. The requested and approved privileges revealed in part, "Endotracheal Intubation, Ventilation Management, acute and chronic." The Pulmonologist (E, MD) who was on-call and consulted, refused to come and see Patient #3 on 9/9/2017 to provide treatment necessary after the initial examination to stabilize the patient's identified emergency medical condition, when requested by the ED physician. VIII. A review of the medical record of Patient #4 was performed. The Patient was admitted on [DATE] at 5:49 AM. A nurse's note at 5:50 AM on 9/28/17 read: "Presenting complaint: EMS states: Called to a residence for altered mental status." Another nurse's note at this same time read: "Respiratory: hyperventilation, RR (respiratory rate) 40." Another nurse's note at this time read: "Triage completed." A nurse's note on 9/28/17 at 6:19 AM read: "Assist provider with intubation." A nurse's note of 9/28/17 at 6:30 AM read: "(I, MD) is attending physician." An Emergency Department Physician note of 9/28/17 at 7:22 AM read: "This ... presents to ER via EMS ground with complaints of altered mental status. An Emergency Department physician note of 9/28/17 at 7:23 AM read: "Respiratory: severe respiratory distress is noted. Respirations: tachypnea, Kussmaul respirations." An Emergency Department Physician note by I, MD on 9/28/17 at 7:46 AM read: "Pt had a severe metabolic acidosis despite breathing over 50 times a minute, so patient was intubated. Call placed to the on-call (E, MD) of pulmonary for ventilator management. Because this patient does not have insurance, he is refusing to consult and the patient will have to be transferred." An Emergency Department Physician note at 8:00 AM on 9/28/17 by I, MD read: "Transfer ordered to Bayfront Medical Center, Diagnosis are Type 1 Diabetes Mellitus with Ketoacidosis, Hyperkalemia, Acute Kidney Failure, IV drug abuse. Reason for transfer: Pulmonology - higher level of care. ... Condition is serious. ... Symptoms have improved." A review of the hospital's credentials file "delineation of Privileges for the on-call Pulmonologist (E, MD) was reviewed. The Delineation of Privileges for (E, MD) was "Pulmonology" and the effective dates were 3/1/2016 to 2/28/2018, and board approval on 2/21/2016. The requested and approved privileges revealed in part, "Endotracheal Intubation, Ventilation Management, acute and chronic." A review of the hospital's Emergency On-call Roster dated 9/28/2017 verified that the on-call Pulmonologist (E.MD) was on-call for Pulmonology services when Patient #4 presented to the ED. The On-Call Pulmonologist (E, MD) refused to come and see Patient #4 in response to a call from the ED physician (I, MD). The facility failed to ensure that (E, MD) who was on-call for Pulmonology services and consulted come to the hospital's emergency department and see Patient #4 on 9/28/2017 to provide treatment necessary after the initial examination to stabilize the patient's identified emergency medical condition ,when requested by the ED physician. IX. A review of the medical record of Patient #5 was performed. A nurse's note of 9/6/17 at 11:20 PM read: "Presenting complaint: Patient states: Patient in ED (Emergency Department) from after taking 40 pills of Clonazepam 0.5 MG (milligrams) and 20 pills of zolpidem as a suicide attempt. Patient is sleepy, patient also appears to have fallen, hematoma noted to back of head." A nurse's note of 9/6/17 at 11:21 PM read: "(B, DO) is attending physician." A nurse's note of 9/6/17 at 11:40 PM read: "Assist provider with intubation ..." As prior text indicates, the patient was now intubated. An Emergency Department physician note on 9/6/17 at 11:46 PM by B, DO read: "No Pulmonologist and Hospitalist. NP (Nurse Practitioner) O, ARNP (Advanced Registered Nurse Practitioner) declined ICU (Intensive Care Unit) without the On-Call Pulmonologist (E, MD) who decline consult." An Emergency Department physician note of 9/6/17 at 11:49 PM by B, DO read: "Transfer ordered to Bayfront Medical Center. diagnosis is [DIAGNOSES REDACTED]... Symptoms have improved." A nurse's note on 9/6/17 at 11:49 PM read: "ED care complete, transfer ordered by MD (Medical Doctor)." An Emergency Department physician note by B, DO on 9/7/17 at 12:14 AM described the intubation process. A review of the hospital's Emergency On-Call Roster dated 9/06/2017 verified that the On-Call Pulmonologist (E.MD) was On-Call for Pulmonology services when Patient #5 presented to the ED. A review of the credentials file for the On-Call Pulmonologist (E, MD) did not reveal any evidence of a lack of skills or abilities applicable to #5. The on-call Pulmonologist refused to come and see Patient #5 after being called by Physician B, DO (Doctor of Osteopathy). The facility failed to ensure that (E, MD) who was on-call for Pulmonology services and consulted come to the hospital's emergency department and see Patient #5 on 9/6/2017 to provide treatment necessary after the initial examination to stabilize the patient's identified emergency medical condition. As for E, MD's (on-call Pulmonologist) position on the Emergency Department requests regarding Patient #3, #4 and #5, during an interview with him on 10/6/17 at 11:51 AM, he stated that in each of the calls from the Emergency Department physicians for these patients he was aware that his response would affect whether or not the patients would be admitted to the hospital, when requested by the ED physician. X. A review of the medical record of Patient #6 was performed. The patient was admitted on [DATE] at 1:24 AM. A nurse's note on 9/16/17 at 1:25 AM read: "Pt found by EMS tripoding on side of road. ... Pt had swollen tongue upon arrival and was intubated en route. ... Care prior to arrival: See EMS report. Assisted ventilation ..." A nurse's note on 9/16/17 at 1:27 AM read: "Behavior is patient sedated and intubated. ... Respiratory: Airway via oral intubation." An Emergency Department physician note of 9/16/17 at 1:55 AM by P, MD read: "The patient has shortness of breath at rest. Onset: The symptoms/episode began/occurred at an unknown time. Duration: The symptoms are continuous. ... At their worst, the symptoms were incapacitating in the emergency department the symptoms have improved mildly. ... PT was intubated ... by EMS." An Emergency Department physician note on 9/16/17 at 1:44 AM by P, MD, documenting an event at 2:03 AM read: "Response to treatment: the patient's symptoms have mildly improved after treatment. Physician consultation: (H, MD) was contacted at 2:03 AM, regarding consult. Pulmonary on call (G, MD) being covered by (H, MD) who is refusing consultation, recommends transfer of patient to Bayfront St. Pete." A nurse's note of 9/16/17 at 3:11 am documented an event on 9/16/17 at 2:07 AM. It read: "Initial call made to transfer center @ 2:07 AM." An Emergency Department physician note by P, MD on 9/16/17 at 2:12 AM read: "Respiratory: Respirations: poor air movement. Breath sounds: wheezing, that is severe, decreased breath sounds that are moderate." An Emergency Department Physician note of 9/16/17 at 3:26 AM by P, MD read: "Transfer ordered to Bayfront Medical Center. Diagnosis are unspecified asthma with status asthmaticus, acidosis, respiratory with hypercarbia, other psychoactive substance abuse, hypokalemia. Reason for transfer: Pulmonology - Higher level of Care. ... Condition is critical. ... Symptoms are unchanged." A review of the hospital's Emergency On-call Roster dated 9/16/2017 verified that the On-Call Pulmonologist (E.MD) was On-Call for Pulmonology services when Patient #6 presented to the ED. A review of the facility's credentialing file titled "Request for Clinical Privileges and Record of Privileges Granted" dated 10/15/01 for Pulmonologist H, MD was reviewed. The clinical privileges revealed the "Areas of Practice" checked off were, "Internal Medicine and Pulmonary and Critical Medicine." The On-Call Pulmonologist refused to come and see Patient #6 after being called by Physician (P, MD). The facility failed to ensure that (H, MD) who was on-call for Pulmonology services and consulted come to the hospital's emergency department and see Patient #6 on 9/16/2017 to provide treatment necessary after the initial examination to stabilize the patient's identified emergency medical condition when, requested by the ED physician..

Based on review of medical records, on-call rosters, policies and procedures, Physician Credentialing Files/Delineation of privileges, and interviews, the facility failed to ensure that medical treatment was provided that was within the capacity that minimizes the risk of the individual's health, as evidenced by the refusal of the on-call Pulmonologist Physician to consult on 5 (#2, #3, #4, #5, & #6) of 20 sampled patients who were intubated and on the ventilator. As this resulted in inappropriate transfers for Patient #2, Patient #3, Patient #4, Patient #5 and Patient #6. The findings include: A review of facility policy, "Transfers Policy" revealed the following: "When the patient's emergent need for service is not available in the organization, the patient is transferred to the facility which is most appropriate and capable of providing the service. No patient is arbitrarily transferred on the basis of financial status or the ability to pay." A review of the facility's policy titled, "EMTALA Emergency Transfers Policy" Approval date 6/8/2018, Review Date 6/12/2017 revealed in part, ` An Emergency Appropriate Transfer to another hospital will be appropriate only in those cases in which...The transferring Hospital provided medical treatment within it's Capabilities that minimizes the risks to the individual's health." Patient #2 A review of the medical record of Patient #2 was performed. The document, "Patient Transfer Form," for Patient #2, signed by the patient on 9/18/17 at 12:44 AM read: "The patient is being transferred because of failure, refusal or inability of an on-call physician to respond. On-Call physician name: (H, MD)." The document "Patient Transfer Form," also read: "Additional physician documentation to be completed for transfers from the emergency room on ly. The patient presented to the hospital requesting emergency medical treatment and the hospital provided a Medical Screening Examination and stabilization services to the extent possible ... Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated, or has been requested by the patient's legal guardian. ... The patient is being transferred because of failure, refusal or inability of an on-call physician to respond. On-Call physician name: (H, MD)." A physician note of 9/18/17 at 1:16 AM by I, MD, MD read: "Transfer ordered to Bayfront Medical Center. Diagnosis are Acute Respiratory Failure with hypoxia, [DIAGNOSES REDACTED], pneumonia, unspecified organism. Reason for transfer: other. ... Condition is serious. ... Symptoms have improved." A nurse's note on 9/18/17 at 1:16 AM read: "ER care complete, transfer ordered by MD. A nurse's note at 1:52 AM on 9/18/17 read: "Patient left the ED (Emergency Department)." A review of the facility's credentialing file titled "Request for Clinical Privileges and Record of Privileges Granted" dated 10/15/01 for Pulmonologist H, MD was reviewed. The clinical privileges revealed the "Areas of Practice" checked off were, "Internal Medicine and Pulmonary and Critical Medicine." A review of the facility's On-Call Roster dated 9/18/2017 verified that the On-Call Pulmonologist (H, MD) was on call, while Patient #2 was in the ED. A review of the Physician call log for Patient #2 revealed that the on -Call Pulmonologist was called on 9/18/2018 at 0010 and returned call at 0010; called at 0015 and returned call at 0015; and called at 0025 and returned call at 0025. During an interview of the CEO on 10/4/17 at approximately 1:45 PM, he confirmed that Bayfront Health Spring Hill would have to be capable to provide services to Patient #2 if the on call Pulmonologist had accepted him and that there was a violation of the expectations of the "Transfer Policy" as quoted above regarding the care of Patient #2. Patient #3 A review of the medical record of Patient #3 was performed. An emergency room Physician note of 9/9/17 at 8:23 AM by L, MD read: Physician consultation: (E, MD) was called at 8:24 AM, was contacted at 8:28 AM, regarding consult, patient's condition, (E, MD) refused the pt consult." An Emergency Department Physician note on 9/9/17 at 8:28 AM by L, MD read: "Other consultation: Bayfront Medical Center, was alerted at 8:29 AM, discussed with ER attending (N, MD) who accepted patient for transport to ER (emergency room ) at 8:49 AM." An Emergency Department physician note of 9/9/17 at 8:50 AM by I, MD read: " ... Spring Hill Regional Hospital does not immediately have the required specialist, pulmonologist refused to consult on pt." An Emergency Department physician note by L, MD on 9/9/17 at 8:53 AM read: "Transfer ordered to Bayfront Medical Center, Diagnosis are respiratory failure, pneumonia, sepsis, jaundice, pancreatic pseudo cyst, coagulopathy secondary to Coumadin, anemia, alcohol abuse. ... Reason for transfer: Pulmonology - Higher level of care. ... Condition is critical. ... Symptoms have improved." A nurse's note on 9/9/17 at 8:53 AM read: "ER (emergency room ) care complete, transfer ordered by MD." The document "Patient Transfer Form," signed by the patient on 9/9/17 at 8:55 AM read: "Additional physician documentation to be completed for transfers from the emergency room on ly. The patient presented to the hospital requesting emergency medical treatment and the hospital provided a Medical Screening Examination and stabilization services to the extent possible ... Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated, or has been requested by the patient's legal guardian. ... The patient is being transferred because of failure, refusal or inability of an on-call physician to respond. On-Call physician name: (E, MD)." A nurse's note on 9/9/17 at 10:49 AM read: "Patient left the ED (Emergency Department)." A review of the hospital's credentials file "delineation of Privileges for the on-call Pulmonologist (E, MD) was reviewed. The Delineation of Privileges for (E, MD) was "Pulmonology" and the effective dates were 3/1/2016 to 2/28/2018, and board approval on 2/21/2016. The requested and approved privileges revealed in part, "Endotracheal Intubation, Ventilation Management, acute and chronic." A review of the facility's on-call roster dated 9/18/2017 verified that the on-call Pulmonologist (H, MD) was on call, while patient #3 was in the ED. Patient #4 A review of the medical record of Patient #4 was performed. An Emergency Department Physician note at 8:00 AM on 9/28/17 by I, MD read: "Transfer ordered to Bayfront Medical Center, Diagnosis are Type 1 Diabetes Mellitus with Ketoacidosis, Hyperkalemia, Acute Kidney Failure, IV drug abuse. Reason for transfer: Pulmonology - higher level of care. ... Condition is serious. ... Symptoms have improved." The document "Patient Transfer Form," signed by the patient on 9/28/17 at 8:00 AM read: "Additional physician documentation to be completed for transfers from the emergency room on ly. The patient presented to the hospital requesting emergency medical treatment and the hospital provided a Medical Screening Examination and Stabilization services to the extent possible ... Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated, or has been requested by the patient's legal guardian. ... The patient is being transferred because of failure, refusal or inability of an on-call physician to respond. On-Call physician name: (E, MD)." A nurse's note on 9/28/17 at 9:29 AM read: "Transferred by EMS ground to Bayfront Medical Center." A nurse's note on 9/28/17 at 9:32 AM read: "Patient left the ED." A review of the facility's On-Call Roster dated 9/18/2017 verified that the on-call Pulmonologist (H, MD) was On Call, while Patient #4 presented to the ED. A review of the credentials file for E, MD did not reveal any evidence of a lack of skills or abilities applicable to #4. Patient #5 A review of the medical record of Patient #4 was performed The document "Patient Transfer Form," signed by Patient #5 on 9//7/17 at 12:25 AM (patient had written "9/7/10") read: "Additional physician documentation to be completed for transfers from the emergency room on ly. The patient presented to the hospital requesting emergency medical treatment and the hospital provided a Medical Screening Examination and stabilization services to the extent possible ... Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated, or has been requested by the patient's legal guardian. ... The patient is being transferred because of failure, refusal or inability of an on-call physician to respond. On-Call physician name: (E, MD)." The handwritten time indicated on this document conflicts with nursing documentation, below, which indicates a departure at 12:14 AM. A nurse's note of 9/7/17 at 12:14 AM read: "RN (Registered Nurse) escorted patient out of department to Bayfront St. Pete with EMS." A nurse's note of 9/7/17 at 1:51 AM read: "Patient left the ED." A review of the credentials file for E, MD did not reveal any evidence of a lack of skills or abilities applicable to #5. A review of the facility's on-call roster dated 9/18/2017 verified that the on-call Pulmonologist (H, MD) was on call, while Patient #5 presented to the ED. Patient #6 A review of the medical record of Patient #6 was performed .The document "Patient Transfer Form," signed by the patient (Patient #6) on 9/16/17 at 3:20 AM read: "Additional physician documentation to be completed for transfers from the emergency room on ly. The patient presented to the hospital requesting emergency medical treatment and the hospital provided a Medical Screening Examination and stabilization services to the extent possible ... Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated, or has been requested by the patient's legal guardian. ... The patient is being transferred because of failure, refusal or inability of an on-call physician to respond. On-Call physician name: (H, MD)." An Emergency Department Physician note of 9/16/17 at 3:26 AM by P, MD read: "Transfer ordered to Bayfront Medical Center. Diagnosis are unspecified asthma with status asthmaticus, acidosis, respiratory with hypercarbia, other psychoactive substance abuse, hypokalemia. Reason for transfer: Pulmonology - Higher level of Care. ... Condition is critical. ... Symptoms are unchanged." A nurse's note on 9/16/17 at 4:15 AM read: "O2 (oxygen) via ventilation terminated at this time. Patient transported out via EMS." A review of the facility's on-call roster dated 9/18/2017 verified that the On-Call Pulmonologist (H, MD) was on call, while Patient #6 presented to the ED. A review of the credentials file for H, MD did not reveal any evidence of a lack of skills or abilities applicable to #6. The hospital had the capacity to provide treatment within the medical capability of the on-call pulmonologists, to minimize the risks of Patient #2, #3, #4, #5, and #6 these individuals health but were instead transferred out to other acute care hospitals when pulmonary services were available at Bayfront Health Springhill. During an interview of the Chief Executive Officer on 10/6/17 at approximately 3:45 PM, he confirmed the preceding.

Based on interviews, medical records reviews, policies /procedures review, on-call list review, medical staff re-appointment application review, bed census review, ambulance report review, and review of medical staff bylaws, the facility failed to ensure that resources that were available to the hospital, including the availability of on-call physicians (Pulmonologist) provided further evaluation and treatment after the initial examination that was necessary when requested by the Emergency Department for 2 (#4 and #5) of 20 sampled patients that were intubated and placed on the ventilators. Refer to findings in Tag A- 2404. Based on interview, medical record review, policies/procedures review, on- call schedules review, bed census report review, and review of the medical bylaws, the facility failed to provide within the capabilities of the staff, and facilities available at the hospital, for further examination and treatment as required to stabilize a medical condition for 2 (Patient #4 and #5) of 20 patients presenting to the facility. Refer to findings in Tag A-2407. Based on review of medical records, on-call schedules, bed census reports, and policies and procedures, and interviews the facility failed to provide medical treatment that was within its capacity that minimizes the risk of the of the individuals health as evidenced by the refusal of the pulmonary on-call physician to consult on 2 (#4 & #5) of 20 sampled patients. This resulted in inappropriate transfer of patient #'s 4 and 5. Refer to findings in Tag A- 2409.

Based on review of medical records, on-call schedules, medical staff by-laws review, bed census reports, and policies and procedures, and interviews, the facility failed to provide medical treatment that was within its capacity that minimizes the risk of the of the individuals health as evidenced by the refusal of the pulmonary On-Call Physician to consult on 2 (#4 & #5) of 20 sampled patients. As this resulted in inappropriate transfer of Patient #'s 4 and 5. Findings: Review of the facility's transfer form for Patient #4 dated 9/26/2017 revealed in part, "Section C" Additional PHYSICIAN DOCUMENTATION TO BE COMPLETED FOR TRANSFERS FROM THE emergency room on LY. The patient presented to the Hospital requesting emergency medical treatment and the Hospital has provided a Medical Screening Examination and stabilization services to the extent possible, given the Hospital's current capacity and/or capabilities. Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated. Further review revealed the ED physician checked the box which indicated that patient (#4) is being transferred because of failure, refusal ...of an on-call. Staff A's name, address and phone number was listed. Review of the On Call List showed/verified that Staff A was the on call Physician for pulmonary on 9/26/2017 and 9/27/2017. Review of the bed census report dated 9/26/2017 revealed the ICU (Intensive Care Unit) had 14 open beds; and on 9/27/2017 the ICU had 15 open beds. Review of the facility's transfer form for Patient #5 dated 9/14/2017 revealed in part, "Section C" Additional PHYSICIAN DOCUMENTATION TO BE COMPLETED FOR TRANSFERS FROM THE emergency room on LY. The patient presented to the Hospital requesting emergency medical treatment and the Hospital has provided a medical screening examination and stabilization services to the extent possible, given the Hospital's current capacity and/or capabilities. Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated. Further review revealed the ED physician checked the box which indicated that patient (#5) is being transferred because of failure, refusal ...of an on-call. Staff A's name, address and phone number was listed. Review of the On Call List showed/verified that Staff A was the on call physician for pulmonary on 9/14/2017. Review of the bed census report dated 9/14/2017 revealed the ICU had 11 open beds. Interviews: During an interview on 10/04/17 at 10:50 AM, ICU (Intensive Care Unit) Manager stated that if there is a patient in the ED on a ventilator, they will need to have the ED get a pulmonary consult before sending the patient to ICU. The ICU Manager stated they have had to transfer patients to another facility within the system if the patient is on a ventilator and there is no pulmonary consult. During an interview on 10/04/17 at 11:10 AM, Director of ED stated that any transfer is reviewed by the Medical Director of the ED. They have had 2 patients in month of September 2017 they have had to transfer to another facility due to the pulmonary on call physician not seeing the patients after being called Policy and Procedures: The facilities policy titled "EMTALA-Emergency Transfer", CHS Compliance Policy and Procedure G2B, effective Date: [DATE], Date Revised: September 2013 was reviewed. The policy showed in part, "PROCEDURE ...If a patient comes to the Hospital and is determined to have an Emergency Medical Condition following a Medical Screening Examination, the hospital must provide further examination and treatment, including hospitalization if necessary, as required to stabilize the Emergency Medical Condition within the capabilities of the staff and facilities available at the hospital ...An emergency appropriate transfer to another Hospital will be appropriate only in those cases in which: ...The transferring Hospital provided medical treatment within its capabilities that minimizes the risks of the individual's health." The hospital's Medical Staff Bylaws, Policies, and Rules and Regulations, revised 2017 were reviewed. The Medical Staff by-laws showed, in part "Additionally, if any phase of the MSE discloses that it is clinically inappropriate to transport the patient to the other sites for services, then in any such case the on-call physician should immediately be required to attend to that patient where the patient is located. The facility failed to ensure that there policy and procedure were followed as evidenced by transferring Patients #4 (9/27/2017) and Patient #5 (9/14/2017) to other acute care hospitals, when pulmonary on- call services and Intensive Care Unit beds were available to Bayfront Health Brooksville. This resulted in inappropriate transfers for Patient #4 and #5.

Based on interviews, medical records reviews, policies /procedures review, on-call list review, medical staff re-appointment application review, bed census review, ambulance report review, and review of medical staff bylaws, the facility failed to ensure that resources that were available to the hospital, including the availability of on-call physicians (pulmonologists) provided further evaluation and treatment after the initial examination that was necessary when requested by the Emergency Department for 2 (#4 and #5) of 20 sampled patients that were intubated and placed on the ventilators. Findings: Review of the EMS Ambulance Report for Patient #4 dated 9/26/2017, the narrative revealed in part, "Called for a reported Psychiatric problem/Suicide attempt ...on arrival a ...male patient ...Chief Complaint of Overdose ....Patients ... State #4 took 15 Augmentin and 20 Flexeril. At 20:20, the patient was found unresponsive on the floor ...Initial assessment revealed the patient had GCS of 3 (eye-1, Verval-1, Motor-1) with V/S 132/78, P-136, RR-15." The patient was intubated by EMS by EMS personnel prior to arrival to the ED. Review of the medical record for Patient #4 showed that on 09/26/17 at 20:35, the patient was triaged as an ESI level 1- "Resuscitate." The ED nurse documented on 9/26/17 at 2150 that Patient #4 appeared agitated, 2202 Ventilator settings set Parameters were: Vent Mode: Assist control set, Tidal Volume 550cc Vent rate: 14 Set FiO2 40% and PEED -5cmH20. The ED Physician documented the following on 9/26/2017: at: 2141 the patient presents with decreased responsiveness; at 21:44 Respiratory: No distress on Ventilator; at 20:33 the patient was medically screened; 9/27/2017 at 00:11" PULMONOLOGY AT THIS FACILITY WOULD NOT CONSULT ON THIS PATIENT. THUS THE HOSPITALIST WOULD NOT ADMIT THIS PATIENT WITHOUT PULMONOLOGY CONSULT ON THIS PATIENT. PT. TO BE TX'D (TRANSFERRED)" TO ANOTHER ACUTE CARE FACILITY FOR HIGHER LEVEL OF CARE on 9/27/2017 at 1:23 AM intubated on ventilator. Patient #4 disposition Summary was documented, "9/27/2017 Diagnosis are Acute Respiratory failure, OVERDOSE" The patient's condition was listed as Critical. Review of the on call list showed/verified that Staff A was the on call physician for pulmonary on 9/26/2017 and 9/27/2017. Review of the bed census report dated 9/27/2017 revealed the ICU (Intensive Care Unit) had 15 open beds. The Pulmonologist (Staff A) who was on call on 9/27/2017 refused to consult on Patient #4 when requested by the ED physician as Patient #4 required the emergency services of the Pulmonologist that was available at the hospital when the patient (MDS) dated [DATE]. Review of the medical record for Patient #5 showed that on 09/14/17, the patient presented on pain pills and having suicidal thoughts. Patient #5 arrived from home with law enforcement. The patient was triaged acuity was listed as an ESI Level 2, which is "Emergent." The ED physician documented the following on 9/1/4/2017: at 12:23 the patient presents to the emergency department with depression ...a history of substance abuse ...a history of suicide gesture ... took pill/medications ...STATES WANTED TO KILL HIMSELF. PT IS VERY DROWSY AND DRY HEAVING IN THE ED. DIFFICULT TO KEEP AWAKE ...EXAM 09/14 12:27 ...The patient appears in obvious distress, severely distressed obviously ill, uncomfortable ...12:27 Respiratory: mild respiratory is noted. Respirations shallow respirations that is mild, Breath sounds: are normal clear throughout. At 12:39, G-Tube placement: gastric lavage: Performed via NG tube with patient sedated tolerated well. Intubation ...ventilated and ventilator; 9/14/17 11:37 Patient medically screened ...9/14/2017 15:27 Physician Consultation: Staff A (Pulmonologist on-call) was called ...15:32 Physician consultation: was contacted regarding consult, and will see patient STAFF IS REFUSING THE CONSULTS SO [AT WILL BE TRANSFERRED OUT" Patient #5 was then transferred to higher care facility at 5:05 PM for overdose, respiratory failure (intubated on ventilator). Review of the on call list showed/verified that Staff A was the on call physician for Pulmonary on 9/14/2017. Review of the bed census report dated 9/14/2017 revealed the ICU had 11 open beds The Pulmonologist (Staff A) was on call on 9/14/2017 refused to consult on Patient #4 when requested by the ED physician as Patient #5 required the emergency services of the Pulmonologist that was available at the hospital when the patient (MDS) dated [DATE]. Interviews: During an interview on 10/04/17 at 10:50 AM, ICU (Intensive Care Unit) Manager stated that if there is a patient in the ED on a ventilator, they will need to have the ED get a Pulmonary Consult before sending the patient to ICU. The ICU Manager stated they have had to transfer patients to another facility within the system if the patient is on a ventilator and there is no Pulmonary Consult. During an interview on 10/04/17 at 11:10 AM, Director of ED stated that any transfer is reviewed by the Medical Director of the ED. They have had 2 patients in month of September 2017 they have had to transfer to another facility due to the pulmonary On Call Physician not seeing the patients after being called. During an interview on 10/04/17 at 11:41 AM, Unit Secretary/Monitor Technician stated he receives an on call list for each specialty monthly and does an update each day for any changes in the schedule. He stated when they need to call an on call specialist, they call the operator who will have the on call specialist call the ED. They will continue calling every 15 minutes until the on call specialist returns the call. If no contact with the on call Specialist after an hour, they will contact the House Supervisor or Administrator on call to find out who next can be called. When they are ready to transfer a Patient, the transfer call center is contacted with the information needed to transfer the patient. During an interview on 10/04/17 at 3:50 PM, ED physician, when asked if there were problems getting a group of physicians to see a patient in the ED, stated, "Yes, usually Pulmonary." If they are unable to get a hold of pulmonary, they will talk with the Medical Director of ED. They usually can handle ventilators in the ED, but the patient is always transferred if there is no pulmonary consult. During an interview on 10/05/17 at 12:20 PM, Chief Executive Officer stated that there have been problems with the pulmonary physicians, who have been refusing to see patients in the ED. The Pulmonary physicians felt there were too many uninsured patients from the ED and were not getting paid for the services provided. During an interview on 10/05/17 at 12:45 PM, Medical Director of the ED stated that the Pulmonary group will not see patients in the ED if they do not have insurance. Even if the patient goes to the ICU (Intensive Care Unit), the patient is transferred if not seen by the on call Pulmonary Physician. He stated the patients in the ED on ventilators are not getting pulmonary management. The ED physicians can manage the ventilator, but then will transfer the patient. The pulmonary group states that the patient on the ventilator needs to be admitted to the ICU first, then the patient will be seen by the pulmonary physician in the ICU. During an interview on 10/05/17 at 1:20 PM, Staff A (Pulmonary Physician, On call for Patients #4 and #5) stated that he did not come in to see Patients #4 and #5 because he was not asked by the ED physician to do so. If he is on call for the ED, the ED knows he could come in, but he has not been asked to do so. He stated, "The ED states that it is a consult and that means that I do not need to see the patient until after they are admitted to the ICU. I do not tell the ED physician what to do with their patients." He stated he has never asked if patients has insurance before seeing patients in the ED. He stated "The ED needs to tell me why they want me to see a patient in the ED. I have told the ED physicians and administration about this. When the ED calls, I need to know what they need, they can stabilize the patient on the ventilator in the ED." The facility failed to ensure that their policies and procedures were followed as evidenced by failing to ensure that the specialist (Pulmonologist) "on-call" for duty after the initial medical screening examination provided further evaluation and/or treatment as necessary to stabilize Patient #4 and Patient #5 emergency medical conditions. Review of the facility's policy on EMTALA (Emergency Medical Treatment and Labor Act): Record review of the facility's policy titled "EMTALA- Provisions for On-Call Coverage," dated 11/2003, showed that each hospital should have a documented system for providing on-call coverage, so that the ED is at all times aware of physicians, including specialists and sub specialists, who are available to provide screening and treatment necessary to stabilize individuals with EMC (Emergency Medical Conditions). If the hospital offers a service to the public, the service should be available through on-call coverage of the ED and should be reflected on the on-call list. Record review of the facility's policy titled, "Emergency Medical Treatment and Patient Transfers," dated 09/2013,showed that Medical Screening Examination is in the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC. Such screening must be done within the hospital's capacity and available personnel, including on-call physicians. The Medical Screening is an ongoing process and the medical records must reflect it. On Call List refers to the list that the hospital is required to maintain that defines those physicians who are "On -Call" for duty after the initial MSE (Medical Screening Examination) to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC. The purpose of the On-Call list is to ensure that the ED is prospectively aware of each physician; including specialists, who are available to provide treatment necessary to stabilize individuals with EMC. Transfer will not be delayed in order to obtain insurance information. The insurance cannot be verified until an MSE and any other medical treatment that is required is provided. Record review of the facility's policy titled "EMTALA-Reporting," dated 09/2013, stated an On-Call Physician who fails or refuses to come to the hospital within a reasonable period of time, as requested , to evaluate or stabilize the patient, must be reported. Each hospital should have a documented system for providing on-call coverage, so that the ED is at all times aware of which physicians, including specialists, are available to provide screening and treatment necessary to stabilize individuals with EMC. If a hospital offers a service to the public, the service should be available through the on call coverage for the ED and should be reflected on the on-call list. Review of Medical Staff Bylaws, Policies, and Rules and Regulations: Record review of the Medical Staff Bylaws, Policies, and Rules and Regulations, revised 2017, showed under section three, Emergency Departments recognized ER (emergency room ) call rosters are determined by the Medical Executive Committee (MEC) based on the need to provide emergency care or urgent follow up to patients seeking emergency services or who require admission. The recognized call rosters include Pulmonary. All unassigned patients are assigned to the service concerned with the treatment of the problem or diseases. Under consultations, it showed that any physician must be credentialed to manage a ventilator, or a pulmonologist consult must be generated upon intubation. Additionally, if any phase of the MSE discloses that it is clinically inappropriate to transport the patient to the other sites for services, then in any such case the on-call physician should immediately be required to attend to that patient where the patient is located. Further review of Staff A medical staff Re-Appointment Application, dated 02/25/16, showed that duties are to care for unassigned patients and participation in the on-call coverage of the ED. This document also revealed that Staff A (Pulmonologist ) on call membership category was "Active", Primary Campus was "Bayfront Health Brookville and Spring Hill Hospitals" , Department "Medicine" and Privileges "Pulmonary". The appointment period time was "03/01/16 to 2/28/2018.

Based on interview, medical record review, policies/procedures review, on- call schedules review, bed census report review, and review of the medical bylaws, the facility failed to provide within the capabilities of the staff, and facilities available at the hospital, for further examination and treatment as required to stabilize a medical condition for 2 (Patient #4 and #5) of 20 patients presenting to the facility. Findings: Review of the medical record for Patient #4 showed that on 09/26/17, the patient presented to the Emergency Department (ED) by Emergency Medical Services (EMS) unconscious after an overdose. The patient was intubated by EMS prior to arrival. At 12:11 AM, Staff A (Pulmonary Specialist) was called and would not consult on this patient. Review of the On Call List showed that Staff A was the On Call Physician for Pulmonary on this date. Review of the bed census report dated 9/27/2017 revealed the facility had multiple ICU beds available. Further review of the medical chart showed that Patient # 4 transferred on 09/26/17 at 1:23 AM to a higher care facility for respiratory failure/overdose (intubated on ventilator). Review of the medical record for Patient #5 showed that on 09/14/17, the patient presented on pain pills and having suicidal thoughts. Patient #5 arrived from home with Law Enforcement. At around 12:39 PM, Patient #5 was intubated. Staff A (Pulmonary Specialist) was contacted at 3:32 PM and refused consult. Review of the on Call List showed that Staff A was the On Call Physician for Pulmonary on this date. Review of the bed census report dated 9/14/2017 revealed the facility had multiple ICU beds available. Patient #5 was then transferred to higher care facility at 5:05 PM for overdose, respiratory failure (intubated on ventilator). Interviews: During an interview on 10/04/17 at 10:50 AM, ICU (Intensive Care Unit) Manager stated that if there is a patient in the ED on a ventilator, they will need to have the ED get a pulmonary consult before sending the patient to ICU. The ICU Manager stated they have had to transfer patients to another facility within the system if the patient is on a ventilator and there is no Pulmonary Consult. During an interview on 10/04/17 at 11:10 AM, Director of ED stated that any transfer is reviewed by the Medical Director of the ED. They have had 2 patients in month of September 2017 they have had to transfer to another facility due to the Pulmonary on Call Physician not seeing the patients after being called. During an interview on 10/04/17 at 11:41 AM, Unit Secretary/Monitor Technician stated he receives an on call list for each specialty monthly and does an update each day for any changes in the schedule. He stated when they need to call an On Call Specialist, they call the operator who will have the On Call Specialist call the ED. They will continue calling every 15 minutes until the On Call Specialist returns the call. If no contact with the On Call Specialist after an hour, they will contact the House Supervisor or Administrator on call to find out who next can be called. When they are ready to transfer a patient, the transfer call center is contacted with the information needed to transfer the patient. During an interview on 10/04/17 at 3:50 PM, ED physician, when asked if there were problems getting a group of physicians to see a patient in the ED, stated, "Yes, usually pulmonary." If they are unable to get a hold of Pulmonary, they will talk with the Medical Director of ED. They usually can handle ventilators in the ED, but the patient is always transferred if there is no Pulmonary Consult. During an interview on 10/05/17 at 12:20 PM, Chief Executive Officer stated that there have been problems with the Pulmonary Physicians, who have been refusing to see patients in the ED. The Pulmonary Physicians felt there were too many uninsured patients from the ED and were not getting paid for the services provided. During an interview on 10/05/17 at 12:45 PM, Medical Director of the ED stated that the Pulmonary group will not see patients in the ED if they do not have insurance. Even if the patient goes to the ICU (Intensive Care Unit), the patient is transferred if not seen by the on call Pulmonary Physician. He stated the patients in the ED on ventilators are not getting Pulmonary management. The ED physicians can manage the ventilator, but then will transfer the patient. The Pulmonary group states that the patient on the ventilator needs to be admitted to the ICU first, then the patient will be seen by the Pulmonary Physician in the ICU. During an interview on 10/05/17 at 1:20 PM, Staff A (Pulmonary Physician, On call for Patients #4 and #5) stated that he did not come in to see Patients #4 and #5 because he was not asked by the ED physician to do so. If he is on call for the ED, the ED knows he could come in, but he has not been asked to do so. He stated "The ED states that it is a consult and that means that I do not need to see the patient until after they are admitted to the ICU. I do not tell the ED physician what to do with their patients." He stated he has never asked if patients has insurance before seeing patients in the ED. He stated, "The ED needs to tell me why they want me to see a patient in the ED. I have told the ED physicians and administration about this. When the ED calls, I need to know what they need, they can stabilize the patient on the ventilator in the ED." Review of the facility's policy on EMTALA (Emergency Medical Treatment and Labor Act): Record review of the facility's policy titled "EMTALA- Provisions for On-Call Coverage," dated 11/2003, showed that each hospital should have a documented system for providing on-call coverage, so that the ED is at all times aware of physicians, including specialists and sub specialists, who are available to provide screening and treatment necessary to stabilize individuals with EMC (Emergency Medical Conditions). If the hospital offers a service to the public, the service should be available through on-call coverage of the ED and should be reflected on the on-call list. Record review of the facility's policy titled, "Emergency Medical Treatment and Patient Transfers," dated 09/2013,showed that Medical Screening Examination is in the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC. Such screening must be done within the hospital's capacity and available personnel, including on-call physicians. The medical screening is an ongoing process and the medical records must reflect it. On call list refers to the list that the hospital is required to maintain that defines those physicians who are "On -Call" for duty after the initial MSE (Medical Screening Examination) to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC. The purpose of the On-Call list is to ensure that the ED is prospectively aware of each physician; including specialists, who are available to provide treatment necessary to stabilize individuals with EMC. Transfer will not be delayed in order to obtain insurance information. The insurance cannot be verified until an MSE and any other medical treatment that is required is provided. Record review of the facility's policy titled "EMTALA-Reporting," dated 09/2013, stated an On-Call Physician who fails or refuses to come to the hospital within a reasonable period of time, as requested , to evaluate or stabilize the patient, must be reported. Each hospital should have a documented system for providing on-call coverage, so that the ED is at all times aware of which physicians, including specialists, are available to provide screening and treatment necessary to stabilize individuals with EMC. If a hospital offers a service to the public, the service should be available through the on call coverage for the ED and should be reflected on the on-call list. Review of Medical Staff Bylaws, Policies, and Rules and Regulations: Record review of the Medical Staff Bylaws, Policies, and Rules and Regulations, revised 2017, showed under section three, Emergency Departments recognized ER (emergency room ) call rosters are determined by the Medical Executive Committee (MEC) based on the need to provide emergency care or urgent follow up to patients seeking emergency services or who require admission. The recognized call rosters include Pulmonary. All unassigned patients are assigned to the service concerned with the treatment of the problem or diseases. Under consultations, it showed that any physician must be credentialed to manage a ventilator, or a pulmonologist consult must be generated upon intubation.