Based on staff and patient interview, and review of medical records and CAH policies, it was determined the hospital failed to ensure 1) on-call physicians responded to and treated patients who required further stabilizing care, and 2) CAH policies clearly defined expectations of on-call physicians. These failures directly impacted 1 of 10 (#7) ED patients who required stablizing care beyond that immediately available in the ED. This resulted in the unnecessary transfer of a patient to another hospital and created the potential for the patient to experience medical complications due to delayed treatment. Findings include: 1. Patient #7 was a [AGE] year old female who (MDS) dated [DATE] at 2:49 AM. Her "Triage Report," dated 11/03/14 at 3:01 AM, stated she complained of abdominal pain. Her "EMERGENCY PHYSICIAN RECORD," dated 11/03/14 beginning at 2:55 AM, stated she had undergone gastric bypass surgery in 2005. Gastric bypass surgery is performed at the location of the stomach and proximal small bowel. A CT Scan was conducted on Patient #7. The report, dated 11/03/14 at 12:54 PM, stated "Postsurgical changes are present from gastric bypass. There is a short segment of intussusception [the bowel folds back on itself] at the small-bowel anastomosis in the left upper abdomen but this does not appear to be the site of obstruction." The report stated the obstruction appeared to be at the distal end of the small bowel. Patient #7's "EMERGENCY PHYSICIAN RECORD," dated 11/03/14 beginning at 2:55 AM, stated she complained of nausea, vomiting, and chills. The physician diagnosed Patient #7 with a bowel obstruction and intussusception. The form stated the ED physician spoke with Physician A, the surgeon on-call. It stated the surgeon " ...recommended transfer out." No consultation note by Physician A was present in the medical record. Patient #7's ED record stated an IV was started and she was given medication for pain and nausea. An "Interfacility Transfer Consent and Checklist, dated 11/03/14 at 5:50 AM, stated Patient #7 was accepted for transfer to an acute care hospital, approximately 23 miles from the CAH. A nursing progress note, dated 11/03/14 at 6:20 AM stated Patient #7 was transferred to the receiving hospital by ambulance at that time. The Operative Report from the receiving hospital, dated 11/06/14 at 7:31 PM, stated surgery was performed on Patient #7 at the receiving hospital on [DATE]. Patient #7 was interviewed on 1/15/15 beginning at 2:15 PM. She stated she went to the ED early in the morning of 11/03/14. She stated she was diagnosed with a bowel obstruction. She stated she had requested to see Physician A but he would not see her. She stated she was transferred to another hospital where surgery was performed that morning to treat her bowel obstruction. Documents titled "Group On Call Schedules" for November 2014, stated Physician A was the on-call surgeon for the CAH between 11/01/14 and 11/08/14. The ED physician who treated Patient #7 was interviewed on 1/14/15 beginning at 5:45 PM. He stated Physician A was on-call the morning of 11/03/14. He stated he called Physician A at 3:00 AM and asked him to examine Patient #7. He stated Physician A refused to see Patient #7 because she had a history of gastric bypass surgery. Physician A was interviewed on 1/14/15 beginning at 10:40 AM. He stated he was board certified in general surgery. He stated he was on-call on the morning of 11/03/14. He stated he did not remember the conversation with the ED physician regarding Patient #7. He stated he did not treat patients who had gastric bypass surgery. He stated he did not come to the hospital to evaluate Patient #7. On 1/15/15 beginning at 8:55 AM, Physician A's credentials file was reviewed with the Medical Staff Assistant in charge of maintaining credentials files. Physician A's file stated he was board certified in general surgery. The file stated he had privileges to perform gastric and bowel resections and "Small and large bowel surgeries." The Medical Staff Assistant stated there were no restrictions on the type of bowel surgery Physician A performed. The CAH failed to ensure the on-call surgeon evaluated and treated Patient #7. 2. The CAH's "Medical Staff Rules and Regulations, Number: 28 EMERGENCY CALL," approved 6/27/12, stated specialty physicians such as surgeons would form an "emergency call rotation." However, the rules and regulations did not specify the responsibilities of on-call physicians. The rules and regulations did not specify if physicians were required to come to the hospital, to examine patients, or time frames for such activities. The Chief of the Medical Staff was interviewed on 1/14/15 beginning at 11:35 AM. He stated the bylaws did not specify the duties of on-call physicians and did not specify time frames to report to the CAH when called. The CAH failed to develop and implement policies and procedures to ensure on-call specialty physicians responded to treat patients with emergency medical conditions.

Based on staff and patient interviews and review of medical records and hospital policies, it was determined the CAH failed to ensure it met its special responsibilities in emergency cases related to physician on-call requirements. This resulted in the inability of the CAH to ensure patients with potential emergency medical conditions received emergency services from on-call physicians consistent with needs. Findings include: Section 42 CFR 489.20(l) of the provider's agreement requires that CAH's comply with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. Under the provisions of §489.24, CAH's that participate in Medicare are required under EMTALA to ensure physician on-call schedules are maintain in a manner that best meets the needs of emergency patients. Refer to C2406 as it relates to the failure of the CAH to ensure physician on-call practices met the needs of patients.