Based on a review of policies, procedures; 5 open and 15 closed emergency department (ED) records, it was revealed that 1) upon an ED physician request for an on-call surgical consult, the surgeon refused the consult; and 2) no current effective tracking of on-call physician responses to consult requests was found. Patient #1 was an adult patient who presented to the emergency department in early December. A triage at 0520 revealed a chief complaint of vomiting blood. Patient #1 had a history in part, of hernia and enlarged blood vessels in the esophagus that presented a bleeding risk. Patient #1 was also on the liver transplant list for liver failure. A medical screening exam revealed in part, a large umbilical hernia for which Computed Tomography revealed an incarcerated hernia. An incarcerated hernia is when a part of the bowel moves through the abdominal wall which can cause bowel obstruction and/or cut off blood flow to parts of the intestine. An incarcerated hernia may frequently be life-threatening and require emergency surgical intervention. The ED physician contacted the on-call surgeon for further surgical evaluation of patient #1. A progress note following that contact revealed in part, " ...it seemed that the CT scan demonstrated an incarcerated ventral hernia. (Pt. #1) did not have any physical signs of obstruction at this time and had no further vomiting but did have pain and tenderness and a palpable hernia ...I have contacted general surgery, (surgeon) responding he is familiar with the patient. I was requested (sic) to see and evaluate the patient however refused to do so stating that the patient should likely be transferred to an academic center. I explained this could take some time and requested a bedside evaluation the patient see if this would be practical or required any further surgical intervention. I was concerned that waiting for any delayed time to be transferred to be detrimental the patient's condition. Despite this information the request for surgical evaluation was still refused. I therefore contacted the patient's transplant center (transplant hospital). Explained the situation that we were dealing with. Their surgeon there also stated that it seemed like this could be addressed here and then transferred for further definitive care to the tertiary center. Patient #1 was accepted by a surgeon at the receiving hospital. The physician Certification of Medical Necessity prior to transfer revealed that patient #1 was stable, and had a diagnosis of an Incarcerated Ventral Hernia with conditions at transport of GI bleed, and possible pancreatitis. Patient #1 was transferred to the receiving hospital at 2008. The hospital EMTALA On-Call Coverage policy (effective 5/1/2016) revealed in part, "B. A refusal or failure of a physician to comply with this policy or his/her on-call obligations shall be reported immediately to the Chief Medical Officer, or designee, for review. Observation of the On-Call consult phone system revealed a log which documented the requesting physician name, the name of the requested consulting physician, the times of each call, each response and the time intervals between them. The log did not document whether the requested consulting physician actually completed a consult. While the On-Call Policy included all required elements, no definitive way to determine actual outcomes of consult requests was found other than to determine which patient records required consult, and then review each record individually. Further, non-compliance was dependent on consistent reporting between physicians. Based on this, no QAPI or Ongoing Professional Performance Evaluation tracking of ED On-call compliance/non-compliance was found at the time of survey. Based on all documentation, the hospital failed to meet regulatory requirements for On-call Physicians, resulting in a delay in care and the potentially unnecessary transfer of a patient with an Emergency Medical Condition.

Based on a review of the policy "Admission to the Behavioral Health Unit" (ABHU) (reviewed April 2016), the Behavioral Health Unit Central Log (BHCL) for referrals from other hospital emergency departments (ED), and interview, it was revealed that, 1) a psychiatrist determined that referred patient (A) was "too acute" for the behavioral health unit; 2) a psychiatrist determined that referred patient (B) did not require inpatient care, and 3) in practice, the hospital conditions the acceptance of referred behavioral health patients who have already been determined to have an emergency psychiatric condition on whether there are psychiatric patients in process of ED evaluation in the hospital ED. The hospital behavioral health unit (BHU) admits both voluntary and involuntary patients to the 18 bed unit. A review of the BHU census for 5/24/2017 revealed a beginning and ending census of 12 patients. Therefore 6 beds were available for admission. An untimed referral request for admission of patient (A) was denied with the notation, "due to acuity of patient." A request for the referral record revealed that the hospital did not keep referral records of denied patients, so it could not be known on what "acuity" basis patient (A) was denied admission. The ABHU policy revealed no specific contraindication for admission based on "Acuity." Based on the fact that the hospital had the capacity and capability to admit an involuntary patient which represented the highest available level of care, the hospital had a responsibility to admit patient (A). A review of the BHU census for 11/14/2017 revealed a beginning census of 16 and an ending census of 14. Therefore, 2-4 beds were available for admission. An untimed referral request for the admission of patient (B) revealed the notation, "Not clinically indicated for continuation of care - Denied." Based in the fact that the referring hospital had already determined an emergency condition, the hospital could not make a different determination and had a responsibility to admit patient (B). Interview with a psychiatric evaluator at approximately 1115 revealed the practice that referrals of psychiatric patients from other ED's who had been determined to have an emergency psychiatric condition were not to be accepted, if there were psychiatric patients in the hospital ED who were in process of evaluation but who had not yet been determined to have an emergency psychiatric condition. Based on this information, the hospital would hold a bed for a psychiatric patient in the hospital ED who ultimately might be determined not to have an emergency psychiatric condition.