Based upon medical record review, policy review, document review and interview, the facility did not comply with all the provisions for the availability of on-call physicians and delay in examination and/or treatment. Please reference findings under Tag A 2404 and 2408.

Based on policy review, document review, medical record review and interview, the on-call Urologist did not respond to calls or present to the facility for an emergency consultation for Patient #1 on 05/16/18. Failure to respond to a consult request can delay treatment and/or contribute to an adverse patient outcome. Findings include: Review of the "Medical Staff Rules and Regulations" dated 04/18/18 indicates the on-call practitioner should respond to calls from the ED within 30 minutes and arrive to the hospital to evaluate the patient within another 30 minutes for emergent conditions. Review of policy " Transfer- Inter Institutional Patient Transfers and Medical Screening Exam " last revised 05/20/04 indicates the medical screening examination (MSE) includes the use of on-call physicians, as appropriate, to determine whether a patient has an emergency medical condition (EMC). If the ED physician or Attending physician determines a consultation by a specialist is necessary to further access or stabilize a patient with an EMC, the appropriate on-call physician will be notified and expected to respond in 30 minutes. Review of the physician on-call schedule for May 2018 revealed Staff (R), Urologist, was on-call for World Urology on May 15-16, 2018. Medical record review dated 05/16/18 for Patient #1 revealed the following: - The "Transition of Care" note at 02:00 AM and Physician Assistant note (no time) indicates the preliminary ultrasound report showed no blood flow to the left testicle with an enlarged epididymis (tube located behind the testicle). A page was made to discuss findings with Staff (R), on-call Urologist. The ultrasound final report and call back from the on-call Urologist is pending. - At 02:30 AM, the final ultrasound report indicates a Urology consult is necessary for suspected testicular torsion (condition that occurs when the spermatic cord from which the testicle is suspended twists, cutting off the blood supply to the testicle). The findings were discussed with Staff (J), ED Attending MD. - Staff (J), ED Attending Physician note (no time) indicates Patient #1 had a sonogram and was found to have torsion. The Urologist was called on multiple occasions. Patient #1 was transferred to another hospital for more definitive care. Interview on 01/07/19 at 01:03 PM with Staff (J), ED Attending Physician revealed testicular torsion is an emergency. He never received a call back from Staff (R), on-call Urologist and a decision was made to transfer Patient #1.

Based on medical record review and interview, there was a delay in the treatment and the transfer of Patient #1, who had an emergency medical condition (EMC), to a higher level of care. A delay in treatment and/or transfer of a patient with an EMC can result in an adverse patient outcome. Findings include: Medical record review for Patient #1 revealed that on 05/15/18 at 10:18 PM, Patient #1 arrived at the emergency department (ED) with complaints of left testicle pain. At 10:21 PM, he was triaged and at 10:22 PM he was seen by Staff (I), Physician Assistant (PA). However, Staff (I), PA did not order an ultrasound until 11:59 PM or laboratory/urine studies until 01:59 AM (testing used to diagnosis testicular torsion). On 05/16/18 at 02:00 AM, the care of Patient #1 was transferred from Staff (I), PA to Staff (J), ED Attending Physician. The ultrasound final report and call back from the on-call Urologist were pending. At 02:30 AM, the final ultrasound report indicates an Urology consult is necessary for suspected testicular torsion. The findings were discussed with Staff (J), ED Attending MD. The on-call Urologist never called the ED clinical staff back for consultation and the order to transfer Patient #1 to a higher level of care was not written until 04:00 AM. Patient #1 did not leave the facility until approximately 05:00 AM. Interview on 01/07/19 at 01:03 PM with Staff (J), ED Attending Physician revealed testicular torsion is an emergency. He never received a call back from the on-call Urologist and a decision was made to transfer Patient #1.

Based on medical record review, interview and policy review 4 out of 10 Emergency Department (ED) medical records had incomplete triage assessments (Patient #1-4). An incomplete assessment could result in patient needs not being addressed. Findings include: Review of facility policy, Patient Suicide Risk Assessment and Environmental Risk Evaluation last revised 2/8/18 revealed that all patients who are admitted with or who answer yes to one of the following: 1. Emotional or behavioral disorder 2. Feeling down, depressed or hopeless or, 3. Any thoughts of harming self or better off not being alive, will have a suicide risk assessment utilizing the SAD PERSONS scale (assessment tool to determine suicide risk) completed. The SAD score as well as evaluations of the person's physical condition are addressed upon triage and are documented in the electronic medical record. Review on 5/18/18 of ED medical records revealed a SAD PERSONS evaluation was not completed during triage for Patient #1-4, despite documentation of mental health concerns and suicidal ideation on presentation to the ED. Interview with Staff (A), Vice President of Patient Care Services and Staff (B), Corporate Director on 5/18/18 at 1:00 PM verified the above findings.