Banner Boswell Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR §489.20 and 42 CFR §489.24, responsibilities of Medicare participating hospitals in emergency cases. Finding include: Hospital policy titled, “EMTALA - Medical Screening Examination and Stabilization Treatment”, revealed: “ ...III. Policy: ...D. On-Call and Attending Physicians. 1. The Hospital shall maintain a list of physicians to serve on the on-call roster in a manner that best meets the needs of its patients in accordance with available resources, including the availability of on-call physicians. The list must reflect coverage for the types of services routinely offered at the Hospital ....3. All Hospitals must maintain an on-call roster ...4. The Hospital must strive to provide adequate specialty on-call coverage consistent with the services provided at the Hospital and the resources that are available ....5. The Hospital must have written on-call policies that define the responsibilities of the on-call physician to respond, examine and treat patients with an Emergency Medical Condition. The attending or on-call physician must come to the Hospital to examine and provide necessary stabilizing care when requested to do so by the emergency department physician or the QMP providing services to the Patient. Physicians must respond to calls from the emergency department within 30 minutes. The Hospital shall report to the Medical Staff any physician failure to respond timely and appropriately to the Dedicated Emergency Department ....7. The Hospital shall maintain policies and procedures to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond his/her control ....K. Hospital Obligation To Accept Transfers. 1. Any hospital with Specialized Capabilities or Facilities or regional referral centers that serve rural areas and that has Capacity, regardless of whether the hospital has a Dedicated Emergency Department, must accept an appropriate transfer of an unstable patient who requires the specialized capabilities of the hospital from any referring hospital, regardless of financial consideration or proximity of other Hospitals. The Hospital may not delay acceptance of a Patient with an unstabilized EMC pending receipt or verification of financial information. 2. The Hospital with Specialized Capabilities or Facilities cannot delay or refuse the transfer based on the transport services selected by the Transferring hospital ....4. After the Patient has been accepted and the acceptance has been documented, financial information may be requested and alternative Transfer sites may be suggested which are consistent with the Patient’s insurance. A Patient with an unstable EMC will not be refused care because of any financial or insurance concerns, and the Transfer will not be delayed to obtain financial/insurance information. 5. The Hospital need not accept the Transfer of a Patient from a Transferring hospital that has the Capability and Capacity to stabilize the individual ....” Hospital document titled, “Medical Staff Rules and Regulations,” revealed: “ ...1.3 Emergency Department Call: 1.3.1 Coverage Responsibilities. Physicians serving on the call roster of the Emergency Room are responsible to cover their call or assure coverage by a Medical Center Medical Staff member with appropriate privileges, and to notify the Medical Staff Services’ office of any changes prior to any changes being made ....” Banner Health Transfer Services (BHTS) document titled, “ABOUT Resource Definitions,” revealed: “ ...Provider Decision/Explanation ...Decision ...Declined ...Explanation ...D-Physician declined ...Definition ...MD has the capability, facility has the capacity but, MD unable to accept the patient in transfer. Explanation required in MD notes and explanation does not fall under any other MD status definition ....” The policies for on-call physician responsibilities were requested. None were provided. Hospital specialty on-call schedule for December 2024 revealed Provider #6 was on-call for general surgery from 12/22/2024 0700 through 12/23/2024 0700. Review of Hospital transfer request log from November 2024 through January 2025 revealed Hospital #2 attempted to transfer Patient #1 to Hospital #2 on 12/22/2024. The log revealed the transfer request outcome was labeled as “provider declined.” Transcript of phone call between sending hospital, Hospital #2, and Transfer Center for Hospital #1 dated 12/22/2024 at 19:16 revealed: Hospital #2: “ ...I’m calling from (Hospital #2) ...I have a patient here that we would like to set up like a transfer, general surgeon, consult, for a small bowel obstruction. ...” Transfer Center for Hospital #1: “ ...are you the RN, provider, HUC?” Hospital #2: “No, I’m one of the ED HUCs here.” Transfer Center for Hospital #1: “Okay, who is the provider?” Hospital #2: “It’s (Provider #8) ....” Transfer Center for Hospital #1: Gathers Patient #1’s name and date of birth Transfer Center for Hospital: #1: “And you said diagnosis is SBO?” Hospital #2: “I’m sorry?” Transfer Center for Hospital #1: “Small bowel obstruction?” Hospital #2: “Yeah, yeah , yeah” Transfer Center for Hospital #1: “And is (Provider #8) available for a quick question?” Hospital #2: “Yes, give me one second” Hospital #2: “Hey, this is (Provider #8)” Transfer Center for Hospital #1: “ ...transfer (Patient #1)?” Hospital #2: “Yes, got a small bowel obstruction, we don’t have a general surgery on call” Transfer Center for Hospital #1: “No problem, is (Patient #1) medically stable for transfer?” Hospital #2: “Medically stable for transfer” Transfer Center for Hospital #1: “Perfect, any emergent risk for life or limb?” Hospital #2: “No” Transfer Center for Hospital #1: “And what type of bed would you like for (Patient #1)?” Hospital #2: “Med surg” Transfer Center for Hospital #1: “Just a couple of quick questions, I’m assuming no to history of transplant, injury, trauma, and (inaudible)?” Hospital #2: “Yep, no history” Transfer Center for Hospital #1: “Perfect, Covid screen?” Hospital #2: “Negative” Transfer Center for Hospital #1: “Also assuming non-bariatric, incarcerated or need for a sitter?” Hospital #2: “Correct” Transfer Center for Hospital #1: “Any potential need for IR?” Hospital #2: “No” Transcript of phone call between on-call Provider #6 at Hospital #1, and Transfer Center for Hospital #1 dated 12/22/2024 at 22:20 revealed: Transfer Center for Hospital #1: “ ...presented with nausea and vomiting, abdominal pain, CT scan showed a large ventral hernia, with large and small bowel with bowel obstruction. History of hypertension, diabetes, CKD and cholecystectomy. They got 300 out of the NG tube and they are wanting to transfer for general surgery. Do you want to do a doc to doc?” Provider #6: “No. I’m confused, just because they do surgery at (Hospital #2)” Transfer Center for Hospital #1: “Yeah they don’t have general surgeon today” Provider #6: “Are they going to have one tomorrow?” Transfer Center for Hospital #1: “(Hospital #2) will have it at 7 o’clock in the morning” Provider #6: “Yeah, so they should consult their surgeon at 7 o’clock in the morning” Transfer Center for Hospital #1: “Okay, I will tell them that” Provider #6: “I’m not going to be, I’m not going to be coming in and seeing the patient tonight” Transfer Center for Hospital #1: “Okay, I’ll let them know” Transcript of phone call between Provider #8 at Hospital #2 and Transfer Center for Hospital #1 dated 12/22/2024 at 22:30 revealed: Transfer Center for Hospital #1: “I spoke with (Provider #6), (Hospital #1) is my only open place with beds. Nobody in the east valley has general surgery ....It’s either waitlist somewhere or (Hospital #1). (Hospital #1) said since you’re going to have gen surgeon in the morning, (Provider #6) not coming in tonight, just have your gen surg see them tomorrow, that it isn’t worth the transfer” Provider #8: “Okay, who suggested that?....” Transfer Center for Hospital #1: “(Provider #6) ...general surgeon at (Hospital #1)” Provider #8: “Okay” Discussed Patient #1’s past surgery and previous surgeon. Provider #8: “Alright, well I’ll talk to my hospitalist and I’ll reach back out if they are willing to accept without a surgeon until the morning” Transfer Center for Hospital #1: “Yeah, I mean by the time we transfer, you know how sometimes AMR is” Provider #8: “Yeah my only worries just (inaudible) ...who knows if the general surgeon” Transfer Center for Hospital #1: “(Provider #6) goes I’m not going to see (Patient #1) tonight” Document titled, “Notes Summary” for Patient #1’s transfer request from BHTS dated 12/22/2024, revealed: 12/22/2024 19:20 - “Per (Provider #8) requesting transfer for surg, MS bed stable, covid screen neg non-emergent” 12/22/2024 19:23 - “s/w (Provider #8) (Patient #1) presented with N/V and abd pain CT scan shows large ventral hernia with large and small bowel with SBO PMH: HTN, DM, CKD, cholecystectomy treated with NG tube 36.8, 154/66, 69, 16, 97% ra” 12/22/2024 19:25 to 21:51 - BHTS contacted another hospital. 12/22/2024 22:09 - “MS, request sent to (Hospital #1) placement” 12/22/2024 22:23 - “s/w (Provider #6) case presented stated ...thought (Hospital #2) had surgery, explained (sic)(Hospital #1) does not at this time, asked when they will have, the writer explained at 0700 12/23 (Provider #6) stated ...not going to come in to see the pt tonight. Pt can see (Hospital #2) gen surg in the am” 12/22/2024 22:24 - “s/w (Provider #8) made aware that (Provider #6) wants the pt stay at (Hospital #2) and have Gen surg see pt in am when they have gen surg again” Further review of Transfer Center for Hospital #1 records revealed there was no doc to doc performed for Patient #1’s transfer request. Review of Patient #1’s medical record from Hospital #2 revealed: “ ...Emergency Room Report ...BIBA: C/O N/V times 3 days with assosciated (sic) chest and abdominal pain ...pain is constant, worse with vomiting. has been unable to keep ...medications down. last BM was 3 days ago ...not passing gas ...Physical Exam Initial Vital Signs ...T (oral): 36.8 DegC ...HR: 84...RR: 18 ...Pain Scale: 8 = Severe pain ...BP: 148/82 ...Assumed Care ...Time: 12/22/2024 18:48 ...WBC ...17.0K/uL High ...Neutrophils #...14.64K/uL High ...Monocytes #...1.10K/uL High ...Creatinine 2.47mg/dL High ...Lactic Acid ...2.4mmol/L High ...XR Abdomen ...Impression: NG tube present in stomach ...CT Abdomen and Pelvis ...Findings: ...A large right anterior abdominal wall hernia is present containing multiple large and small bowel loops. The stomach is distended with fluid. There is rather marked distension of proximal small bowel with fluid and air bubbles. The colon for the most part is decompressed ...Impression: 1. Large right anterior abdominal wall hernia containing both large and small bowel appears to be producing a high degree small bowel obstruction ....Management Discussions: ...Consulting provider/service: general surgery ...12/22/24 22:30 treatment decisions included admission to (Hospital #2), No acute intervention overnight, On call general surgery can manage at (Hospital #2) ...Coded Diagnoses ...Severe sepsis ...SBO (small bowel obstruction) ...Large ventral hernia ....History and Physical ...12/22/2024 22:55 ...(Provider #6) general surgeon at (Hospital #1) was consulted and states that patient does not require surgical intervention tonight and is safe for admission here at (Hospital #2) with surgical consult tomorrow when available ....Operative Note ...12/23/2024 17:08 ...Findings ...Obstructed, incarcerated recurrent incisional hernia with closed loop small bowel obstruction ...Once the hernia was completed released I encountered another additional hernia in the left lower quadrant that was much smaller in size, that sac excised as well and sent to pathology in combination with prior specimen. A lysis of adhesion was then performed ....I identified the site of obstruction, there was a fibrous stenotic area as well as a related closed-loop bowel obstruction that had decompressed distal small bowel. I lysed the closed-loop obstruction. I then thoroughly investigated this segment of bowel. This segment of bowel was in the terminal ileum and is approximately 50cm proximal from the ileocecal valve. While the bowel was peristalsing the mesentery appeared extremely devascularized. I was worried about a delayed low flow state to this area of bowel and decided to perform a small bowel resection, this was reinforced as there was also a fibrous stenotic area that I feared would cause chronic partial small bowel obstructions if left alone ....” Employee #9 confirmed during an interview conducted on 02/19/2025 that there is only one specialty on-call schedule for the hospital. Employee #9 confirmed there are no policies for on-call physician responsibilities, and their responsibilities are covered in the medical staff rules and regulations. Provider #7 confirmed the physicians on-call are expected to answer calls from the hospital’s ED, as well as transfer requests to the hospital. Provider #7 confirmed it is the physician individual medical decision to accept or decline the transfer request. Provider #7 confirmed the sending hospital determines if there’s an emergent need for transfer. Employee #27 confirmed Hospital #2 called the transfer center for Hospital #1 with the intent to transfer Patient #1 for general surgery. Employee #9 further confirmed it was documented Provider #6 declined Patient #1’s transfer request, and reported they were not going to come in to see the patient, and for Patient #1 to wait when general surgery is available next morning at Hospital #2.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interviews, it was determined the hospital failed to accept a transfer of an emergency patient who required specialized services not offered at the referring hospital. This deficient practice poses a risk to the health and safety of patients if there is a delay in care, and transfers are not accepted to provide emergency interventions leading to medical complications or death. Findings include: Hospital policy titled, “EMTALA - Medical Screening Examination and Stabilization Treatment”, revealed: “ ...III. Policy: ...D. On-Call and Attending Physicians. 1. The Hospital shall maintain a list of physicians to serve on the on-call roster in a manner that best meets the needs of its patients in accordance with available resources, including the availability of on-call physicians. The list must reflect coverage for the types of services routinely offered at the Hospital ....3. All Hospitals must maintain an on-call roster ...4. The Hospital must strive to provide adequate specialty on-call coverage consistent with the services provided at the Hospital and the resources that are available ....5. The Hospital must have written on-call policies that define the responsibilities of the on-call physician to respond, examine and treat patients with an Emergency Medical Condition. The attending or on-call physician must come to the Hospital to examine and provide necessary stabilizing care when requested to do so by the emergency department physician or the QMP providing services to the Patient. Physicians must respond to calls from the emergency department within 30 minutes. The Hospital shall report to the Medical Staff any physician failure to respond timely and appropriately to the Dedicated Emergency Department ....7. The Hospital shall maintain policies and procedures to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond his/her control ....K. Hospital Obligation To Accept Transfers. 1. Any hospital with Specialized Capabilities or Facilities or regional referral centers that serve rural areas and that has Capacity, regardless of whether the hospital has a Dedicated Emergency Department, must accept an appropriate transfer of an unstable patient who requires the specialized capabilities of the hospital from any referring hospital, regardless of financial consideration or proximity of other Hospitals. The Hospital may not delay acceptance of a Patient with an unstabilized EMC pending receipt or verification of financial information. 2. The Hospital with Specialized Capabilities or Facilities cannot delay or refuse the transfer based on the transport services selected by the Transferring hospital ....4. After the Patient has been accepted and the acceptance has been documented, financial information may be requested and alternative Transfer sites may be suggested which are consistent with the Patient’s insurance. A Patient with an unstable EMC will not be refused care because of any financial or insurance concerns, and the Transfer will not be delayed to obtain financial/insurance information. 5. The Hospital need not accept the Transfer of a Patient from a Transferring hospital that has the Capability and Capacity to stabilize the individual ....” Hospital document titled, “Medical Staff Rules and Regulations,” revealed: “ ...1.3 Emergency Department Call: 1.3.1 Coverage Responsibilities. Physicians serving on the call roster of the Emergency Room are responsible to cover their call or assure coverage by a Medical Center Medical Staff member with appropriate privileges, and to notify the Medical Staff Services’ office of any changes prior to any changes being made ....” Banner Health Transfer Services (BHTS) document titled, “ABOUT Resource Definitions,” revealed: “ ...Provider Decision/Explanation ...Decision ...Declined ...Explanation ...D-Physician declined ...Definition ...MD has the capability, facility has the capacity but, MD unable to accept the patient in transfer. Explanation required in MD notes and explanation does not fall under any other MD status definition ....” The policies for on-call physician responsibilities were requested. None were provided. Hospital specialty on-call schedule for December 2024 revealed Provider #6 was on-call for general surgery from 12/22/2024 0700 through 12/23/2024 0700. Review of Hospital transfer request log from November 2024 through January 2025 revealed Hospital #2 attempted to transfer Patient #1 to Hospital #2 on 12/22/2024. The log revealed the transfer request outcome was labeled as “provider declined.” Transcript of phone call between sending hospital, Hospital #2, and Transfer Center for Hospital #1 dated 12/22/2024 at 19:16 revealed: Hospital #2: “ ...I’m calling from (Hospital #2) ...I have a patient here that we would like to set up like a transfer, general surgeon, consult, for a small bowel obstruction. ...” Transfer Center for Hospital #1: “ ...are you the RN, provider, HUC?” Hospital #2: “No, I’m one of the ED HUCs here.” Transfer Center for Hospital #1: “Okay, who is the provider?” Hospital #2: “It’s (Provider #8) ....” Transfer Center for Hospital #1: Gathers Patient #1’s name and date of birth Transfer Center for Hospital: #1: “And you said diagnosis is SBO?” Hospital #2: “I’m sorry?” Transfer Center for Hospital #1: “Small bowel obstruction?” Hospital #2: “Yeah, yeah , yeah” Transfer Center for Hospital #1: “And is (Provider #8) available for a quick question?” Hospital #2: “Yes, give me one second” Hospital #2: “Hey, this is (Provider #8)” Transfer Center for Hospital #1: “ ...transfer (Patient #1)?” Hospital #2: “Yes, got a small bowel obstruction, we don’t have a general surgery on call” Transfer Center for Hospital #1: “No problem, is (Patient #1) medically stable for transfer?” Hospital #2: “Medically stable for transfer” Transfer Center for Hospital #1: “Perfect, any emergent risk for life or limb?” Hospital #2: “No” Transfer Center for Hospital #1: “And what type of bed would you like for (Patient #1)?” Hospital #2: “Med surg” Transfer Center for Hospital #1: “Just a couple of quick questions, I’m assuming no to history of transplant, injury, trauma, and (inaudible)?” Hospital #2: “Yep, no history” Transfer Center for Hospital #1: “Perfect, Covid screen?” Hospital #2: “Negative” Transfer Center for Hospital #1: “Also assuming non-bariatric, incarcerated or need for a sitter?” Hospital #2: “Correct” Transfer Center for Hospital #1: “Any potential need for IR?” Hospital #2: “No” Transcript of phone call between on-call Provider #6 at Hospital #1, and Transfer Center for Hospital #1 dated 12/22/2024 at 22:20 revealed: Transfer Center for Hospital #1: “ ...presented with nausea and vomiting, abdominal pain, CT scan showed a large ventral hernia, with large and small bowel with bowel obstruction. History of hypertension, diabetes, CKD and cholecystectomy. They got 300 out of the NG tube and they are wanting to transfer for general surgery. Do you want to do a doc to doc?” Provider #6: “No. I’m confused, just because they do surgery at (Hospital #2)” Transfer Center for Hospital #1: “Yeah they don’t have general surgeon today” Provider #6: “Are they going to have one tomorrow?” Transfer Center for Hospital #1: “(Hospital #2) will have it at 7 o’clock in the morning” Provider #6: “Yeah, so they should consult their surgeon at 7 o’clock in the morning” Transfer Center for Hospital #1: “Okay, I will tell them that” Provider #6: “I’m not going to be, I’m not going to be coming in and seeing the patient tonight” Transfer Center for Hospital #1: “Okay, I’ll let them know” Transcript of phone call between Provider #8 at Hospital #2 and Transfer Center for Hospital #1 dated 12/22/2024 at 22:30 revealed: Transfer Center for Hospital #1: “I spoke with (Provider #6), (Hospital #1) is my only open place with beds. Nobody in the east valley has general surgery ....It’s either waitlist somewhere or (Hospital #1). (Hospital #1) said since you’re going to have gen surgeon in the morning, (Provider #6) not coming in tonight, just have your gen surg see them tomorrow, that it isn’t worth the transfer” Provider #8: “Okay, who suggested that?....” Transfer Center for Hospital #1: “(Provider #6) ...general surgeon at (Hospital #1)” Provider #8: “Okay” Discussed Patient #1’s past surgery and previous surgeon. Provider #8: “Alright, well I’ll talk to my hospitalist and I’ll reach back out if they are willing to accept without a surgeon until the morning” Transfer Center for Hospital #1: “Yeah, I mean by the time we transfer, you know how sometimes AMR is” Provider #8: “Yeah my only worries just (inaudible) ...who knows if the general surgeon” Transfer Center for Hospital #1: “(Provider #6) goes I’m not going to see (Patient #1) tonight” Document titled, “Notes Summary” for Patient #1’s transfer request from BHTS dated 12/22/2024, revealed: 12/22/2024 19:20 - “Per (Provider #8) requesting transfer for surg, MS bed stable, covid screen neg non-emergent” 12/22/2024 19:23 - “s/w (Provider #8) (Patient #1) presented with N/V and abd pain CT scan shows large ventral hernia with large and small bowel with SBO PMH: HTN, DM, CKD, cholecystectomy treated with NG tube 36.8, 154/66, 69, 16, 97% ra” 12/22/2024 19:25 to 21:51 - BHTS contacted another hospital. 12/22/2024 22:09 - “MS, request sent to (Hospital #1) placement” 12/22/2024 22:23 - “s/w (Provider #6) case presented stated ...thought (Hospital #2) had surgery, explained (sic)(Hospital #1) does not at this time, asked when they will have, the writer explained at 0700 12/23 (Provider #6) stated ...not going to come in to see the pt tonight. Pt can see (Hospital #2) gen surg in the am” 12/22/2024 22:24 - “s/w (Provider #8) made aware that (Provider #6) wants the pt stay at (Hospital #2) and have Gen surg see pt in am when they have gen surg again” Further review of Transfer Center for Hospital #1 records revealed there was no doc to doc performed for Patient #1’s transfer request. Review of Patient #1’s medical record from Hospital #2 revealed: “ ...Emergency Room Report ...BIBA: C/O N/V times 3 days with assosciated (sic) chest and abdominal pain ...pain is constant, worse with vomiting. has been unable to keep ...medications down. last BM was 3 days ago ...not passing gas ...Physical Exam Initial Vital Signs ...T (oral): 36.8 DegC ...HR: 84...RR: 18 ...Pain Scale: 8 = Severe pain ...BP: 148/82 ...Assumed Care ...Time: 12/22/2024 18:48 ...WBC ...17.0K/uL High ...Neutrophils #...14.64K/uL High ...Monocytes #...1.10K/uL High ...Creatinine 2.47mg/dL High ...Lactic Acid ...2.4mmol/L High ...XR Abdomen ...Impression: NG tube present in stomach ...CT Abdomen and Pelvis ...Findings: ...A large right anterior abdominal wall hernia is present containing multiple large and small bowel loops. The stomach is distended with fluid. There is rather marked distension of proximal small bowel with fluid and air bubbles. The colon for the most part is decompressed ...Impression: 1. Large right anterior abdominal wall hernia containing both large and small bowel appears to be producing a high degree small bowel obstruction ....Management Discussions: ...Consulting provider/service: general surgery ...12/22/24 22:30 treatment decisions included admission to (Hospital #2), No acute intervention overnight, On call general surgery can manage at (Hospital #2) ...Coded Diagnoses ...Severe sepsis ...SBO (small bowel obstruction) ...Large ventral hernia ....History and Physical ...12/22/2024 22:55 ...(Provider #6) general surgeon at (Hospital #1) was consulted and states that patient does not require surgical intervention tonight and is safe for admission here at (Hospital #2) with surgical consult tomorrow when available ....Operative Note ...12/23/2024 17:08 ...Findings ...Obstructed, incarcerated recurrent incisional hernia with closed loop small bowel obstruction ...Once the hernia was completed released I encountered another additional hernia in the left lower quadrant that was much smaller in size, that sac excised as well and sent to pathology in combination with prior specimen. A lysis of adhesion was then performed ....I identified the site of obstruction, there was a fibrous stenotic area as well as a related closed-loop bowel obstruction that had decompressed distal small bowel. I lysed the closed-loop obstruction. I then thoroughly investigated this segment of bowel. This segment of bowel was in the terminal ileum and is approximately 50cm proximal from the ileocecal valve. While the bowel was peristalsing the mesentery appeared extremely devascularized. I was worried about a delayed low flow state to this area of bowel and decided to perform a small bowel resection, this was reinforced as there was also a fibrous stenotic area that I feared would cause chronic partial small bowel obstructions if left alone ....” Employee #9 confirmed during an interview conducted on 02/19/2025 that there is only one specialty on-call schedule for the hospital. Employee #9 confirmed there are no policies for on-call physician responsibilities, and their responsibilities are covered in the medical staff rules and regulations. Provider #7 confirmed the physicians on-call are expected to answer calls from the hospital’s ED, as well as transfer requests to the hospital. Provider #7 confirmed it is the physician individual medical decision to accept or decline the transfer request. Provider #7 confirmed the sending hospital determines if there’s an emergent need for transfer. Employee #27 confirmed Hospital #2 called the transfer center for Hospital #1 with the intent to transfer Patient #1 for general surgery. Employee #9 further confirmed it was documented Provider #6 declined Patient #1’s transfer request, and reported they were not going to come in to see the patient, and for Patient #1 to wait when general surgery is available next morning at Hospital #2.”