Banner Desert 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: 52757 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. FINDINGS INCLUDE: Policy titled, “ EMTALA - Medical Screening Examination and Stabilization Treatment “ , revealed: “ ... “ EMTALA - Medical Screening Examination and Stabilization Treatment “ , revealed: “ ... Purpose/Population: A. Purpose: Banner Health provides care for individuals presenting to its hospitals (and Dedicated Emergency Departments, as defined below) with emergency medical conditions without discrimination and regardless of their payor status or eligibility for financial assistance. This Policy outlines Banner Health ’ s commitment to comply with the requirements of the federal Emergency Medical Treatment and Active Labor Act ( “ EMTALA “ ) codified at 42 U.S.C. § 1395dd, and its implementing regulations, codified at 42 C.F.R. § 489.24 ... III. Policy:... D. on-Call and Attending Physicians ... 5. The Hospital must have written on-call policies that define the responsibilities of he 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 .... “ Hospital document titled, “ Banner Health Desert Medical Center General Rules and Regulations “ , revealed: “ ... 6.0 EMERGENCY ROOM ... 6.1 MEDICAL STAFF MEMBER EMERGENCY CALL RESPONSIBILITIES. Physicians shall serve on the on-call roster based on need for coverage, unassigned and emergency patients as determined by the applicable department, the Medical Executive Committee, Administration and the EMTALA policy, as required. Refer to Medical Staff Emergency Department On-Call Policy and Procedure for approved call requirements ... 6.5 EMERGENCY CALL RESPONSE TIME. The on-call physician must respond in person, if requested to do so by the Emergency Department physician or, in the case of obstetrics, by the Obstetrical RN. An on-call physician may send an advanced practice provider to the Emergency Department to evaluate the patient but the physician must provide all care necessary to stabilize the patient as requested by the Emergency Department physician ... 6.5.1 STAT Call Response Time. Physicians must respond within 10-15 minutes to a STAT call from the ED ... “ One (1) out of twenty (20) medical records reviewed revealed that the facility did not follow its own Policy and Procedures when providing emergency services in the Emergency Department. Review of Patient #1 ED medical record dated 08/07/2025 revealed Patient #1 arrived via private vehicle to the ED on 08/07/2025 at 1420. Patient #1 ’ s medical record which revealed the following: Pediatric surgery emergent consult order placed at 1604 and Pediatric GI called at 1650. Pediatric surgery emergent consult order placed at 1655 and Pediatric surgery called regarding consult at 1716. Pediatric surgery emergent consult order placed at 1844 and Pediatric surgery returned call at 1854. Pediatric surgery emergent consult order placed at 1951 and returned call at 2010. Review of Patient #1 nursing triage note dated 08/07/2025 at 1423 revealed: “ ... ED Triage ... Chief complaint: abdominal pain beginning today. Abdominal distention normal per mom. Nausea reported. No vomiting, no fever. Decreased activity. History of malabsorption. Has NG tube .... “ Review of Patient #1 ED provider note dated 08/07/2025 at 1516 revealed: “ ... Chief Complaint abdominal pain beginning today. Abdominal distention normal per mom. Nausea reported. No vomiting, no fever. Decreased activity. History of malabsorption. Has NG tube ... History of Present Illness 3-year-old {male} with history of absorption currently status post NG tube approximately 1 month ago, previous right sided lobectomy when {she} was 1 years old, presents to the ED today with complaints of abdominal pain, abdominal distention and nausea and vomiting. {Mom} states the patient woke up this morning seem to be acting {her} normal self {she} does have some baseline on and off abdominal distention that {she} went to daycare today daycare called and said that {she} was complaining of abdominal pain and to come and pick {her} up. {Mom} brought {her} immediately afterwards. Upon my interview patient was actively throwing up nonbloody nonbilious. Patient does have abdominal distention. Does seem to have some mild discomfort of the abdominal region as well. {Mom} states no other significant concerns at this time and {she} has been acting normally prior to going to daycare. {Mom} does note that {she} has been having diarrhea for approximately the past week ... Management Discussions / Escalation of Care / Consultations: peds surgery ... Reexamination/Reevaluation. Impression: Severely gaseous distended loops of bowel in the abdomen, which appear to be large bowel. Possible bowel wall thickening. Cannot exclude colitis. Approx 1600: I paged pediatric surgery at this time as we do have concern for significant large bowel distention and possible obstruction ...1650: Have paged out for pediatric surgery however received a call back from pediatric GI mistakenly. Did not fully discuss the case with pediatric GI as we wanted to speak with pediatric surgery first. At that point put in another consult to speak with pediatric surgery. 1716: Spoke with surgery (Nicole) over the phone and discussed the case. Surgery initially recommending possible transfer to PCH as the patient had some follow up with PCH and does not typically follow at Banner. If no transfer can continue workup. Decision was made to proceed with more advanced imaging in the ED secondary to the patients clinical status ... 1853: Personally assessed CT imaging, large dilated loops of bowel. At this point we are still concerned of acute intraabdominal pathology including obstruction, ileus, ischemia and other emergent abdominal process. Paged surgery at this time. Had discussion that they were about to start a case upstairs but with the patient remaining ill appearing, elevated lactate, tachycardic despite resuscitation that we would like surgery to see the patient prior to case which they were agreeable to. Approx 1900: Surgery down to see the patient, requesting call to radiology to expedite read. Call was placed to radiology and message was forwarded to prioritize this read. Repeat lactate, bmp added on. Bedside with surgery, NG tube was placed so further decompression could be attempted. Digital rectal did not successfully decompress. Surgery evaluating patient and recommending transfer at this time ... Expressed to surgery team that we did not feel the patient was appropriate for transfer. Surgery recommended possible repeat bolus and to transfer. Approx 1930: Do not feel that transferring the patient is appropriate at this time for 2 reasons. First the patient has an acute intra-abdominal process requiring surgical management and we have the capacity at our hospital to perform this surgery and patient has been evaluated by surgery and it would be an EMTALA violation to transfer. The patient’s {mom} is not requesting transfer and there is no continuity care because the patient does not follow with the surgical team at Phoenix children. Second reason is due to the patient’s clinical status because patient is acutely ill, septic and shock and has dilated bowel clinically and deemed unstable and transfer would delay any operative management, this concern was expressed to the surgery team. Paged and discussed case with PICU who will come and see the patient. 1952: PICU discussion in ED. At this time repeat lactate resulted. pH 6.908, CO2 38.6, HCO3 7.7, lactate 9.94. At time of discussion we were called to room for eval and rapid response at this time secondary to patient decreased responsiveness. Patient was found to be non responsive, team members present already giving oxygen. Patient HR approximately 100 but was not responsive to sternal rub. RR around 20 but hypoxic on occasional steady reads on pulse oximetry. Surgery was paged again and notified about the patient’s deteriorating status they state that they cannot come to bedside because they are in the OR with a separate case, it was made clear that the patient is critically ill and cannot be transferred. Secondary to patient’s clinical significant change in status and decreased responsiveness decision was made to intubate the patient. Rapid response was called. Obtained second IV access line. Gave code dose epi as patient was hypotensive with systolics in the 60s/50s. Did still have pulses at this time. I tried intubation with 5.5 tube and S2 blade with glide. Unsuccessful one attempt. Patient was then bagged for oxygenation in between attempts. Second attempt with 4.5 tube and was unsuccessful. Patient bagged for oxygenation and at this point intensivist Dr. Tievers was also bedside and was able to successfully DL a 4.5 tube. After successful intubation, the patient lost pulses and PALS was initiated. See code documents for details. Multiple rounds of CPR, patient was found to be asystole first pulse check, pulseless bradycardia, and then regained pulses after several doses of epinephrine. Patient received 1unit per kg of bicarb and Calcium and magnesium during the code as well. PICU attempted lines as well but were not able to be obtained while in ED. Surgery was called during the code as well to update status as patient had regained pulses and update them, APP Nicole came to bedside and requested that we admit the patient to the PICU. Patient was subsequently started on epinephrine drip, maintenance fluids, and admitted to PICU .... “ Employee #2 confirmed on 08/13/2025 that the consulted physician must respond in person to a consult that is paged STAT. Employee #2 confirmed the consulted surgeon did not see the patient in the Emergency Department when requested by the Emergency Provider until approximately 1 hour and 45 minutes after the emergency consult was requested.”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 52757 Based on review of documents and staff interviews, it was determined the hospital failed to ensure: 1. the On-Call Pediatric Surgeon responded in the required timeframe for an Emergency Department consult and 2. the On-Call Pediatric Surgeon had a back up physician in place if the On-call Pediaric Surgeon was unavailable. FINDINGS INCLUDE: Policy titled, “ EMTALA - Medical Screening Examination and Stabilization Treatment “ , revealed: “ ... “ EMTALA - Medical Screening Examination and Stabilization Treatment “ , revealed: “ ... Purpose/Population: A. Purpose: Banner Health provides care for individuals presenting to its hospitals (and Dedicated Emergency Departments, as defined below) with emergency medical conditions without discrimination and regardless of their payor status or eligibility for financial assistance. This Policy outlines Banner Health ’ s commitment to comply with the requirements of the federal Emergency Medical Treatment and Active Labor Act ( “ EMTALA “ ) codified at 42 U.S.C. § 1395dd, and its implementing regulations, codified at 42 C.F.R. § 489.24 ... II. Definitions:... C. Capabilities: the capabilities of the staff and the facilities. Capabilities of the staff means the level of care that the personnel of the Hospital can provide within the training and scope of their professioal licenses and includes on-call physicians. Capabilities of the facilities available to the Hospital include physical space, equipment, supplies and specialized services that the hospital provides as well as ancillary services routinely available to the Hospital ...M. On-call Physician List: a list of physicians who are on call ...III. Policy:...12. A Physician, QMP or other hospital personnel may contact the Patient ’ s physician to seek advice regarding the Patient ’ s medical history and needs that may be relevant to the MSE or treatment, provided that such consultation does not inappropriately delay the MSE or Stabilizing treatment ... 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 .... “ Hospital document titled, “ Banner Health Desert Medical Center General Rules and Regulations “ , revealed: “ ...6.2.2 Cover/Backup. A covering on-call physician for the scheduled on-call physician must have appropriate privileges at BDMC ... 6.3.1 Responsibilities of On-Call Physician. The on-call physician must (within the scope of his/her privileges):... b) consult on unassigned patients with emergency medical conditions in the ED ... 8.1 The Medical Staff. 8.1.1 Organization: The medical shall shall be organized into clinical departments. Each department shall have a minimum of five (5) Active Staff embers; if at any time the Active Staff membership falls below the minimum, the department shall automatically be dissolved and its members shall become members of an appropriate clinical department, as determined by the Executive Committee, which department shall assume the functions of the dissolved department, as necessary ... 8.1.1.1 Clinical Departments. The current clinical departments are:... 7) Pediatric - Medicine 8) Pediatric Surgical Subspecialties ... 8.1.3.1 Functions of the Departments: Each department shall:... D) Adopt policies and procedures and monitor its members’ adherence to them; E) Coordinate professional services within the department with those of other departments, medical center nursing and ancillary patient care services;.... “ Pediatric Specialty on-call schedules dated May, June, July, August 2025. Trauma Surgical Pediatric Urology Pediatric Nephrology Pediatric Gen Surg Peds CVT Pediatric Neurosurg Pediatric Hospitalist Pediatric Orthopedic Review of Patient #1 ED medical record dated 08/07/2025 revealed Patient #1 arrived via private vehicle to the ED on 08/07/2025 at 1420. Patient #1 ’ s medical record which revealed the following: Pediatric surgery emergent consult order placed at 1604 and Pediatric GI called at 1650. Pediatric surgery emergent consult order placed at 1655 and Pediatric surgery called regarding consult at 1716. Pediatric surgery emergent consult order placed at 1844 and Pediatric surgery returned call at 1854. Pediatric surgery emergent consult order placed at 1951 and returned call at 2010. Review of Patient #1 nursing triage note dated 08/07/2025 at 1423 revealed: “ ... ED Triage ... Chief complaint: abdominal pain beginning today. Abdominal distention normal per mom. Nausea reported. No vomiting, no fever. Decreased activity. History of malabsorption. Has NG tube .... “ Review of Patient #1 ED provider note dated 08/07/2025 at 1516 revealed: “ ... Chief Complaint abdominal pain beginning today. Abdominal distention normal per mom. Nausea reported. No vomiting, no fever. Decreased activity. History of malabsorption. Has NG tube ... History of Present Illness 3-year-old {male} with history of absorption currently status post NG tube approximately 1 month ago, previous right sided lobectomy when {she} was 1 years old, presents to the ED today with complaints of abdominal pain, abdominal distention and nausea and vomiting. {Mom} states the patient woke up this morning seem to be acting {her} normal self {she} does have some baseline on and off abdominal distention that {she} went to daycare today daycare called and said that {she} was complaining of abdominal pain and to come and pick {her} up. {Mom} brought {her} immediately afterwards. Upon my interview patient was actively throwing up nonbloody nonbilious. Patient does have abdominal distention. Does seem to have some mild discomfort of the abdominal region as well. {Mom} states no other significant concerns at this time and {she} has been acting normally prior to going to daycare. {Mom} does note that {she} has been having diarrhea for approximately the past week ... Management Discussions / Escalation of Care / Consultations: peds surgery ... Reexamination/Reevaluation. Impression: Severely gaseous distended loops of bowel in the abdomen, which appear to be large bowel. Possible bowel wall thickening. Cannot exclude colitis. Approx 1600: I paged pediatric surgery at this time as we do have concern for significant large bowel distention and possible obstruction ...1650: Have paged out for pediatric surgery however received a call back from pediatric GI mistakenly. Did not fully discuss the case with pediatric GI as we wanted to speak with pediatric surgery first. At that point put in another consult to speak with pediatric surgery. 1716: Spoke with surgery (Nicole) over the phone and discussed the case. Surgery initially recommending possible transfer to PCH as the patient had some follow up with PCH and does not typically follow at Banner. If no transfer can continue workup. Decision was made to proceed with more advanced imaging in the ED secondary to the patients clinical status ... 1853: Personally assessed CT imaging, large dilated loops of bowel. At this point we are still concerned of acute intraabdominal pathology including obstruction, ileus, ischemia and other emergent abdominal process. Paged surgery at this time. Had discussion that they were about to start a case upstairs but with the patient remaining ill appearing, elevated lactate, tachycardic despite resuscitation that we would like surgery to see the patient prior to case which they were agreeable to. Approx 1900: Surgery down to see the patient, requesting call to radiology to expedite read. Call was placed to radiology and message was forwarded to prioritize this read. Repeat lactate, bmp added on. Bedside with surgery, NG tube was placed so further decompression could be attempted. Digital rectal did not successfully decompress. Surgery evaluating patient and recommending transfer at this time ... Expressed to surgery team that we did not feel the patient was appropriate for transfer. Surgery recommended possible repeat bolus and to transfer. Approx 1930: Do not feel that transferring the patient is appropriate at this time for 2 reasons. First the patient has an acute intra-abdominal process requiring surgical management and we have the capacity at our hospital to perform this surgery and patient has been evaluated by surgery and it would be an EMTALA violation to transfer. The patient’s {mom} is not requesting transfer and there is no continuity care because the patient does not follow with the surgical team at Phoenix children. Second reason is due to the patient’s clinical status because patient is acutely ill, septic and shock and has dilated bowel clinically and deemed unstable and transfer would delay any operative management, this concern was expressed to the surgery team. Paged and discussed case with PICU who will come and see the patient. 1952: PICU discussion in ED. At this time repeat lactate resulted. pH 6.908, CO2 38.6, HCO3 7.7, lactate 9.94. At time of discussion we were called to room for eval and rapid response at this time secondary to patient decreased responsiveness. Patient was found to be non responsive, team members present already giving oxygen. Patient HR approximately 100 but was not responsive to sternal rub. RR around 20 but hypoxic on occasional steady reads on pulse oximetry. Surgery was paged again and notified about the patient’s deteriorating status they state that they cannot come to bedside because they are in the OR with a separate case, it was made clear that the patient is critically ill and cannot be transferred. Secondary to patient’s clinical significant change in status and decreased responsiveness decision was made to intubate the patient. Rapid response was called. Obtained second IV access line. Gave code dose epi as patient was hypotensive with systolics in the 60s/50s. Did still have pulses at this time. I tried intubation with 5.5 tube and S2 blade with glide. Unsuccessful one attempt. Patient was then bagged for oxygenation in between attempts. Second attempt with 4.5 tube and was unsuccessful. Patient bagged for oxygenation and at this point intensivist Dr. Tievers was also bedside and was able to successfully DL a 4.5 tube. After successful intubation, the patient lost pulses and PALS was initiated. See code documents for details. Multiple rounds of CPR, patient was found to be asystole first pulse check, pulseless bradycardia, and then regained pulses after several doses of epinephrine. Patient received 1unit per kg of bicarb and Calcium and magnesium during the code as well. PICU attempted lines as well but were not able to be obtained while in ED. Surgery was called during the code as well to update status as patient had regained pulses and update them, APP Nicole came to bedside and requested that we admit the patient to the PICU. Patient was subsequently started on epinephrine drip, maintenance fluids, and admitted to PICU .... “ Employee #2 confirmed on 08/13/2025 that Banner Desert is a level one (1) trauma center and that they are required to fit a criteria of who is on call, which includes pediatric surgery. Employee #2 confirmed on 08/13/2025 that the consulted physician must respond in person to a consult that is paged STAT. Employee #2 confirmed the consulted surgeon did not see the patient in the Emergency Department when requested by the Emergency Provider until approximately 1 hour and 45 minutes after the emergency consult was requested. Employee #2 also confirmed on 08/13/2025 that there can be a mid level provider that will respond to consults if the on-call physician is unable to at that time. Employee #2 confirmed the mid level provider that was called to evaluate the patient was unavailable as they were in surgery with the on-call surgeon. Employee #2 confirmed that the covering on-call physician did not respond to the consult according to the Banner Desert Rules and Regulations. Employee #2 confirmed there was no back up on-call pediatric surgeon.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 52757 Based on review of hospital documents, medical records, and staff interviews, it was determined the hospital failed to provide stabilizing treatment to a patient (Patient #1) seeking emergency treatment for abdominal pain associated to possible bowel obstruction in a pediatric patient.This deficient practice poses a risk to the health and safety of patients if emergency care and options are not provided to patients with an Emergency Medical Condition. FINDINGS INCLUDE: Policy titled, “ EMTALA - Medical Screening Examination and Stabilization Treatment “ , revealed: “ ... Purpose/Population: A. Purpose: Banner Health provides care for individuals presenting to its hospitals (and Dedicated Emergency Departments, as defined below) with emergency medical conditions without discrimination and regardless of their payor status or eligibility for financial assistance. This Policy outlines Banner Health ’ s commitment to comply with the requirements of the federal Emergency Medical Treatment and Active Labor Act ( “ EMTALA “ ) codified at 42 U.S.C. § 1395dd, and its implementing regulations, codified at 42 C.F.R. § 489.24 ... H. Emergency Medical Condition or EMC: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and/or a Psychiatric Emergency) such that the absence of immediate medical attention could reasonable be expected to result in:... c. Serious dysfunction of any bodily organ or part ...M. On-Call Physician List: a list of physicians who are on call ... III. Policy: A. Medical Screening Examination ( “ MSE “ )... 4. Triage establishes the order in which an individual will be evaluated and is not considered an emergency MSE. 5. AN MSE will be conducted to determine whether the patient has an EMC. The hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the patient’s needs and must continue until the EMC is stabilized or the patient is admitted or appropriately transferred ... 12. The MSE includes ancillary services routinely available to the Hospital along with available personnel, which includes on-call physicians, in determining whether an EMC exists ... 14. A Physician, QMP or other hospital personnel may contact the Patient ’ s physician to seek advice regarding the Patient ’ s medical history and needs that may be relevant to the MSE or treatment, provided that such consultation does not inappropriately delay the MSE or Stabilizing Treatment ... D. On-Call and Attending Physicians. 1. The Hospital shall maintain a list of physicians to service 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 ... 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 ... 8. The hospital may permit on-call physicians to schedule elective surgery or other procedures during the time they are on call provided that the physician and the Hospital have a back-up plan when the on-call physician is unable to respond in a reasonable time .... “ Hospital document titled, “ Banner Health Desert Medical Center General Rules and Regulations “ , revealed: “ ... 6.0 EMERGENCY ROOM ... 6.1 MEDICAL STAFF MEMBER EMERGENCY CALL RESPONSIBILITIES. Physicians shall serve on the on-call roster based on need for coverage, unassigned and emergency patients as determined by the applicable department, the Medical Executive Committee, Administration and the EMTALA policy, as required. Refer to Medical Staff Emergency Department On-Call Policy and Procedure for approved call requirements ... 6.5 EMERGENCY CALL RESPONSE TIME. The on-call physician must respond in person, if requested to do so by the Emergency Department physician or, in the case of obstetrics, by the Obstetrical RN. An on-call physician may send an advanced practice provider to the Emergency Department to evaluate the patient but the physician must provide all care necessary to stabilize the patient as requested by the Emergency Department physician ... 6.5.1 STAT Call Response Time. Physicians must respond within 10-15 minutes to a STAT call from the ED ... “ Review of Patient #2 through Patient #20 ’ s medical record revealed they were treated according to facility policy and procedure. Review of Patient #1 ED medical record dated 08/07/2025 revealed Patient #1 arrived via private vehicle to the ED on 08/07/2025 at 1421. Review of Patient #1 nursing triage note dated 08/07/2025 at 1423 revealed: “ ... ED Triage ... Chief complaint: abdominal pain beginning today. Abdominal distention normal per mom. Nausea reported. No vomiting, no fever. Decreased activity. History of malabsorption. Has NG tube .... “ Review of Patient #1 ED provider note dated 08/07/2025 at 1516 revealed: “ ... Chief Complaint abdominal pain beginning today. Abdominal distention normal per mom. Nausea reported. No vomiting, no fever. Decreased activity. History of malabsorption. Has NG tube ... History of Present Illness 3-year-old {male} with history of absorption currently status post NG tube approximately 1 month ago, previous right sided lobectomy when {she} was 1 years old, presents to the ED today with complaints of abdominal pain, abdominal distention and nausea and vomiting. {Mom} states the patient woke up this morning seem to be acting {her} normal self {she} does have some baseline on and off abdominal distention that {she} went to daycare today daycare called and said that {she} was complaining of abdominal pain and to come and pick {her} up. {Mom} brought {her} immediately afterwards. Upon my interview patient was actively throwing up nonbloody nonbilious. Patient does have abdominal distention. Does seem to have some mild discomfort of the abdominal region as well. {Mom} states no other significant concerns at this time and {she} has been acting normally prior to going to daycare. {Mom} does note that {she} has been having diarrhea for approximately the past week ... Management Discussions / Escalation of Care / Consultations: peds surgery ... Reexamination/Reevaluation. Impression: Severely gaseous distended loops of bowel in the abdomen, which appear to be large bowel. Possible bowel wall thickening. Cannot exclude colitis. Approx 1600: I paged pediatric surgery at this time as we do have concern for significant large bowel distention and possible obstruction. Patient does have a significant elevated white count of 35 at this time as well. Lactate and further labs were added on at this time. Ceftriaxone ordered. patient given pain medications and nausea medications as well at this time. Patient alert and requesting water at this time. Will hold off PO at this time. CBC with significant WBC to 35, normal Hb, pts elevated. BMP shows normal Na, K decreased at 3.2, CO2 of 15, Ca 8.7, gap 19, glucose 285, ALT 44. Acidosis could be 2/2 dehydration or intraabdominal process or infection, fluids and ab ordered ... 1650: Have paged out for pediatric surgery however received a call back from pediatric GI mistakenly. Did not fully discuss the case with pediatric GI as we wanted to speak with pediatric surgery first. At that point put in another consult to speak with pediatric surgery. 1716: Spoke with surgery (Nicole) over the phone and discussed the case. Surgery initially recommending possible transfer to PCH as the patient had some follow up with PCH and does not typically follow at Banner. If no transfer can continue workup. Decision was made to proceed with more advanced imaging in the ED secondary to the patients clinical status. {She} remains tachycardic and ill appearing. Blood pressure stable, 02 sats stable. Abdomen still distended at this point. Lactate elevated 6.0. Patient receiving 20cc/kg bolus and antibiotics. Approximately 10 minutes later surgery called back and reported they had seen the KUB and would CT the patient if no transfer. CT ordered ... 1853: Personally assessed CT imaging, large dilated loops of bowel. At this point we are still concerned of acute intraabdominal pathology including obstruction, ileus, ischemia and other emergent abdominal process. Paged surgery at this time. Had discussion that they were about to start a case upstairs but with the patient remaining ill appearing, elevated lactate, tachycardic despite resuscitation that we would like surgery to see the patient prior to case which they were agreeable to. Approx 1900: Surgery down to see the patient, requesting call to radiology to expedite read. Call was placed to radiology and message was forwarded to prioritize this read. Repeat lactate, bmp added on. Bedside with surgery, NG tube was placed so further decompression could be attempted. Digital rectal did not successfully decompress. Surgery evaluating patient and recommending transfer at this time ... Expressed to surgery team that we did not feel the patient was appropriate for transfer. Surgery recommended possible repeat bolus and to transfer. Approx 1930: Do not feel that transferring the patient is appropriate at this time for 2 reasons. First the patient has an acute intra-abdominal process requiring surgical management and we have the capacity at our hospital to perform this surgery and patient has been evaluated by surgery and it would be an EMTALA violation to transfer. The patient’s {mom} is not requesting transfer and there is no continuity care because the patient does not follow with the surgical team at Phoenix children. Second reason is due to the patient’s clinical status because patient is acutely Ill, septic and shock and has dilated bowel clinically and deemed unstable and transfer would delay any operative management, this concern was expressed to the surgery team. Paged and discussed case with PICU who will come and see the patient. 1952: PICU discussion in ED. At this time repeat lactate resulted. pH 6.908, CO2 38.6, HCO3 7.7, lactate 9.94. At time of discussion we were called to room for eval and rapid response at this time secondary to patient decreased responsiveness. Patient was found to be non responsive, team members present already giving oxygen. Patient HR approximately 100 but was not responsive to sternal rub. RR around 20 but hypoxic on occasional steady reads on pulse oximetry. Surgery was paged again and notified about the patient’s deteriorating status they state that they cannot come to bedside because they are in the OR with a separate case, it was made clear that the patient is critically ill and cannot be transferred. Secondary to patient’s clinical significant change in status and decreased responsiveness decision was made to intubate the patient. Rapid response was called. Obtained second IV access line. Gave code dose epi as patient was hypotensive with systolics in the 60s/50s. Did still have pulses at this time. I tried intubation with 5.5 tube and S2 blade with glide. Unsuccessful one attempt. Patient was then bagged for oxygenation in between attempts. Second attempt with 4.5 tube and was unsuccessful. Patient bagged for oxygenation and at this point intensivist Dr. Tievers was also bedside and was able to successfully DL a 4.5 tube. After successful intubation, the patient lost pulses and PALS was initiated. See code documents for details. Multiple rounds of CPR, patient was found to be asystole first pulse check, pulseless bradycardia, and then regained pulses after several doses of epinephrine. Patient received 1unit per kg of bicarb and Calcium and magnesium during the code as well. PICU attempted lines as well but were not able to be obtained while in ED. Surgery was called during the code as well to update status as patient had regained pulses and update them, APP Nicole came to bedside and requested that we admit the patient to the PICU. Patient was subsequently started on epinephrine drip, maintenance fluids, and admitted to PICU .... “ Patient #1 ’ s medical record revealed that the patient was taken for abdominal surgery at 2338. Employee #2 confirmed on 08/13/2025 that the initial page for pediatric surgery was at 1604 and the patient was not seen until approximately 1900. Employee #2 also confirmed that there was a back-up physician, who was a physician assistant that was with the pediatric surgeon. There was not another back-up with both of them being in a procedure.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 52757 Based on review of hospital documents and staff interviews, it was determined the hospital failed to ensure there was not a delay in treatment and care to pediatric patient (Patient #1) who was requiring a pediatric surgery consult and abdominal surgery for a bowel obstruction. FINDINGS INCLUDE: Policy titled, “ EMTALA - Medical Screening Examination and Stabilization Treatment “ , revealed: “ ... Purpose/Population: A. Purpose: Banner Health provides care for individuals presenting to its hospitals (and Dedicated Emergency Departments, as defined below) with emergency medical conditions without discrimination and regardless of their payor status or eligibility for financial assistance. This Policy outlines Banner Health ’ s commitment to comply with the requirements of the federal Emergency Medical Treatment and Active Labor Act ( “ EMTALA “ ) codified at 42 U.S.C. § 1395dd, and its implementing regulations, codified at 42 C.F.R. § 489.24 ... H. Emergency Medical Condition or EMC: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and/or a Psychiatric Emergency) such that the absence of immediate medical attention could reasonable be expected to result in:... c. Serious dysfunction of any bodily organ or part ...M. On-Call Physician List: a list of physicians who are on call ... III. Policy: A. Medical Screening Examination ( “ MSE “ )... 4. Triage establishes the order in which an individual will be evaluated and is not considered an emergency MSE. 5. AN MSE will be conducted to determine whether the patient has an EMC. The hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the patient’s needs and must continue until the EMC is stabilized or the patient is admitted or appropriately transferred ... 12. The MSE includes ancillary services routinely available to the Hospital along with available personnel, which includes on-call physicians, in determining whether an EMC exists ... 14. A Physician, QMP or other hospital personnel may contact the Patient ’ s physician to seek advice regarding the Patient ’ s medical history and needs that may be relevant to the MSE or treatment, provided that such consultation does not inappropriately delay the MSE or Stabilizing Treatment ... D. On-Call and Attending Physicians. 1. The Hospital shall maintain a list of physicians to service 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 ... 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 ... 8. The hospital may permit on-call physicians to schedule elective surgery or other procedures during the time they are on call provided that the physician and the Hospital have a back-up plan when the on-call physician is unable to respond in a reasonable time .... “ Hospital document titled, “ Banner Health Desert Medical Center General Rules and Regulations “ , revealed: “ ... 6.0 EMERGENCY ROOM ... 6.1 MEDICAL STAFF MEMBER EMERGENCY CALL RESPONSIBILITIES. Physicians shall serve on the on-call roster based on need for coverage, unassigned and emergency patients as determined by the applicable department, the Medical Executive Committee, Administration and the EMTALA policy, as required. Refer to Medical Staff Emergency Department On-Call Policy and Procedure for approved call requirements ... 6.5 EMERGENCY CALL RESPONSE TIME. The on-call physician must respond in person, if requested to do so by the Emergency Department physician or, in the case of obstetrics, by the Obstetrical RN. An on-call physician may send an advanced practice provider to the Emergency Department to evaluate the patient but the physician must provide all care necessary to stabilize the patient as requested by the Emergency Department physician ... 6.5.1 STAT Call Response Time. Physicians must respond within 10-15 minutes to a STAT call from the ED ... “ Review of Patient #1 ED medical record dated 08/07/2025 revealed Patient #1 arrived via private vehicle to the ED on 08/07/2025 at 1421. Review of Patient #1 nursing triage note dated 08/07/2025 at 1423 revealed: “ ... ED Triage ... Chief complaint: abdominal pain beginning today. Abdominal distention normal per mom. Nausea reported. No vomiting, no fever. Decreased activity. History of malabsorption. Has NG tube .... “ Review of Patient #1 ED provider note dated 08/07/2025 at 1516 revealed: “ ... Chief Complaint abdominal pain beginning today. Abdominal distention normal per mom. Nausea reported. No vomiting, no fever. Decreased activity. History of malabsorption. Has NG tube ... History of Present Illness 3-year-old {male} with history of absorption currently status post NG tube approximately 1 month ago, previous right sided lobectomy when {she} was 1 years old, presents to the ED today with complaints of abdominal pain, abdominal distention and nausea and vomiting. {Mom} states the patient woke up this morning seem to be acting {her} normal self {she} does have some baseline on and off abdominal distention that {she} went to daycare today daycare called and said that {she} was complaining of abdominal pain and to come and pick {her} up. {Mom} brought {her} immediately afterwards. Upon my interview patient was actively throwing up nonbloody nonbilious. Patient does have abdominal distention. Does seem to have some mild discomfort of the abdominal region as well. {Mom} states no other significant concerns at this time and {she} has been acting normally prior to going to daycare. {Mom} does note that {she} has been having diarrhea for approximately the past week ... Management Discussions / Escalation of Care / Consultations: peds surgery ... Reexamination/Reevaluation. Impression: Severely gaseous distended loops of bowel in the abdomen, which appear to be large bowel. Possible bowel wall thickening. Cannot exclude colitis. Approx 1600: I paged pediatric surgery at this time as we do have concern for significant large bowel distention and possible obstruction. Patient does have a significant elevated white count of 35 at this time as well. Lactate and further labs were added on at this time. Ceftriaxone ordered. patient given pain medications and nausea medications as well at this time. Patient alert and requesting water at this time. Will hold off PO at this time. CBC with significant WBC to 35, normal Hb, pts elevated. BMP shows normal Na, K decreased at 3.2, CO2 of 15, Ca 8.7, gap 19, glucose 285, ALT 44. Acidosis could be 2/2 dehydration or intraabdominal process or infection, fluids and ab ordered ... 1650: Have paged out for pediatric surgery however received a call back from pediatric GI mistakenly. Did not fully discuss the case with pediatric GI as we wanted to speak with pediatric surgery first. At that point put in another consult to speak with pediatric surgery.1716: Spoke with surgery (Nicole) over the phone and discussed the case. Surgery initially recommending possible transfer to PCH as the patient had some follow up with PCH and does not typically follow at Banner. If no transfer can continue workup. Decision was made to proceed with more advanced imaging in the ED secondary to the patients clinical status. {She} remains tachycardic and ill appearing. Blood pressure stable, 02 sats stable. Abdomen still distended at this point. Lactate elevated 6.0. Patient receiving 20cc/kg bolus and antibiotics. Approximately 10 minutes later surgery called back and reported they had seen the KUB and would CT the patient if no transfer. CT ordered ... 1853: Personally assessed CT imaging, large dilated loops of bowel. At this point we are still concerned of acute intraabdominal pathology including obstruction, ileus, ischemia and other emergent abdominal process. Paged surgery at this time. Had discussion that they were about to start a case upstairs but with the patient remaining ill appearing, elevated lactate, tachycardic despite resuscitation that we would like surgery to see the patient prior to case which they were agreeable to. Approx 1900: Surgery down to see the patient, requesting call to radiology to expedite read. Call was placed to radiology and message was forwarded to prioritize this read. Repeat lactate, bmp added on. Bedside with surgery, NG tube was placed so further decompression could be attempted. Digital rectal did not successfully decompress. Surgery evaluating patient and recommending transfer at this time ... Expressed to surgery team that we did not feel the patient was appropriate for transfer. Surgery recommended possible repeat bolus and to transfer. Approx 1930: Do not feel that transferring the patient is appropriate at this time for 2 reasons. First the patient has an acute intra-abdominal process requiring surgical management and we have the capacity at our hospital to perform this surgery and patient has been evaluated by surgery and it would be an EMTALA violation to transfer. The patient’s {mom} is not requesting transfer and there is no continuity care because the patient does not follow with the surgical team at Phoenix children. Second reason is due to the patient’s clinical status because patient is acutely Ill, septic and shock and has dilated bowel clinically and deemed unstable and transfer would delay any operative management, this concern was expressed to the surgery team. Paged and discussed case with PICU who will come and see the patient. 1952: PICU discussion in ED. At this time repeat lactate resulted. pH 6.908, CO2 38.6, HCO3 7.7, lactate 9.94. At time of discussion we were called to room for eval and rapid response at this time secondary to patient decreased responsiveness. Patient was found to be non responsive, team members present already giving oxygen. Patient HR approximately 100 but was not responsive to sternal rub. RR around 20 but hypoxic on occasional steady reads on pulse oximetry. Surgery was paged again and notified about the patient’s deteriorating status they state that they cannot come to bedside because they are in the OR with a separate case, it was made clear that the patient is critically ill and cannot be transferred. Secondary to patient’s clinical significant change in status and decreased responsiveness decision was made to intubate the patient. Rapid response was called. Obtained second IV access line. Gave code dose epi as patient was hypotensive with systolics in the 60s/50s. Did still have pulses at this time. I tried intubation with 5.5 tube and S2 blade with glide. Unsuccessful one attempt. Patient was then bagged for oxygenation in between attempts. Second attempt with 4.5 tube and was unsuccessful. Patient bagged for oxygenation and at this point intensivist Dr. Tievers was also bedside and was able to successfully DL a 4.5 tube. After successful intubation, the patient lost pulses and PALS was initiated. See code documents for details. Multiple rounds of CPR, patient was found to be asystole first pulse check, pulseless bradycardia, and then regained pulses after several doses of epinephrine. Patient received 1unit per kg of bicarb and Calcium and magnesium during the code as well. PICU attempted lines as well but were not able to be obtained while in ED. Surgery was called during the code as well to update status as patient had regained pulses and update them, APP Nicole came to bedside and requested that we admit the patient to the PICU. Patient was subsequently started on epinephrine drip, maintenance fluids, and admitted to PICU .... “ Patient #1 ’ s medical record revealed that the patient was taken for abdominal surgery at 2338. Employee #2 confirmed on 08/13/2025 that the initial page for pediatric surgery was at 1604 and the patient was not seen until approximately 1900. Employee #2 also confirmed that there was a back-up physician, who was a physician assistant that was with the pediatric surgeon. Employee #2 confirmed there was not another back-up provider with both of them being in a procedure.”