Hackensack Meridian Health Pascack Valley Medical

“SCOPE OF RADIOLOGIC SERVICES CFR(s): 482.26(a) [§482.26 Condition of Participation: Radiologic Services The hospital must maintain, or have available, diagnostic radiologic services...] §482.26(a) Standard: Radiologic Services The hospital must maintain, or have available, radiologic services according to the needs of the patients. This Standard is not met as evidenced by: 50602 Based on the review of one of thirteen medical records (Patients (P)2), review of facility policy, and staff interviews, it was determined that the facility failed to ensure ultrasounds are interpreted by a vascular provider within 24 hours as required by facility policy. Findings include: Facility policy titled, “Radiology Critical Test_Critical Test Results,” effective on 10/14/25, stated “ ...4. Vascular Testing Specific Procedures and Critical Results ...The assigned Vascular Provider has 24 hours from the time the critical/positive study is completed to confirm (electronically sign) the final interpretation ...” On 11/13/25 at 12:50 PM, medical record review was conducted with Staff (S)1, S2, and S3. The following medical record containing a STAT (to be done immediately) vascular ultrasound order lacked evidence of interpretation by a vascular provider within 24 hours of the exam completion. P2’s medical record contained a STAT Ultrasound Doppler Venous Legs Bilateral order signed on 10/27/25 at 1:19 PM. The exam was performed on 10/27/25 at 1:41 PM. The result, which showed “ ...a normal venous duplex examination of bilateral lower extremities with no evidence of DVT[deep vein thrombosis, blood clot in the vein] ...” was dictated and electronically signed on 10/29/25 at 10:39 AM. Upon interview, S1 confirmed that the STAT ultrasound tests reviewed should have been read and signed by the vascular provider within 24 hours, in accordance with facility policy. S1 clarified that it was not stated in the old policy, but it was generally expected that the providers complete them within 24 hours. S1 stated the requirement is now explicitly stated in the most updated policy reviewed.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 43214 Based on medical record review, staff interviews, and review of facility documents, it was determined the facility failed to ensure that all patients receive the necessary medical/surgical treatment (A0129). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to patients. Findings include: On 04/15/25 at 2:17 PM, an IJ was identified for the facility’s failure to ensure that all patients receive the necessary medical/surgical treatment (A0129). On 04/15/25 at 4:38 PM, Staff (S)1 (Director of Quality) and S2 (Quality Coordinator) were notified and the IJ template was provided. An acceptable removal plan was received on 04/16/25 at 10:55 AM. The facility took immediate action and began providing re-education to all physician staff on the facility’s policies regarding EMTALA, Chain of Command, On-Call, NJ Bill of Rights, and AMA (Against Medical Advise). Any staff not present were sent a memo and will receive an in-service prior to the start of their next shift. The State Agency was able to verify implementation of the removal plan on 04/16/25 at 1:53 PM and the IJ was resolved. Verification of the implementation was completed through signed attestation of staff education and staff interviews. Cross Reference: 482.13(b) Patient Rights: Exercise of Rights”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 43214 Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that all patients receive the necessary medical/surgical treatment regardless of the ability to pay. Findings include: Review of facility document titled, “New Jersey Patient Bill of Rights,” stated, “Your Rights as a Patient. Each patient at the Medical Centers of [name of facility] has the following rights ... : LEGAL RIGHTS: To treatment and medical services without discrimination based on ... ability to pay, or source of payment. ...” A review of Patient (P)1’s medical record revealed the following: P1 presented to the facility’s Emergency Department (ED) on 04/03/25 at 12:45 PM with a chief complaint of finger laceration. The ED Provider Note from 04/02/25 at 1:03 PM stated, “ ... Chief Complaint: Patient presents with Finger Laceration. HPI [History of Present Illness] ... The patient states [he/she] was at work using a table saw, when [he/she] lost control and sustained lacerations to [his/her] L[left] thumb and L [left] 2nd finger. The patient states part of [his/her] second finger was amputated. ...” In the ED, a consult was placed to S22, the on-call Hand Surgeon, who was unavailable and requested that S19 (Hand Surgeon), be contacted. The ED Provider Note from 04/02/25 at 1:03 PM stated, “ ... ED COURSE, CLINICAL IMPRESSION, & DISPOSITION: ED Course ... 1318 [1:18 PM] Patient ate at 10am, so [S19] will take [him/her] to OR [Operating Room] when [he/she] is NPO [nothing by mouth] for 8 hrs [hours]. [He/She] is requesting medicine to admit [him/her] for surgery. [He/She] will take [him/her] to the OR for repair later today. 1320 [1:20 PM] [S19] suggested Xeroform and Kerlix dressing, npo [nothing by mouth]; iv [intravenous] abx [antibiotics]. 1325 [1:25 PM] Tetanus re-updated, abx given, currently [he/she] is neurovascularly intact. We did bedside doppler with good radial and ulnar pulses. 1347 [1:47 PM] Case discussed with Dr.[name] (Hospitalist) who accepts the patient for admission. [He/She] will go to the OR with [S19] at 6pm tonight. ...” P1 was admitted to the 3 West Medical Surgical unit on 04/33/25 at 2:45 PM. The Nursing Note from 04/03/25 at 6:20 PM stated, “ ... Patient off unit to OR with OR nurses. In NAD [No Acute Distress].” The Nursing Note from 04/03/25 at 6:40 PM stated, “ ... Patient returned from OR was sent back by OR surgeon. Per OR nurse, there was a problem with patient insurance coverage and surgeon Dr [S19].” The Internal Medicine Clinical Note dated 04/03/25 at 7:40 PM stated, “Spoke to patient and friend/neighbor at bedside. They vocalized dissatisfaction with the delay in care. Despite offering transfer, patient and friend state that they want to leave immediately to visit [name of another facility]. Declined signing AMA. RN called to remove IV catheter. Patient will not be driving, [his/her] friend/neighbor will be driving [him/her] directly to ER [Emergency Room].” The Discharge Summary Note from 04/03/25 at 7:46 PM stated, “ ...HOSPITAL COURSE: ...presented to the ED [Emergency Department] for evaluation of a finger laceration. [His/Her] left, non-dominant, hand got caught on the wood he/she was cutting and it pulled his/her hand through the table saw. [He/She] suffered a partial amputation of the distal phalanx of the left 2nd digit along with soft tissue laceration to the left thumb. Hand surgeon, [S19], consulted. Pt was admitted for planned OR procedure. A discrepancy with financial coverage lead to the surgeons’ cancellation of the procedure. ...” On 04/15/25 at 11:24 AM, a telephone interview was conducted with S22 (Hand Surgeon), who confirmed he/she was the scheduled on-call provider for the specialty of hand surgery on 04/03/25. S22 stated, he/she was contacted for P1’s case, and was unavailable, so he/she asked the facility to reach out to S19 (Hand Surgeon). S22 explained that he/she received a text message from S20 (ED physician) stating that S19 was going to take care of the patient. S22 stated, around 7:00 PM, he/she received a call from S23 (Hospitalist) that S19 came in and refused to take care of P1. S22 then called S19, who told S22 he/she would not take care of P1 because he/she was told it was a worker’s compensation case then found out the patient did not have insurance. At 1:04 PM, a telephone interview was conducted with S20 (ED Physician). He/she stated that S22 was not available, and that he/she asked to have S19 called to take the case. S19 was called and talked about the case. Pictures of the injury were sent to S19, and S19 stated to S20 that the patient looked Spanish and asked if he/she spoke English. S19 also asked if the patient had insurance, and S20 responded that he/she did not know the patient’s insurance status. S20 indicated that he/she brought the phone to P1’s bedside so S19 could ask P1 questions. S20 explained that S19 asked P1 if he/she was employed, and how he/she is paid. S20 stated that the patient responded he/she was an independent contractor, and he/she gets paid by checks, and pays taxes. At that time, S19 agreed to take the patient to surgery and instructed the staff to keep the patient NPO and to apply a dressing to the patient’s hand. S20 stated that he/she texted S22 to inform him/her that S19 was taking the patient to surgery. S20 was asked if physicians usually ask if a patient has insurance, and he/she responded, “sometimes the plastic surgeons and orthopedic doctors do ask about insurance, however, in the Emergency Room we don’t ask those questions, so if they are on-call and start to ask those questions, I usually stop them. Technically, S19 was not on-call and I did not want him/her to refuse to see the patient so I allowed him/her to ask the questions, but typically I would not allow it.” On 04/16/25 at 11:32 AM, a telephone interview was conducted with S19. S19 explained that the ED called and said that [S22] was away, and said P1 was scheduled for surgery tomorrow but we are worried. S20 sent S19 clinical pictures and, x-ray images. S19 indicated he/she thought “it looked pretty bad” and agreed to take the patient to the OR. S19 stated, he/she did not speak with P1 before coming to the hospital. S19 stated P1 had eaten so he/she could go to the OR after he/she had been NPO for 8 hours, so in this case 6 PM or later. S19 explained that when he/she was examining P1 in the pre-operative area, there were a lot of discrepancies with the story of how P1 obtained his/her injury. S19 indicated P1 told three versions of where and when the injury occurred. S19 further stated he/she then became uneasy and nervous and called P1’s employer. S19 explained that P1’s employer acknowledged that he/she knew P1 but said that he/she did not want anything to do with this and was short with him/her. S19 explained that he/she canceled P1’s surgery because he/she was nervous and called S22 to inform him/her. The above findings were reviewed with S1 (Director of Quality) and S2 (Quality Coordinator) at the time of discovery.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 43214 Based on medical record review, staff interviews, and review of facility documents, it was determined the facility failed to ensure that 1.) medical staff adheres to the established on-call requirements; and 2.) medical staff carry out its responsibilities of preparing and completing documentation of all services provided in a timely manner. Findings include: 1. Facility document titled, “Medical Staff Bylaws,” revised 12/03/20, stated, “ ... ARTICLE II: MEDICAL STAFF MEMBERSHIP ... 2.2-1 GENERAL QUALIFICATIONS ... c. Be determined to (1) adhere to the ethics of their respective professions; ... 2.5 BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP Except for the Emeritus Staff Members, the ongoing responsibilities of each Member of the Medical Staff include: a. providing patients with the quality of care meeting the professional standards of the Medical Staff of this Hospital; b. abiding by the Medical Staff Bylaws, Rules and Regulations, Medical Staff Policies, the Hospital Code of Conduct; ... h. making appropriate arrangements for coverage for his or her patients as determined by the Medical Staff. ...n. participating (to the extent requested to do so by Hospital) in an emergency services “on-call” panel established by the Hospital to ensure availability of specialty services to all patients of the Hospital (including inpatients). ...” Facility policy titled, “On-Call Schedule,” effective 05/13/19, stated, “ ... Policy: It is the policy of the Medical Staff at [name of facility] to make its resources available ensure availability of specialty services to all patients of the Hospital including in patients. In order to meet this obligation, the Hospital requires the members of its Medical Staff with Active of Courtesy clinical privileges, in accordance with the Medical Staff Bylaws, be available to provide healthcare services that are ordinarily available at [facility] on an emergency basis. Procedure: ... 9. Members of the Medical Staff are required to be at the Hospital within one hour of being called for an emergency consultation, and respond via phone within 15 minutes or sooner if required by the department in which a physician is a member. 1. If the scheduled on-call physician is unable to respond due to circumstances beyond the physician’s control, the applicable departments will determine whether to attempt to contact another specialist on the Medical Staff or arrange for a transfer. Any on-call physician who has refused or failed to appear within a reasonable time will be referred to the respective Department Chairperson for further action. 2. A physician’s unavailability when on-call, refusal to respond to call or any other violation of this policy is a serious matter. If the refusal or failure to respond is found to be deliberate, or if it is a repeated occurrence, the matter shall be referred to the Medical Executive Committee for further investigation and appropriate disciplinary action.” During the review of Patient (P)1’s medical record the following was revealed: P1 presented to the facilities Emergency Department (ED) on 04/03/25 at 12:45 PM, with a chief complaint of finger laceration. The ED Provider Note dated 04/02/25 at 1:03 PM stated, “ ... Chief Complaint: Patient presents with Finger Laceration. HPI [History of Present Illness] ... The patient states [he/she] was at work using a table saw, when [he/she] lost control and sustained lacerations to [his/her] L [left] thumb and L [left] 2nd finger. The patient states part of [his/her] second finger was amputated. ... ED COURSE, CLINICAL IMPRESSION, & DISPOSITION: ED Course ... 1305 [1:05 PM] Case discussed with Dr [S22-on call hand surgeon]. [He/She] is recommending bedside Doppler to make sure the ulnar pulses are within normal limits. [He/She] is stating that [he/she] may not be available until midnight, so [he/she]is requesting [S19] to be consulted.” On 04/15/25 at 11:24 AM, a telephone interview was conducted with S22 (Hand Surgeon), who confirmed he/she was the scheduled on-call provider for the specialty of hand surgery on 04/03/25. During the interview, S22 indicated that he/she was contacted for P1’s case however was unavailable, and stated, “I was seeing patients at my office, and I had a meeting after that so there was a possibility that I wouldn’t be available until closer to midnight, so I asked them to reach out to S19 (Hand Surgeon).” S22 explained that a short while later he/she received a text message from S20 (ED physician) stating that S19 was taking care of the patient. S22 explained that around 7:00 PM, he/she received a call from S23 (Hospitalist) indicating that S19 came in and refused to take care of P1. S22 indicated he/she then called S19, who stated that he/she would not take care of P1 because he/she was told it was a worker’s compensation case then found out that P1 did not have insurance. S22 further stated, the facility called once again requesting for him/her to come in to provide care to P1, and S22 responded that he/she could possibly go in after the meeting or the next morning. S22 stated, he/she left the meeting early at approximately 9:00 PM to head in to see P1 and was informed by S23 (Hospitalist) that P1 left AMA (Against Medical Advice). During the interview, S22 explained that when he/she takes call for the facility it is rare for the hand surgeons to get called in; that 80-90% of the time he/she is on-call he/she will carry on with a regular workday. S22 stated, “if we get a call it is only with questions that can be answered without going in, and if it is more urgent and I can’t make it in, I’ll ask them to call someone else or I’ll request for the patient to be transferred to another facility.” S22 explained that the facility was aware that when he/she is on call he/she is usually in the office seeing patients and would not be available right away. S22 indicated that for routine cases, he/she will usually come to see the patient after seeing all of his/her office patients. When asked if there was a timeframe for him/her to come in when on-call, for urgent cases, S22 responded, “I run a very busy practice and can’t leave my patients.” S22 confirmed that while he/she is usually only on-call at one facility at a time, there have been occasions where he/she has been on-call for multiple facilities at the same time and stated, “When they call me, I am usually never available to come in.” At 1:04 PM, a telephone interview was conducted with S20 (ED Physician). When asked if there were frequent issues with on-call physicians not being available when called for consults, S20 stated that there were often delays, not just for the hand surgeons but for different disciplines, because the on-call physicians will have OR cases or office hours. On 05/16/25 during an interview with S1 (Director of Quality), he/she acknowledged that there is an issue with the facility’s current on-call practices with certain specialties and that it’s being discussed with the Patient Safety Triage Committee and will be escalated if necessary. 2. Facility document titled, “Medical Staff Bylaws” revised 12/03/20, stated, “ ... ARTICLE II: MEDICAL STAFF MEMBERSHIP ... 2.2-1 GENERAL QUALIFICATIONS ... c. Be determined to (1) adhere to the ethics of their respective professions; ... 2.5 BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP Except for the Emeritus Staff Members, the ongoing responsibilities of each Member of the Medical Staff include: a. providing patients with the quality of care meeting the professional standards of the Medical Staff of this Hospital; b. abiding by the Medical Staff Bylaws, Rules and Regulations, Medical Staff Policies, the Hospital Code of Conduct; ... d. preparing and completing in a timely fashion, medical records for all the patients whom the Member provides care in the Hospital; e. abiding by the lawful ethical principles of professional and specialty associations, as applicable; ... g. working cooperatively with Members, nurses, Hospital administration and others so as not to adversely affect patient care; ...” A review of P1’s medical record revealed the following: P1 presented to the facilities ED on 04/03/25 at 12:45 PM with a chief complaint of finger laceration. The ED Provider Note from 04/02/25 at 1:03 PM stated, “ ... Chief Complaint: Patient presents with Finger Laceration. HPI [History of Present Illness] ... The patient states [he/she] was at work using a table saw, when [he/she] lost control and sustained lacerations to [his/her] L [left] thumb and L [left] 2nd finger. The patient states part of [his/her] second finger was amputated. ...” In the ED, a consult was placed to S22, the on-call Hand Surgeon, who was unavailable and requested that S19 (Hand Surgeon), be contacted. The ED Provider Note from 04/02/25 at 1:03 PM states, “ ... ED COURSE, CLINICAL IMPRESSION, & DISPOSITION: ED Course ... 1318 [1:18 P.M.] Patient ate at 10am, so [S19] will take [him/her] to OR[Operating Room] when [he/she] is NPO [nothing by mouth] for 8 hrs [hours]. [He/She] is requesting medicine to admit [him/her] for surgery. [He/She] will take [him/her] to the OR for repair later today. 1320 [1:20 PM] [S19] suggested Xeroform and Kerlix dressing, npo [nothing by mouth]; iv[intravenous] abx[antibiotics]. 1325 [1:25 PM] Tetanus re-updated, abx given, currently [he/she] is neurovascularly intact. We did bedside doppler with good radial and ulnar pulses. 1347 [1:47 PM] Case discussed with Dr.[name] (Hospitalist) who accepts the patient for admission. [He/She] will go to the OR with [S19] at 6pm tonight.” P1 was admitted to the 3 West Medical Surgical unit on 04/03/25 at 2:45 PM. The Nursing Note from 04/03/25 at 6:20 PM stated, “ ... Patient off unit to OR [Operating Room] with OR nurses. In NAD [No Acute Distress].” The Nursing Note from 04/03/25 at 6:40 PM stated, “ ... Patient returned from OR was sent back by OR surgeon. Per OR nurse, there was a problem with patient insurance coverage and surgeon Dr [S19].” On 04/16/25 at 11:32 AM, a telephone interview was conducted with S19. S19 explained that when he/she was examining P1 in the pre-operative area, there were a lot of discrepancies with the story of how P1 obtained his/her injury. S19 indicated P1 told three versions of where he/she was when the injury occurred with the table saw. S19 stated he/she then became uneasy and nervous and called P1’s employer. S19 explained that P1’s employer acknowledged that he/she knew P1 but said that he/she did not want anything to do with this and was short with him/her. S19 explained that he/she canceled P1’s surgery because he/she was nervous and called S22 to inform him/her. S19 confirmed he/she did not unwrap P1’s bandages to assess P1’s injury. When asked if he/she would usually look at an injury he/she was coming in to perform surgery on, S19 indicated that he/she would. During the interview, S19 indicated he/she did not explain the reason for canceling the surgery to P1. S19 stated that he/she started to document in P1’s medical record but then deleted it because he/she did not know what to write. S19 confirmed he/she communicated with the OR nurses and the anesthesiologist that P1’s surgery was canceled. S19 confirmed he/she did not communicate with P1’s Attending Physician/Hospitalist (S23). S19 stated, “I thought my responsibility was to communicate with the other on-call physician.” Review of P1’s medical record lacked evidence of any notes by S19. P1’s medical record lacked S19’s documentation of the cancellation and communication with any other providers regarding the cancelled procedure. These findings were reviewed at time of discovery with S1 (Director of Quality) and S2 (Quality Coordinator) on 04/16/25.”