HospitalInspections.org

Based on review of documents, medical records and staff interview it was determined the hospital failed to ensure the on-call physician responded to a call from the Emergency Department (ED) physician in one (1) of twenty (20) medical records reviewed (patient #1). This has the potential to negatively affect all patients in an emergency situation in need of a specialist.

Findings include:

1. Patient #1 presented to the ED on 11/28/11 with complaints of a nose bleed. After the ED physician performed a medical screening exam, the on-call otolaryngologist was paged three (3) times and did not respond to the pages.

2. During an interview with the on-call otolaryngologist in the afternoon of 12/5/11, he revealed he was on call 11/28/11. He also stated he was sleep deprived and exhausted from being on call the previous evening, and he had fallen asleep on his couch and did not hear his pages. He did receive another page around 0400 for another patient, responded to this page and discovered after he arrived at the hospital, he had missed the earlier pages for patient #1.

3. During an interview conducted in the morning of 12/6/11 with the ED physician, he revealed this on-call physician has always responded to pages. He also stated this physician comes to the hospital to see patients even when he isn't on call.