HospitalInspections.org

Based on observation, review of documentation and interviews with facility staff, the facility failed to provide medical treatment within its capacity that minimizes the risks to the individual's health for 1 of 20 medical records reviewed.

The findings were:

During the review of Patient #1's medical record on 4/11/23, it was observed that Patient #1 required Oral Maxillofacial Surgery (OMFS) consultation for their medical care and the OMFS on-call (Staff #7) was contacted but did not respond back. Due to the non-response from OMFS (Staff #7), the patient was transferred to another hospital.

During the review of OMFS On-Call schedule for 7/28/22 on 4/11/23, it was observed that the OMFS on-call was a different surgeon (Staff #8).

During the interview of the Director of Patient Safety (Staff #1) on 4/11/23 at 1450, Patient #1's medical record was reviewed and Staff #1 was asked to comment on Patient #1's care:
Staff #1: Per the medical record, ED physician contacted ENT. Attempted to contact OMFS at 2034 and was unable to make contact. ED physician transferred to facility with OMFS availability to ensure continuity of care. Per the call schedule, Staff #7 was not on call at the time, and the appropriate OMFS on call was not contacted. As a result, the ED physician made the decision to move forward with the transfer.