HospitalInspections.org

Intakes: NJ00141711

A. Based on one (1) of twenty-one (21) medical records reviewed, staff interview, and facility document review, it was determined that the facility failed to ensure that all physicians respond to a requested Emergency Department [ED] consult within 20 minutes, in accordance with the facility's Medical Staff Rules and Regulations.

Findings include:

Reference: Facility document titled, "Medical Staff Rules and Regulations" states, "... 4.4 In the event that a physician is unavailable it is the responsibility of that physician to arrange for coverage for their practice. ... 4.10 Physicians are expected to respond to all calls by phone or in person from anywhere in the hospital ... 10.1 Physicians who do not respond within 20 minutes should be subject to disciplinary actions ... 10.4 If a particular specialty is not available or the on-call physician cannot respond due to circumstances beyond his/her control, the respective Department Chair will be called ..."

1. A review of Medical Record #1 conducted on 12/15/20, revealed the following:

a. Patient #1 arrived in the ED on 11/14/20 at 3:50 PM, with complaints of abdominal pain and constipation.

i. At 1840 [6:40 PM], a portable chest x-ray result stated, "free air under diaphragm ..."

ii. At 2012 [8:12 PM], ED Course documentation stated, "Received call from radiology, patient has pneumoperitoneum and colitis."

iii. At 2057 [8:57 PM], a CT Scan of the abdomen and pelvis result stated, " ... 2. Moderate pneumoperitoneum."

iv. Documentation under "Medical Decision Making" stated, "Perforated Bowel" and "Septic Shock".

b. A phone call order dated 11/14/20 at 1839 [6:39 PM] stated, "Phone call to PCP [primary care physician] Please call: [name of PCP] ..." There is documentation under phone call order that the ED Unit Assist called Staff #53 (the PCP), at 1840 [6:40 PM], 1852 [6:40 PM] and 1901 [7:01 PM].

i. ED documentation indicated that Staff #50, an ED Physician, spoke with Staff #53, at 1902 [7:02 PM]. Documentation under ED notes stated, "... ED Course as of Nov [November] 14 1921 [7:21 PM] ... D/w [discussed with] [PCP] adv [advised] [name of preferred surgeon] for consult ..."

c. A phone call order dated 11/14/20 at 1903 [7:03 PM] stated, "Phone call to PCP Please call: [name of preferred surgeon for consult] ..."

i. There is documentation that Staff #54 (an ED Unit Assist) called Staff #52, the preferred surgeon, at 1904 [7:04 PM], 1909 [7:09 PM], 2050 [8:50 PM] and 2139 [9:39 PM].

ii. There is no evidence that Staff #52 responded to the ED's consult (call) request at 1904, 1909, 2050 and 2139, in accordance with the facility Medical Rules and Regulations.

iii. There is no evidence that the Department Chair was notified when the requested physician did not return the ED's call.

d. Staff #47, an ED Physician, documented in the "ED Notes," dated 11/14/20 at 2049 [8:49 PM], "Medical Decision Making: From previous ED attending, patient has pneumoperitoneum on cxr [chest x-ray] and [the name of the PCP] who called to admit the patient. [name of PCP] requested transfer to [initials of another facility] as there are no icu [intensive care unit] in [initials of ED facility], requested [PCP preferred surgeon] (surgery) be consulted. However, there was a delay in care and surgery did not call back. ..."

e. On 12/15/20 at 1:00 PM, Staff #51 confirmed the above findings.

2. On 12/15/20, during staff interviews, the following was revealed:

a. At 10:17 AM, Staff #49, an ED Unit Assist, stated, "When the order for a consult or call order is placed in the computer I will call the requested physician. I wait 20 minutes and if no call back then I call again. This process is repeated until an hour has passed. The ED physician is notified if there is not a call back within the hour."

b. At 1:00 PM, Staff #51 stated that the consult call procedure is to call the PCP and see who they would like called, and then call that physician, wait 20 minutes and if no return call, continue calling every 20 minutes, up to an hour, before escalating to the head of the department.

c. On 12/16/20 at 10:50 AM, during interview, Staff #27 stated that all physicians or the covering physician for the practice, are called for a consult in the ED, and must respond within 20 minutes.

i. Staff #27 confirmed that the physician who was called for a surgery consult (Staff #52), for Patient #1, did not return the call on 11/14/20.

3. The above findings were confirmed with Staff #1 and Staff #2.



41646

B. Based on staff interview and review of the facility on-call physician lists from 7/1/20 through 12/31/20, it was determined that the facility failed to identify the individual names of physicians on-call, for all disciplines.

Findings include:

1. On 12/16/20 at 12:15 PM, a review of the facility "Service Schedule" for October, November, and December 2020 revealed the following:

a. Under "Vascular Surgery," the name of a group was listed, and not the name of an individual physician, on the following dates: 9/21-10/4, 10/12-10/18, 10/26-11/8, 11/16-11/22, 11/30-12/13, 12/21-12/27.

2. At 12:35 PM, Staff #27 confirmed that the name of an individual physician should be on the Service Schedule, and not the name of a group.