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Based on staff interviews and review of medical records, policies/procedures and Medical Staff Bylaws, the facility failed to comply with the Medicare provider agreement as defined in 489.20 and 489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

Findings:

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag A 2404 On-call Physicians
The facility failed to maintain a complete and accurate list of physicians who were on-call for duty after the initial examination, to provide further specialized evaluation and treatment to stabilize an individual with an emergency medical condition.

Based on review of facility documents and staff interviews, the facility failed to ensure the hospital maintained a list of on-call physicians which contained the names of specialist physicians who were to be contacted first and were primarily responsible for on-call coverage. This failure created the potential for confusion and delay of physician response as well as the potential for negative patient outcome.

The findings:

1. Tour of the facility's Emergency Department (ED) at the main campus was conducted on 9/5/12 at approximately 10:00 a.m. The ED Manager was asked about the physician on-call list, which s/he referred to the Unit Secretary to explain. The ED Medical Director referred to an on-call book, however, the book at the nurse's station did not contain a clearly understandable list of each specialist on-call. At approximately 10:40 a.m., the Unit Secretary was asked who was on-call for each specialty, such as Orthopedics. S/he stated, "I won't know who is on-call until they call me back. I write down who calls back." The Unit Secretary referred to a form at the desk which contained some hand-written names and numbers next to specialty services, as well as pages of notes listing which service was paged, for which patient, who requested the page, who returned the call, and at what time the calls/pages were made. The Unit Secretary was asked if s/he called the numbers every morning to find out who was on-call that day. S/he responded, "I don't call at the beginning of the shift." The Unit Secretary continued, "When we page the surgeon, we page the resident, not the attending. Unless it is specified to page the attending, I call the resident." The secretary was asked if Nurse Practitioners or Physician Assistants were ever first to call. S/he stated that most of the first calls "are residents" but that "Hem/Onc are fellows, except on the weekends 8 - 2 the Hem page goes to a NP." The secretary explained that not all the secretaries used the same process of writing down the physician who responded on the daily form. S/he stated, "All the secretaries do it different, I've found, or they don't do it." S/he stated that s/he documented who responded next to the services that were utilized most frequently: 20 total. There were 17 service names and numbers that did not have a physician or provider name listed beside them. When asked about those numbers, the Unit Secretary stated, "ENT and Barbara Davis are a dedicated pager so we don't know who is on-call until we call." The ED Manager stated, "If there is not a response from a resident, it is escalated to an attending. The majority of specialties are here (in house) because they have to be for Level I Trauma."

b. A second interview was conducted with the ED Manager at approximately 1:55 p.m. When asked why the physicians' names who were on-call were not listed on the daily form used in the ED, s/he stated, "They could go back and look at the calendar and see who is on-call as opposed to their practice which is just call with the phone number."

c. The on-call lists were provided by the facility. Twenty different on-call lists, each for a different specialty, were evidenced. On each list there was often not only one practitioner who was on-call, but rather a first call followed by other practitioners to call thereafter. Additionally, not every specialty listed an on-call practitioner. Pediatric Otolaryngology (Ear/Nose/Throat), for example, only had "ENT Service" listed as the first call for every Monday through Friday, 7 a.m. - 5 p.m., excluding holidays. For the month of September, six days had a fellow listed, who was to be called before the attending was called, and an attending was listed for each day. There was no central list which compiled who was on-call for each day of the month, therefore, when calling the desired service, it would be necessary to flip through the 20 pages to find the service, then find the day, time, and identify who was first to call.

d. A third interview was conducted with the ED Manager at approximately 4:00 p.m. S/he confirmed that the ENT service had no first-call name identified listed on several days of the on-call list. That morning at 7:33 a.m., the Unit Secretary documented s/he had paged the ENT service and a physician called back at 7:34 a.m. The physician's name, however, was not identified on the otolaryngology call list of residents and attendings, therefore, not only was there no physician listed as on-call, but also the physician who called back was not listed on the specialty's roster. The ED Manager confirmed this finding. The Manager was asked about the Barbara Davis Center, which also used a dedicated pager, and described that is was a Center on campus for first-time diabetic patient as well as current patients. The Manager stated there was someone on-call there after hours. The Manager stated the facility was working on a process for a more organized call system but that it had not yet been defined or implemented.

2. Tour of the facility's ED at its west campus was conducted on 9/6/12 at approximately 8:20 a.m. The Clinical Manager was asked what specialties serviced the ED. S/he stated, "Ortho is one of the services that comes here." The Manager was asked how they contact Ortho and if an on-call list existed. S/he stated, "We have a phone number for the PA for the Network of Care (the facilities outside of the main campus)." The Manager was asked if a list of the attending physicians was obtained every day, to which s/he stated, "No." S/he stated they could just call the main campus' ED to obtain that information.

a. The west campus' on-call list was provided when back at the facility's main campus. The on-call list contained an "OB Track Deck Doc" on-call for every Friday night, although facility staff specifically stated all obstetric patients would be stabilized and immediately transferred.

3. Tour of the facility's ED at its south campus was conducted on 9/6/12 at approximately 9:40 a.m. The Clinical Manager was asked what specialists serviced the ED. S/he stated, "We use surgery specialists. A lot of Parker (the adjacent hospital) MDs are Children's credentialed." The on-call list was provided and several of the days of the month were entirely blocked in red. The Manager stated, "Red is non-credentialed. They (patients) would be transferred if on red." The Director of the Network of Care stated General and Ortho practitioners would be expected to respond to the ED "as long as they are credentialed." S/he continued, "We have a process for checking the on-call on a daily basis. We use the main campus for everything else. They are called (at the main campus) so they can accept the transfer prior to moving the patient. We get the list from the main campus."

4. The facility's Medical Staff Policies and Procedures, last revised 8/12, stated the following regarding On-Call Responsibilities of Physicians, in part: "The hospital must maintain a list of physicians on its medical staff who have privileges at the hospital." The document continued, "Call schedules will include name and contact information for the provider on call It is the responsibility of each 'on-call' specialty physician to inform he hospital of the following: - Their availability to the ED of his/her schedule 'on-call' period or that of a qualified alternate in the event he/she is temporarily unavailable. - Notification if a substitution is made. - Updating contact information." The Responsibilities of the on-call physician section stated, in part: "- Immediate availability, at least by telephone, to the ED/UC provider - Responds to the ED to medically screen or stabilize patients with an emergency medical condition - Arrive within a reasonable timeframe, generally within 30 minutes." The document also stated, "Residents and other trainees who are providing call coverage are responsible for timely response to the ED/UC center as outlined above. If a response is inadequate, the attending physician on call will be contacted." Additionally, the document stated, "Each specialty is required to develop an escalation plan for inadequate or untimely response."

a. The Clinical Manger and the Business Coordinator of the facility's "One-Call" service were interviewed on 9/6/12 at approximately 11:00 a.m. The Clinical Manager stated the purpose of One-Call was to connect community physicians with physicians at the facility and "if someone internal needs to connect we do that too." The Manager stated they had the on-call schedules for each different department. The Business Coordinator stated, "We get a request for a specialist and send out the page. If we don't hear back in two minutes, we keep escalating it up every two minutes to the attending on-call." The Clinical Manager stated, "The ED can call us: we have a live answer 24/7. Our role is to be those people to have that info." The One-Call staff was unable to determine how frequently the Emergency Department utilized their service. When asked about the ENT schedule, the Business Coordinator stated, "The ENT schedule provided is the same as the ED has." The schedule was reviewed and it reflected a phone/pager number but no practitioner's name for Monday through Friday daytime service, except holidays. The Business Coordinator stated, "The attending is back-up (for ENT). Some don't use the attending as back-up. Nephrology uses the attending as their primary." When asked if in-house care calls would be made to the attending first, s/he stated, "In-house would go up the chain: not the attending first."

b. Upon exit from the facility at approximately 11:45 a.m., the Chief Medical Officer stated the "ultimate responsible physician is the attending physician, not the resident." However, although the attending was listed on the provided on-call lists, the attending was most often not the first physician to be called, staffs' practice routinely did not utilize the on-call lists, some services did not have a first call provider's name listed, and one facility site did not have a credentialed provider on the on-call list for each day.