HospitalInspections.org

Based on document review and staff interview, it was determined the Hospital failed to provide physician on call availability to ensure compliance with 42 CFR 489.20 and 42 CFR 489.24. This has the potential to affect all patients receiving care in an Emergency Department that treats approximately 75 patients per day.

Findings include:

1. The Hospital failed to ensure physician on call availability. See deficiency cited at A2404.

Based on document review and staff interview, it was determined the Hospital failed to ensure on call physicians were available and posted on the schedule. This has the potential to affect all patients receiving care in an Emergency Department that treats approximately 75 patients per day.

1. On 03/20/17 at 2:30 PM, the "General Surgery, On-Call Schedule" for the Emergency Department was reviewed. There was no physician listed on the schedule for March 15, 20 and 27.

2. On 03/20/17 at 2:40 PM, the "Medical Staff Roster" was reviewed and it indicated the Hospital had five (5) General Surgeons on staff.

3. On 03/21/17 at 1:30 PM, the "Hospital Medical Staff Rules & Regulations" were reviewed. Under "2.2.2 Call b. Call Schedule: The Hospital is required to maintain a list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an Emergency Medical Condition."

4. On 03/21/17 at 10:20 AM, an interview with the Chief Medical Officer (E #2) was conducted. E #2 confirmed the Hospital did not have a general surgeon posted on the Emergency Department on call roster for the 15th, 20th, and 27th of March 2017. E #2 indicated the Hospital and the surgeons were currently in negotiations for on call compensation and one surgeon was unable to provide services due to an unforeseen medical condition. E #2 also indicated the Hospital By-Laws only allow the physicians to take call 1 time every 4 days. E #2 stated that coverage for the 5th of March was covered by other surgeons who volunteered however, it was never posted on the on call schedule. E #2 indicated there was no guaranteed on call surgical coverage for the 20th and 27th and there was no one posted on the schedule.