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Based on interviews and review of services offered, specialty physician on call list, and clinical records it was determined that the facility did not comply with 42 CFR 489.20 and 489.24 for two (#1, #4) of twenty records reviewed. This practice does not ensure patients are not unnecessarily transferred and may cause a delay treatment.

Findings include:

1. Patient #1 presented to the Emergency Room (ER) on 3/26/11 with leukocytosis, right hydronephrosis with possible abscess, and bilateral pneumonia. The documentation showed the reason for transfer was a need for specialized care for urology. ER physician notes dated 3/27/11 at 1:02 a.m. indicated the condition was considered an emergency due to severe pain and acute onset of symptoms. ER physician note at 1:08 a.m. revealed three attempts to contact a physician (a physician who was not on-call). The documentation noted the physician would not be back in town until April 4, 2011.

2. Patient #4 presented to the ER and was triaged on 3/26/11 at 11:48 a.m. with a chief complaint of bleeding from the penis for about 1 week but worse today. Physician's note at 12:18 p.m. revealed the patient was considered an emergency due to severe pain and acute onset of symptoms. The ER physician noted at 2:25 p.m. that there was no urology service on call. ER physician documentation at 2:57 p.m. revealed the patient required a transfer due to availability of specialty care.

Review of the facility's license revealed the facility was required to provide a minimum of 20 days of coverage per month in March of 2011 for urology.

Review of the on call list for Urology, which was in force as of 3/26/11, had the name of a physician who was not authorized to return to work as of that date.

Review of the on-call list for Urology for March 2011, effective 3/23/11, revealed that 20 days were covered. It was found that the days of 3/19, 3/20, 3/21, 3/23 and 3/24/11 were covered solely by an ARNP (Advanced Registered Nurse Practitioner). The days of 3/24, 3/25, 3/26, 3/27, 3/28 and 3/29/11 were shown to have coverage by a physician different from the one mentioned as being called for patient #1. This physician had not been authorized to perform on-call duties. Also, two of this physician's days (3/25/11 and 3/26/11) had shared appointments with the ARNP.

Interview with the Quality Director on 6/29/11 at approximately 2:15 p.m. revealed the facility had no policy which addressed what the facility was to do in situations in which a particular specialty was not available or the on-call physician could not respond because of circumstances beyond the physician's control. The Quality Director stated that the physician on the on-call list for 3/26/11 had been on a medical leave of absence since late December of 2010. To date the physician had not provided the facility with proper releases from physicians which would enable the facility to authorize a return to on-call status. She stated he had independently contacted the call center on approximately 3/23/11 and told them he would be on call. The call center, in response, placed him on the list. She stated that the Emergency Department pulled the schedule on 3/23/11 and were aware at the time that he was not officially approved to return to work. As to whether they had taken steps to immediately inform appropriate parties, such as the call center, of the lapse at that time, she stated they were not aware of any such attempt. She stated that the call center became aware of the deficiency on 3/25/11. She stated that she could not produce any evidence of his name being removed from the schedule for the remainder of the month. The ER had to respond to two cases requiring urological services on 3/26/11 with transfers, a day where an on-call urologist appeared on the official schedule.

Based on interview, record review and review of facility documentation it was determined that the facility failed to maintain an accurate and complete on call list for urological services to provide further evaluation and/or treatment necessary to stabilize a patient with an emergency medical condition for two (#1, #4) of twenty sampled cases. This practice may cause an unnecessary delay in treatment.

Findings include:

1. Patient #1 presented to the Emergency Room (ER) on 3/26/11. Review of the triage record revealed the patient was was triaged at 5:33 p.m. Nursing documentation dated 3/27/11 at 12:02 a.m. revealed another acute care facility was contacted regarding transfer. The diagnosis was leukocytosis, right hydronephrosis with possible abscess, and bilateral pneumonia. Nurse's note dated 3/27/11 at 12:45 a.m. noted the patient was transferred at 1:00 a.m. The documentation showed the reason for transfer was a need for specialized care for urology. ER physician notes dated 3/27/11 at 1:02 a.m. indicated the condition was considered an emergency due to severe pain and acute onset of symptoms. ER physician note at 1:08 a.m. revealed three attempts to contact a physician (a physician who was not on-call). The last attempt was through the House Supervisor. The documentation noted the physician would not be back in town until April 4, 2011.

2. Patient #4 presented to the ER and was triaged on 3/26/11 at 11:48 a.m. with a chief complaint of bleeding from the penis for about 1 week but worse today. The patient indicated it felt like he had to urinate but could not. Physician's note at 12:18 p.m. revealed the patient was considered an emergency due to severe pain and acute onset of symptoms. The ER physician noted at 2:25 p.m. that there was no urology service on call. The patient was to be transferred to another acute care facility. ER physician documentation at 2:57 p.m. revealed the patient required a transfer due to availability of specialty care. Nurse's note at 6:04 p.m. revealed the patient was transferred.

Review of the facility's license revealed the facility was required to provide a minimum of 20 days of coverage per month in March of 2011 for urology.

Review of the on call list for Urology, which was in force as of 3/26/11, had the name of a physician who was not authorized to return to work as of that date.

Review of the on-call list for Urology for March 2011, effective 3/23/11, revealed that 20 days were covered. It was found that the days of 3/19, 3/20, 3/21, 3/23 and 3/24/11 were covered solely by an ARNP (Advanced Registered Nurse Practitioner). The days of 3/24, 3/25, 3/26, 3/27, 3/28 and 3/29/11 were shown to have coverage by a physician different from the one mentioned as being called for patient #1. This physician had not been authorized to perform on-call duties. Also, two of this physician's days (3/25/11 and 3/26/11) had shared appointments with the ARNP. The facility effectively had only nine days of coverage available out of the required twenty.

Interview with the Quality Director on 6/29/11 at approximately 2:15 p.m. revealed the facility had no policy which addressed what the facility was to do in situations in which a particular specialty was not available or the on-call physician could not respond because of circumstances beyond the physician's control. The Quality Director stated that the physician on the on-call list for 3/26/11 had been on a medical leave of absence since late December of 2010. To date the physician had not provided the facility with proper releases from physicians which would enable the facility to authorize a return to on-call status. She stated he had independently contacted the call center on approximately 3/23/11 and told them he would be on call. The call center, in response, placed him on the list. She stated that the Emergency Department pulled the schedule on 3/23/11 and were aware at the time that he was not officially approved to return to work. As to whether they had taken steps to immediately inform appropriate parties, such as the call center, of the lapse at that time, she stated they were not aware of any such attempt. She stated that the call center became aware of the deficiency on 3/25/11. She stated that she could not produce any evidence of his name being removed from the schedule for the remainder of the month. The ER had to respond to two cases requiring urological services on 3/26/11 with transfers, a day where an on-call urologist appeared on the official schedule.

A review of the initial schedule for March revealed that as of 3/16/11, only seven days of the required twenty days had been scheduled. A review of facility policy "Call Schedule" revealed the following: " The call roster will be prepared on a monthly basis and will be completed and available by the beginning of the month." This policy was not followed. The preceding was confirmed in an interview with the Quality Manager on 6/29/11 at approximately 3:00 p.m.

A review of the facility's "Hospital Emergency Services" document revealed that the facility stated urology would be "provided on a limited basis by exemption or partial exemption." They had not chosen the available option of having a transfer agreement. This was confirmed in an interview of the Quality Manager and Emergency Services Vice President on 6/29/11 at approximately 5:45 p.m.