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Based on review of the medical records, interviews and Governing Body Bylaws, Medical Staff Rules & Regulations, it was determined that the Governing Body failed to ensure that the facility ensured that a physician was on call and available for medical emergencies. Specifically, the facility lacked the availability of an MD/DO on 4/12/23 when one patient (P) (P#1) of five sampled patients was found unresponsive. This noncompliance had the potential to adversely affect all patients.

The findings include:

Review of progress notes dated 4/12/23 at 9:00 p.m., revealed P#1 was received unresponsive but breathing and had a pulse. Vital signs were within normal limits. 911 was called and arrived 10 minutes later. P#1 was taken to a nearby facility for evaluation. Attempted to contact on-call providers Medical Doctor (MD) GG and Psychiatric Mental Health Nurse Practitioner (PMHNP) HH to get an order for transfer but they did not answer or call back. Family member of P#1 was notified of the transfer.

A review of facility's incident report form dated 4/12/23 at 10:00 pm revealed that P#1 was found unresponsive but breathing and with a bounding (strong) pulse. Sternal chest rub performed. P#1 was still unresponsive. 911 called. P#1's vital signs were taken and were within normal limits. Emergency Medical Service (EMS) arrived 10 minutes later. Still unresponsive during EMS assessment. P#1 taken to a nearby facility for further evaluation. Attempted to contact on-call providers but there was no response. Another attempt to contact on-call providers was made at 5:00 a.m., and there was still no response.
A review of progress notes dated 4/13/23 at 4:10 a.m. revealed that Registered Nurse Supervisor (RN Supervisor) AA helped RN BB complete an incident report. RN Supervisor AA instructed RN BB to notify the on-call provider and P#1's family of the incident. Email sent to the Chief Executive Officer (CEO), Director of Nursing (DON) and the Administrator on Call (AOC).

An interview was conducted with the CEO EE on 10/3/23 at 10:30 a.m., in the conference room. CEO EE revealed she had been with the facility for two years. She went on and revealed the facility had an ongoing performance improvement program that evaluated their providers. She said providers are evaluated when they are initially credentialed, and then continuous through Focused Professional Practice Evaluation (FPPE), Peer Review process, and Ongoing Professional Practice Evaluation (OPPE). She said the facility currently had a new provider group and said after the root cause analysis (RCA) was completed, they put in place that the Medical Director would be the back-up on-call provider if staff are unable to reach the provider who was intended to be on-call. CEO EE further revealed she was confident in the new provider group and that the facility had not had any on-call issues since the incident occurred.

A telephone interview took place with Registered Nurse (RN) BB on 10/3/23 at 11:41 a.m. RN BB revealed she remembered the incident on 4/12/23 that involved P#1. She said she had been passing out medication when she was alerted by behavioral health associate (BHA) FF that P#1 was unresponsive. She said she left the medication room to go assess him. She said she checked his pulse, respiration rate and blood sugar; everything was within normal limit (WNL). RN BB said they called 911 and called the on-call provider. She said she was unable to reach the on-call provider. RN BB further said that when they transfer patients to another facility, they send copies of the patient's Medication Administration Record (MAR), a Face sheet, legal status, and a Memorandum of Transfer (MOT) with EMS. She said RN Supervisor AA was helping her with paperwork that night and thought she completed everything. RN BB further revealed RN Supervisor AA had called the receiving facility to provide a nurse-to-nurse report for P#1.

A review of the facility's Governing Body Bylaws last approved on 3/18/23 revealed that the Governing Body was ultimately accountable for the safety and quality of care, treatment, and services provided by the Facility. The primary function of the Governing Board was to assure that the Facility and its Medical Staff provided quality medical care that met the needs of the community.

A review of the facility's Medical Staff Rules and Regulations, last effective 5/26/23 revealed that there was a physician who possessed skills and knowledge in behavioral health services on-call to the Hospital on a 24-hour basis. All physicians who were members of the Active Medical Staff participated in the on-call roster unless exempted by Medical Director. The Medical Director would be administratively responsible for maintaining the Hospital's on-call roster.