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BAYLOR SCOTT AND WHITE MEDICAL CENTER UPTOWN
ON CALL PHYSICIANS
Tag No.: A2404
Based on record review and interviews, the Facility failed to have written policies and procedures for on-call specialized physicians after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. Additionally, the facility failed to ensure policies and procedures were in place if on-call physicians could not cover or respond during their scheduled time.
The findings were:
The bylaws, policies, rules, and regulations were reviewed, and no physician on-call policy or procedure was found or provided when requested from the facility.
Interviews-Communication
1. During the entrance conference on 02/23/2025 at approximately 9:15 AM, with Staff # 6, Patient Pre-Operation and Respiratory Manager, the Information Request Sheet was provided to the facility. Included in the sheet was a request for the on-call physician policy. This was verbally acknowledged by Staff # 6.
2. An interview with Staff # 5, PhD, Director of Quality on 02/24/2025 at approximately 11:15 AM revealed the following:
I have reviewed the Bylaws, Rules and Regulations, and Policies, and I can't find anything regarding our on-call physicians.