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JOHNSON MEMORIAL HOSPITAL
COMPLIANCE WITH 489.24
Tag No.: A2400
Based on document review and interview, the facility on call provider failed to return an emergency contact request while "on call" at 0453 hours on 04/15/2024, and the facility "on call" policy failed to identify a specific timing requirement in minutes that a provider must respond to a request while "on call" in the review of 1 of 27 medical records and EMTALA policies.
Findings Include:
1. See findings cited at 42 CFR 489.20(r)(2) and 489.24(i)(1-2), A2404.
ON CALL PHYSICIANS
Tag No.: A2404
Based on document review and interview, F1 (Acute Care Facility) failed to ensure MD1, Medical Doctor, Obstetrician Gynecologist who was the primary service contact on the facility "on call" list, failed to respond to an emergency request for service at 0453 hours on 04/15/2024.
Findings Include:
1. Facility policy titled "EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA) POLICY", 8395.MS 2014, last approved 09/2021, indicated under Policy: 3. F1 expected on call practitioners to make reasonable efforts to respond timely to requests from the F1 Emergency Department.
2. Review of P1's medical record indicated that MD1, Medical Doctor, Obstetrician Gynecologist was called at 0454 hours on 04/15/2024 as the listed primary provider "on call" for the facility Obstetrics Service. MD1 did not respond, and an alternate provider had to be contacted.
3. Review of F1's "on call" list indicated MD1 was listed as being on call 04/15/2024.
4. On 06/18/2024 at 1200 hours, S1, Director of Quality and Safety, confirmed that MD1 was called at 0454 hours on 04/15/2024 as the primary "on call" Obstetrics Service provider, no call back was subsequently received from MD1. S1 also confirmed that the facility policy for Emergency Medical Treatment And Labor ACT (EMTALA) only specifies that "on call" providers will make "reasonable efforts" to respond in a timely manner. S1 confirmed no definitive numeric time requirement exists. S1 confirmed there are no definitive instructions for staff on what to do if contingencies or difficulties occur when attempting to reach the provider who is on the "on call" listing.