HospitalInspections.org

Based on review of hospital policies/procedures, documents, Medical Staff Bylaws, and interviews, it was determined that the hospital's Emergency Department failed to require:

1. on-call general surgery consultations were provided by a physician;
2. on-call physician orthopedic surgical services; and
3. on-call cardiologists were hospital-privileged, and available for onsite stabilizing treatment.

Findings include:

The hospital policy titled Emergency On-Call Physician Schedule (written 09/13) requires: "...Purpose: To identify physicians as being 'on-call' for a specific rotation to provide treatment necessary to stabilize individuals with emergency medical conditions...The on-call list will include the names of the individual physicians who are on-call...The Hospital must provide sufficient on-call services to meet the needs of the community in accordance with available physician resources...Where call is voluntary - physicians who have been approved for Staff membership may request addition to the emergency department call rotations by contacting the Medical Staff Services Department...An on-call physician must be available and accessible by telephone during time on-call and must respond to all calls. Physicians must respond to call from the Emergency Department within 30 minutes. The on-call physician must respond in person, if requested to do so by the Emergency Department physician...Any physician who is unable to take call when assigned, is responsible for finding qualified coverage by a physician on the medical staff with appropriate privileges, for a specific rotation, and for notifying the Medical Staff Services Department or ED (after hours) of a change in coverage...Medical Staff exemptions from service on the call schedule may be granted (e.g. senior physicians) but the hospital must maintain adequate on-call services if permitting physicians to selectively take call for their own patients...." The policy was "written 09/13," approved by the Medical Executive Committee on 09/16/13 (according to minute notes), approved by the Board of Directors on 09/24/13 (according to minute notes), and approved for the Medical Staff on 10/08/13, (according to minute notes).

The hospital policy titled ER (Emergency Room) Scope of Service (written 03/12) requires: "...An on-call list of specialty physicians is maintained to assist in stabilizing patients...."

The hospital's policy titled Cobra/EMTALA Guidelines (written 04/00) requires: "...EMTALA is applicable to any physician who is responsible for the examination, treatment or transfer of an individual to whom EMTALA applies, including an on-call physician and other members of the medical staff who provide for the care of such an individual...On-Call List means the list of physicians who are 'on-call' after the initial medical screening examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition...On-Call Coverage. The Hospital will maintain a list of physicians who are on-call to come to the Hospital to consult or provide treatment necessary to stabilize an individual with an emergency medical condition if necessary...."

The Medical Staff Bylaws require: "...Categories of the medical staff...members of this category shall take emergency department call...The consulting category...members of this category have the same responsibilities as active category members with the exception of emergency department call...."

1. The hospital's Emergency (Department) Call List revealed that Physician Assistant-Certified (PA-C) was the "Surgeon On Call" on 02/04/14, 02/06/14, 02/08/14 and 02/10/14.

PA-C #4 confirmed, during an interview conducted on 04/08/14 at 1600, that he was the Surgical First Assist and takes ED call for General Surgeon #6, approximately 3 x week since approximately 08/2013. He described the process whereby the ED provider examines the patient, then contacts PA-C #4, who consults, then typically contacts the General Surgeon #6, for further direction as needed.

PA-C #4's credential file revealed the following:

Current privileges for Physician's Surgical Assist, dated 09/04/12, signed by the Chief Executive Officer (CEO) on 09/05/12, for a 2 year period.

The document titled Allied Health Professional Scope of Practice (signed by PA-C #4 on 07/13/12) revealed: "...Surgery Physician Assistant (requested privileges for) Evaluating and treating a wide variety of urgent and emergency conditions under the direction of the supervising physician...Prohibited Functions:...Is not permitted to substitute for an attending or on-call physician for the Emergency Department...A physician assistant may not independently perform consultations in place of the supervising physician...." The form requires the signature and date of the sponsoring physician, however this information was not documented.

The document titled Department Assessment and Report revealed: "Department recommends that: The applicant be appointed...That privileges requested be approved...." The Surgery Committee chairperson signed the form on 08/15/12. The Medical Executive Committee's Assessment and Recommendation committee chairperson signed on 08/20/12, and the Board of Directors approved the appointment, per signature, on 09/04/12.

The Surgeon Agreement by and between General Surgeon #6 and PA-C #4, signed and dated 08/07/2013 by both parties, confirmed that General Surgeon #6 was the supervising physician for PA-C #4. General Surgeon #6, confirmed during an interview conducted on 04/10/14 at 0900, that PA-C #4, takes ED general surgery call for her. The surveyor asked the physician about the PA's scope of practice that indicates he may not independently perform consultations. General Surgeon #6 responded that she was not aware of and not sure of the specifics related to consultations.

ED Medical Director physician #1, Chief Nursing Officer #2, and ED physician #3, all verified that PA-C #4 takes ED call for General Surgeon #6, and provides surgical consultations.

The hospital permits a non-physician to provide initial general surgery consultation/evaluation, contrary to hospital policies, and PA-C job description/scope of services.

2. The hospital policy titled Medical/Surgical Department Scope of Service #NR-MS1008 (written 02/14) requires: "...The conditions of patients admitted to the Medical/Surgical Unit include...Orthopedic disorders...."

The hospital has one (1) orthopedic surgeon on staff, however, the ED Call list does not include orthopedics.

Orthopedic Surgeon, physician #10, indicated during an interview conducted on 04/10/14 at 0930: "...the ED calls when something (orthopedic related) comes into the ED - I'm available unless I'm out of town...I don't know what the patient's financial status is - they don't tell me...." The physician stated that there was "nothing in writing" that he's on call, but stated he takes calls, consults, and/or comes to the hospital if he's "available" to do so. He confirmed that he is not on the On-Call List and has no obligation to take call. He stated that this practice works better for the hospital and the community.

ED Medical Director, physician #1, stated during an interview conducted on 04/08/14 at 1500, that Orthopedic Surgeon physician #10 is "available anytime when he's in town...we've called him many times...a lot of phone consultations...."

The Chief Nursing Officer (CNO) confirmed during an interview conducted on 04/08/14 at 1500, that Physician #10 is not assigned to take ED call.

The hospital offers orthopedic services but failed to delineate or require on-call coverage responsibilities for orthopedics.

3. The hospital policy titled Medical/Surgical Department Scope of Service #NR-MS1008 (written 02/14) requires: "...The conditions of patients admitted to the Medical/Surgical Unit include...Cardiovascular disorders...."

The ED Call list revealed that on 04/12/14 and 04/13/14, Cardiology On-Call on call was "(Name of hospital #2) Heart (hospital)."

The CNO indicated during an interview conducted on 04/08/14 at 1500, that (Name of hospital #2) Heart Hospital (located 75 miles away) cardiologists were available for phone consultation only, did not provide onsite stabilizing treatment, and were not privileged for Cobre Valley Regional Medical Center.

ED Medical Director, Physician #1, indicated during an interview conducted on 04/08/14 at 1500, that (Name of hospital #2) Heart Hospital cardiologists were "on-call" for phone consultation only, and that there was no requirement or expectation to provide on-site ED services.

The hospital permits (Name of hospital #2) Heart Hospital cardiologists (a group of physicians not individually identified) to be on-call for the ED who are not current members of the medical staff, and that are not expected to come to the hospital to provide stabilizing services. In addition, ED Medical Director physician #1, and the CNO, verified that the hospital did not have any contract/agreement/policy with (Name of hospital #2) Heart Hospital to provide cardiology services.