HospitalInspections.org
Bringing transparency to federal inspections
COOPERMAN BARNABAS MEDICAL CENTER
COMPLIANCE WITH 489.24
Tag No.: A2400
Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure 1). On-call coverage of a designated provider for services offered in the emergency department (ED) (Q2404); and 2). a process in place for timely care of an ED patient in the event there is not a physician on-call for the services needed (Q2404).
Cross Reference:
CFR 489.24(j) - Availability of On-call Physicians
ON CALL PHYSICIANS
Tag No.: A2404
Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure 1). On-call coverage of a designated provider for services offered in the emergency department (ED); and 2). a process in place for timely care of an ED patient in the event there is not a physician on-call for the services needed.
Findings include:
1. On 2/12/25 at 1:30 PM, a review of the ED on-call list of specialty providers for the past three months (December 2024, January 2025, and February 2025), revealed the following:
The group name "NJ [New Jersey] Cardiology" was designated on-call for the following dates:
December 1-17, and 19-28, 2024
January 1-21, and 23-31, 2025
February 2-17, 21, 24-26, and 28, 2025
The group name "TPOC [an orthopedic group]" was designated on-call for December 2, 5-11, 13-15, 23-29, 2024
The group name "Dr. [Name of Physician] group (an infectious disease group)" was designated on-call for the following dates:
December 16-22, 2024
January 1, 3-5, 2025
On the following dates, the on-call for the specialty "Infect Disease 24hr 8a-8a" stated, "consult provider of choice" for January 6-12, 2025.
At 1:48 PM, upon interview, Staff (S) 3, Director of Accreditation and Licensure Quality and Standards, stated that the printed schedule did not best capture the on-call physicians. S3 stated that the facility uses an internet based on call schedule that can be accessed by all staff. S3 stated that eventhough the schedule that was provided to the surveyors may indicate group names, the online resource should designate the physician on-call name and not the group. For the above dates and names in questions, S3 logged in using the online on-call schedule and confirmed the dates and the listed group names, not an individual provider, from the above findings.
On 2/12/25 at 2:45 PM, upon interview, S30, the Chief Medical Officer, stated that the oversight of maintaining the on-call schedule is the responsibility of the Department Chairs and Chiefs. The department Chairs and Chiefs assign the provider members to the call schedule.
At 3:05 PM, the above findings were shared with S31, Vice President Quality and Patient Safety. S31 stated that he/she had issues with the on-call schedule in the past and the facility worked to mitigate the issue. S31 stated that he/she is aware that designated provider names should be on the on call schedule instead of groups and confirmed that the facility would work to ensure that current and future schedules would reflect a designated provider instead of a group or physician choice.
2. On 2/12/25 at 1:30 PM, a review of the ED on-call list of specialty providers for the past three months (December 2024, January 2025, and February 2025), revealed the following ED specialties did not have an on-call physician assigned:
The specialty "ED Card [Cardiology] 24hr 8a-8a" was not assigned on: December 2024: 12/1, 12/3, 12/6, 12/17, 12/20, 12/22, 12/27; January 2025: 1/1, 1/2, 1/5, 1/21, 1/23-24, 1/26-27, 1/29-30; February 2025: 2/1, 2/3, 2/5, 2/7-9, 2/13, 2/15-16, 2/21, 2/24, 2/26, 2/28.
The specialty "NJCA [New Jersey Cardiology Associates] On-Call Day 8a-5p" was not assigned on: December 2024: 12/7-8, 12/21-22, 12/28-29; January 2024: 1/4-5, 1/25-26; February 2024: 2/1-2, 2/8, 2/16-17.
The specialty "NJCA [New Jersey Cardiology Associates] On-Call Night 5p-8a" was not assigned on: December 2024: 12/2, 12/4, 12/5, 12/7-11, 12/13-17, 12/19-29.
The specialty "Peds [Pediatric] Ortho [Orthopedic] Att [Attending] 24hrs [hours] 7a-7a" was not assigned on: December 2024: 12/2, 12/7-11, 12/13-16, 12/23-29.
The specialty "Infect [Infectious] Disease 24hr 8a-8a" was not assigned on: December 2024: 12/17-22; January 2025: 1/1-12, 1/27-31; February 2025: 2/1, 2/17-23.
Upon request on 2/12/25 at 3:05 PM, to S3 and S30, was unable to provide a documented process or procedure concerning the protocol on how to care for an ED patient when the specialty on-call provider is not available.