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Based on observation, record review, and staff interviews. The facility failed to comply with §489.24(j)(1). The hospital must maintain an on-call list.

Based on observation, record review, and staff interviews, the facility failed to maintain a complete neurology on-call list of physicians available to provide treatment from December 16th to December 27th, 2024.

See Tag 2404

Based on observation, record review, and staff interviews, the facility failed to maintain a complete neurology on-call list of physicians available to provide treatment from December 16th to December 27th, 2024.

A.
A review of the document titled "Neurology On-Call" for the past 6 months revealed the following:
No one was scheduled for December 16th to December 27, 2024.

B.
A review of the document titled "Rules and Regulations," Section 11 D, page 50, revealed the following: "ON-CALL RESPONSIBILITIES
"It is the responsibility of the Physician, Dentist, Oral and Maxillofacial Surgeon, or Podiatrist (as applicable) who is scheduled to be on-call to the Emergency Department to be listed on the schedule (by name, with appropriate contact information), to respond when contacted and requested by the Emergency Department and, upon request, to provide consultations and/or accept responsibility to care for unassigned patients, as outlined in the Medical Staff Bylaws, these Rules and Regulations, and other applicable Policies.89"
89 Medical Staff Bylaws, Section 7.A.1.(b) (requiring the on-call physician to respond via telephone within 30 minutes after initial contact and appear within 30 minutes of a request by Emergency Department personnel. Also requiring a Practitioner who is responsible for responding to patients in the hospital - such as when on call for a group practice - to respond via telephone within 30 minutes after initial contact and appear within 60 minutes of a request by a Medical Staff Member, APP, or other licensed health care provider who is involved in the patient's care)."

A review of the document titled "Medical Staff Bylaws" Section 7.A.1.(b) revealed the following:
"Additional Criteria for Medical Staff Members: (1) agree to and fulfill the following specific response time requirements in a prompt, efficient, and professional manner:
(i) when on-call for the Emergency Department, be available on a continuous basis, either personally or by arranging appropriate coverage, such that the Practitioner can and does:
orespond via telephone within 30 minutes after initial contact from the Hospital; and
oappear within 30 minutes of a specific request by Emergency Department personnel requesting the Practitioner's personal presence to attend to a patient in the Emergency Department;"


C.
An interview with Staff # 5, Regional Director DFW East Region, on 04/08/2025 @ 1:46 PM: "When there is no on call coverage we utilize the telestroke program for the region. It is a network of physicians that can be consulted virtually and assess if the patient needs immediate transfer to a comprehensive center."

An additional interview on 04/09/2025 at 7:48 AM Staff # 5 added: "we do not accept transfers in that need neurology and if we have a patient that needs neurology we transfer them out to an appropriate facility. "