HospitalInspections.org

Based on the findings at A2404 the facility failed to ensure compliance with CFR 489.24.

Based on interview, record review and policy review, the facility failed to ensure on-call coverage for Maxillofac Surgery was available and failed to maintain a correct on-call log.

Findings include:

The facility Medical Staff rules and regulations approved by the Medical Executive Committee on September 20, 2012, documented:

- "...IV. Emergency Department (ED) Call
In order to participate in the Emergency Department call schedule rotation, the physician must adhere to the VHS (Valley Health System) Emergency Department Call Policy, as well as the following eligibility criteria and requirements specific to this facility:

1. Active Medical Staff members in the specialties of Primary Care (Internal Medicine/Family Practice), STEMI (ST elevation myocardial infarction), Cardiology, General Surgery, Neuro Surgery, Orthopedic Surgery, Cardiovascular Surgery, Oral and Maxillofacial, and OB/GYN (obstetrics/gynecology) have the responsibility for covering Emergency Department call as required by the Medical Executive Committee.

2. Participation in Emergency Department call is on a voluntary basis. If at any time it is determined that through voluntary call the hospital is unable to meet the needs of the patient population served, call will revert to a mandatory call for all eligible participants in their respective specialties ... "

The facility's on-call list from August - December 2012 and January 2013, documented Employee #6 as the only Oral and Maxillofacial Specialist available for on-call everyday.

There was no documented evidence an Oral and Maxillofacial Specialist was listed on the on-call schedule for the months of May - July 2012 and from February - April 2013.

On 5/8/13 in the afternoon, the ED Medical Director (Employee #3) indicated there had been no available Oral and Maxillofacial Surgeon available for on-call for the ED. The ED Medical Director was not aware Employee #6's name was being listed on the on-call schedule for the months of August - December 2012 and January 2013. The ED Medical Director was not aware the Medical Staff rules and regulations listed Oral and Maxillofacial Surgey as one of the required specialist to cover on-call for the ED.

On 5/8/13 in the afternoon, the ED Medical Director indicated Employee #6 was not supposed to be on the ED on-call schedule from August 2012 - January 2013. The ED Medical Director indicated the facility was assisting Employee #6 with building his practice due to Employee #6 recently transferring to Nevada from another State. The ED Medical Director indicated Employee #6 was not required to come to the ED if he was contacted for a case. There was no contract for Employee #6 to be on-call for the ED.

On 5/8/13 in the afternoon, the Director Clinical Care Services (Employee #1) indicated there was no on-call coverage for Oral and Maxillofacial surgery for the ED. Employee #1 indicated Employee #6 was not supposed to be listed on the on-call ED schedule since Employee #6 was not required to come to the ED if he was contacted.