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LANCASTER GENERAL HOSPITAL
ON CALL PHYSICIANS
Tag No.: A2404
Based on a review of facility documents and staff interviews ( EMP), it was determined the facility failed to have an on-call policy for physicians.
Findings include:
The facility was unable to produce a policy and procedure relating to physicians being on-call.
In an interview at approximately 10:08 AM on January 31, 2020, EMP6 and EMP12 confirmed that the facility does not have a specific on-call policy. EMP 13 confirmed that the facility does not have a policy stating that individual physician's names must be identified on the on-call schedule.
APPROPRIATE TRANSFER
Tag No.: A2409
Based on review of medical records, policy and procedure, and interviews with staff, it was determined the facility failed to complete an appropriate transfer to another medical facility.
Findings include:
Review of medical record 7 revealed medical records did not contain paperwork per their policy.
Review of the Emergency Medical Treatment and Active Labor Act Compliance Policy with an effective date of 1/3/19 revealed the facility did not follow their policy. Policy states "LGH sends to the receiving hospital all available medical records relative to the patients' Emergency Medical Condition that are available at the time of transfer, including, for example, results of any tests and the informed written consent or physician's certification, as well as the name and address of any on-call physician who refused or failed to appear within a reasonable time to provide necessary stabilizing treatment."
In an interview at approximately 11:00 AM on January 31, 2020, EMP12 and EMP 13 confirmed medical records were not provided to medical facility patient was transferred to. Also, confirmed by EMP 5 and EMP 6 the transfer checklist and patient transfer form was not completed.