HospitalInspections.org

Based on a review of the medical records of 5 patients who presented to the emergency department, review of hospital policies and procedures, review of physician credentials, review of emergency department central logs, review of the physician on call list, and interviews with administrative staff, it was determined that each facility within the system failed to have a physician on call list that identifies the name of an individual physician to ensure compliance with the requirements of 42 CFR 489.20(r)(2).

Findings include:

1. The system failed to have a physician on call list that identifies the name of an individual physician. Cross reference 489.20(r)(2)

Based on staff interview and review of the Emergency Department (ED) on call list for Virtua West Jersey Hospital at Berlin, Camden, Voorhees, and Marlton, it was determined that the system failed to ensure that a physician on call list that identifies the name of an individual physician on call for a specialty, is maintained.

Findings include:

1. Review of the OB/GYN on call schedule revealed the following:

a. The Physicians on-call schedule for February-May 2012 for the OB/GYN stated, "All unassigned patients requiring gynecological or obstetrical care should be referred to the inhouse Center for Women Resident/Attending, by calling the Virtua Operator."

b. There was no physician's name or phone number provided on the on-call schedule.

c. The above was verified by Staff #1.