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Based on review of facility documentation, facility policy and procedure and staff interview, it was determined the facility failed to ensure that individual names of physicians are identified on the facilities on-call list for the Gastroenterology and Neruology specialties.

Findings include:

Facility document titled, "BYLAWS OF THE MEDICAL STAFF OF ATLANTICARE REGIONAL MEDICAL CENTER", approved on 12/8/22, states " ... 6.13-7. Service On Call and Interpretation Rosters. The appropriate Department and/or Division Chairs shall make and administer on-call rosters, and rosters for the interpretation of tests, as required to meet the needs of the Hospital and patients and any criteria for service on such rosters ..."

Facility policy titled "Medical Staff Physicians On-Call Policy" revised 8/22, states "... Call Procedure: ...2. In the event that the physician has a scheduling conflict with the published schedule, it is the physician's responsibility to promptly arrange for appropriate coverage by a substitute physician with similar credentials and ensure the online on-call schedule is updated. If there is an unforeseen circumstance beyond the reasonable control of the physician, which arises on the day of an on-call assignment, the on-call physician must immediately notify the Emergency Department and attempt to arrange for an appropriate substitute. ...4. ...During periods when a particular specialty is not available to take call or coverage is temporarily limited because the on-call physician is unable to respond to call due to a situation beyond his/her reasonable control (e.g., transportation failures, personal illness, etc.), the patient will be stabilized within the capabilities of the hospital and may be transferred pursuant to the hospital transfer policy. ..."

1. On 6/27/23 at 10:53 AM, during a tour of the Mainland Campus Emergency Department (ED), the on-call list was observed at the nurse's station. The "Gastro" on-call was documented as "[Group Name]" with a phone number next to it. An interview with Staff (Mainland) #29 (SML29), an ED technician, was conducted in the presence of Staff (Mainland) #13 (SML13), Nurse Manager. SML29 stated that if a Gastro consult was needed, he/she would call the number next to the group name. SML29 and SML13 confirmed the number was the office number for the Gastro group. SML29 stated that during normal business hours, he/she would talk to the office manager at the group and they would get in touch with the on-call doctor. SML29 stated that sometimes the office manager would let him/her know which doctor was on, and sometimes he/she would not. SML29 stated that he/she is not aware if the consultant calls back or not, and stated that if they haven't called back, then the requesting provider usually asks for another call. SML29 and SML13 stated that the ED department does not track the time in which the on-call doctor calls back or if the on-call doctor calls back and a second call needs to be placed.

On 6/28/23, the on-call list for all specialties was requested from August 2022 through June 2023. On 6/29/23 the on call lists were provided and reviewed. Review of the physician on-call lists for the Gastroenterology specialty revealed the following:

For the month of September 2022, the name of the physician on-call states, "[Physician Group Name]" under each day of the month. There was no identification of an individual physician on-call, listed.

For the month of October 2022, the name of the physician on-call states, "[Physician Group Name]" under each day of the month. There was no identification of an individual physician on-call, listed.

For the month of November 2022, the name of the physician on-call states, "[Physician Group Name]" under each day of the month. There was no identification of an individual physician on-call, listed.

For the month of December 2022, the name of the physician on-call states, "[Physician Group Name]" under each day of the month. There was no identification of an individual physician on-call, listed

On 6/29/23, during an interview with Staff (Mainland) #10 (SML10), Chairman of Emergency Services, he/she explained that the facility only has one GI group that is used and that is why the group name is listed. SML10 explained that the ED secretary would call a consult into the GI group when a GI consult is needed. SML10 indicated there have been no reported delays in reaching the GI group during office hours.

During a tour of the City Campus ED on 6/28/23 at 11:20 AM, Staff #16CC (Nurse Practitioner) and Staff #17CC (Unit Secretary) stated all staff have access to the Manilla online scheduling system to look up the physician's on-call schedule. A request was made to Staff #3CC (Assistant Vice President, Nursing) and Staff #7CC (ED Supervisor) for the physician on-call lists for January 2023 to June 2023.

Review of the physician on-call lists for the Gastroenterology specialty revealed the following:

For the month of February 2023, the name of the physician on-call states, "On-Call C" under each day of the month. There was no identification of an individual physician on-call, listed.

For the month of March 2023, the name of the physician on-call states, "On-Call C" under each day of the month. There was no identification of an individual physician on-call, listed.

For the month of April 2023, the name of the physician on-call states, "On-Call C" under each day of the month. There was no identification of an individual physician on-call, listed.

For the month of May 2023, the name of the physician on-call states, "On-Call C" under each day of the month. There was no identification of an individual physician on-call, listed.

For the month of June 2023, the name of the physician on-call states, "On-Call C" under each day of the month. There was no identification of an individual physician on-call, listed.

Review of the physician on-call lists for the Neurology specialty revealed the following:

For the month of February 2023, the name of the physician on-call states, "Teladoc General" on the following dates: 6, 7, 8, 9, 10, 27, and 28. There was no identification of an individual physician on-call listed.

For the month of March 2023, the name of the physician on-call states, "Teladoc General" on the following dates: 1, 2, 3, 6, 7, 8, 9, and 10. There was no identification of an individual physician on-call, listed.

For the month of June 2023, the name of the physician on-call states, "Teladoc General" on the following dates: 26, 27, 28, 29, and 30. There was no identification of an individual physician on-call, listed.

Upon interview on 6/29/23 at 1:05 PM, Staff #3CC stated, "There is always someone on call, however, they may not be reflected on the physician call list. There are departments that input information into the system and they may not have updated the information like they should. We recognize that there are gaps with the on-call lists."


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