HospitalInspections.org

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Based on document review and interview, the facility failed to: (A) Identify the individual physician assigned for on-call duty by name, in three (3) of fifteen (15) on-call service schedules; and (B) Establish written policies and procedures (P&P) for the On-call Physician list.

This failure placed patients at increased risk for delayed evaluation and treatment.

Findings for (A):
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The Emergency Department's (ED) Anesthesia On-call Physician List, dated 2/1/2022 to 4/30/2022, directed ED staff to call a cellular phone number. The name of the individual physician assigned for on-call duty was not listed for all days within that time period.

The Psychiatry Consult Child On-call Physician List, dated 2/1/2022 to 4/30/2022, listed "Psychiatry In-Patient 8:30AM-4:30PM" for sixty-three (63) days within that time period; and "CPEP (Psychiatric ER) 5:00PM-8:30AM" for eighty-nine (89) days within that time period. The name of the individual physician assigned for on-call duty was not listed.

The Psychiatry Consult Adult On-call Physician List, dated 2/1/2022 to 4/30/2022, listed "Psychiatry In-Patient 8:30AM-4:30PM" for sixty-four (64) days; and Psychiatry Consult Pager 4:30PM-8:30AM" for eighty-nine (89) days within that time period. The name of the individual physician assigned for on-call duty was not listed.

These findings were confirmed during interview of Staff P (Chief Nursing Officer/Chief Regulatory Officer) and Staff Q (Department of Health Liaison) on 4/11/2022 at 2:45PM. Staff P stated that for Anesthesia Services, "If they have to go to surgery, they hand the beeper off to another doctor," and "That's why they have it [the on-call physician] listed as 'Call cell number,' and not by name."
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Findings for (B):
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Upon request, the facility could not furnish a written policy and procedure (P&P) for On-call Physicians for the ED.

This finding was confirmed during interview of Staff F (Patient Safety/Quality Coordinator) on 4/11/2022 at 3:02PM. Staff F stated, "I just became aware of it now. If we knew about it, it would have been in there already. There is no on-call policy for the ED. The individual departments know who is on call, and each department has their own on-call list."
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