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Based on review of Medical Staff Bylaws/Rules and Regulations, physician credentials files, physician written statement, and staff interview, it was determined that the facility failed to ensure compliance with 42 CFR 482.24, Special Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Findings were:

Cross refer to A2404 as it relates to the facility's failure to maintain a list of physicians who were on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with emergency medical conditions requiring the expertise of a plastic surgeon..

Based on review of Medical Staff Bylaws/Rules and Regulations, physician credential files, physician written statement, and staff interview, it was determined that the facility failed to maintain a list of physicians who were on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with emergency medical conditions requiring the expertise of a plastic surgeon.

Findings were:

Medical Staff Bylaws and Rules/Regulations, approved and adopted by the Medical Staff on 04/19/12 and approved and adopted by the Board of Trustees on 04/23/12, were reviewed. Section H, titled Emergency Department Call Coverage, revealed the On-Call list was comprised of practitioners with appropriate privileges. The Categories of the Medical Staff subject to inclusion on the On-call list were Active and Affiliate. Physicians 55 years old and/or older or physicians that had provided 20 years of On-Call service were entitled to submit a written request for exemption from call coverage to the Medical Executive Committee for consideration. The request had to be submitted one year in advance of the expected date of call coverage exemption to ensure adequate call coverage and became effective upon approval of the Medical Executive Committee.

Review of the facility's Medical Staff roster revealed that there were six (6) physicians listed with Plastic Surgery as their specialty. All six (6) were either listed as Active or Affiliate Medical Staff. Review of the physicians' credential files revealed that three (3) of the six (6) physicians (#3, #5, and #8) did not meet the established criteria for exemption from Emergency Department (ED) Call Coverage.

An interview was conducted with the ED Director on 05/22/12 at 3:00 p.m. in the Administrative Conference Room. The daily Call Schedule for Specialty On-Call ED coverage for 12/01/11 through 05/22/12 was reviewed. The interviewee confirmed that Plastic Surgery did not provide on-call ED coverage during the reviewed time period.

A written statement was provided by the Chief Medical Officer for the Coliseum Health System. The physician related that approximately two years ago Coliseum representatives met with the Plastic Surgeons to establish a position on plastic surgery and the types of cases that should be referred to the Level One Trauma Center because of their trauma expertise. Coliseum Northside had no trauma center. Before this meeting, there had been significant disagreement among Plastic Surgeons, Ears Nose and Throat (ENT) specialists and Maxillofacial/Oral Surgeons on which specialty would assume responsibility for specific types of injuries. It was determined that serious maxillofacial injuries would be transferred to the local Level One Trauma Center. There was not any decision made to discontinue plastic surgery coverage for those injuries that were appropriate for plastics. The Chief Medical Officer acknowledged that it had been called to his/her attention that there was no Plastic Surgery call and that there has not been a Plastic Surgery call for the Emergency Department at Coliseum Northside during the past year. The physician stated that he/she was not sure but speculated that the lack of coverage occurred due to significant miscommunication as the result of the decision on what he/she called trauma plastics. The Chief Medical Officer further stated that the Medical Staff takes issues such as this very seriously and are working to correct those processes requiring modification.

The facility failed to ensure that an on call list was maintained for plastic surgeons in a manner that best meets the needs of individuals who present to the hospital with emergency medical conditions requiring the expertise of plastic surgeons.