HospitalInspections.org

Based on interviews and facility document review, it was determined the facility staff failed to comply with §489.24 - Special Responsibilities of Medicare Hospitals in Emergency Cases.

The findings include:

The facility staff failed to ensure the facility's written policies and procedures for 'on-call physicians' addressed: (a) if an on-call physician is allowed to schedule elective surgery during the time he/she is on call and (b) if an on-call physician is allowed to have simultaneous on-call duties.

Please see Tag A2404 for additional information.

Based on interviews and facility document review, it was determined the facility staff failed to ensure the facility's written policies and procedures for 'on-call physicians' addressed: (a) if an on-call physician is allowed to schedule elective surgeries during the time he/she is on call and (b) if an on-call physician is allowed to have simultaneous on-call duties.

The findings include:

On the morning of 6/6/17 the facility's policy and procedure entitled "EMERGENCY MEDICAL TREATMENT AND PATIENT TRANSFER" (the effective date and the reviewed date both were February 11, 2015) was reviewed by the surveyor. The surveyor was unable to find evidence of the policy and procedure addressing: (a) if an on-call physician is allowed to schedule elective surgery during the time he/she is on call and (b) if an on-call physician is allowed to have simultaneous on-call duties.

On 6/6/17 at 10:30AM, the facility's Quality Manager (Staff Member (SM) #5) was asked to provide the facility policies and procedures that addressed if on-call physicians can have simultaneous on-call duties and/or be allowed to schedule elective surgeries during the time he/she is on call.

On 6/6/17 at 11:19AM, the facility's Risk Manager (Staff Member (SM) #4) reported there was not a policy and procedure addressing if a physician could schedule elective surgeries for the same time the physician was on-call. SM #4 stated physicians are allowed to do elective surgeries during the time they are on-call but would be expected to have a back-up plan to deal with emergency on-call cases. During an interview on 6/6/17 at 2:00PM, SM #4 added that an emergency patient would bump an elective procedure.

On 6/6/17 at 2:00PM, SM #4 stated the facility does not allow simultaneous on-call duties. SM #4 had earlier provided the survey team with a 'COMMUNITY CALL POLICY' (this policy was documented as effective from January 1, 2017 - December 31, 2017; the last date of the signatures of those approving this policy was 1/25/17); this policy detailed the facility providing "emergency on-call coverage for general surgery and gastroenterology" for another local hospital. The survey team was not provided with a policy and procedure that detailed guidance for simultaneous on-call duties other than the aforementioned policy which only addressed the approval of simultaneous on-call duties for two specific specialties at two specific facilities.

On 6/6/17 at 4:15PM, the survey team met with the facility's administrative team; the administrative team included but was not limited to SM #4, SM #5, the facility's CEO, and the facility's CNO. The failure to have written policies and procedures to address scheduling elective surgeries for the same time period a physician is on-call and the failure to have written policies and procedures to address simultaneous on-call duties for situation that would not be covered by the 'COMMUNITY CALL POLICY' was discussed.