HospitalInspections.org

Based on staff interview and review of the Emergency Department (ED) on call lists, it was determined that the facility 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 on call list for Internal Medicine revealed that a physician group was listed as on call for 21 out of 29 days for the month of February 2012. An individual physician was listed the remaining 8 days.

2. Review of the on call list for Internal Medicine revealed that a physician group was listed as on call for 21 out of 31 days for the month of March 2012. An individual physician was listed the remaining 10 days.

3. Review of the on call list for Internal Medicine revealed that a physician group was listed as on call for 22 out of 30 days for the month of April 2012. An individual physician was listed the remaining 8 days.

4. Review of the on call list for Internal Medicine revealed that a physician group was listed as on call for 23 out of 31 days for the month of May 2012. An individual physician was listed the remaining 8 days.

5. Review of the on call list for Internal Medicine revealed that a physician group was listed as on call for 20 out of 30 days for the month of June 2012. An individual physician was listed the remaining 10 days.

6. Review of the on call list for Internal Medicine revealed that a physician group was listed as on call for 22 out of 31 days for the month of July 2012. An individual physician was listed the remaining 9 days.

7. Review of the on call list for Internal Medicine revealed that a physician group was listed as on call for 22 out of 31 days for the month of August 2012. An individual physician was listed the remaining 9 days.

8. The above findings were confirmed by Staff #1.

Based on a staff interview and medical record review on 8/28/12, it was determined that the facility failed to ensure that all patients are evaluated by qualified medical personnel within four hours of coming to the ED.

Findings include:

1. On 2/25/12, Patient #1 presented to the ED at 1515 with a complaint of right leg pain. Documentation in the medical record indicated that the patient was triaged at 1649. At 1725, the patient's pain was assessed and documented as 10 out of 10 on the pain scale. At 2040, the patient's pain was 8 out of 10 on the pain scale. There was no documented time in the medical record indicating when the patient was visited by qualified medical personnel.

a. The first physician order was documented in the medical record at 2108.

b. Documentation in the medical record indicated that the patient was in the ED for 5 hours and 53 minutes before the first physician's order was entered at 2108.

2. During an interview, Staff #3 stated that Physician's orders are entered into the computer right after the patient is examined.