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HIALEAH HOSPITAL 651 E 25TH ST HIALEAH, FL 33013 Jan. 8, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interviews and reviews of medical records, policies and procedures, on-call schedules, Medical Staff By-Laws, Facility license, and Medical Staff Roster the facility failed to ensure that the hospital maintained an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital's patients who are receiving services required with the resources available to the hospital , including the availability of on-call cardiothoracic surgeon for one (SP#1) of ten (10) sampled patients. Refer to findings in Tag A-2404.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
Based on interviews and reviews of medical records, policies and procedures, on-call schedules, Medical Staff By-Laws, Facility license, and Medical Staff Roster, the facility failed to ensure that the hospital maintained an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital's patients who are receiving services required with the resources available to the hospital, including the availability of an on-call cardiothoracic surgeon for one (SP#1) of ten (10) sampled patients.

The findings included:

Review of the facility's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) policy," reviewed 07/09, state that if a physician on the call list is called by the emergency department physician to provide emergency screening or treatment, the physician must respond within a reasonable time in accordance with the time established in the facility's by-laws.

Review of the facility's Bylaws, reviewed 04/13, in Section R-18.17, documents that when a physician fails to respond or answer ER (emergency room ) calls appropriately, or leaves a physician to cover the call who does not have appropriate privileges at Hialeah Hospital, or is otherwise not performing his or her responsibilities with respect to ER call the physician will be referred to the Peer Review Committee for investigation and to determine the appropriate action to be taken.
The Bylaws also state that the call requirement is mandatory for all members including peripheral/vascular and thoracic specialists unless meeting the exemption requirement.

The hospital 's "emergency room Call Schedule December 2014" was reviewed. The review of the schedule revealed that on December 1, 2014 Hialeah Hospital had a thoracic surgeon on call when SP #1 presented to the hospital.

A review of the medical record revealed that SP #1 arrived at the facility on 12/1/2014 at 11:09 PM with complaints of shortness of breath. The patient's vital signs were abnormal: Blood Pressure was 187/94 (ideally Blood pressure lower than 120/80); Pulse 120 (normal pulse 60- 100). On 12/02/145 at 3:36 AM the physicians Notes for Sampled Patient (SP#1) reported that after receiving the (computed tomography- pictures of structures within the body created by a computer) it was found an aortic dissection (Occurs when a tear in the inner wall of the aorta causes blood flow between the layers of the wall of the aorta forcing the layers apart. Associated with severe chest pain) with dissection flap, [the named Internal Medicine Physician] was notified and we called [named "on call" cardio-thoracic surgeon] for a consult STAT (immediately).

The Emergency Department (ED) nurses notes on 12/02/14 at 3:30 AM stated that a call was placed to [named "on call" cardio-thoracic surgeon], unable to leave message, phone just sounds like a fax tone. At 4:00 AM another note stated, "call placed to [named alternate cardio-thoracic surgeon]-unable to leave a message (just beeps), NSG (nursing) supervisor made aware. At 4:38 AM, a another entry in the nursing notes stated,"I updated [named Internal Medicine Physician] about thoracic surgeon has not called back." At 4:58 AM the note then stated, "call placed to transferring hospital [named hospital #2] transfer center."

The ED nurses notes on 12/02/14 at 5:00 AM stated, "spoke with [named physician] he works with [named "on call" and named alternate cardiothoracic surgeons). He confirmed phone numbers.

Review of SP#1's Transfer Form showed that the patient was transferred to hospital #2 on 12/02/14 at 7:21 AM. The reason for transfer was documented, "required medical services not available."

Review of the facility's license showed that thoracic and vascular services are provided at the facility.

Review of the facility's Medical Staff Roster showed that there were four Thoracic Surgeons on staff at the facility.

On 01/07/15 at 1:10 PM, the emergency room (ER) physician for SP#1 stated that the patient came in with chest pain and high blood pressure. The CT(Computerized Tomography) scan showed aortic aneurysm. Then we consulted [named "on call" cardio-thoracic surgeon. We couldn't find him. He was not available to us. The doctor was called by the charge supervisor. No one answered.

On 01/07/15 at 1:15 PM, Staff D, an ER charge nurse stated, [named "on call" cardio-thoracic surgeon] was on vacation. [Named alternate cardiothoracic surgeon] was "on call." The phone just beeped when we called no message was left.


On 01/09/15 at 10:53 AM, the Nursing Supervisor stated that nobody got in touch with [named alternate cardio-thoracic surgeon]. She stated, nobody was answering. It rang and just cut off. We verified the phone number with the nursing supervisor at [hospital #3]. We asked them if they had any other number and the number they gave us was the same number we had.

The facility failed to maintain an on call list that best meet the needs of patients who were receiving services that required the specialized services (thoracic) as listed on the on call schedule available at the hospital , including the services of the on call thoracic surgeon for SP#1 on 12/1/2014.