The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

METROSOUTH MEDICAL CENTER 12935 S GREGORY BLUE ISLAND, IL 60406 Oct. 2, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on document review, and interview, it was determined that the Hospital failed to ensure compliance with A 2404. This potentially affected all patients presenting to the Emergency Department (ED) with orthopedic injuries.

Findings include:

1. The Hospital failed to ensure all physician speciality services were available via an on-call system in the ED.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
Based on document review and interview, it was determined that in the Emergency Department (ED) the Hospital failed to ensure all physician speciality services were available via an on-call system. This potentially affected all patients presenting to the Emergency Department (ED) with orthopedic injuries.

Findings include:

1. On 10/1/15 the Hospital's ED on call list of Hospital speciality's was reviewed. The list failed to include Orthopedic Surgery as a service that was on call to the ED.

2. The Hospital's By-Laws and Rules and Regulations, dated December 2014 were reviewed on 10/1/15. The Rules and Regulations required, "Article VI Emergency Medical Screening, Treatment, Transfer & On-Call Roster Policy...6.2...6.2(d) The rotation call list, containing the names and phone numbers of the on-call physicians shall be posted in the Emergency Department."

3. The Hospital's "Patient Care Scope of Services," for the Emergency Department (revised 3/2014), reviewed on 10/1/15, required, "Types of Patients...Patient care in the Emergency Department is focused around a patient population...The most common types of illnesses seen are...orthopedic..."

4. The Hospital's application to the Joint Commission (dated 10/31/14) included orthopedic surgery as a service provided by the Hospital.

5. The Hospital's "2015 Plan for the Provision of Patient Care," was reviewed on 10/1/15. The Plan included, "MetroSouth Medical Center provides the community with an extensive range of healthcare services including but not limited to...Orthopedics."

6. The Hospital's active physician roster was reviewed on 10/1/15. The roster included 8 orthopedic surgeons on staff at the Hospital. The personnel files of the orthopedic surgeons were reviewed on 10/2/15. Of the 8 surgeons 7 (MD #3, 4, 5, 7, 8, 9 and 10) were credentialed in the "Core Privileges". MD #6 was credentialed in "hand" procedures only.

7. The Hospital's "Clinical Privileges in Orthopedic Surgery," (revised 2015) was reviewed on 10/2/15. The Core Privileges included, "Admit, perform history and physical...provide surgical and non-surgical care to patient..."

8. On 10/1/15 at approximately 8:15 AM the ED physician (MD#1) on duty 9/26/15 from 11:00 AM to 11:00 PM was interviewed. MD#1 stated there is not an "on-call schedule for orthopedics in the ER." MD#1 stated the orthopedic physicians are not required to be on-call.

9. The Hospital's Orthopedic Surgery core procedures dated 7/30/08 was reviewed on 10/2/15. The Orthopedic Surgery privileges included, "Note this list is a sampling of procedures included in the orthopedic surgery core...not intended to be all encompassing...Closed reduction of fractures and dislocations of the peripheral skeleton...open and closed reductions of fractures, open reduction and internal fixation of fractures and dislocations of the peripheral skeleton..."

10. On 10/2/15 at approximately 1:10 PM the Interim Chief Executive Officer stated the Hospital does have an on-call list for the physicians, however "yes it is a fact, it does not include orthopedic specialty."