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Based on review of policy and procedure, Medical Staff By-laws, clinical records, on-call schedules and staff interview, the hospital failed to ensure an on-call list was maintained to meet the needs of the patients for 1 (Patient #1) of 19 sampled emergency room patients reviewed for transfers from a total sample of 20. This resulted in Patient #1 being transferred to another facility for orthopedic services because the ED staff was unaware there was an Orthopedist on-call at the hospital. The hospital failed to develop and implement written policies and procedures for on-call procedures for on-call physicians to have simultaneous on-call duties, scheduling of elective surgery and procedures for when specialty physicians were unavailable. Findings:

Review of the Medical Staff Rules and Regulations/Medical Staff By-Laws, dated December 2011, and provided as current by S12 Director of Medical Staff Services, revealed in part the following: Section II. Emergency Service....11. Consultations, Referrals & Emergency Department Call....D. The rotation call list, containing the names and phone numbers of the on-call physicians shall be posted in the Emergency Department.....the rotation call list shall be used to select a private physician to provide the necessary consultation or treatment for the patient. The Emergency Department physician's determination shall control whether the on-call physician is required to come in to personally assess the patient. A physician who has been called from the rotation list may not refuse to respond.....E. (1) All members of the Active and Provisional Active Staff with appropriate privileges shall participate in the on-call backup to the Emergency Department....
Article IV: Medical Staff Qualifications, Responsibilities, and Privileges
Emergency Department Call - (c) Scheduling - The Emergency Department call schedule will consist of physician representative of each of the services provided by the Hospital to the general public. The MEC (Medical Executive Committee) will determine the extent of coverage required by specialty, which shall be based upon the frequency of emergency cases requiring care within such specialty, the likelihood that the patient's recovery would be compromised by the unavailability of such specialist, and the number of Practitioners within such specialty having the obligation to participate in the call schedule. The determination of the level of need and the manner in which this need is met shall be subject to the review and approval of the Board of Trustees to insure full compliance with EMTALA and all applicable laws pertaining to care of emergency patients.

Review of the hospital's policies and procedures revealed no documented evidence of an On-Call policy or procedure.

Patient #1
Review of the emergency department record for Patient #1 revealed the patient was a [AGE] year old female who presented to the emergency department (ED) on 02/11/13 at 9:54 a.m. with the complaint of right shoulder pain from a fall 2 days prior to arrival. Review of the record revealed the patient was diagnosed with a closed right humerus fracture and a closed pelvic fracture. Further review of the record revealed Hospital "B" was contacted at 12:45 p.m. for transfer of Patient #1. The record revealed Patient #1 was transferred to Hospital "B" at 1:25 p.m. on 02/11/13 for "specialty care unavailable at this facility." There was no documented evidence the orthopedic physician on-call was consulted for Patient #1.

Review of the On-Call schedule for Orthopedics for February 2013, provided by S12 Director of Medical Staff Services, revealed S7 Orthopedic MD (Medical Doctor) was on call on 02/11/13.

In a face-to-face interview on 03/27/13 at 11:15 a.m. S11 ED Physician verified he was the ED physician on duty on 02/11/13. After reviewing the ED record for Patient #1, S11 ED Physician stated he had to transfer the patient because there was no orthopedist on-call at the hospital. At this time S13 Clinical Coordinator ED who was present for the interview, stated she worked as the charge nurse in the ED on 02/11/13 and stated the on-call schedule for orthopedics that was posted in the ED on 02/11/13 had no one on-call for 02/11/13. S13 Clinical Coordinator ED provided copies of 3 on-call orthopedic schedules for February 2013. Review of the on-call schedule with a revised date of 02/04/13 - 11:00 a.m. revealed on 02/11/13 through 02/17/13, "no coverage" was documented. Also provided for review was another on-call orthopedic schedule with a revised date of 02/11/13 - 10:21 a.m. S13 Clinical Coordinator ED stated the night clerk prints and posts the on-call schedule in the ED. S13 Clinical Coordinator ED verified the schedule with "no coverage" was posted in the ED and stated she did not know why the on-call schedule was not posted when it was revised on 02/11/13 at 10:21 a.m.

In a face-to-face interview on 03/27/13 at 12:05 p.m., S7 Orthopedic MD stated he was the only physician in his practice and at best there were 2-3 orthopedic physicians to take call. S7 Orthopedic MD stated at one time, he had been on-call 15 days in a row. S7 Orthopedic MD stated he did his surgeries on Tuesdays and Thursdays and verified he was on-call for the ED on some Tuesdays and Thursdays.

In a face-to-face interview on 03/27/13 at 12:00 p.m., S12 Director of Medical Staff Services stated on 02/11/13, S5 Medical Director ED called her to confirm there was no one on call for orthopedics for the week. S12 Director of Medical Staff Services stated she then contacted the clinic and they provided another on-call schedule by email. S12 Director of Medical Staff Services stated at 10:21 a.m. 02/11/13 she had the revised schedule with orthopedics on-call and she printed and hand delivered the schedule to the ED, "within minutes".

In a face-to-face interview on 03/27/13 at 3:20 p.m., S1 CNO (Chief Nursing Officer) stated she was unable to find any policies and procedures for the hospital's on-call process. S1 CNO stated all the hospital had was the Medical Staff Rules and Regulations that specified someone was on call and the number of days the physician can take call. S1 CNO confirmed there were no hospital policies that identified the hospital's procedure when specialized physicians were not available, and there was no policy regarding on-call physicians scheduling elective surgery during the time they were on-call. S1 CNO stated she did not know why the on-call orthopedic schedules were switched on 02/11/13. S1 CNO confirmed an orthopedist was on-call for the hospital on [DATE] at the time Patient #1 was transferred to Hospital "B".