HospitalInspections.org

Based on staff interview, medical record review, and review of facility documents, it was determined that the facility failed to ensure an on-call physician responded to the Emergency Department (ED) within 20 minutes of being called in accordance with facility policy.

Findings include:
Facility policy, "Physician On-Call Response Policy" (effective 4/4/24) states, "...Policy: ...The provisions of EMTALA apply not only to the Emergency Department but...also to the physicians who provide on-call coverage. ...Procedure: ...5. The on-call physician must respond by phone within 20 minutes of being called, and be physically present at the hospital within 60 minutes of being requested. ..."

On 6/5/24, during review of Patient (P)1's medical record, the following was revealed:

On 5/9/24 at 8:26 AM, P1 arrived at the ED with abdominal pain and vomiting. At 13:04 (1:04 PM), a Computed Tomography (CT) scan resulted with a small bowel obstruction. Staff (S)22 (ED Physician Assistant) consulted another facility to initiate a transfer, due to P1's history of a liver transplant there. On 5/10/24, while waiting for a bed at the accepting facility for transfer, S19 (ED Physician) documented calling a consult to S40, the On-Call General Surgeon, at 9:28 AM. At 10:58 AM, 1 hour and 30 minutes later, S19 documented a "second call to surgery on-call." At 11:16 AM, 18 minutes later, S19 documented that S18, another general surgeon, returned his/her call.

During a telephone interview on 6/5/24 at 1:19 PM, S19 stated that he/she paged S40 on 5/10/24, but that S18 called back from the same surgical group because "the on-call schedule was wrong."

A review of the "[Facility Name] On-Call Schedule General Surgery May 2024" confirmed S40 was documented as the on-call general surgeon on 5/10/24.

Review was conducted of P24's medical record, another patient who presented to the ED on 5/10/24. S36 (ED Advanced Practice Nurse) documented the following in P24's medical record on 5/10/24: "Patient placed in Emergency Department physician observation status at 1230 on 5/10/24 pending consult from [named] [S40]. ... [Named] [S40] states [he/she] cannot see the patient as [he/she] is in [named other facility]." Further review revealed another surgeon, S35 (General Surgeon) arrived to see the patient at approximately 16:04 (4:04 PM).

On 6/6/24 at 11:00 AM, S4 (Chief Medical Officer-CMO) stated that S18, S35, and S40, are all part of the same general surgery practice, and "they cover each other." S4 confirmed that if a physician was on-call at this facility, they should be on-call at this location only. The above findings were confirmed by S4 (CMO) and S6 (ED Assistant Nurse Manager) at this time.

At 11:27 AM, a telephone interview was conducted with S35 (General Surgeon) in the presence of S5 (Quality RN). S35 confirmed that he/she works in a group with S18 and S40. S35 stated that when on-call at this facility, "the priority is here. Many physicians have block times at other hospitals. One or two of us have block times, but one of us is always available." S35 stated that when a hospital is paging him/her when on-call, the call "goes to the office during business hours and the office calls us. If I'm in the operating room, I have the OR [operating room] staff answer the phone, and have the office call the [available] physician or the OR staff call the [available] physician." S35 stated that when paged, the expectation is to return the call "immediately." S35 stated that if the surgeon on-call changes to another surgeon, their office should notify the hospital.

At 1:03 PM, these findings were reviewed with S4, who confirmed that the facility does not follow a community on-call plan, and that the expectation is for the on-call physician to be available to this facility when on call.