HospitalInspections.org

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to maintain a list of physicians who are on-call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition.

Findings include:

1. Review of the specialty on-call schedules for the Emergency Department from September 24, 2012, through June 2, 2013, revised December 26, 2012, revealed that on September 24-30, October 8-14, October 22-28, November 5-11, November 19-25, December 3-9, December 17-23, December 31-January 6, January 14-20, January 28-February 3, February 11-17, February 25-March 3, March 11-17, March 25-31, April 8-14, April 22-28, May 6-12, and May 20-26, "ASP Ortho" was listed as on-call for Orthopedics.

2. At approximately 9:26 AM on February 14, 2013, EMP2 confirmed that ASP Ortho is a physician group name, which consists of approximately seven physicians. When asked how staff know which physician is on-call, EMP2 stated, "There is one phone number. You call ASP's phone number and they [individual answering the phone] have them [on-call physician] call."

3. When asked, at approximately 10:08 AM on February 14, 2013, if the facility has a specific on-call policy, EMP2 confirmed that the facility does not have a specific on-call policy. EMP2 further confirmed that the facility does not have a policy stating that individual physician names must be identified on the on-call schedule.