HospitalInspections.org

Based on record review and interview the facility failed to have written policies in place for when there is no provider available to be scheduled for call coverage. This deficient practice could possibly lead to all patients not receiving the care they need when presenting to the emergency department.

The findings are:

A. Record review of the facility's Medical Staff Bylaws dated 11/2023 on page 6 under, " ...Obligations of Active Status [active member of the medical staff of the hospital]" stated, "Each member of the Active Staff shall: ... (d) serve on the on-call roster for the purpose of assignment to service or charity patients and for providing backup specialty coverage in the ER [Emergency Room] ..." No evidence was found on what the facility will do if there is no provider available to be scheduled for call coverage.

B. Record review of the facility's Medical Staff Rules and Regulations dated 11/2023 on page 4, Article 2 stated, "Unless specifically exempted by the medical executive committee for good cause shown, each member of the Active and Active Non-Admitting Staff [medical staff that do not have admitting privileges at the hospital], except full time. . . physicians will be assigned in rotation to a back-up call schedule for the Emergency Department. Fulfillment of this assignment shall be a prerequisite to Staff appointment and re-appointment. The establishment of ad hoc specialty [specialty when needed] and subspecialty [specialty that is part of a larger specialty] call schedules is encouraged as a means to provide proper back-up to the emergency department. However, in the event of a conflict, the doctor on the formal ER back-up call schedule is responsible for providing or arranging for appropriate care for the patient requiring inpatient care - either in this hospital or another facility capable of caring for the patient. If there is a conflict with the published schedule, it is the staff member's responsibility to notify the applicable department chairman and the emergency room director at least 48 hours prior to the scheduled rotation." No evidence was found on what the facility will do if there is no provider available to be scheduled for call coverage.

C. Record review of the facility's policy titled, "EMTALA [Emergency Medical Treatment and Labor Act] - Rules for Emergency Department Call Coverage" dated 01/25/2021 stated, "The ED [Emergency Department] is staffed by emergency physicians with whom Hospital has entered into a contract for continuous physician coverage of the ED on a twenty-four hour a day, seven day a week basis. An ED Unassigned Call Schedule ("Unassigned Call Schedule") has also been established for the purpose of providing specialty coverage for emergency patients in accordance with federal law and the EMTALA policy; and to offer emergency treatment to patients beyond that which can be provided by the ED physicians." This policy included what to do if a physician on-call does not respond to a call or is not available, it did not provide a written process on what to do if a specialty is not available due to lack of available providers.

D. Record review of the facility's document titled "Transfer Log" from 10/1/2024 through 10/15/2024, revealed there were 20 patients denied for transfer into the facility because there was no provider available for call coverage for services normally offered by the hospital like Gastrointestinal (GI, intestinal tract), ENT (Ear, Nose, Throat), Plastic surgery (offered for reconstruction after an injury), and Neurology (brain and nervous system).

E. During an interview on 10/17/2024 at 11:40 AM with S(Staff)1, non-clinical, S1 confirmed that the hospital did not have a written process for when there is no provider available to be scheduled for call coverage. S1 explained that the hospital will not accept transfer patients when a specialty physician in not available. This facility was not able to provide any other documentation such as contracts to clarify on-call requirements.