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Based on interview and record review the facility failed to follow their own internal policy regarding the development of an on-call schedule based upon patient needs for a particular specialty physician. The facility census was 10.

Findings Included:

1. Review of the facility ' s policy titled, " EMTALA (Emergency Medical Treatment and Labor Act)-Provision of On-Call Coverage, " revised 10/06, showed the following:

- Staff should develop a list of physician specialists available for on-call coverage of the ED in a manner that best meets the needs of the individuals protected under EMTALA.
- Relevant factors considered in determining on-call requirements include the frequency with which the hospital ' s patients typically require services of on-call physicians, and the number of physicians in a particular specialty.
- All relevant factors are considered in determining the on-call requirements for physicians.

Review of facility data (facility collected data from 01/10-12/10 on those orthopedic patients admitted versus those that were transferred) showed 67 total cases presented during that period of time, six of which were admitted, 61 transferred, or 91%. Those 61 transferred received repair of femur fractures, intertrochanteric fractures, etc. and were not identified as being unmanageable or having a different diagnosis than the six patients admitted and treated.

Review of a policy entitled, "EMTALA-Provision of On-Call Coverage," revised 02/09, showed the Board of Trustees is responsible for assuring adequate on-call coverage of specialty services to meet the patient and community needs.

The facility failed to produce evidence they considered all relevant factors when determining the orthopedic suregons would be excluded from taking call.

Review of facility on-call schedules, on 03/10/11, for the prior six months, showed the following:
- The pediatric specialty was represented on the on-call schedule as being covered twenty-four hours daily, seven days a week.
- The obstetric specialty was represented on the on-call schedule as being covered twenty-four hours daily, seven days a week.
- The general/vascular surgery specialty was represented on the on-call schedule as being covered one to four days monthly.
- The orthopedic specialty was not represented on the on-call schedule.

Review of the hospital ' s operating room schedule provided on 3/16/11 revealed an orthopedic surgeon performs surgery in the hospital "all day" on Mondays, Wednesdays and every other Friday, and 12 -3 PM every other Tuesday, and "all day" alternating Tuesdays.

Review of the hospital's surgical schedule from 09/01/10-02/28/11, showed there were 233 total inpatient surgeries, 189 of which were performed by the orthopedic surgeons, or 81% of the total inpatient surgeries performed.

Even though the orthopedic surgeons performed 81% of the inpatient surgical procedures in this facility, the facility failed to follow their policy and identify the extent to which the community required this service and failed to include the orthopedic surgeons in the on-call list of physicians available to provide emergency room patients with further evaluation or treatment to stabilize an orthopedic emergency.

Based on interview and record review the facility failed to ensure the availability of orthopedic on-call physicians in the Emergency Department (ED) in order to meet the needs of the patients in the community. The facility census was 10.

Findings Included:

1. McCune Brooks is a 25-bed critical access hospital whose Medical Staff includes six orthopedic surgeons with core privileges that include the capability to provide care to orthopedic patients ranging from open reduction and internal fixation of fractures, and dislocations of the peripheral skeleton, to joint replacements, to arthroscopic procedures.


Review of the facility ' s policy titled, " EMTALA (Emergency Medical Treatment and Labor Act)-Provision of On-Call Coverage, " revised 10/06, showed the following:

- Staff should develop a list of physician specialists available for on-call coverage of the ED in a manner that best meets the needs of the individuals protected under EMTALA.
- Relevant factors considered in determining on-call requirements include the frequency with which the hospital ' s patients typically require services of on-call physicians, and the number of physicians in a particular specialty.
- All relevant factors are considered in determining the on-call requirements for physicians.

Review of facility on-call schedules, on 03/10/11, for the prior six months, showed the following:
- The pediatric specialty was represented on the on-call schedule as being covered twenty-four hours daily, seven days a week.
- The obstetric specialty was represented on the on-call schedule as being covered twenty-four hours daily, seven days a week.
- The general surgery specialty was represented on the on-call schedule as being covered one to four days monthly.
- The orthopedic specialty was not represented on the on-call schedule.

During an interview on 03/10/11 at 8:35 AM, two ED physicians (Physician A and B) stated the hospital had no orthopedic physicians on-call for the ED patients. There were; however, six independent orthopedic surgeons on their medical staff that did outpatient, elective surgeries in the hospital.

During interviews on 03/10/11 at 9:50 AM, on 03/11/11 at 8:40 AM, and on 04/04/11 at 3:00 PM, the Chief Nursing Officer (CN0) stated the hospital had not had orthopedic on-call physicians for at least eight years. The CNO also stated the six orthopedic physicians that do elective surgeries in the hospital perform approximately 50% of all surgeries performed in the operating room. The CNO stated that the orthopedic surgeons utilize a Physicians' Assistant (PA) to care for their surgical inpatients post-operatively but the hospital did not maintain an on-call list for their services after hours or on the weekends. The CNO stated each orthopedic surgeon has his/her own PA and the nurses know who they are, and can call them after hours and on weekends.

Review of the hospital ' s operating room schedule provided on 3/16/11 revealed an orthopedic surgeon performs surgery in the hospital "all day" on Mondays, Wednesdays and every other Friday, and 12 -3 PM every other Tuesday, and "all day" alternating Tuesdays.

Review of the hospital's surgical schedule from 11/06/10-02/04/11 (about 90 days) showed the orthopedic surgeons had performed three open reductions with internal fixation on three inpatients' femurs (thigh bone).

Review of the hospital's surgical schedule from 09/01/10-02/28/11, showed there were 233 total inpatient surgeries, 189 of which were performed by the orthopedic surgeons, or 81% of the total inpatient surgeries performed.

Even though the orthopedic surgeons performed 81% of the inpatient surgical procedures in this facility, the facility failed to include them in the list of on call physicians thereby limiting the resources available to individuals presenting to the emergency department with an orthopedic emergency.