HospitalInspections.org

Based on review of facility documents and staff interviews (EMP), it was determined that the facility failed to require the Medical Staff to have written policies and procedures to provide a clear delineation or responsibility for providing on call services by the active Medical Staff, as demonstrated by lack of inclusion of the minimum call requirements in the medical staff rules and regulations.

Findings include:

Review of Medical Staff Rules and Regulations dated August 31, 2011 revealed, "2.2 UNASSIGNED EMERGENCY PATIENTS The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that for all patients who present to an Emergency Department, the Hospital must provide for an appropriate medical screening examination within the capability of...2.2.1 Definition of Unassigned Patient: Patients who present to an Emergency Department and require admission and/or treatment shall have a practitioner assigned by the Emergency Department physician if one or more of the following criteria are met: ...d. The practitioner has the ability to see the patient within a timeframe in compliance with medical staff guidelines. e. The patient's needs falls within the practitioner's delineated scope of privileges."

1. Further review of Medical Staff Rules and Regulations, dated August 31, 2011, revealed no inclusion of specialists on call requirements. Interview with EMP5 on August 9, 2012 at 3:50 PM confirmed that the current rules and regulations do not include a statement or policy regarding specialists on call requirements. EMP5 stated, "There is an old policy, from 2009 but it was not included in the revision of the rules and regulations. It should have been." When asked how physicians would access this information, EMP5 stated that the information would be given to them as needed.

2. Review of the above-mentioned policy, "Minimum Call Requirement Policy" dated 10/22/2009 on August 10, 2012, revealed, "Purpose: To provide services to patients .... and to provide a clear delineation of responsibility of active medical staff. Policy Statement The minimum requirement for call for Active Medical Staff is one in four for performing emergency service, accepting unassigned patients or performing consults in each specialty or sub-specialty in which privileges are held. For any physician whose primary practice is at another facility, as defined by Medical Staff Bylaws Article 12.9-1(b), the minimum requirement for call is four days per month. ..."

3. Review of Medical Staff Bylaws Article 12.9-1(b) revealed, ".... Meeting attendance requirements for Active Staff are waived at BRMC [Bradford Regional Medical Center] along with voting privileges if documentation is provided that (a) their primary hospital is not BRMC ...." Further interview of EMP5 on August 20, 2012, when asked how it is determined where a physician's primary practice is located, revealed, "They pretty much tell us. OTH2 prefers to work at Olean because they give him/her 2 [OR] rooms when he/she is doing surgery. OTH3 prefers to work at Kane." When asked how a representative from an outside agency could tell from the credential file where a physician's primary practice is located, EMP5 responded, "You couldn't."