Based on review of policies/procedures, medical staff rules and regulations, medical staff roster, on-call physician schedules, and staff interviews, the Critical Access Hospital (CAH) failed to maintain a list of specialty physicians on call to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. The CAH staff identified an average of 128 patients presenting to the ED (Emergency Department) requesting emergency care per month. Failure to maintain a list of on-call specialty physicians available for consultation for ED patients could potentially result in patients not receiving an appropriate evaluation and/or a delay in stabilizing treatment for their emergency medical conditions. Findings include: 1. Review of CAH emergency room policy/procedure titled "Medical Staff Call Coverage", dated 6/2015, revealed the following in part, ". . . One physician shall be available to the emergency care area within thirty minutes through a medical staff call roster. Specialty consultation shall be available per telephone or by transfer to a designated hospital where definitive care can be provided. . . . " Review of CAH emergency room policy/procedure titled "Relationship to other Departments", dated 6/2016, revealed the following in part, ". . . SURGERY PERSONNEL: Two people are on call for surgery each day. They are notified in the event of emergency surgery or when additional personnel are needed in the emergency department. The individuals on call are listed on the physician's call schedule. . . ANESTHESIA: Our anesthetist is on call 24 hours a day for any emergency surgery. . . ." 2. Review of Medical Staff Rules and Regulations, approved May 17, 1999, revealed the lack of a requirement for on-call responsibilities for specialty physicians to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. The Medical Staff Rules and regulations revealed the following in part, ". . . Hospital personnel will be on call for emergency surgery. A published on-call list shall be maintained in the emergency area, surgery area, and all nursing area. . . ." 3. Review of the CAH's Medical Staff roster revealed three general surgeons with surgical privileges at the CAH were listed. Review of the monthly emergency room provider schedules and back up emergency room physician schedules from January 2016 through July 2016 did not reveal a general surgeon nor was anesthesia provider listed on the on-call list. Review of "Western Iowa Surgery" Call List for July 2016, provided by Staff F, Advanced Registered Nurse Practitioner (ARNP), on 7/25/15 at 5:05 PM, revealed one of three general surgeons listed as on call for each day as described by Staff F. 4. During an interview on 7/21/16 at 7:50 AM, Staff B, Physician, stated the facility has a surgeon out of [another town] we can call for when requested for a consult with an emergency patient and when they are asked to come they come. During an interview on 7/25/16 at 11:20 AM, Staff F, ARNP, stated the facility has a surgeon and anesthesia provider on call. During an interview on 7/25/16 at 11:55 AM, Staff G, Physician, stated the facility has a surgeon available for emergency surgery conditions. During an interview on 7/25/16 at 4:30 PM, Staff A, Chief Nursing Officer (CNO), and Staff H, Chief Operating Officer (COO), stated the following when asked about a surgeon's call schedule - both staff replied they do not have a surgeon call schedule. The surgeons are out of [another town] and if they need emergency surgery here they call them to see if they can come. Staff A and Staff H stated that surgery group performed scheduled surgeries at this hospital. During a further interview on 7/25/16 at 5:05 PM, Staff F, ARNP, stated there was a July 2016 surgery call list of surgeon on call from [another town] that the facility can call if emergency surgery was needed and provided a copy of that call list. Staff F stated the types of emergency surgeries performed at the hospital included acute appendectomy, emergency wound closure, and acute bowel obstruction. Staff F stated have nurses listed on call for surgery. Staff F stated have anesthesia on call but there was not a list as they always use the same group. During an interview on 7/25/16 at 5:15 PM, Staff A, CNO, stated the types of surgeries that were done at the facility on an emergency basis included appendectomy and lithotripsy. Staff A acknowledged surgical nursing staff were on call for emergency surgery and have those staff listed on the call schedule. Staff A further stated have Certified Registered Nurse Anesthetist (CRNA) group that the facility used for planned surgery. The CRNAs are not paid to be on call so there is not a call schedule for CRNAs. Staff A, when asked about a call list to include surgeons, replied the surgeons were not technically on call for this facility because they are on call for [another town]. Staff A stated if there is an emergency surgery needed the facility staff try to call these surgeons, who were credentialed here and do scheduled surgeries here, to see if they were available and if so the surgeons would come to this facility and if not available the patient would be transferred. Staff A acknowledged this facility did not maintain a call list to verify which surgeon was on call and when. Staff A acknowledged the lack of any policy/procedure that addressed a requirement for on-call responsibilities for specialty physicians to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition.