Based on medical record review, document review and interview, in one (1) of 20 medical records reviewed, the facility failed to have written policies and procedures to ensure that the care needs of patients are met when on-call physicians are permitted to schedule elective surgery with their on-call duties (Patient #1). This failure may result in delay care of patients requiring evaluation and treatment by on-call physicians. Findings include: Review of medical record for Patient #1 identified a six (6) year old who presented to the Emergency Department (ED) on 5/09/18 at 3:45 PM after a fall. A full x-ray revealed multiple fractures of the right arm. At 5:30 PM, the ED physician's notes revealed she had a phone call consult with Staff C, orthopedist who "agreed to evaluate the patient in the ED for cast, consulted anesthesia. Anesthesia evaluated patient and then re-discussed case with orthopedist at which time the decision to transfer the patient was made." The patient remained in the ED until 10:00 PM when he was transferred to another hospital. There was no documentation in the medical record that the orthopedist examined the patient. Review of the on call schedule revealed Staff C, an orthopedist was on-call for the ED on 5/09/18 from 7:00 AM - 7:00 PM. During an interview conducted on 7/16/18 at 12:30 PM, Staff C stated that he was operating on elective patients in the operating room on 5/09/18 until about 9:00 PM - 10:00 PM and that he was the orthopedic consultant for the ED on 5/09/18. Staff C acknowledged that he did not go to the ED to examine Patient #1 on 5/09/18. When questioned about ED emergencies while he is operating, he stated he would see patients between cases. Review of the facility's rules and regulations and bylaws revealed there was no protocol or direction for consultations in the ED. The facility did not have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because the physician is in elective surgery simultaneously with their on-call duties. This finding was shared with Staff A, the Director of Quality on 7/13/18 at approximately 3:00 PM. .

Based on medical record review, document review and interview in seven (7) of 24 medical records reviewed, it was determined the facility failed to maintain a central log of each patient who presented to the facility for emergency care. This was evident for Patients #s 2, 3, 4, 5, 6, 7 and 8. Findings include: Review of the dedicated emergency department (ED) log revealed: Patient #2 (MDS) dated [DATE] with a complaint of suicidal ideation. There was no documentation of the patient's name or medical record number in the ED log. Patient #3 (MDS) dated [DATE] because she wanted to kill herself. There was no documentation of the patient's name or medical record number in the ED log. Similar findings were noted to be missing information in the ED log for Patients #4, #5, #6, #7 and #8. The facility's policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA) last reviewed 4/13 states "a 24-hour log is maintained reflecting medical record number, name, age, gender, date, time and means of arrival." This finding was shared with the Staff A, the Director of Quality on 7/16/18 at 3:30 PM.