San Juan Regional Medical Center Inc.

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must 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 of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 47302 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.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47480 Based on observation and record review the facility failed to protect the patient from exposure to disease causing pathogens (microorganisms that cause disease) for 1 (P (Patient) P6) of 11(P1-P11) patients. This deficient practice could likely cause infection, sepsis (a very serious life-threatening medical emergency), or death of all patients in the facility. The findings are: A. Record review of the facility’s policy “Hand Hygiene” “Effective Date: 11/08/2022” revealed: 1. “Hands will be decontaminated by using an alcohol-based hand cleanser ...or soap and water in the following clinical situation: After contact with body fluids or excretions (waste materials like urine or feces) ...wound dressings.” B. During an observation on 02/22/2024, at 1:00 pm of a dressing change performed on P6 by Staff (S)11, Registered Nurse (RN). S11 applied hand sanitizer before entering the room and putting on gloves. S11 placed the open clean dressing packages directly on the patient’s sheet without a barrier (an underpad or disposable sheet used to protect items that are placed on top, like dressings, from what may be on the sheets or bed, like stool). S11 then removed a dressing from a 2 centimeter (cm) (a measure of length) by 2 cm unstageable pressure wound (a type of pressure wound that has a full-thickness skin and muscle loss with dead tissue covering the wound bed preventing the assessment of the true depth of the wound) on the left knee, applied (a brand name wound gel made from honey) with a finger, and placed the new dressing over the wound. S11 then removed the dressing from a 1.5 cm by 1.5 cm P6’s right heel, applied (a brand name wound gel made from honey) with the same finger, and placed a new dressing over the wound. S11 did not change gloves or perform hand hygiene between the dressing changes on the two sites potentially cross-contaminating the right heel wound with pathogens from the left knee wound by using the same gloved finger to apply (a brand name wound gel made from honey). It was later observed that there was stool (feces) leaked from P6 colostomy (an opening in the belly that connects the colon to the skin to empty stool to the outside of the body into a bag) on the sheet where the clean dressing packages were placed potentially contaminating the dressings with stool. Contamination of wounds with pathogens and/or stool could cause infection, sepsis, or death as a result of sepsis.”