HospitalInspections.org

Based on interview and review of clinical records, Medical Staff Bylaws, Rules, and Regulations it was determined that the facility failed to provide medical services, according the to the Bylaws, to meet the needs of the patients for one (#1) of three records reviewed. This practice does not ensure patient goals and safety are maintained.

Findings include:

1. Patient #1 History and Physical dated 12/27/09 indicated the presence of a large cyst on the right neck with serosanguineous drainage, drains with the same drainage, and multiple staples on the right flank. The History revealed a recent discharge from another acute care facility for facial reconstruction with a skin muscle flap over a titanium jaw.
Review of attending physician admission orders dated 12/27/09 did not reveal evidence of orders for wound care, care of the staples, or the drains.
Review of wound care nurse documentation dated 12/29/09 at 2:30 p.m. revealed the presence of a hematoma between incision, staples, and the presence of old blood oozing. The recommendation was for a surgeon to evaluate.
Physician order dated 12/29/09 at 6:00 p.m. instructed for a plastic surgery consult. Physician orders dated 12/29/09 at 8:15 p.m. instructed to consult a specified plastic surgery for the skin flap open area and consult general surgery for a hematoma.
Review of computerized consult request noted the consult to the plastic surgeon was entered on 12/29/09 at 10:08 p.m. Review of the general surgeon noted the request for consult was made on 12/30/09 at 5:32 a.m.
Review of surgeon consult notes dated 12/30/09 noted the surgeon was signing off the case. The documentation noted the care would be better handled by a plastic surgeon and that the general surgeon was not comfortable with the case. There was no evidence of the plastic surgeon consult being conducted.
Interview with a Registered Nurse on 1/15/10 at approximately 4:20 p.m. revealed the plastic surgeon's office was called on 12/29/09, 12/30/09, and 12/31/09 and was then informed the surgeon was not available.
Review of Medical Staff Bylaws and Rules and Regulations dated 7/09 revealed if a consult is called to a physician not on call they may refuse the request. If the request is refused, as soon as the decision is made not to accept the consult, it is the physician's "responsibility to directly notify the requesting physician".
Interview with the Chief Nursing Officer on 1/15/10 at approximately 3:40 p.m. revealed the specified plastic surgeon had refuse to see the patient on 12/29/09 and there was no other plastic surgeon on call. Review of the physician on call list revealed there were no plastic surgeons on call from 12/27/09 to 12/31/09.
Physician orders dated 12/30/09 instructed to discharge in the morning with home health care and to follow up with the original surgeon.
Physician progress note dated 12/20/09 revealed the family member was upset with the plastic surgeon not seeing the patient.
Physician orders dated 12/31/09 at 12:15 p.m. instructed to call the same plastic surgeon for a consult STAT and for wound care.
The interviews and review of documentation indicated the plastic surgeon failed to notify the attending physician of the refusal of the case per the Bylaws Rules and Regulations. The attending physician failed to ensure wound care needs were met and find alternative wound care when a consult was not performed.

Based on interviews and review of clinical records, the Registered Nurse failed to supervise and evaluate nursing care for two (#1, #3) of three patients reviewed. This practice does not ensure patient goals are achieved.

Findings include:

1. Patient #1's nursing Admission Database dated 12/27/09 showed the presence of the wounds on the jaw, neck, and right flank with serosanguinous drainage, staples, and drains.
Review of attending physician admission orders dated 12/27/09 did not reveal evidence of orders for wound care, care of the staples, or the drains. Review of nursing documentation did not show evidence of the nurse contacting the attending physician for orders.
Nursing documentation dated 12/29/09 at 3:45 a.m. indicated the muscle flap to the right neck had open areas the wound was covered, and the physician was to be notified in the morning.
Review of wound care nurse documentation dated 12/29/09 at 2:30 p.m. revealed the presence of a hematoma between incision, staples, and the presence of old blood oozing. The recommendation was for a surgeon to evaluate. Physician orders dated 12/29/09 at 8:15 p.m. instructed to consult a specified plastic surgery for the skin flap open area.
Review of consults did not show evidence of the plastic surgery consult being conducted.
Interview with a Registered Nurse who cared for the patient on 1/15/10 at approximately:20 p.m. revealed the consulting physician office was called on 12/29/09, 12/30/09, and 12/31/09 and the attending physician was notified on 12/31/09 that the consult would not be performed.
Review of nursing documentation did not reveal evidence of the plastic surgeon's office being called on 12/29/09 or 12/30/09. The nursing documentation did not contain evidence of the wound needs being supervised, evaluated, or coordinated by the Registered Nurse.

Review of nursing assessments did not show evidence of assessments of the wounds being performed on 12/28/09,

Review of graphic sheet and nursing notes documentation from 12/27/09 to 12/31/09 did not show evidence of the patient receiving the physician ordered tube feeding on 12/30/09 evening shift or the night and day shift of 12/31/09.


2. Patient's #3's admission database dated 12/27/09 indicated the presence of am indwelling suprapubic urinary catheter that was changed every three weeks. The notation stated the urinary catheter was to be changed tomorrow 12/28/09. Review of the History and Physical revealed a diagnosis of a Urinary Tract Infection. Review of nursing documentation dated 12/28/09 and 12/29/09, the date of discharge, did not show evidence of the urinary catheter being changed. Review of the nursing and physician documentation from admission to discharge did not reveal evidence of the Registered Nurse informing the physician of the need to change the Suprapubic urinary catheter on 12/28/09.