HospitalInspections.org

Based on clinical record review and staff interview, it was determined the governing body failed to ensure the medical staff is accountable to the governing body by enforcing adherence to the By-Laws and facility procedures/protocol in the delivery of quality care provided to patients.

The findings include:

1. Record review for patient #1 reveals nursing notes on 1/1/10 as follows:
8:00 PM: patient complains of nausea and vomiting unrelieved by 3 doses of the ordered medication, Zofran; physician on call to be paged;
9:00 PM: Dr #5 called and case discussed; stated that he is not on call and Dr #3 should be paged;
9:39 PM: text message to Dr #3;
10:22 PM: no response to text, repeat page sent out; patient resting quietly though still complains of nausea;
11:00 PM: repeat call to Dr #3;
12:15 AM: no response from Dr #3, text to Dr #6;
1:00 AM: no response; repeat page sent out to Dr #6;
1:20 AM: call received from Dr #6 and new orders for Compazine and Tylenol.

During an interview with the RM (risk manager) on 04/01/10 at 3:15 PM, he was asked about nursing attempts to contact a physician for this patient, without response, from 01/01/10 at 8:00 PM through 01/02/10 at 1:00 AM. The risk manager responded that physicians are expected to respond to calls/pages within the hour; if the physician does not respond, nursing is to report to their direct supervisor, who will contact a physician and report the non-responsive physician to nursing management; nursing management will report to the Medical Director and/or the Department Head, who will speak with the offending physician; if a pattern emerges or it is affecting patient care, the physician will be referred to the Medical Executive Committee.

2. Record review for patient #4 reveals documentation of a case evaluation by Dr #3 on 01/01/10 at 10:31 AM. At 11:00 AM, the nurse documented that the patient is requesting to speak with the Internal Medicine doctor, and Dr #3 was paged; at 11:30 AM, the nurse documented that Dr #3 was on the floor and was made aware of the patient's request; a nursing note at 2:00 PM documents that the nurse spoke with Dr #3 and made him aware that the patient was extremely frustrated that he has not seen him today; Dr #3 states that he will be in to see the patient. At 4:15 PM, the nurse documented that the patient remains upset that he has not been seen by Dr #3; repeated pages to Dr #3 remain unanswered.

3. It was identified in both of the above examples that Dr. #3 failed to respond to pages over an extensive period of time. In both circumstances, other physicians had to be sought for a response.

Nursing documentation for 01/01/10, regarding repeated requests from patient #4 to see Dr #3, indicate that the patient did request to speak with someone in administration and administration did come to the floor to see the patient. The nursing documentation indicates that administration did contact Dr #3 and were informed that he was waiting for test results before speaking with the patient and that nursing had been instructed to contact him when these test results were available. It is clear in the 01/01/10 nursing notes that when Dr. #3 was made aware (for the second time) that the patient was extremely frustrated that he had not yet been seen by Dr #3, the doctor responded that he would be in to see the patient. There is no evidence in the nurses notes that Dr #3 made the nurse aware that he was awaiting test results before speaking with the patient. In fact, documentation of the nurse's repeated unanswered attempts to contact Dr #3, provide evidence to the contrary. It is to be noted that Dr. #3 failed to answer these repeated calls/pages to ascertain if the continued calls were for clinical reasons other than the patient's request to see him.

Additional staff interviews conducted on 4/1/10 between 3:30 PM and 4:30 PM disclosed the following:

The Director of Telemetry states that the attending physician is expected to see the patient at least daily and is expected to return calls within the hour; if a physician is not meeting these expectations, it is reported through the chain of command and, if significant, an incident report would be completed and sent to Risk Management. She states that she is aware of no complaints regarding Dr #3.

The Director of Internal Medicine states that if a physician is not seeing patients or responding to calls/pages, the complaint would be forwarded to the Department Chair, who would address the physician. He states that if there is a significant pattern or an adverse affect
to patient care, the physician would be referred to the Medical Executive Committee. He states that he is aware of no complaints related to Dr #3.

The RN House Supervisor states that physicians are expected to see patients daily and respond to calls/pages within the hour. She states complaints of physicians not meeting these expectations would be forwarded to their immediate supervisor. She states that she does
recall one patient who was upset because Dr #3 would not come in to discharge so that the patient could fly back to New York but does not recall the patient's name.

A 4th floor RN charge nurse states that physicians are expected to see patients daily and respond to call/pages within an hour. She states that physicians not meeting these expectations would be reported through the chain of command. She states that she is aware of no complaints regarding physician's not seeing patients and is aware of no complaints regarding Dr #3.

A 4th floor RN states that physicians are expected to see patients daily and respond to call/pages within an hour. She states that physicians not meeting these expectations would be reported through the chain of command. She states that she does recall one patient who was upset because Dr #3 would not come in to discharge so that the patient could fly back to New York but does not recall the patient's name.

The Chief Medical Officer states that physicians not seeing patients on a daily basis or not responding to calls/pages would be referred to the Department Chair; if the issues became a pattern or were affecting patient care, it would be referred to Risk Management, Peer
Review and/or the Office of Professional Services. He states that if such a complaint comes to him and there is no pattern or adverse patient effect, he will speak with the physician and remind him/her of the hospital policies. He states that he is not aware of any complaints related to Dr #3.

An ER physician states that he is aware of no complaints related to Dr #3.

Record review for patient #4 reveals a case evaluation note documented by Dr #3 on
01/01/10, although other documentation in the clinical record make it apparent that Dr #3 did not see the patient on 01/01/10. Review of this case evaluation note reveals physician documentation of a review of the patient's case, lab work, etc but makes no claim that the physician saw the patient. Policy does, as reported by staff, require the physician to see patients daily.

Staff interviews indicate consistency in all "not being aware of complaints against Dr #3," however, the following is to be noted:
During an interview with the Risk Manager on 04/01/10 at 4:45 PM, he states that the hospital's compliance department is currently conducting an internal audit of patient records for Dr's #3 and #4. This bears evidence that the facility has been made aware (source unknown at this time) of concerns regarding Dr #3. In addition, clinical nursing notes dated 01/01/10 document that patient #4 spoke with someone in Administration and Administration did respond. At the time of this survey, no evidence was found or provided to indicate that the facility's governing body has taken steps to address the reported and documented problems involving Dr #3. No documentation was found or provided to indicate that an investigation was conducted into patient #4's complaint to Administration of not being seen by Dr #3, as is required under Patient Rights/Grievances (verbal / written) at 42 CFR part 482.13(a)(2) which specifies the governing body's responsibility for the effective operation of the grievance process, and 42 CFR part 482.13(a)(2)(ii) which requires the grievance
process to have time frames of the grievance and the provision of a response.

No interview was conducted with Dr. #3 as he was reportedly on vacation at the time of this survey.