HospitalInspections.org

Based on medical record review, staff interview, and facility document review, it was determined that the Governing Body failed to ensure that all medical staff respond to a requested Emergency Department [ED] consult within 20 minutes, in accordance with the facility Medical Staff Rules and Regulations. (Cross Refer Tag A0048)

Based on one (1) of ten (10) medical records reviewed, staff interview, and facility document review, it was determined that the facility failed to ensure that all staff respond to an Emergency Department [ED] consult request within 20 minutes, in accordance with the facility Medical Staff Rules and Regulations.

Findings include:

Reference: Facility document titled, "Medical Staff Rules and Regulations" states, "... 4.4 In the event that a physician is unavailable it is the responsibility of that physician to arrange for coverage for their practice. ... Facility document titled, "Medical Staff Rules and Regulations" states, " ... 4.10 Physicians are expected to respond to all calls by phone or in person from anywhere in the hospital (excluding the Emergency Department. (See 10.1) within 30 minutes of being called. ... PART TEN: Emergency Department Requirements 10.1 Physicians who do not respond within 20 minutes should be subject to disciplinary actions ... 10.4 If a particular specialty is not available or the on-call physician cannot respond due to circumstances beyond his/her control, the respective Department Chair will be called ..."

1. A review of Medical Record #1 conducted on 12/15/20, revealed the following:

a. Patient #1 arrived in the ED on 11/14/20 at 3:50 PM, with complaints of abdominal pain and constipation.

i. At 1840 [6:40 PM], a portable chest x-ray result indicated, "free air under diaphragm ..."

ii. At 2012 [8:12 PM], ED Course documentation stated, "Received call from radiology, patient has pneumoperitoneum and colitis."

iii. At 2057 [8:57 PM], a CT Scan of the abdomen and pelvis result stated, " ... 2. Moderate pneumoperitoneum."

iv. Documentation under "Medical Decision Making" stated, "Perforated Bowel" and "Septic Shock".

b. A phone order dated 11/14/20 at 1839 [6:39 PM] indicated, "Phone call to PCP [primary care physician] Please call: [name of PCP] ..." There is documentation under "phone call order," that the ED Unit Assist called Staff #14 (the PCP), at 1840 [6:40 PM], 1852 [6:52 PM] and 1901 [7:01 PM].

i. ED documentation indicated that Staff #13, an ED Physician, spoke with Staff #14, at 1902 [7:02 PM]. Documentation under ED notes stated, "... ED Course as of Nov [November] 14 1921 [7:21 PM] ... D/w [discussed with] [PCP] adv [advised] [name of preferred surgeon] for consult ..."

c. A phone order dated 11/14/20 at 1903 [7:03 PM] stated, "Phone call to PCP Please call: [name of preferred surgeon for consult] ..."

i. There is documentation indicating Staff #11 (an ED Unit Assist) called Staff #8, the preferred surgeon, at 1904 [7:04 PM], 1909 [7:09 PM], 2050 [8:50 PM] and 2139 [9:39 PM].

ii. There is no evidence that Staff #8 responded to the ED's consult (call) request at 1904, 1909, 2050 and 2139, in accordance with the facility Medical Rules and Regulations.

iii. There is no evidence that the Department Chair was notified when the requested physician did not return the ED's call.

d. Staff #1, an ED Physician, documented in the "ED Notes" dated 11/14/20 at 2049 [8:49 PM], "Medical Decision Making: From previous ED attending, patient has pneumoperitoneum on cxr [chest x-ray] and [the name of the PCP] called to admit the patient. [name of PCP] requested transfer to [initials of another facility], as there are no icu [intensive care unit] in [initials of ED facility], requested [PCP preferred surgeon] (surgery) be consulted. However, there was a delay in care and surgery did not call back. ..."

e. On 12/15/20 at 1:00 PM, Staff #3 confirmed the above findings.

2. On 12/15/20, during staff interviews, the following was revealed:

a. At 10:17 AM, Staff #12, an ED Unit Assist, stated, "When the order for a consult or call order is placed in the computer, I will call the requested physician. I wait 20 minutes and if no call back then I call again. This process is repeated until an hour has passed. The ED physician is notified if there is not a call back within the hour."

b. At 1:00 PM, Staff #3 stated that the consult call procedure is to call the PCP and see who they would like called, and then call that physician, wait 20 minutes and if no return call, continue calling every 20 minutes, up to an hour, before escalating to the head of the department.

c. On 12/16/20 at 10:50 AM, during interview, Staff #6 stated that all physicians or the covering physician for the practice, are called for a consult in the ED, and must respond within 20 minutes.

i. Staff #6 confirmed that the physician who was called for a surgery consult (Staff #8), for Patient #1, did not return the call on 11/14/20.

3. The above findings were confirmed with Staff #1 and Staff #2.

This finding resulted in an Immediate Jeopardy (IJ) because the delay in care placed the patient with a perforated bowel at risk for harm when the surgeon failed to respond to the facility. The Administrator was informed of the IJ and was provided with the IJ Template on 12/16/20 at 2:03 PM.

On 12/18/20, the facility submitted an acceptable Removal Plan for the Immediate Jeopardy findings. The facility developed educational information for ED team members involved, with provider notifications and return calls. Interviews with ED staff indicated that staff education has been completed for key staff members involved in provider notification. Ongoing efforts to educate all ED staff prior to their next scheduled shift is in progress. As a result, the Immediate Jeopardy for Tag A0048 was removed.

Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that everyone entering the facility are provided a screening to identify and isolate Coronavirus Disease 2019 (COVID-19) in accordance with policy and procedures and Centers for Disease Control (CDC) guidelines.

Findings include:

Reference #1: CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel [HCP] During the Coronavirus Disease 2019 (COVID-19) Pandemic Infection Control Guidance (updated December 14, 2020) states, " ...Recommended routine infection prevention and control (IPC) practices during the COVID-19 Pandemic ...Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19 ...Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control. Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19, absence of a diagnosis of SARS-CoV-2 infection in the prior 10 days, and confirm they have not been exposed to others with SARS-CoV-2 infection during the prior 14 days."

Reference #2: Facility document,"Facility Entrance Screening During a Pandemic or Epidemic Policy" states, "1. Entrances to the facility will be limited as needed for screening purposes. 2. Entrance door will be covered by a trained screener ...6. All persons entering the facility will have their temperature taken."

1. Upon entrance to the facility, in the Main Lobby, the following events occurred:

a. On 12/14/20 at 9:30 AM, this surveyor and four (4) other surveyors were greeted by Staff #25, instructed to stand for a thermal temperature reading, informed of temperature, and directed to wait at the information desk.

b. On 12/16/20 at 9:15 AM, this surveyor and four (4) other surveyors were greeted by Staff #25, instructed to stand for a thermal temperature reading, informed of temperature, and directed to wait at the information desk.

c. Staff #25 did not ask any screening questions to assess for symptoms of COVID-19 or exposure to others with suspected or confirmed SARS-CoV-2 infection on either date listed above.

2. On 12/14/20 at 12:08 PM, an interview with Staff #15 revealed that there are three (3) designated entrances into the facility; the main entrance, physician entrance, and employee entrance.

a. On 12/14/20 at 12:20 PM, during a tour with Staff #2, it was revealed that the employee entrance was not covered by a trained screener.

i. Upon interview with Staff #2, he/she stated that employees are required to self-screen on their respective work units, document temperatures, and lack of COVID-19 signs and symptoms.

ii. At 10:05 AM, during a tour of the Special Care Unit "Gold 5", a review of the Staff Self Screening Log revealed that for six (6) of fifteen (15) days in the month of December 2020, temperature screening or absence of signs and symptoms for COVID-19 for staff members were not documented.

iii. The above findings were confirmed with Staff #31 and Staff #45 on 12/15/20 at 1:20 PM.

b. On 12/14/20 at 12:22 PM, a tour of the physician entrance revealed that the entrance was not covered by a trained screener. Signage located on the door directed staff to self-screen temperatures and absence of signs and symptoms of COVID-19.

i. Facility policy, "Facility Entrance Screening During a Pandemic or Epidemic Policy", does not include a practice for staff to self-screen for COVID-19.

ii. On 12/15/20 at 1:20 PM, Staff #31 and Staff #45 confirmed there was no policy for self screening of staff.

iii. Staff #31 and Staff #45 stated that education on self-screening for staff was not written or documented.

iv. The above findings were confirmed with Staff #2 at 1:52 PM.