HospitalInspections.org

Based on a review of the clinical record, the chief executive officer was not responsible for managing the hospital.

Findings were:

During a review of the clinical record for patient #1, it was revealed that patient #1s stay at Scott & White Hospital from 4-21-10 to 4-26-10 was classified as "observation".

Hospital policy and procedure titled Utilization Review Policy - Attachment E states, in part, " Patients on Observation status that do not meet Inpatient criteria within 48 hours are sent o the Case Management Director/URC Designee for review. Pertinent information is listed on Observation review in ClinTrak documentation system. In the case where a patient does not meet Inpatient criteria within 48 hours, and the Attending Physician requests continued hospital Observation the UR Nurse may call selected Physician Advisor of a like service on the UR Committee for review. The URC Physician Advisor may discuss findings with Attending Physician. If the PA of Attending Physician does not concur the Chief Medical Officer is notified for further discussion of the case. Determination for Medical Necessity is determined within 24 hours. Patient will be discharged or admitted as an Inpatient depending on findings. Observation cases will be tracked and monitored daily by Case Management Director and UM Manager. "

By keeping the patient in "observation" status greater than 72 hours, the CEO responsible for managing the hospital failed to ensure that the facility enforced their own policy regarding patients on observation status.

The above was confirmed in an interview with the Chief Nursing Executive and the Chief Medical Officer on the afternoon of 9-20-10 in the administrative area conference room.