HospitalInspections.org

Based on a review of medical records (MR) and interview with staff (EMP) it was determined the facility failed to ensure the patient's right to have the family member and primary care provider notified upon admission to the hospital for 10 of 10 medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9 and MR10).

Findings include.

A review on December 19, 2016, of the "Statement of Patient Rights" did not list the right to have the family member of physician notified promptly of admission to the hospital.

Review on December 19, 2016, of MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9 and MR10 revealed that these patients were admitted to the hospital. There was no documented evidence patients were asked if they wanted their family member and primary care provider notified of their admission to the hospital and/or that their primary care physician was notified by the facility of the patient's admission to the hospital.

An interview conducted on December 19, 2016, at 10:30 AM, with EMP1 confirmed there was no documented evidence currently contained in the medical records to ascertain if the patients desired to have their the family member and primary care provider notified upon admission to the hospital.

Based on a review of facility policy, medical records (MR) and interview with staff (EMP) it was determined the facility failed to provide good quality care when they failed to provide timely wound management and/or consultation with the operating surgeon for one patient (MR10).

Findings include:

A review on December 19, 2016, of the facility policy "# 601 Patient Bill of Rights" revealed, " ... Wellspan Health will strive to uphold the rights of patients as described in the Statement of Patient's Rights ... "

A review completed on January 5, 2016, of MR10 by a Department of Health Physician revealed MR10 was a 69 year old male who had a revision of the left hip replacement on October 24, 2016, and was admitted to Wellspan Surgery and Rehabilitation Hospital on October 28, 2016, for rehabilitation. Further diagnosis included Congestive Heart Failure, Hypertension, Hyperlipidemia, Three Vessel Coronary Artery Disease and Diabetes Mellitus. A review of the History and Physical dated October 28, 2016, revealed, " ... placed on aspirin and Plavix for deep venous thrombosis prophylaxis ... left hip has a lateral surgical bandage that is clean and dry ... "

Futher review MR10 revealed the patient had physician orders on October 29, 2016, at 0900 for the following medications which have anticoagulant effect: Aspirin 81 milligrams (mg) orally once daily, Plavix 75 mg orally once daily and Enoxaparin 40 mg by sub-cutaneous injection daily. Further review of physician orders for October 29, 2016, at 18:38 for MR10 revealed, " ... Notify Provider (for significant leakage; signs or symptoms of infection; general wound deteriorate) ... "

Review of Nursing Progress notes for November 3, 2016, at 3:52 PM revealed, " ... dressing to left hip incision CDI ... " Review of Nursing Progress notes for November 5, 2016, at 3:13 PM revealed, " ... Dressing to left hip saturated with serous drainage ..." Further review of Nursing Notes for MR10 dated November 6, 2016, at 4:27 PM revealed, " ... Dressing to left hip changed this afternoon due to a large amount of serous drainage ... Spoke with wife in regards to pts OSS follow up appt that was scheduled for 1515 on 11/7. Did not see order for appt. Spoke with secretary and no transport arranged. Informed wife we will call OSS in the am and speak with Dr. [name redacted] to see if appointment necessary or can be rescheduled after discharge ... "

Review of the Physician Progress note for November 7, 2016, at 22:58 revealed " ... patient developed increase serosanguinous drainage from left hip wound today ... Will arrange Ortho follow f/u at OSS ... "

Review of the Physician Discharge Summary for MR10 revealed " ... Ultrasound showed a fluid collection consistent with hematoma. ... The plan is for the patient to be discharged from Wellspan Surgery and Rehabilitation Hospital and his wife will take him to OSS where he will undergo outpatient incision and drainage procedure of the left hip hematoma by Dr. [name redacted]... "

An interview conducted on December 19, 2016, at 10:33 AM with EMP1 confirmed that the follow-up appointment for MR10 "was missed ... I don't know why this happened."