HospitalInspections.org

Based on document review and interview, the governing body failed to ensure the medical staff was accountable for the quality of care provided to one (1) patient (C#1).

Findings:

1. At 10:30 AM on 09/07/10, review of policy #ADM 2.06, Event Reporting, Page 3 of 4, Management, C. indicated "Issues associated with members of the Medical Staff will be referred to the appropriate Section for investigation as part of the peer review process."

2. Review of Medical Staff Rules & Regulations, Policy # MS 1.02, page 6, 800., Response to Urgent Situations indicated "It is the responsibility of all members of the Medical Staff who provide patient care to quickly and accurately resolve immediate and urgent clinical concerns. If a clinical concern is not resolved, the healthcare professional will follow the chain of command until the issue is resolved."

3. Review of Incident Summary for incident on 02/26/10 at 6:35 AM indicated the web based report was entered by S#6, who wrote that at 6:45 AM, S#6 spoke by phone with MD#2 regarding patient's deteriorating condition, increased shortness of breath (SOB) and pain. MD#2 indicated a call would be made to a pulmonologist (MD#4). At 6:55 AM, after patient had received Morphine 4 mg IVP, S#6 again spoke via phone with MD#2, expressing concern for increasing SOB. Ativan was ordered and it was indicated that MD#4 "would be in to see the pt ASAP." At 7:13 AM, S#6 spoke with MD#4, who advised to call MD#3 as "he is in-house." Call to MD#3 placed at 7:15 AM and returned at 7:19 AM. MD#3 stated "this pt has been here since the 22nd so what is the emergency" The web based report indicated Nurse Manager Comments as "reviewed" and lacked Risk Management Comments.

4. Review of Acute Care Quality and Safety Committee Agenda for April 14th, 2010 indicated Event Report Summary, which included incident report related to C#1, for February/March 2010 was presented by S#1, but lacked any action/recommendation/follow-up.

5. Review of Adult Medicine Standards Committee Minutes (Quality Assurance/Performance Improvement) for April 2010 indicated a mortality case was reviewed (C#1), but lacked any action/recommendation/follow-up.

6. At 1:50 PM on 09/07/10, review of C#1's medical record Progress Notes for 02/26/10 indicated lack of documentation that C#1 was seen by a physician between 6:15 AM and 7:27 AM on 02/26/10. Nursing notes of 02/26/10 indicated at 5:40 AM, MD#5 stated "will be up to see patient as soon as (he/she) is done with current patient in er." At 7:15 AM, MD#3 was paged and answered at 7:19 AM. Patient deteriorating condition was explained to MD#3 and that MD#2 "stated a chest tube needed to be placed quickly." MD#3 stated "this pt has been here since the 22nd so what is the emergency" S#6 explained that symptoms had increased and patient was "in distress." MD#3 stated this is not an emergency, it is on the 4th floor, and I will come when I have time." At 7:27 AM, MD#6 was at bedside with respiratory and started process for chest tube placement. At 7:40 AM, MD#6 paged MD#3 to come to bedside. At 7:45 AM, MD#3 arrived at bedside, stating "how long has the patient been like this" and "no one told me (C#1) was in distress." 8:40 AM, chest tube insertion completed by MD#3 with MD#6 assisting.

7. In interview at 3:00 PM on 09/07/10, S#1 confirmed the findings and indicated that there was no peer review process regarding C#1, no recommendation for action or action taken by Quality Assurance/Performance Improvement, no inservicing and no medical staff counseling.

Based on document review and interview, the facility failed to ensure a written response to the patient regarding the resolution of a patient grievance, to include the name of the hospital contact person, the steps taken to investigate, the results and date of completion in one (1) instance (C#1).

Findings:

1. At 10:30 AM on 09/07/10, review of policy #ADM 2.05, Patient Complaint and Grievance Policy, Page 2 of 3, Procedures, 1. Patient Grievance Process, I. indicated "The patient will receive a written response regarding the resolution of the patient complaint. This written response will include:
? the name of the hospital contact person;
? the steps taken on behalf of the patient to investigate the grievance;
? the results of the grievance process except that information protected by peer review;
? and the date of completion."

2. Interview with S#1 at 10:30 AM on 09/07/10 indicated no written response was sent to the complainant.

3. No written response to complainant was verified via e-mail at 12:18 PM on 09/07/10 by S#7.

Based on document review and interview, the hospital failed to ensure the identification of opportunities for improvement in quality of care concerns in one (1) instance (C#1).

Findings:

1. At 10:30 AM on 09/07/10, review of policy #ADM 2.06, Event Reporting, Page 3 of 4, Management, C. indicated "Issues associated with members of the Medical Staff will be referred to the appropriate Section for investigation as part of the peer review process."

2. Review of Medical Staff Rules & Regulations, Policy # MS 1.02, page 6, 800., Response to Urgent Situations indicated "It is the responsibility of all members of the Medical Staff who provide patient care to quickly and accurately resolve immediate and urgent clinical concerns. If a clinical concern is not resolved, the healthcare professional will follow the chain of command until the issue is resolved."

3. Review of Incident Summary for incident on 02/26/10 at 6:35 AM indicated the web based report was entered by S#6, who wrote that at 6:45 AM, S#6 spoke by phone with MD#2 regarding patient's deteriorating condition, increased shortness of breath (SOB) and pain. MD#2 indicated a call would be made to a pulmonologist (MD#4). At 6:55 AM, after patient had received Morphine 4 mg IVP, S#6 again spoke via phone with MD#2, expressing concern for increasing SOB. Ativan was ordered and it was indicated that MD#4 "would be in to see the pt ASAP." At 7:13 AM, S#6 spoke with MD#4, who advised to call MD#3 as "he is in-house." Call to MD#3 placed at 7:15 AM and returned at 7:19 AM. MD#3 stated "this pt has been here since the 22nd so what is the emergency" The web based report indicated Nurse Manager Comments as "reviewed" and lacked Risk Management Comments.

4. Review of Acute Care Quality and Safety Committee Agenda for April 14th, 2010 indicated Event Report Summary, which included incident report related to C#1, for February/March 2010 was presented by S#1, but lacked any action/recommendation/follow-up.

5. Review of Adult Medicine Standards Committee Minutes (Quality Assurance/Performance Improvement) for April 2010 indicated a mortality case was reviewed (C#1), but lacked any action/recommendation/follow-up.

6. At 1:50 PM on 09/07/10, review of C#1's medical record Progress Notes for 02/26/10 indicated lack of documentation that C#1 was seen by a physician between 6:15 AM and 7:27 AM on 02/26/10.

7. In interview at 3:00 PM on 09/07/10, S#1 confirmed the findings and indicated that there was no peer review process regarding C#1, no recommendation for action or action taken by Quality Assurance/Performance Improvement, no inservicing and no medical staff counseling.