HospitalInspections.org

Based on medical record (MR) review, document review, and interview, in 1 (one) of 20 medical records reviewed, it was determined that (a) the Physician Assistant (PA) did not escalate the change in a patient's condition to an Attending Physician and (b) the patient was not transferred to a higher level of care in a timely manner.

Findings include:

Review of the MR for Patient #2 identified: On 10/10/2018, a 68 year old male was brought to the facility via EMS with c/o dizziness, and weakness and was admitted. On 10/14/2018, at approximately 10:30 PM, he complained of shortness of breath (SOB). During the night, the patient's clinical presentation dynamically changed. On 10/15/18 at 6:25 AM, patient's pulse oximetry decreased to 61% (Normal 95%-100%). Patient was rushed to a step-down unit where an attempt to intubate failed. At 6:29 AM, patient was in Sinus Bradycardia and at 6:41 AM, in Asystole. At 6:51 AM, resuscitative measures were discontinued and the patient expired.

During interview on November 29, 2018 at 3:09 PM, Staff C, Physician Assistant who provided medical care, stated that patient #2 "did not appear to have SOB as he was speaking in full sentences, but he was saying that he has SOB." Staff C also stated that she was observing the patient closely. She said that at some point, she attempted to contact an Attending Physician to assess the patient, but the physician was busy with admitting another patient. Staff F, Corporate Director of Regulatory Affairs, who was present at the interview, stated there were three available physicians that could be contacted, but none was contacted.

During interview on November 30, 2018 at approximately 3:00 PM, Staff D, RN stated that she along with the Physician Assistant performed patient's initial physical assessment together. Staff D stated, patient complained of SOB and that she and her supervising Nurse advised Staff C to transfer the patient to a higher level of care in the Step-down Unit but Staff C said "no" and brought another Physician Assistant with her to see the patient. In the morning at 6:15 AM, patient was transferred to Step-down unit where he expired at 6:51 AM.

Review of Staff C's "Position Summary" document, revealed that a Physician Assistant is required to perform duties "In consultation with patient's Attending Physician, Physician Assistant establishes a presumptive diagnosis and initiates the work up of the patient by ordering appropriate laboratory studies. Under supervision, is responsible for the management of patient's medical issues following diagnosis."

Staff C did not follow this requirement. This finding was brought to the attention of Staff F, Corporate Director of Regulatory Affairs during interview on December 3, 2018 at 11:00 AM.

Based on medical record (MR) review, document review, and interview, in 1 (one) of 20 medical records reviewed, it was determined that the facility did not implement it's plan of correction for an incident involving the care provided by a Physician Assistant (PA).


Findings include:

Review of the MR for Patient #2 identified: On 10/10/2018, a 68 year old male was brought to the facility via EMS with c/o dizziness, and weakness and was admitted. On 10/14/2018 at approximately 10:30 PM, he complained of shortness of breath (SOB). During the night, the patient's clinical presentation dynamically changed. On 10/15/18 at 6:25 AM, patient's pulse oximetry decreased to 61% (Normal is (95%-100%). Patient was rushed to a step-down unit where an attempt to intubate failed. At 6:29 AM, patient was in Sinus Bradycardia; and at 6:41 AM, in Asystole. At 6:51 AM, resuscitative measures were discontinued and the patient expired.

The facility reviewed the incident and recognized that there is room for improvement and planned to audit proper escalation of cases by PAs to Attending Physicians.

During interview on 12/3/18 at 11:00AM, it was verified by Staff F, Corporate Director of Regulatory Affairs, that the facility had not performed any Audits.