HospitalInspections.org

Based on interview, clinical record review and the facility policy & procedures review, it was determined the facility failed to ensure 1 of 10 sampled patients (#6) care was provided in accordance with hospital policy for critical laboratory results.

The finding includes:

Clinical record review reveals Patient #6 was admitted through the Emergency Department (ED) to the 2nd floor Intensive Care Unit (ICU) on 2/01/14, with a previous medical history that included Status post (S/P) left hip intertrochanteric fracture with a past surgical repair, Atrial Fibrillation, Anemia, Current Multiple Pressure ulcers, and Cardiac Pacemaker.

A review of the record with the ICU director, Staff ID #10, revealed a blood result positive for yeast "Candida Glavrata." Results were called by the laboratory on 2/09/14 at 4:37 AM to the ICU Nurse. The ICU nurse then called and left a telephone voice mail message to the attending Physician (ID #12) as a critical lab finding at 4:55 AM (within 30 minutes as required). The Physician (#12) responded to the critical laboratory result when making rounds on 2/09/14 at 4:40 PM (approximately 12 hours later) by ordering the anti-fungal medication Fluconazole 400 mg IV daily one time dose for treatment of this blood yeast infection.

The Infectious Disease (ID) Physician (#12) who attended Patient #6 was not available for interview during this compliant survey. Physician (ID #11) was interviewed by telephone on 3/13/14 at 12:06 PM. This interview revealed that the 12 hours period between the critical blood culture results posting and Physician order for anti-fungal medication (Fluconazole) administration "May or may not be significant as the Patient currently was receiving several other anti-biotics." Review of the clinical record indicates the following medication were currently in the patient's medication regimen: Flagyl 750 mg, Ceftriaxone 2 GM, Rocephin 2 Gm IV, Cefazolin 2 GM IV every 8 hours.

The Vice President of Regulatory Compliance (ID #1) was interviewed on 3/13/14 at 12:15 PM. During this interview she stated the Physician may have not received this telephone voice mail of the lab results and saw the critical lab results upon his Patient rounds on 2/09/14 at 4:10 PM.

The Vice President of Regulatory Compliance (ID #1) acknowledged the facility P&P for Critical values page #2 of 11 indicates in the section "C" to "D." Critical values/interpretations will be reported to a responsible physician within thirty (30) minutes, and the responsible Physician will respond within thirty (30) minutes.