HospitalInspections.org

Based on document review and interview, the governing body failed to ensure the medical staff facilitated appropriate patient transport to a higher level of care per hospital policy in one (1) instance (Patient # 1).

Findings include:

1. Review of the hospital policy titled, "Standards of Care-Urgent Care", policy number EX-36, issued date June 2007, indicated for "patients requiring a higher level of care the physician will facilitate transport to a nearby hospital to provide a higher level of care. In an emergency, the patient will be stabilized and 911 called". This policy was last revised in March 2018.

2. Review of the closed MR (medical record) for patient # 1 indicated the patient was a 52 y/o (year/old) who had presented to H # 1"s (Acute Care Hospital) Urgent Care on 02/03/2019 at 3:15 pm. The patient's medical history included, but were not limited to, MI (myocardial infarction), HTN (hypertension-high blood pressure), CVA (cardiovascular accident), and diabetes.
The MR summary for patient # 1's visit dated 02/03/2019 indicated the following:
A. At 3:15 pm the "Assessment" form documentation indicated the patient's chief complaint was "L" (left) "arm numbness/tingling since waking up this am, L upper shoulder pain, sharp CP (chest pain) this am". At 3:25 pm the patient's vital signs were documented as blood pressure (BP) 154/96 (systolic/diastolic), pulse (P) 97, respirations (R) 18, and oxygen (O2) saturation 96% while on room air.
B. At 3:55 pm the "ECG" (Electrocardiography), indicated "normal sinus rhythm, inferior infarct age undetermined, and abnormal ECG".
C. The "Physician Note" (no time documented) by MS # 1 (Physician), indicated "refer to ER" (Emergency Room).
D. At 4:01 pm the "Nurses Note" indicated the "pt" (patient) entered H # 1 with a "c/o (complaints of) L arm numbness, L upper shoulder pain, and reported some slight, sharp CP this am. Pt denies CP at this time. Pt found to be still c/o L arm & shoulder numbness/pain". MS # 1 was "notified of pt's complaints & condition". MS # 1 ordered EKG (ECG) for the patient. "During the EKG" the patient "c/o CP returning upon palpation". MS # 1 examined the patient and "advised that pt go to ER". The MR lacked documentation, which indicated MS # 1 facilitated appropriate transport to a nearby hospital to provide a higher level of care.
E. Patient # 1 was transferred by private car versus 911 being called for transport.

3. In interview on 02/11/2019 at approximately 12:00 pm with administrative staff member A # 1 (Chief Operating Officer-COO/Chief Nursing Officer-CNO), confirmed that H # 1 "has no chest pain protocol and/or policy/procedure".

Based on document review and interview, the facility failed to ensure patients were provided care in a safe setting by facilitating appropriate transport (Patient # 1), and implementing timely interventions (Patient # 3) for patients in need of a higher level of care in two (2) instances.

Findings include:

1. Review of the hospital policy titled, "Patient Rights and Responsibilities", policy number A-17, issued date June 2007, indicated the "patient has the right to receive care in a safe setting". This policy was last reviewed January 2019.

2. Review of the hospital policy titled, "Standards of Care-Urgent Care", policy number EX-36, issued date June 2007, indicated for "patients requiring a higher level of care the physician will facilitate transport to a nearby hospital to provide a higher level of care. In an emergency, the patient will be stabilized and 911 called". This policy was last revised in March 2018.

3. The "Medical Staff Rules and Regulations", adopted by the "Board of Managers" 01/12/2009, indicated on page one (1) under "Patient Right's" the "patient has the right to receive "care in a safe setting". The "Rules and Regulations" were last amended on 11/13/2018.

4. Review of Credential files for Medical Staff member MS # 2 (Physician), indicated appropriate documentation which included education, reappointment to the active medical staff, hospital privileges, and current medical license. The "Reappointment Letter" dated and signed 01/21/2019 by C # 1 (Chief Executive Officer-CEO), indicated on behalf of the "Board of Managers" of H # 1 (Acute Care Hospital), MS # 2's "clinical privileges have been granted as specified on the enclosed clinical delineation forms". Please review these carefully as "you have only been granted permission to perform those procedures outlined on the attached privilege form". The "Clinical Privileges" forms for MS # 2 lacked invasive procedure privileges for "Cardiac Catheterization Angiography, Coronary Angioplasty, and Angiographic Stent placement". The "Application Attestation" dated 08/14/2018 by MS # 2, indicated he/she had acknowledged that "I have received and read the Medical Staff bylaws and rules and regulations. I agree to abide by the terms of the Medical Staff bylaws rules and regulations; policies and procedures". If appointed or granted clinical privileges "I specifically agree to: Abide by generally recognized ethical principles applicable to my profession", and provide "care and supervision" to "all patients" within the hospital for "whom I have responsibility".

5. Review of the "Timecard Editor" dated 01/16/2019 indicated the following time punches for the Cath lab (Catheterization Laboratory) team:
1. NS # 5 (Registered Nurse-RN) punched in at 6:53 am and punched out at 3:32 pm. NS # 5 punched back in at 6:35 pm and punched out at 9:21 pm.
2. NS # 3 (RN) punched in at 7:31 am and punched out at 3:53 pm. NS # 3 punched back in at 6:35 pm and punched out at 9:04 pm.
3. RT # 1 (Radiology Technician) punched in at 7:29 am and punched out at 3:35 pm. RT # 1 punched back in at 5:13 pm and punched out at 9:12 pm.
4. NS # 4 (RN) punched in at 6:16 am and punched out at 2:44 pm. NS # 4 punched back in at 7:16 pm and punched out at 9:04 pm.
5. NS # 2 (RN)punched in at 7:38 am and punched out at 3:53 pm. NS # 2 punched back in at 6:28 pm and punched out at 9:04 pm.
6. NS # 1 (RN) punched in at 6:29 am and punched out at 2:55 pm. NS # 1 punched back in at 6:51 pm and punched out at 9:21 pm.

6. Review of the closed MR (medical record) for patient # 1 indicated the patient was a 52 y/o (year/old) who had presented to H # 1's (Acute Care Hospital) Urgent Care on 02/03/2019 at 3:15 pm. The patient's medical history included, but were not limited to, MI (myocardial infarction), HTN (hypertension-high blood pressure), CVA (cardiovascular accident), and diabetes.
The MR summary for patient # 1's visit dated 02/03/2019 indicated the following:
A. At 3:15 pm the "Assessment" form documentation indicated the patient's chief complaint was "L" (left) "arm numbness/tingling since waking up this am, L upper shoulder pain, sharp CP (chest pain) this am". At 3:25 pm the patient's vital signs were documented as blood pressure (BP) 154/96 (systolic/diastolic), pulse (P) 97, respirations (R) 18, and oxygen (O2) saturation 96% while on room air.
B. At 3:55 pm the "ECG", indicated "normal sinus rhythm, inferior infarct age undetermined, and abnormal ECG".
C. The "Physician Note" (no time documented) by MS # 1 (Physician), indicated "refer to ER" (Emergency Room).
D. At 4:01 pm the "Nurses Note" indicated the "pt" (patient) entered H # 1 with a "c/o (complaints of) L arm numbness, L upper shoulder pain, and reported some slight, sharp CP this am. Pt denies CP at this time. Pt found to be still c/o L arm & shoulder numbness/pain". MS # 1 was "notified of pt's complaints & condition". MS # 1 ordered EKG (ECG) for the patient. "During the EKG" the patient "c/o CP returning upon palpation". MS # 1 examined the patient and "advised that pt go to ER". Per MS # 1 the "pt is ok to go via personal car".

7. Review of the closed MR for patient # 3 indicated the patient was a 76 y/o who presented to H # 1 on 01/16/2019 at (arrival time not documented) with c/o (complaint of) chest pain times two (2) days. The patient was admitted to H # 1's Intensive Care Unit (ICU) on 01/16/2019 at 5:30 pm. The patient's diagnoses included, but were not limited to, coronary insufficiency and hypertension (high blood pressure).
The MR summary for patient # 3's admission on 01/16/2019 indicated the following:
A. At 2:50 pm the "Physician" verbal orders by MS # 4 (Physician), indicated to order laboratory (lab) tests which included, but were not limited to, a Troponin and a D-Dimer. MS # 4 also ordered a 12 lead EKG.
B. At 2:55 pm the "Nurses Initial Assessment" note by NS # 7 (Registered Nurse-RN), indicated the patient was experiencing chest pain for two (2) days that worsened with deep breaths. The patient's vital signs were documented as BP RUA (right upper arm) 173/79, LUA (left upper arm) 175/77, P 105, R 16, and O2 saturation 98% on four (4) L's (liters) NC (nasal cannula). The patient's pain location was documented as "left chest".
C. At 3:03 pm the ECG results, indicated "Sinus tachycardia" (elevated heart rate), "inferior infarct, age undetermined, anterolateral" (front and left) "infarct, age undetermined, and abnormal ECG".
D. At 3:15 pm H # 4 (Contracted Laboratory) documented the patient's lab specimens had been collected (drawn).
E. At 3:20 pm the patient's vital signs were taken by NS # 7 and documented as BP in the LUA 150/72, P 103, R 16, O2 saturation 98% on 4L NC.
F. At 3:40 pm the patient's vital signs were taken by NS # 7 and documented as BP 155/73, P 107, R 16, O2 saturation 97% on 4L NC.
G. At 3:54 pm H # 4 documented the specimens had been received.
H. At 4:10 pm H # 4 documented "High" D-Dimer results of 0.52 ug/mL (microgram/milliliter) with the normal range of 0.00-0.49 ug/mL.
I. At 4:19 pm H # 4 documented "results called" to NS # 7 at H # 1's Urgent Care. The resulted Troponin level was a PH (panic high) of 738 ng/L (nanograms per Liter) with the normal range of 0-14 ng/L.
J. At 4:38 pm the patient's vital signs were taken by NS # 7 and documented as BP 138/65, P 97, R 16, O2 saturation 97% on 4L NC.
K. The "Physician Order" at (time not documented) by MS # 4, indicated to admit the patient and call MS # 2 for orders.
L. At 7:27 pm the "Invasive Cath lab (Catheterization Laboratory) Procedure" documentation, indicated MS # 2 arrived and the case was started.
M. At 8:55 pm the "Operative Report" dictated by the "surgeon" MS # 2, indicated the "Preoperative Diagnosis" was "Acute anterolateral wall ST-elevation myocardial infarction" (STEMI).

8. In interview on 02/11/2019 at approximately 12:05 pm with administrative staff member A # 2 (Billing Manager), confirmed only two patients were transferred from H # 1. One of the patients drove themselves.

9. In interview on 02/13/2019 at approximately 12:40 pm with administrative staff member A # 1 (Chief Operating Officer-COO/Chief Nursing Officer-CNO), confirmed the "cath lab staff works 8:00 am to 4:30 pm daily and they are not on call after hours".

10. In interview on 02/13/2019 at approximately 2:50 pm with nursing staff member NS # 7, confirmed patient # 3 presented to H # 1 with c/o (complaints of) chest pain, had an "abnormal ECG", and was being admitted to the ICU. The "patient was packed up and ready to go to the unit" when the critical Troponin level was received by phone. The "physician" MS # 4 "was sitting right there" and he/she asked me to wait because he/she "wanted to call" MS # 2. At that time MS # 2 indicated "to change the admission from a regular admission to an ICU admission". I "notified the inpatient unit and they said I had to wait to bring the patient because they had to switch it around in the system". The patient stayed in Urgent Care where "I took another set of vital signs" before taking the patient "up to" ICU "around 5:30 pm". The "patient was just sitting down there waiting" to go to the unit.

11. In interview on 02/13/2019 at approximately 12:00 pm with nursing staff member NS # 9 (RN), confirmed remembering "everyone was talking" about "we had a STEMI come in". The "Cath lab" personnel "doesn't have call". That "patient should have been sent out". What if "after the doctor planned the Cath procedure and one of the team couldn't come back in?" It "was a delay in care".

12. In interview on 02/13/2019 at approximately 12:35 pm with nursing staff member NS # 3 (RN), confirmed "we don't take call", and "we don't usually do emergency cases here". Everything "is based on routine cases. Normally we wouldn't do a STEMI here". When "I was hired" it was discussed that we would "not to do on call" for cases. The "patient should have been sent out".

13. In interview on 02/13/2019 at approximately 2:40 pm with administrative staff member A # 1, confirmed that the "ICU nurse who takes medical/surgical patients would have to give report of his/her patients before he/she could take an ICU patient". If an ICU nurse had four (4) patients "yes" he/she "would have to give report to possibly four (4) different nurses".

14. In interview on 02/13/2019 at approximately 2:58 pm with administrative staff member A # 1, confirmed that patient # 1 "should have went to the ER by ambulance not in a private car".

15. In interview on 02/13/209 at approximately 3:20 pm with administrative staff member A # 1, responded "I cannot answer that question" when asked if there was a delay in care for patient # 3.

Based on document review and interview, the facility failed to ensure an appointed medical staff member provided appropriate patient care within the scope of his/her granted and documented board approved privileges according to the medical staff bylaws in one (1) instance. (MS # 2)

Findings include:

1. The "Plan for Provision of Care", dated January 2019, indicated on page four (4) "the scope of care of each practicing and licensed member of the medical staff is delineated through the clinical privileging process according to the bylaws of the medical staff", and on page fourteen (14) the "organizational performance improvement goals are to "maximize patient safety and minimize patient and organization risk of adverse occurrences", and on page sixteen (16) "individuals with clinical privileges provide medical services in accordance with the Bylaws, Rules and Regulation of the Medical Staff".

2. The "Medical Staff Bylaws", indicated on page four (4) the "purpose" of the medical staff were to ensure "all patients" admitted to "or treated" in any of the "facilities, departments", or services of the hospital "shall receive quality of care consistent with the practices and services in similar communities", on page fifteen (15) the "responsibilities" of the medical staff if granted appointment would be "an agreement to abide by all policies" of the hospital, including "all Bylaws, Rules and Regulations", and on page twenty (20) the general "Clinical Privileges" of the "Medical Staff appointment or reappointment" as such shall not confer any clinical privileges or right to practice at the hospital. "Each individual who has been appointed to the Medical Staff shall be entitled to exercise only those clinical privileges specifically granted by the Board." The "Bylaws" were last amended on 11/13/2018.

3. Review of Credential files for Medical Staff member MS # 2 (Physician), indicated appropriate documentation which included education, reappointment to the active medical staff, hospital privileges, and current medical license. The "Reappointment Letter" dated and signed 01/21/2019 by C # 1 (Chief Executive Officer-CEO), indicated on behalf of the "Board of Managers" of H # 1 (Acute Care Hospital), MS # 2's "clinical privileges have been granted as specified on the enclosed clinical delineation forms". Please review these carefully as "you have only been granted permission to perform those procedures outlined on the attached privilege form". The "Clinical Privileges" forms for MS # 2 lacked invasive procedure privileges for "Cardiac Catheterization Angiography, Coronary Angioplasty, and Angiographic Stent placement". The "Application Attestation" dated 08/14/2018 by MS # 2, indicated he/she had acknowledged that "I have received and read the Medical Staff bylaws and rules and regulations. I agree to abide by the terms of the Medical Staff bylaws rules and regulations; policies and procedures". If appointed or granted clinical privileges "I specifically agree to: Abide by generally recognized ethical principles applicable to my profession", and provide "care and supervision" to "all patients" within the hospital for "whom I have responsibility".

4. Review of the closed MR (medical record) for patient # 3 indicated the patient was a 76 y/o (year/old) who presented to H # 1's (Acute Care Hospital) Urgent Care Departement on 01/16/2019 at (arrival time not documented) with c/o (complaints of) chest pain times two (2) days.
A. At 7:27 pm the "Invasive Cath Lab (Catheterization Laboratory) Procedure" documentation, indicated MS # 2 "arrived" to the Cath lab and the "case was started".
B. At 8:55 pm the "Operative Report" dictated by "Surgeon" MS # 2, indicated the "Preoperative Diagnosis" was "Acute anterolateral wall ST-elevation myocardial infarction" (STEMI). The "Procedure Note" indicated a "left coronary system angiogram and right coronary artery catheter angiogram"with a left ventricular and selective coronary artery angiography" was performed. The "decision" was "made for proximal stenting" of the "right coronary artery", and "angioplasty of the ostium right coronary artery" were performed. "Then a right femoral artery angiography was performed".

5. In interview on 02/13/209 at approximately 3:22 pm with administrative staff member A # 1 (Chief Operating Officer-COO/Chief Nursing Officer-CNO), responded MS # 2 "should have been privileged for invasive Cath lab procedures by the Board".