HospitalInspections.org

Based on interview, record review and a review of facility documentation, the facility failed to ensure that the medical staff enforced bylaws pertaining to the authentication of Physician Assistant entries by a physician for 1 of 5 sampled patients (#1).

Findings:

Patient #1's History and Physical of 5/24/21 by Physician A read, "She underwent a colonoscopy on 5/13/21 which showed luminal narrowing in the mid sigmoid colon. The colonoscope was unable to be advanced beyond this location. This was presumed to be from her diverticular disease. She presents to discuss treatment options..... Assessment/Plan: .... We will proceed with laparoscopic sigmoid colectomy, with possible left hemicolectomy to include area of diverticulitis." An Operative Report of 6/02/21 at 12:18 AM by Physician A for a date of service of 5/25/21 read, "Procedure: Laparoscopic left hemicolectomy. Laparoscopic mobilization of splenic flexure. Left ureterolysis. Flexible sigmoidoscopy."

The record had daily Physician Assistant (PA) notes. Notes were entered in the medical record by PAs on the following dates and times: 5/26/21 at 1:12 PM, 5/27/21 at 8:24 AM, 5/28/21 at 9:04 AM, 5/29/21 at 8:40 AM, 5/30/21 at 8:58 PM, and 5/31/21 at 9:04 AM. None of these PA notes were countersigned by a physician.

A review of Medical Staff Rules and Regulations revealed the following: "The attending or supervising physician will review and authenticate all entries (i.e., admission history and physical, operative / procedure notes, or discharge summary) made in the medical record by members of the Allied Health Professional Staff within 24-hours. The signature signifies that the attending or supervising physician has reviewed the patient's medical record and approved the care rendered by the Allied Health Professional....Definition of Allied Health Professionals: Physician Assistants...."

On 6/08/21 at approximately 12:05 PM, Physician A confirmed that he had not signed the PA notes as of 6/07/21. He stated that for him to discover alerts on PA notes needing signatures required that he log into a separate computer-based program system. He confirmed that this had not been done in the case of patient #1. Thus, the facility was not in compliance with this policy.

On 6/08/24 at 1:14 PM, the Vice President of Quality confirmed the findings.