HospitalInspections.org
Bringing transparency to federal inspections
VALLEY HOSPITAL MEDICAL CENTER
CONTRACTED SERVICES
Tag No.: A0085
Based on record review and interview, the facility failed to provide a signed transfer agreement.
Findings include:
The facility's medical transfer agreement was reviewed as part of the Governing Body review and was expired as of 2010.
The Regulatory Specialist indicated the facility had trouble getting the receiving medical facility to sign a new agreement, but the facility had continued to transfer patients to the receiving medical facility in the interim.
PATIENT RIGHTS: INFORMED CONSENT
Tag No.: A0131
Based on policy review, interview and record review, the facility failed to document informed consents for 9 of 36 patients (Patient #19, #23, #25, #26, #27, #29, #30, #31, and #36) for procedures in accordance with its Medical Staff Rules and Regulations approved by its Board of Governors on 11/15/12.
Findings include:
According to the facility's Medical Staff Rules and Regulations (dated 11/15/12), VI. Medical Records "...4. Physicians/Practitioners shall be responsible for obtaining the patient's informed consent. When consent is not obtainable; the reason shall be entered in the patient's medical record. The medical record shall contain evidence of informed consent for operative and invasive procedures and treatments. The medical record will record both the patient's and physician's/practitioner's signature affirming that the physician/practitioner has personally informed the patient, including an explanation of the anticipated procedure(s), potential benefits, risks, problems related to recuperation, the likelihood of success, the possible results of non-treatment, and any significant alternatives..."
On 2/28/13 at 11:45 AM, the Clinical Supervisor of the Cath (Catheterization)) Lab (Laboratory) indicated physicians must sign at the top of the consents for procedures.
The top of the consent form had a section entitled Affirmation Of Informed Consent By Physician with an accompanying space for a designated physician's signature and date/time.
Patient #19
On 2/7/13, Patient #19 was admitted with diagnoses of bypass femoral popliteal.
On 2/11/13 at 2:00 PM, Patient #19 signed a consent for hemodialysis.
The Affirmation of Informed Consent by Physician was unsigned.
Patient #23
On 2/6/13, Patient #21 was admitted for cardiac catheterization.
On 2/6/13 at 11:15 AM, Patient #23 signed a consent for cardiac catheterization.
The Affirmation of Informed Consent by Physician was unsigned.
Patient #25
On 2/8/13, Patient #25 was admitted for cardiac catheterization.
On 2/8/13 at 10:30 AM, Patient #25 signed a consent for cardiac catheterization.
The Affirmation of Informed Consent by Physician was unsigned.
Patient #26
On 02/14/13, Patient #26 was admitted for a cardiac catheterization.
On 02/14/13 at 9:20 AM, Patient #26 signed a consent for a cardiac catheterization.
The Affirmation of Informed Consent by Physician was unsigned.
Patient #27
On 02/13/13, Patient #27 was admitted for implantation of a loop recorder..
On 02/13/13 at 6:30 AM, Patient #27 signed a consent for implantation of a loop recorder.
The Affirmation of Informed Consent by Physician was unsigned.
Patient #29
On 02/22/13, Patient #29 was admitted for an insertion of a internal cardiovascular defibrillator.
On 02/22/13 at 1:05 PM, Patient #29 signed a consent for insertion of a internal cardiovascular defibrillator.
The Affirmation of Informed Consent by Physician was unsigned.
Patient #30
On 02/21/13, Patient #30 was admitted for a cardiac catheterization.
On 02/21/13 at 11:45 AM, Patient #30 signed a consent for a cardiac catheterization.
The Affirmation of Informed Consent by Physician was unsigned.
Patient #31
On 2/23/13, Patient #31 was admitted for cardiac catheterization.
On 2/23/13, Patient #31 signed a blank consent for a procedure in the cath lab.
The Affirmation of Informed Consent by Physician was unsigned for both the cardiac catheterization and the angioplasty performed, and the name of the procedures were not documented on the consent form.
Patient #36
On 2/13/13, Patient #36 was admitted for cardiac catheterization.
On 2/13/13, Patient #36 signed a consent for cardiac catheterization.
The Affirmation of Informed Consent by Physician was unsigned.
MEDICAL STAFF BYLAWS
Tag No.: A0353
Based on record review, interview and policy review, the facility failed to provide emergency on-call coverage for cardiovascular/thoracic surgery as indicated in its Rules And Regulations Of The Medical Staff.
Findings include:
A review of the facility's Emergency On Call for PC Outpatient, PC Inpatient, Pediatrics, CVT Surgery, Stemi, General, Neuro, Ob/Gyn, and Ortho specialties from July 2012 to February 2013 revealed a lack of Cardiovascular/thoracic surgeon on call for emergencies from July 2012 through February 2013, excepting February 14-18, 2013 and February 24-28, 2013.
The Director of Critical Care Services and the Regulatory Specialist acknowledged the lack of cardiovascular/thoracic surgeons for the aforementioned time period for the emergency on call schedule at 4:00 PM on February 28, 2013.
On 2/28/13 at 4:00 PM, the Regulatory Specialist provided two letters announcing the resignations of emergency on call cardiovascular/thoracic surgeons dated May 31, 2012 and June 15, 2012. The letters indicated current providers would no longer provide emergency on call services.
The Regulatory Specialist provided a binder, which included the facility's medical staff rules and regulations with Board of Governor's approval dated 11/15/12.
Under section IV. Emergency Department Call subpoints 1-2 on page 9, "...1.Active Medical Staff members in the specialties of Primary Care (Internal Medicine/Family Practice), STEMI, Pediatrics, Cardiology, General Surgery, Neuro Surgery, Orthopedic Surgery, Cardiovascular Surgery, Oral & Maxillofacial, and OB/GYN have responsibility for covering Emergency Department call as required by the Medical Executive Committee. 2. Participation in Emergency Department call is on a voluntary basis. If at any time it is determined that through voluntary call the hospital is unable to meet the needs of the patient population served, call will revert to a mandatory call for all eligible participants in their respective specialties..."
There was no documented evidence the facility reverted to a mandatory call for all eligible participants.
Complaint #34582
OPERATIVE REPORT
Tag No.: A0959
Based on record review, interview and policy review, a physician at the facility failed to document an operative report as of 2/27/13 (Patient #19).
Findings include:
On 2/7/13, Patient #19 was admitted for a bypass femoral popliteal artery (left).
Operating room nursing documentation showed the procedure occurred between 4:36 PM and 5:44 PM on 2/7/13.
On 2/15/13, Patient #19 was discharged.
On 2/27/13 at 4:14 PM during a review of the medical record, the Regulatory Specialist was asked about an anticipated document reference for the operative report for Patient #19. The Regulatory Specialist and the medical records technician indicated the operative report was not yet documented.
According to the facility's Medical Staff Rules and Regulations (dated 11/15/12), VI. Medical Records "...5. "...Operative reports shall be dictated immediately following surgery for outpatients as well as inpatients and the report promptly signed by the surgeon and made a part of the patient's current medical record...Any physician/practitioner with uncompleted operative reports 24 hours following the day of the operation shall be automatically suspended from operative privileges..."