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WELLSPAN GOOD SAMARITAN HOSPITAL
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on a review of facility policy, medical record (MR) and staff interviews (EMP), it was determined the facility failed to ensure the patient received care in a safe setting for one of ten medical records reviewed (MR1).
Findings include:
A review of Good Samaritan Health System "Patient's Rights and Responsibilities" policy last reviewed April 5, 2013, revealed " ... U. Emergency Care. The right to expect emergency procedures to be implemented without unnecessary delay ..."
A review on August 14, 2014, of MR nursing documentation for January 7, 2013, revealed "1650 Pt O2 in the mid 70's. Charge nurse notified and pt placed on non rebreather @ 15 l/min ... 1700 Pt O2 still dropping Hospitalist attempted to be notified but no response Pt no longer arousing when called by name ... 1715 Hospitalist once again attempted ... 1730 Still no response from Hospitalist ... 1740 Dr. [name] down not in to see pt yet Tried to explain to him the severity of pt Wanted to look through chart first ... 1758 Pt coded ..."
An interview conducted on August 14, 2014, at 11:00 AM with EMP1 confirmed that the hospitalist response to MR1 took 50 minutes.
CONTENT OF RECORD
Tag No.: A0449
Based on a review of Medical Staff Rules and Regulations, medical record (MR), and interview with staff (EMP), it was determined the facility failed to document vital signs in accordance with facility policy and physician order for one of ten medical records reviewed (MR1).
A review on September 5, 2014, of "Medical Staff Rules and Regulations" dated August 20, 2013, revealed "... Medical Staff Rules and Regulations ... Guidelines for Admission ... Intensive Care Unit, 3 South and 2 East Telemetry Monitoring ... All patients requiring hemodynamic monitoring ... .
A review on August 14, 2014, of MR1 revealed a physician's order dated January 6, 2013, at 2317 for "...Vital Signs per Unit Criteria, Every 4 hours ..."
A review on August 14, 2014, of MR1 revealed only one recorded saturated oxygen level on January 7, 2013, at 1650. Further review of the record revealed there were no vital signs or saturated oxygen levels documented from January 7, 2013, at 2230 until January 8, 2013, at 1135.
An interview conducted on August 14, 2014, at 10:00AM with EMP5 confirmed that MR1 failed to contain documentation that vital signs were performed every four hours.