HospitalInspections.org

Based on interview and record review the provider failed to make reasonable attempts to notify the primary care provider of the patient's admission, as chosen by the patient, for 1 of 3 patients (Patient #1).

The findings included:

Review of the clinical record revealed Patient #1 was admitted to a medical surgical floor on 11/25/19. The clinical record documents Patient #1 was alert and oriented and made his own medical decisions. Patient #1's "face-sheet" documents his primary care physician as (Nurse Practitioner's name, to be referred to as Nurse Practitioner "Z").

During interview on 01/15/20 at 1:20 PM, the Patient Safety Director stated they do not notify midlevel providers such as Nurse Practitioners of patient admissions but could provide no evidence that staff asked Patient #1 for his primary physician's contact information.

During review of Patient #1's intake information with Registrar, Staff "C," on 01/15/20 at 3:19 PM, Staff "C" showed and explained Nurse Practitioner "Z" was identified as his primary care provider (PCP) upon admission 11/25/19 and that he answered yes to notify the PCP of his admission. Staff "C" denied responsibility to notify the PCP of admission herself but stated the Unit Secretary may do that.

During interview on 01/15/20 at 3:23 PM, Unit Secretary, Staff "D," showed where and how she can document if she calls PCPs and connects them to the Emergency Room physician. Staff "D" reviewed Patient #1's record and showed documentation of a call to the admitting physician for admission orders but was unable to find evidence of any attempts to notify the primary provider, Nurse Practitioner "Z," of Patient #1's admission.

During interview on 01/15/20 at 5:31 PM, the Patient Safety Director stated she talked to the Physician Liaison who described an automated system whereby physicians can elect to receive notifications of their patients' admissions and may choose from various intervals at which to get a list of their patients who have been admitted, such as daily or more or less often. The Patient Safety Director stated if a patient answers to the Registrar that they would like their PCP notified of their admission, the notification would go out according to that PCP's set preferences. The Patient Safety Director stated since this PCP was not "in the system," they could not receive such notification. The Patient Safety Director did not describe a system for notifying PCPs promptly, or at the time of admission, as required.