HospitalInspections.org

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Based on interview and document review, the Critical Access Hospital failed to ensure staff implemented policies and procedures for medical management of health problems that included conditions requiring a medical consultation for 1 of 1 record reviewed requiring consultation (Patient #914).

Failure to ensure policies are fully implemented risks delayed or inappropriate care and poor patient outcomes.

Findings included:

1. Document review of the hospital's policy and procedure titled, "WhidbeyHealth Medical Staff Policies," no policy number, last approved 06/21, showed the following:

a. The good conduct of medical practice includes proper and timely use of consultation.

b. The attending physician will document the consultation request.

c. The consultant will see the patient as soon as possible, preferably the same day unless other arrangements are made.

2. On 01/17/24 between 9:00 AM and 11:00 AM, Investigator #9 and Emergency Department Nursing Supervisor (Staff #901) and Director of Quality (Staff #902) reviewed the medical record of Patient #914 who was admitted to the hospital on 11/10/23 for treatment of knee pain and suicidal ideation. The review showed an order placed by a physician on 11/11/23 for a palliative care consult. Investigator #9 found no documentation that a consult had been completed, no evidence that the order had been cancelled, and no progress note by the physician regarding the consultation or a change in the plan of care from 11/11/23 to transfer to another facility on 11/21/23 (a period of approximately 10 days).

3. At the time of the review, Investigator #9 interviewed Palliative Care Manager (Staff #904) as to the process for consultation and if this patient had received a consultation as there was no note in the medical record. Staff #904 stated that when they receive a consultation, they would call to discuss with the ordering provider to see if they have bandwidth to consult. Staff #904 stated that if there is no note, the consultation probably wasn't done. Investigator #9 asked if there was documentation as to why the consult was not done and Staff #904 stated that they would not document that.
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