HospitalInspections.org

Based on record review and interview, the hospital failed to ensure enforcement of policy for on call physician facility arrival for four (Patients #9, #10, #13, and #18) of 15 patients reviewed.

Findings:

Review of policy #4.322 titled "Provider coverage in the ER." read in part,
"The provider should be physically present at the hospital within 20 minutes after being called in."

A review of the Emergency Department log showed the following.

Patient #9: On 08/13/23, the nurse called the provider at 11:30 a.m. and the provider arrived at 12:00 p.m., (10 minutes late)

Patient #10 On 09/14/23 the nurse called the provider at 12:30 p.m. and the provider arrived at 1:00 p.m. (10 minutes late)

Patient #13 On 11/03/23 the nurse called the provider at 11:20 a.m. and the provider arrived at 11:50 a.m. (10 minutes late)

Patient #18 On 12/21/23 the nurse called the provider at 11:15 a.m. and the provider arrived at 12:40 p.m. (85 minutes late)

On 01/03/25 at 1:00 p.m. Staff F stated:
1. The physician rules and regulations gave the provider 20 minutes to arrive at the facility once they were called.
2. We have had some difficulty with certain providers arriving at the facility in the alotted time and I have discussed it with them.
3. This has not been brought up in Governing Body or the Medical Executive committee but it will be moving forward.

Based on record review and interview, the hospital failed to ensure timely completion of the medical history and physical for two ( Patient # 2 and # 5 ) of five patients reviewed.

Findings:

A review of policy # 4.5 titled "History and Physical" read in part,
"Patients having outpatient procedures must have a History and Physical that has been completed within 30 days of admission, an update note must be documented within 24 hours of the procedure by the physician."

Patient # 2
A review of medical records showed an admission date of 09/11/24 and did not show a History & Physical was completed.
( 114 days past due ).

Patient # 5
A review of medical records showed an admission date of 11/05/24 and showed a History & Physical was completed on 11/08/24
( three days past due ).

On 01/03/25 at 8:15 a.m. Staff O stated:
History & Physicals are to be signed within 24 hours of the procedure or admission.