HospitalInspections.org

Based on record review, the facility failed to ensure that the medical record was complete in 1 of 21 medical records reviewed (Pt. #8).

Findings:

1) Pt. #8 was a 54-year-old male who was admitted to the emergency department on 08/03/12 at 14:21 with presenting complaint of "chest pain." Vital signs at 14:24 were temperature: 97.8/pulse: 89/respirations: 18/blood pressure: 129/91/SPO2 (oxygen): 95%/O2 (oxygen): RA (room air)/pain: 10/10. According to documentation on the Critical Care Flow Sheet at 14:24, "Reports 10 days of ETOH (alcohol)." At 14:30, vitals signs were: pulse: 88/respirations: 18/BP: 132/84/SPO2: 94%/O2: RA/pain: 10/10. According to documentation on the Critical Care Flow Sheet, "Pt. asking to get up and make phones calls, saying 'oh I'm gonna be alright.'" At 14:35, "pt. states he wants to leave at this time, signed AMA form & left at 1440." The patient's disposition was documented as "AMA." The emergency department record for Pt. #8 dated August 3, 2012 was missing the hospital's signed AMA form. There is no documented evidence that hospital staff received a signed AMA form for refusal of treatment.

2) These findings were verified on 9/25/12 at 1:15 p.m. with the HIM (Health Information Management) Director.

Based on record review, observation, and interview, the facility failed to meet its obligations to provide on-call coverage for patients in need of specialized treatment within the hospital's capabilities (see C-2404).

Based on observation, interview, and record review, the facility failed to maintain a list of on-call physicians to provide treatment necessary to stabilize a patient in need of specialized treatment.

Findings:

1) During a tour of the emergency department on 09/24/12 at 2:00 p.m., a request for schedules of on-call physicians was requested. Instead, lists of physicians from recipient hospitals were produced. ED Nurse #2 verified that the physicians from the recipient hospitals would be contacted for either specialized treatment or transfer. The ED itself does not itself maintain a list of on-call physicians who can be contacted.

2) During interview with the Clinical Director on 09/25/12 at 8:10 a.m., he stated that there are no specialists on staff. He also stated that the doctor of the day is available to assist in the Emergency Department as needed but has primary responsibility for inpatients. The Clinical Director stated that if a specialist is needed, the "referral center" is contacted and will either "accept transfer or make recommendations about appropriate treatment of the problem; usually one or the other." Cass Lake IHS Hospital does not maintain a list of on-call physicians/specialists.

3) Review of the facility's "Daily Schedule Wednesday 9/5/2012" revealed no on-call physicians, other than the Medical Officer of the Day (MOD).

4) Review of The Cass Lake Medical Staff Bylaws and Rules and Regulations dated May 3, 2012, Article IX: Patient Care, Section 1: General, L. states, "Medical Staff Members shall, consistent with clinical privileges and employment duties, participate in a call schedule designating a "Medical Officer of the Day" (MOD) to provide coverage for the Inpatient Service in the absence of the Attending Physician, and clinical consultation for issues regarding outpatients in the absence of their respective primary care providers, and clinical consultation for the Emergency Room and Urgent Care Department." There were no policies and procedures that provide for proper on-call coverage, evidenced by the ED's failure to maintain an on-call list.

5) These findings were verified with the Clinical Director on 09/25/12 at 8:10 a.m.