HospitalInspections.org

Based on staff interviews and medical record review the hospital failed to ensure that physician care, other than surgical care, was provided to one of six patients in the sample (Patient #1) on February 4, 2010. The findings include:

Patient #1 was admitted to the hospital from the emergency department on the evening of February 3, 2010. She had been in the emergency department from approximately 11:00 a.m. until after 5:00 p.m., and did not receive any of her regularly prescribed medications during that time. On admission Surgeon (G) ordered that Patient #1 be kept NPO (Nothing Per Os) for surgery to remove her gallbladder the next morning. Therefore, Patient #1 did not receive any of her regularly scheduled medications that evening. Surgeon (G) wrote admission orders for the surgical procedure the next morning, but did not address any of Patient #1's regularly scheduled medications. Patient #1 had a history of congestive heart failure that was controlled with diuretics and heart medications including Lasix 20 mg three times daily for heart failure. She was also receiving Lisinopril, Potassium, Aspirin, Nitroglycerin, Cholestyramine, Albuterol, Glipizide and Coreg. Surgeon (G) also wrote an order for Patient #1 to be placed on Physician (C)'s list to be seen as Physician (C) is Patient #1's regular attending physician.

Physician (C) was unable to come to work on February 4, 2010 and his patients were not assigned to another physician. Therefore, Patient #1's medications were not ordered as she was not seen by a physician other than Surgeon (G) on February 4, 2009. Patient #1 stated when interviewed on February 19, 2010 at 3:00 p.m. that she knew that she needed her Lasix because she could tell that she was retaining fluid. She stated that she knew she went into congestive heart failure quickly without her Lasix so she began asking for the Lasix on the afternoon of February 4, 2010. Patient #1 stated that she asked two different nurses that came into her room and she sent family member (D) to the desk to ask on the evening of February 4, 2010. They were told that there was no order for the medication, and she did not receive the medication.

On the morning of February 5, 2010, Patient #1 became short of breath and Physician (E) was notified and came to see Patient #1. Physician (E) immediately ordered Patient #1's regularly scheduled medications. Shortly thereafter Patient #1began experiencing chest pain. She was transferred to the intensive care unit, and was treated with intravenous Lasix. After receiving diuretic medications intravenously, Patient #1 recovered rapidly and was able to be discharged from the hospital on February 5, 2010.

When interviewed on February 18, 2010, Physician (E) verified that there had been difficulty determining what patient's assigned to Physician (C) he needed to see on February 4, 2010. He stated that because physician (C) was unable to come to work that day, Patient #1 was not seen by an internist on February 4, 2010 in accordance with the orders of Surgeon (G).

Based on staff interviews and medical record review, the hospital failed to ensure that registered nurses evaluated and intervened in the provision of care for one of six patients whose medical records were reviewed. The findings include:

Patient #1 was admitted to the surgical floor at approximately 5:00 p.m. on the evening of February 3, 2010. Surgeon (G) telephoned a verbal order to the unit at an unidentified time that evening and asked that Patient #1 be placed on the patient list of Physician (C), so that Physician (C) would see Patient #1 on February 4, 2010.

Physician (C) was unable to come to work on February 4, 2010. However, the nurses providing care for Patient #1 did not intervene and ensure that another physician saw Patient #1 on February 4, 2010. On the evening of February 4, 2010, Patient #1 began asking for her regularly scheduled Lasix because she knew that she would experience congestive heard failure without the medication.

When interviewed on February 19, 2010 at 3:00 p.m., Patient #1 stated that she could not identify the nurses that she asked but she knew that she asked two nurses who came into her room to provide her care. She also stated that she asked family member (D) to go to the nurses' station and request that she be given her medications that she regularly took at home because she needed them. This was verified by family member (D) when he was interviewed on the morning of February 17, 2010. Patient #1 and family member (D) both stated that they were told there was no orders for the medications they were requesting be given to Patient #1. The nursing staff failed to follow up on this request and check with a physician to determine if Patient #1 needed orders for her regular medications until the morning of February 5, 2010 when Patient #1 experienced shortness of breath.

Based on the review of six medical records (#1, #2, #3, #4, #5, #6) and staff interviews, the hospital failed to follow their policy regarding the dating and timing of physician orders when they are written by the physicians who have privileges at the hospital. The findings include:

In six of six medical records reviewed there were physician's orders that lacked the time they were written. Examples from the medical record of patient #1 include her orders for admission on February 3, 2010. These orders are not timed. The verbal order for Patient #1 to be placed on Physician's (C)'s list to be seen is not dated or timed. The Nausea and Vomiting Treatment Protocol ordered for Patient #1 following surgery is not dated or timed. The rest of her post surgical orders are not timed. An order to change one of those medication orders is not dated or timed. The order to admit Patient #1 to inpatient status is not timed. The date on orders for discharge appear to be dated February 8, 2010, but Patient #1 was discharged on February 5, 2010. Similar lapses in timing orders were also noted in medical records #2, #3, #4, #5, and #6.

At the time of the on site investigation on February 18, 2010, employees (A) and (B) verified that including the time orders are written is an ongoing problem at the hospital.

The rules and regulations established by the hospital as a part of their by-laws state that all orders, including verbal orders, must be dated, timed, and authenticated promptly and the prescribing practitioner or another practitioner responsible for the care of the patient.