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A. Based on review of one (1) of ten (10) medical records (#1), staff interviews, and review of facility policy and procedures, it was determined that the facility failed to ensure that complete documentation required during the sepsis protocol is implemented.

Findings include:

Reference: Facility policy titled, "Medical Alert- Sepsis Team Response (Adult) and Plan for Severe Sepsis and Septic Shock" states, " ... Documentation: Medical Alert-Sepsis Team response will include the following documentation within 3 hours of Medical Alert Sepsis Team Response Call ...Physician documentation: the Physician ... will use the Sepsis Progress Note template to document the event ..."

1. On 6/16/2021, a review of Medical Record #1 revealed the following:

a. On 5/17/2021 at 12:05 AM, a code sepsis was called with the three (3) hour sepsis protocol to be implemented.

(i) The facility was unable to provide the Sepsis Progress Note template for Medical Record #1.

2. The above findings were confirmed with Staff #1 and Staff #5 on 6/16/2021 at 12:13 PM.

B. Based on review of one (1) of ten (10) medical records (#1), staff interview, and review of facility policy and procedures, it was determined that the facility failed to ensure that Emergency Department (ED) consults are responded to by the consulting physician within twenty (20) minutes of notification.

Findings include:

Reference: Facility policy titled, "Consultations/Routine and Stat" states, "All consults called for an Emergency Medical Condition by the Emergency Department provider for patients requires physician to physician communication and must be responded to by the consulting physician within 20 minutes from the time of notification ..."

1. On 6/16/2021, a review of Medical Record #1 revealed the following:

a. On 5/17/2021 at 11:28 AM, an initial OBGYN (Obstetrician Gynecologist) consult was initiated. The phone call was responded to at 12:33 PM.

(i) The "ED Note-Physician" states, "[facility name] Vaginal Bleeding ...Emergency Department Course and Treatment ... Attempted to call OB for consult at 1128 [11:28 AM] and 136 [1:36 PM] with no answer ...Case discussed with OBGYN at 1233 [12:33 PM] who will come evaluate patient bedside ..."

2. During an interview with Staff #1 on 6/16/2021 at 1:33 PM, he/she confirmed that all emergency department consults are considered Stat.

3. The above findings were confirmed with Staff #1 on 6/16/2021 at 1:35 PM.