HospitalInspections.org

Based on record review and interview the facility failed to have an organized medical staff that is responsible for the quality of the health care provided to one (1) of 10 sampled patients (SP) # 1.

Findings include:
Review of sampled patient (SP) #1 revealed that the patient " Admitting Diagnosis: Gait and activities of daily living dysfunction secondary to subdural hematoma, respiratory failure. Review of the nursing notes dated 05/04/2013 has noted that the Physician was called on 05/04/2013 at 12:24 pm regarding cough, message left. Another nursing note dated 05/04/2013 at 16:20 pm has that a call placed to the physician regarding x-rays done on 04/27/2013. Another nursing note entry dated 05/04/2013 at 19:05 pm has that patient's wife stated that the patient takes before Lexapro 5mgs by mouth daily. Will notify Dr. (physician) when he return the call. There is no documentation that the physician returned the call.

Interview with the Chief Executive Office (CEO) and Director of Quality Management (DQM) conducted on 07-10-13 at 5:25 PM revealed that the all the staff are aware of the policy and procedure regarding physician call backs. The CEO stated that this was an isolated case as there was never a problem contacting the physicians. That the physiatrist is the attending physician and always called for anything. That the supervisor is also notified if there is a problem and so far there was no problem with contacting any physician. That he has not received any problem of this nature. He further stated that he would re-educate all staff immediately regarding this issue.

Interview with the Medical Director conducted on 07-11-13 at 10:30 AM confirmed above findings that he never had any problem regarding physician not calling back because the staff always call him and his service for anything that the patient need and if the consultant is on vacation that the administration is notified and administration verifies to make sure the physician coverage has a privilege at the facility. That he is always available and accessible. That if the patient is too complicated that the patient is transferred to the hospital. He stated that the consultants are very good coming to see the patients and also follows policy and procedure. He also added that if the patient is not medically stable that the patient is not appropriate for acute rehabilitation because the patient need to tolerate therapy with a goal of 3 hours of therapy. He also discussed that if the physician presents a problem that it is presented to the Medical Executive Committee and Peer Review is done.

Interview with SE#5 and SE#6 conducted on 07-11-13 at 1:30 PM and 1:40 PM respectively, revealed that they both are aware of the policy and procedure regarding nursing/physician chain of command, hand off communication and Critical Values that if nurse unable to reach the physician that certain steps are taken. They both stated that they never had any problem with this because the physiatrist's are always available.