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Based on interview and documentation review the Hospital failed to ensure that: 1). the Attending Physician documented the reason a Cardiology Consult was not obtained; 2). the Critical Care Physician authenticated a medical record entry.

NEED TO COMPLETE

Findings included:

1). The Emergency Department Record, dated 12/26/09, indicated that the Patient was admitted to the cardiology service.

The Progress Notes, written by a Resident and dated 12/27/09, indicated that a cardiology consult was going to be obtained.

Review of the medical record determined there was no evidence that a Cardiology Consult had been obtained.

The Patient's assigned Attending Physician (a Hospitalist) was interviewed on 2/9/10 at 1:00 P.M. The Attending said the Hospital was a teaching Hospital and Residents were encouraged to make recommendations however; the Attending was responsible for the care of the Patient. The Attending said although the Patient had a cardiac history there were no new changes in her electrocardiogram. The Attending said the Patient's Troponin level (levels may be elevated with cardiac muscle injury, acute or chronic conditions such as myocarditis [heart inflammation], congestive heart failure, severe infections, kidney disease, and certain chronic inflammatory conditions of muscles and skin) was elevated however; the elevation was due to renal failure and was not cardiac related. The Attending said they were providing the necessary treatments to the Patient and all a Cardiology Consult would have told them was to continue with what they were doing.

Review of the Medical Staff Rules and Regulations indicated that when patient care and management is provided in conjunction with the Medical Education Program the supervision of and concurrence with house staff diagnostic and therapeutic decisions must be documented in the medical record by the attending physician or a faculty physician through the use of progress notes or counter-signature on the resident physician entries.

Review of the Progress Notes indicated that the Attending Physician did not document why a Cardiology Consult was not obtained.

2). Review of the Medical record Progress Notes indicated that an entry was made on 12/28/09 at 9:30 A.M. The entry was not authenticated.

The Critical Care Physician was interviewed on 2/4/10 at 2:05 P.M. The Critical Care Physician reviewed the medical record entry and confirmed had had made the entry.