HospitalInspections.org

Based on interview, record review and review of facility policies, the facility failed to assure 2 of 10 sampled patients received physician care services in a timely fashion (#1 & 2).

Findings:

1. Patient #1's record revealed the patient was transferred via emergency services to the hospital emergency department (ED) on 2/18/17 at 5:49 PM. Diagnosis included upper gastro-intestinal (GI) hemorrhage. The record documented ED physician ordered a consultation for a gastroenterologist (physician B) for "GI bleed" on 2/18/17 at 6:41 PM. Documentation read physician B's GI consultant service was notified at 6:41 PM, and a recipient name was documented. There was no documentation regarding the response time of physician B, the GI consultant.

An intensive care unit (ICU) nurse's note, dated 2/19/17 at 5:10 AM read, "2/18/17 at 10 PM, call placed to (physician B) to report patient's admission and bloody emesis/stool."

A nurse's note, dated 2/18/17 at 10:30 PM, indicated a call was placed to intensivist physician C, and "No call returned from (physician B). Second call placed." A nurse note on 2/19/17 at 5:14 AM read, "11 PM - Call returned from Dr. (physician B). Condition update given. Orders received, entered and followed."

Review of the hospital policy "On-Call Responsibilities", revised 3/05/14, read, "When an on-call physician is requested to respond by the Emergency Department Physician, the physician must: (a) Be immediately available by telephone, to the Emergency Department; and (b) Respond in person, if so requested, within a reasonable time period. Generally, response is expected within 30 minutes. The Emergency Department physician, in consultation with the on-call physician, will determine whether the patient's condition requires the on-call physician to see the patient as soon as possible....(d) Documentation of the time the call is placed at the request of the ED physician and the time the call is returned will be documented in the medical record and the telephone contact log in order to confirm response timeliness."

On 2/18/17, the ED telephone contact log for patient #1 indicated one consultation for the hospitalist. There was no documentation on the contact log for the gastroenterologist for patient #1.

On 2/28/17 at 3:15 PM, the director of the Emergency Services and the Risk Manager revealed the contact log was not completed per hospital policy, and did not contain the ordered GI consultation for patient #1.

A nurse's note read on 2/19/17 at 7:36 AM, "STAT call placed to Dr. (intensivist) regarding Pt. (patient's) SBP (systolic blood pressure) 60s. Will await call back." At 7:45 AM, a nurse's not read, "Addendum: 2/19/17 at 7:56 AM 'Will continue current regimen'." The next concurrent nurse note on 2/19/17 at 7:45 AM read, "Spoke with Dr. (intensivist, physician C) regarding pt. status. She will be here to assess pt. soon. No new orders. Will continue to monitor."

Review of the hospital policy "ICU Physician Staffing (IPS) Standard Revision Date: 8/29/16, second page documented Protocol: To fulfill the IPS standard (hospital name) will operate our critical care units as followed:
a. All patients in the ICUs with the exception of the patients being cared for by the cardiologists for the conditions or procedures defined, are managed or co-managed by one or more physicians who are critical care intensivists.
b. Intensivists are present during daytime hours to provide clinical care exclusively to the ICUs. c. When not present on-site or via telemedicine, intensivist returns pages for emergent changes in patient condition, at least 95% of the time, within five minutes...." Attachment A included documentation of: "Homodynamic - Acute change in systolic blood pressure to <90 mm Hg. heart rate to <40/min or 150/min." Documentation in the nurse notes revealed the intensivist was called at 7:36 AM, and the call returned by the intensivist at 7:45 AM.

2. Record review revealed patient #2 went to the ED with a chief complaint of profuse vomiting, was admitted to the hospital, and received diagnostic care and services. The ED record documented a gastroenterologist (physician B) consultation order for patient #1, dated 2/21/17 at 11:02 AM. The order was classified as a routine consultation. The record indicted the consultation was called to physician B's office at 11:11 AM on 2/21/17.

A nurse's note on 2/21/17 at 8:30 PM read, "pt HR (heart rate) elevated throughout day, only symptom of C/O (complained of) nausea reported by pt. PRN (as needed) Zofran and Lopressor IV (intravenous) given per order protocol. (Physician B) and (3 other physicians) have all been verbally informed of patient status and arrythmias...."

There was no documentation in the patient's record that the physician B's GI consultation was completed, and documentation was not found in the patient's record form physician B. The record reflected the patient was discharged on 2/22/17 to an area nursing facility without any written documentation from physician B.

Review of the hospital Rules and Regulations read, "Any qualified practitioner with clinical privileges in this hospital can be called by the attending physician for consultation within his/her area of expertise. Consultations shall be completed within twenty-four (24) hours from the time the consultant is notified or otherwise specified. STAT (immediate) consult requests must be called physician to physician if immediate surgical evaluation is needed.
#8. Response Time Definitions: 1) Routine - 24 hours 2) Urgent - 4 hours 3) STAT - 30 minutes"

On 2/28/17 at 10:30 AM, the Risk Manager confirmed there was no documentation found that physician B's GI consultation was completed prior to the patient's discharge.