HospitalInspections.org

Based on Medical Staff policy, medical record review, and staff interview, it was determined the Neurologist failed to respond to a consultation request.

Findings include:

MEDICAL STAFF ORGANIZATION, PROCEDURES AND POLICIES (MSOPP) ROLES AND RESPONSIBILITIES OF THE MEDICAL STAFF REQUIRE: "...Urgent...requires immediate physician to physician contact...Non urgent require a documented order...adequate written communication from the consulting physician...timely verbal communication...should be responded to within 24 hours or sooner...."

Patient #4 was seen in the ED on 12/13/10 at 2142 hours, with sudden loss of vision in right eye and numbness and tingling in right hand. The patient was admitted to observation status on 12/14/12 at 0030 hours, for Amaurosis fugax; rule out transient ischemic attack (TIA). The patient was discharged home on 12/15/15 at 0930 hours.

Review of Patient #4's Physician Orders for Admission revealed a written order dated 12/14/10 at 0030, for a neurological consult with Physician #3.

Nurses Assessment & Notes dated 12/14/10 at 2000 hours revealed: Physician #3 paged to see patient; no response.

Review of the medical record revealed no written or verbal communication from the consulting physician to the requesting physician as required per policy.

The Corporate Compliance Officer confirmed during an interview conducted 08/22/12, there was a written order for a neurological consult, however, there was no documented evidence to support the patient received the consult within 24 hours of the order or prior to the patient's discharge.

Based on review of hospital policies/procedures, medical records, and interviews, it was determined that the hospital failed to require accurate medical record documentation for 1 of 1 Emergency Department patient regarding initiating the intravenous (IV) line (Patient #19).

Findings include:

The hospital policy titled Vascular Access: Peripheral IV Therapy Protocol (last revision 05/11), requires: "...No more than 2 attempts at cannulation should be made by any one nurse/licensed radiology technologist...document procedure...."

Patient #19's medical record revealed three (3) attempts to start the IV line; two (2) attempts per Paramedic employee #27, and one (1) attempt per RN #26. RN #26 however confirmed during a teleconference conducted on 08/24/12 at 0715, that he never attempted an IV and that a nurse summoned from the Pediatric Department started the IV on the first attempt.

RN #26 stated that only ED staff have access to the ED's electronic patients' records and that the pediatric nurse, who's full name he did not know, required ED staff to document who started the IV. RN #26 confirmed that he was the assigned nurse but did not document that the pediatric nurse actually placed the IV.

Patient #19's medical record was not accurate in identifying the employee who started the IV.

Based on review of Centers for Disease Control (CDC) guidelines, medical records, and interview, it was determined that the Infection Control Officer failed to require the nursing staff performed appropriate infection control practices when administering injectable medications via the intravenous (IV) line for 1 of 1 patients (Patient #19).

Findings include:

CDC guidelines for administering medication via the IV tubing port require: "...rubber septum should be disinfected with alcohol prior to piercing it..." according to the 08/23/12 website.

Patient #19's medical record revealed that RN #26 administered IV Morphine.

RN #26 confirmed that he did not clean the IV injection site prior to administering Morphine, during a teleconference conducted on 08/24/12 at 0715.