HospitalInspections.org

Based on document review, record review and staff interview it was determined the medical staff failed to follow their own medical staff by-laws, rules and regulations by not ensuring the physician was responsible for the quality of care given to one (1) of ten (10) medical records reviewed (patient #1). This failure has the potential to negatively impact the care given to all patients who present with an unstageable wound, resulting in a sentinel event.

Findings include:

1. Review of the medical record for patient #1 revealed the patient was seen by a physician on a daily basis during his 12/01/16 to 12/09/16 admission. The physician documented he conducted bilateral pedal pulses (pulse taken on the top and inner side of the foot) but did not document any wound on the patient's left foot. The patient's wound became severe and required a below the knee amputation.

2. Review of the medical staff by-laws "Medical History and Physical Examination", last
reviewed 10/27/15, revealed it states, in part: "An updated examination of the patient, including any changes in the patient's condition, must be completed and documented by a physician within 24 hours after admission."

3. Review of the policy and procedure manual "Assessment of Patients", last reviewed 05/20/16, revealed it states, in part A: "Medical Staff: Reassessment-performed ongoing based on patient need, treatment regime, treatment setting, and patient response to care or treatment or at minimum daily."

4. An interview with the Chief of Medical Staff was conducted on 01/18/17 at 3:10 p.m. He stated: "My expectation is for the physicians to document what they are seeing during the assessment of the patient. By reading the documents of the patient's assessments by the physician I can't refute anything you are saying." He concurred with the findings.