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Based on medical record review and interview, in one (1) of six (6) medical records reviewed, the physician failed to conduct timely assessments and interventions for a patient with deteriorating medical condition (Patient #1).

This failure may have resulted in a delay assessment and treatment of the patient's medical condition.

Findings include:

Review of Patient #1 MR revealed:
A 78-year-old male, admitted to orthopedic surgical services on 6/2/22 for fracture of right femur. The patient had comorbidities, including Chronic Lymphocytic Leukemia (CLL). Based on the recommendation of the oncologist (a doctor who treats Cancer), chemotherapy treatment was discontinued for a week pre-operatively to optimize the patient for surgery.

The patient underwent revision of right hip arthroplasty surgery on 6/09/22. Post-surgery, the patient developed confusion and was seen by a geriatric psychiatrist who diagnosed delirium and he was placed on a safety watch and provided with Tylenol 650mg po every four hours around the clock with orders for no narcotics.

On 6/15/22, the patient was deemed medically stable for discharge but refused to be discharged to a sub-acute facility for short-tern rehabilitation. The patient was downgraded to Alternative Level of Care (ALC) status. The Orthopedic Surgical Physicians remained as the primary care team while the patient was on ALC (6/15/22- 7/01/22) and were responsible for the development and interventions of the medical treatment plan.

On 6/22/22 at 2:58 pm, nurse noted the patient was with cough, running nose and fever of 99.2 Fahrenheit. Robitussin given, and the house Physician's Assistant (PA) was made aware." At 10:00 pm, the patient temperature rose to 101.1 F. The PA obtained a urinalysis that resulted positive for infection.

On 6/24/22, the patient tested positive for Covid 19 and was moved to a Covid unit for isolation precautions.

On 6/30/22, labs revealed elevated sodium 157meq/L (Normal range: 135-145meq/L).

On 7/1/22, the primary team (Orthopedics) requested consult with medical services to assess the hypernatremia. On 7/1/22 at 4:00 pm, Medical Services evaluated the patient and noted that Medicine was consulted by the primary (ortho surgical) team for evaluation of severe hypernatremia and Covid pneumonia. Hypovolemia (dehydration), in the setting of poor oral intake was likely worsened secondary to covid infection. Recommendations included intravenous fluids and labs for sodium level every 8 hours. The Medical Consult noted to follow the rest of the medical plan as per primary team (Ortho).

On 7/2/22 at 4:52 am, the nurse noted ... the patient is covid+, and desaturated to 89% on 4L nasal cannula, repositioned and placed on nonrebreather (NRB) with 10L oxygen as per house PA. The hospitalist was paged after attempts to page ortho services with no response.

On 7/2/22 at 5:58 am, nurse documented ...Ortho returned page and updated MD on patient's status and nursing interventions. They requested (ortho) Attending to reassess the patient at bedside. The patient was currently saturating at 98% on 10L NRB.

On 7/2/22 at 9:45 am, the patient was transferred from orthopedic services to medicine services.

On 7/2/22 at 12:04 pm, the medical provider noted, the patient has worsening pneumonia which led to hypercarbic (increase in carbon dioxide in the blood) respiratory failure. At 11:05 am, the patient was intubated and placed on a respirator. He went into cardiac arrest and was coded three times on 7/2 at 7:48 pm, on 7/2 at 10:31 pm and on 7/3 at 3:27 am.

On 7/3/22 at 7:00 am, the patient was admitted to the Medical Intensive Care Unit (MICU) for further medical management. The patient expired on 7/3/22 at 8:59 am. Death certificate showed the cause of death was Septic Shock with concurrent Covid.

There was no documented evidence that significant changes in the patient's medical condition was timely assessed and treated.

On 6/22/22, the Physician Assistant did not evaluate the patient who was reported to have a cough, running nose and a fever.

On 6/24/22, the patient tested positive for Covid 19, the PA did not escalate the patient's condition to the Attending Physician for evaluation and treatment.

Between 6/22-6/23/22, there was no written documentation in the medical record noting the changes in the patient's medical condition, there was no medical examination, no referral for further medical evaluation, and no medical treatment for the patient's condition.

The facility did not implement its policy titled, " Alternate Level of Care (ALC)" last revised 7/2018 that stated "...to designate a patient who is no longer requiring acute hospital care ... the Provider team will continue to see the patient at least every 7 days or more as needed. Physicians are required to document a progress note at least every 7 days or more frequently as the patient's condition warrants. A patient can be placed on ALC and returned to acute status if there is a clinical change in the patient's condition."

The patient was not promptly returned to acute care status when there was a clinical change in his medical condition.
There was no consultation with Infectious Disease for further medical evaluation and treatment of the patient's hospital acquired Covid infection. The patient went untreated between 6/22 to 6/30/2022.

As per the hospital's Policy titled, "Escalation of patient care issues", last revised 3/2021, states...
"Chain of command is utilized to escalate patient care issues, when necessary, to ensure timely interventions and resolve clinical patient care issues. "

There was no escalation of the patient's medical condition by the house PA to the Attending Physician. Consequently, the patient was not evaluated by an Attending Physician from 6/22 to 6/30/22 before his labs on 6/30 revealed a significant increase in sodium levels 157meq/L (Normal range: 135-145meq/L).

During interview conducted on 10/27/2021 at 11:30 am, Staff G, (Director of Medicine), stated the following ... the hypernatremia should have been escalated ... We have attendings on duty 24 hours 7 days a week ... The house staff can escalate to me. It ' s very clear. House staff is encouraged to call. Care of this patient may have fallen short at the possibility of addressing nutrition and hydrating the patient more. Once the sodium started to go up, a more aggressive approach should have happened. Maybe a little closer monitoring. Staff G additionally acknowledged the inadequate physician documentation in the MR.

These findings were discussed with Staff D, Deputy Chief Medical Officer on 10/27/22 at 11:45 am who acknowledged the findings and confirmed medical consultation could have been requested and performed earlier in the patient's hospitalization.


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