HospitalInspections.org

Based on review of the medical record and interviews, it was determined the governing body failed to require that a member of the medical staff assuming care of a patient address medical problems identified in the History and Physical and Progress Notes by another member of the medical staff for 1 of 1 patient (Pt. #4).

Findings include:

Pt. #4 was seen in the Emergency Room on 9/12/09 at 1320 by Medical Staff Member #1 and diagnosed with gastroenteritis, urinary tract infection and renal failure. Additional diagnoses included, nausea, diabetes, hypoxia and congestive heart failure.

Medical Staff Member #2 documented an Admission History and Physical at 1910 which included: "...Of note, the patient adds that he has been having pain to his right ear which started yesterday...The patient states that he does have still some residual ear pain, mostly hears popping in the right ear...Physical Examination...Ears: The right ear is assessed and had thin yellow drainage. Unable to assess the tympanic membrane. There is no redness noted in the canal and no pain with movement...Assessment and Plan...Right ear pain with dizziness. Will defer any further drops in the ear at this time, and re-evaluate in a.m. will continue Meclizine 25mg t.i.d. (three times a day) p.r.n. (as needed)...." (The Meclizine was not a medication that the patient had taken prior to his admission.)

On 9/12/09, at 1913, Medical Staff Member #2 documented in a Progress Note: "...Admit Observation for N/V (nausea and vomiting); Right ear pain and Dizziness...."

During telephone interview on 4/9/10, at 1400, Medical Staff Member #2 stated that she frequently completes Admission Histories and Physicals at request of the Hospitalist when the Hospitalist receives a call from the Emergency Department for an admission. When asked if she would ordinarily have intended to follow up personally in the AM with the patient's ear pain, as she had documented in her History and Physical, she stated that typically, the patient would be seen the next day by the Hospitalist covering the unit. She typically would not follow the patient the next day. She stated that the Hospitalist would typically read over her History and Physical and Assessment and Plan and follow-up. Her intent would be for the Hospitalist to follow-up the next day.

The medical record contains documentation that Medical Staff Member #3 saw the patient and documented progress notes on 9/13/09 at 1013 and 9/14/09 at 1119. Each progress note contains documentation: "...Physical Examination...HEENT (Head, Eyes, Ears, Nose, Throat)...Within normal limits...." The medical record contains no documentation of specific follow-up regarding the right ear pain and drainage or specific description of an examination of the ear.

On 9/13/09, at 1729, Medical Staff Member #6 documented a consultation "...for acute onset of vertigo...." Recommendations included a Brain (Magnetic Resonance Imagery) scan without contrast as well as other tests and "...Meclizine 25mg p.o. (by mouth) daily for 3-5days...."

On 9/14/09, at 1420, a physician documented the MRI report: "...Findings:...Partial fluid opacification of the right mastoid air cells, Mild mucosal thickening in the right maxillary sinus...Impression...No acute intracranial abnormality...Mild age-appropriate global volume loss, and minimal microvascular gliosis...partial fluid opacification of the right mastoid air cells...Incompletely imaged is a disc protrusion causing moderate central canal stenosis at C3-4...."

Nursing documentation contained patient reports of pain as "0" on 9/12/09 at 1814 and 2005, and 9/13/09, at 0723 and 2040. On 2/14/09, at 0732 and 1722, a nurse documented patient report of pain in the right ear with a pain intensity rating of 1 (on scale of 0-10 with 10 being the worst pain). The nurse documented offer of pain medication.

On 9/15/09, at 1010, Medical Staff Member #3 documented: "...patient seen and examined, discharge summary dictated...."

On 9/15/09, at 1335, Medical Staff Member #3 documented a Discharge Summary: "...The patient does complain of some dizziness and we have gotten neurology...to see the patient and he has stated that the patient should get a MRI, MRA and also carotid duplex scan to rule out stroke. All tests including MRI, MRA, and also carotid duplex scan were within normal limits...The patient was advised to continue all his previous home medications and no new medications were added on this admission...." (The patient had continued on the Meclizine during his hospitalization, but was not discharged on this medication.) The discharge summary contains no documentation of the patient's ear pain, drainage, or examination of the ear.

Discharge Instructions signed by the patient on 9/15/09 at 1520 contain no instructions for follow-up for his ear pain: "...Make an appointment with the following doctor when you get home...PCP...1-2 weeks...."

During telephone interview on 4/13/09, at 1315, Medical Staff Member #3, could not recall definitively if he examined the patient's ear during the patient's hospital stay. He could not recall speaking with the family regarding the patient's ear pain, but stated he would probably inform the family that an ear infection can be followed-up with a Primary Care Physician (PCP). He stated that the patient never complained about his ear and his temperature was not elevated and he had no hearing loss. He confirmed that he did not diagnose the patient with an ear infection. He stated that the MRI findings would indicate "Sinusitis or Otitis Media Effusion" and that the MRI was within normal limits as far as indications for a stroke were concerned. He confirmed that his discharge instructions for referral of the patient to his PCP were general follow-up post hospitalization instructions and did not specify follow-up for an ear infection.

On October 9,2009, the patient presented emergently to another hospital. Physician's documentation at 1025, includes the patient's chief complaint as evaluation of the patient for mental status changes, including severe headache, trouble walking, vomiting, and lethargy. An unenhanced (computed tomography) CT scan of the head showed no convincing evidence of intra or extra-axial hemorrhage or definite large vessel infarcts. "...there is asymmetric opacification of the right mastoid air cells, right middle and inner ear, and right external auditory canal. Clinical correlation for malignant otitis externa is recommended...I went back to eval (evaluate) pt and found that there was pus draining from his R (right)ear...pt is diabetic, I therefore added orders for Vanco (Vancomycin) and Cefepime...I spoke with...and she is now aware of ear findings...will consult neuro and arrange for stat LP (Lumbar Puncture)...."

Nursing documentation indicates no patient complaints of pain.

A physician documented a Death Summary on October 12, 2009: "...Date of Admission 10/09/2009...Date of Death...10/09/2009...Time of Death...1310...Cause of Death: Likely acute CVA (Cerebral Vascular Accident), less likely, bacterial meningitis secondary to inner ear infection as the patient was afebrile and CT brain was negative...History of Present Illness...multiple comorbidities and a chronic right ear infection since 09/11/2009...Discussed case with nursing and with infection control. Discussed case with consultants...."