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Based on interview, document and record review, Hospitals A and B failed to ensure that a consistent process was in place to notify a patient's primary care physician when the patient was admitted to the hospital.

Findings:

A review of the hospital's Patient Complaint/Grievance Process was conducted with the Clinical Risk Specialist on 4/3/13 at 8:30 A.M. Three random complaints and grievances were chosen for review. On 3/5/13, the hospital's Risk Management/Patient Relations Department received a complaint from the wife of Patient 47.

A review of Patient 47's medical record was conducted on 4/3/13 at 9:30 A.M. Patient 47 was admitted to Hospital A on 11/23/12 for treatment of acute rectal bleeding and acute abdominal pain according to the Emergency Department physician's record. However, on 12/22/12, Patient 47 expired from a perforated viscus (rupture of a hollow organ in the abdomen). According to Patient 47's wife, and documented in her grievance with the hospital, "wife states pt's (patient) primary MD (physician) at [name of clinic and name of physician] was not made aware that pt was hospitalized, and shocked to learn that he expired."

On 4/3/13 at 10:05 A.M., an interview was conducted with the Director of Patient Safety (DPS). The DPS stated that the hospital did not currently have a policy and procedure in place that addressed the notification of the primary care physician when a patient was admitted to the hospital.

An interview was conducted with the Director of Health Information Services (DHIS) on 4/3/13 at 10:35 A.M. The DHIS stated that when a patient is admitted to the hospital, the patient is asked who is their primary care physician. In addition, when a physician dictates an ED note, history and physical or consultation and requests a carbon copy (cc) to another physician, a copy of that document will be sent to the carbon copied physician via auto-facsimile (autofax). When Patient 47 was in the ED, the ED physician dictated an ED note and requested that a carbon copy be sent to Patient 47's primary care physician (MD 47). However, according to the DHIS, MD 47's profile/information is not in the hospital's autofax database. The DHIS could not provide documentation that MD 47 ever received the ED dictation from the ED MD. The DHIS acknowledged that MD 47 did not receive documents via fax transmittal from the hospital's autofax system.

On 4/3/13 at 11:35 A.M., an interview was conducted with Hospital A's Chief of Staff and Co-Director of Performance Improvement. This MD is also an Emergency Department physician. The Chief of Staff stated that he was aware that when a patient is admitted through the ED to the hospital the patient's primary care physician was to be notified. This MD stated that when he dictated an ED note he would always request that a carbon copy be sent to the patient's primary physician. The Chief of Staff thought that MD 47 would always receive a copy of his ED note when he requested that a carbon copy be sent to him. The Chief of Staff stated that he was not aware that MD 47's profile in the hospital's autofax system was inactive. The Chief of Staff then acknowledged that the process to notify a patient's primary care physician when the patient was admitted though the ED was not a consistent process.

Based on observation, interview and record review, the hospital failed to ensure that the Medical Staff implemented bylaws related to resuscitation status order when 2 of 43 sampled patients' (1, 2) resuscitation status were not written on the Resuscitation Status Order form. In addition 1 of 43 sampled patients (2) did not have a written resuscitation status order on the medical record.

Findings:

1. On 3/29/13 at 9:45 A.M., Patient 1 was observed in bed and was connected to a ventilator (a machine designed to mechanically move breathable air into and out of the lungs, to provide the mechanism of breathing for a patient who is physically unable to breathe, or breathing insufficiently).

An interview with Patient 1's sister and mother was conducted on 3/29/13 at 10:00 A.M. The patient's sister stated that the hospital's ethics committee met on Wednesday (3/27/13) and had recommended Patient 1 to be a DNR (do not resuscitate). According to the patient's sister, the patient had been DNR since 3/27/13. However, according to the Director of Risk Management (DRM), the patient was a full code.

A review of Patient 1's medical record was conducted on 3/29/13 at 12:15 P.M. Patient 1 was admitted to Hospital A on 1/30/13 with diagnoses that included anoxic brain injury per the History and Physical, dated 1/30/13. A physician's order, dated 1/30/13 at 12:50 P.M., indicated that the patient was a full code (the patient is to be resuscitated in the event of a cardiac or respiratory arrest). However, this physician order was not in the patient's medical record located in the unit but was in the medical records office with records that were thinned. In addition, the Resuscitation Physician Orders form could not be located in the patient's medical record.

A review of the hospital's policy and procedure titled Resuscitation Status Orders was conducted on 3/29/13 at 12:30 P.M. The policy indicated that, "The attending physician will designate the patient's resuscitation status on the Patient Wishes for Resuscitation Physician Orders."

A review of the Medical Staff Bylaws was conducted on 4/2/13 at 3:00 P.M. The Medical Staff Bylaws indicated that, "All adult patients should have Resuscitation (Code) Status Orders. The attending physician will designate the patient's resuscitation status on the Resuscitation Status/ Advance Directives Orders form."

An interview with the Assistant Administrator of Nursing (AAN) was conducted on 4/2/13 at 3:30 P.M. The AAN acknowledged that the physician should have documented Patient 1's resuscitation status on the Resuscitation Status Physician Order form.

2. A review of Patient 2's medical record was conducted on 4/2/13 at 10:00 A.M. Patient 2 was admitted to Hospital A on 3/24/13 with diagnoses that included diabetic ketoacidosis (a potentially life-threatening complication in patients with diabetes mellitus) per the History and Physical, dated 3/24/13.

Further review of Patient 2's medical record revealed that no physician's order related to the patient's resuscitation status was present in the medical record. There was also no evidence that a Resuscitation Physician Order form was completed.

A review of the Medical Staff Bylaws was conducted on 4/2/13 at 3:00 P.M. The Medical Staff Bylaws indicated that, "All adult patients should have Resuscitation (Code) Status Orders. The attending physician will designate the patient's resuscitation status on the Resuscitation Status/ Advance Directives Orders form."

An interview with the Assistant Administrator of Nursing (AAN) was conducted on 4/2/13 at 3:30 P.M. The AAN acknowledged that the physician should have documented Patient 1's resuscitation status on the Resuscitation Status Physician Order form.








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Based on observation, interview and record review, Hospital A failed to ensure that pertinent medical information was accessible to staff for 1 of 43 sampled patients (1). Patient 1's written code status order and the Patient Wishes for Resuscitation Physician Order form were not in the patient's active medical record.

Findings:

On 3/29/13 at 9:45 A.M., Patient 1 was observed in bed and was connected to a ventilator (a machine designed to mechanically move breathable air into and out of the lungs, to provide the mechanism of breathing for a patient who is physically unable to breathe, or breathing insufficiently).

An interview with Patient 1's sister and mother was conducted on 3/29/13 at 10:00 A.M. The patient's sister stated that the hospital's ethics committee met on Wednesday (3/27/13) and had recommended Patient 1 to be a DNR (do not resuscitate). According to the patient's sister, the patient had been DNR since 3/27/13. However, according to the Director of Risk Management (DRM), the patient was a full code.

A review of Patient 1's medical record was conducted on 3/29/13 at 12:15 P.M. Patient 1 was admitted to Hospital B on 1/30/13 with diagnoses that included anoxic brain injury per the History and Physical, dated 1/30/13. A physician's order, dated 1/30/13 at 12:50 P.M., indicated that the patient was a full code (the patient is to be resuscitated in the event of a cardiac or respiratory arrest). However, this physician order was not in the patient's medical record located in the unit but was in the medical records office with records that were thinned. In addition, the Resuscitation Physician Orders form could not be located in the patient's medical record.

A review of the hospital's policy and procedure titled Resuscitation Status Orders was conducted on 3/29/13 at 12:30 P.M. The policy indicated that, "The Patient's Wishes for Resuscitation Physician Orders form will be labeled with patient identification and placed in a designated area in chart, accessible to all staff.

An interview with the DRM was conducted on 4/2/13 at 3:00 P.M. The DRM stated that physician's order were thinned by medical records. The DRM also stated that patient code status that were written in a physician's order sheet could be thinned by medical records. The DRM acknowledged that the Patient Wishes for Resuscitation Physician Order form, which were not supposed to be thinned by medical record staff, should have been in Patient 1's active medical record.