HospitalInspections.org

Based on document review and interview, it was determined that the facility failed to ensure the Medical Staff ensure medical care was provided as ordered by the Physician for one (1) of five (5) Patients (Patient # 1).

The findings include:

On September 13, 2022 at 1:00 p.m., a Clinical Record review for Patient # 1 revealed the following:

Inpatient transfer note dated April 19, 2022 by Staff Member # 6 reads in part "It was decided to obtain a CBC (complete blood count) and CRP (c-reactive protein), as well as blood cultures to evaluate for other possible etiologies of fever other than viral."

History and Physical note dated April 19, 2022 by Staff Member # 7 reads in part "ID (Infectious Disease) - following Blood cultures, obtained 4/19 due to fever, daily CBC, CRP.
Lab results: WBC (White Blood Count 15.5 04/19/2022 10:07), CRP 8.4 high, 04/19/2022 10:19."

Progress note dated April 21, 2022 by Staff Member # 7 reads in part "ID - following Blood cultures, obtained 4/19 due to fever, daily CBC, CRP."

An interview with Staff Member # 4 on September 13, 2022 at 1:30 p.m. during the clinical record review revealed "There were no more orders for CBC, CRP and blood cultures after April 19."

An interview with Staff Member # 5 on September 13, 2022 at 2:00 p.m. regarding labs for Patient # 1 revealed "orders were carried out as ordered. The "cultures" were negative."

In conclusion, on two occasions the Physician notes state daily CBC and CRP. There were no daily CBC and CRP obtained.