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Based on review of medical staff bylaws, medical staff credential files and staff interview, the hospital failed to ensure a physician was credentialed based upon delineated clinical privileges for 1 of 3 credential files reviewed (MD #6).

Findings include:

Review of Medical Staff Bylaws dated November 2, 2017 revealed "Article VIII: Privileges 8.1 General 8.1.1 Every Practitioner practicing at the Hospital shall practice within the scope of and be permitted to exercise only those delineated clinical privileges specifically granted by the Board. All individuals exercising clinical privileges shall pledge to provide for continuous care of their patients. 8.1.2 Each Practitioner shall have delineated privileges primarily in the assigned clinical department(s). A Practitioner may have secondary privileges in one or more of the other departments. Clinical privileges may be further delineated within a division, service, and subspecialty or by specific diagnostic or treatment procedures."

Credential file review for MD #6 revealed the physician was Board Certified in Internal Medicine and Infectious Diseases. Review of the "List of Physician Privileges" requested and granted "General Internal Medicine" and "Infectious Disease and International Health." Review of the requested and granted privileges revealed no delineation of specific privileges to define what procedures the physician was allowed to perform. Review of the credentialing file revealed a letter to MD #6 dated July 28, 2018 from the Chief Medical Officer that stated MD #6 was reappointed to the medical staff and granted clinical privileges in the Department of Medicine by the Board of Directors. Review revealed the privileges were valid through July 1, 2020.

Telephone interview on 03/22/2019 at 1500 with the Chair of the Credentialing Committee (MD #7) revealed MD #6 was granted privileges to practice "Internal Medicine and Infectious Diseases." Interview revealed the "scope of practice for general medicine included thoracentesis and paracentesis. A lot of these things run into fulfillment issues." Interview revealed these procedures were not delineated under the approved privileges.

Interview on 03/22/2019 at 1400 with the Interim Manager of the Credentialing Office revealed the categories of "General Internal Medicine" and "Infectious Disease and International Health" were the "core privileges" and there was no further delineation of what privileges MD #6 could perform. Interview confirmed the privilege list should indicate the specific items requested and confirmed the privileges requested and granted were not defined specifically.

Based on review of facility policies and procedure, emergency department medical records, and staff interviews, the emergency department staff failed to provide discharge instructions related to wound care for 2 of 3 sampled emergency department patients with procedures (#9, #19); and failed to report an abnormal lab result that was available after discharge to 1 of 3 sampled emergency department patients (#2).

Findings include:

A. Review on 03/20/2019 of the hospital policy titled, "Discharge of the ED (Emergency Department) Patient Policy" revised 03/2016 revealed, "Upon discharge from the ED, patients will receive follow-up instructions related to care required based on their diagnosis along with directions for seeking subsequent medical care if deemed necessary by the provider, patient or their guardian."

1. Review of the medical record for Patient #9 on 03/19/2019 revealed a 44 year old female that presented to the emergency department (ED) on 02/16/2019 at 1206 with complaints of leaking and a break in her Hickman catheter (a central line used for long periods of time for administering medications and drawing blood). Review of the past medical history for Patient #9 revealed a history of pHTN (pulmonary hypertension) on treprostinil (medication for pHTN) infusion via Hickman catheter and right heart failure due to pHTN. Review of the Physician orders revealed an order for "NPO (nothing by mouth) effective now" at 1327 and an order for "Venous catheter replacement" at 1327. Review of the Pre-procedure H & P (History and Physical) dated 02/16/2019 at 1326 by MD #1 revealed "Assessment/Plan: ... 5. Post-procedure care: ER (emergency room) patient to recover in ER after procedure. ..." Review of the Patient Care Timeline dated 02/16/2019 at 1345 revealed Patient #9 was transported to IR (Interventional Radiology). Review of the Intervention Radiology Brief Op Note dated 02/16/2019 at 1503 by MD #1 revealed "Findings: 1. Successful exchange of existing right IJ (internal jugular [a major blood vessel in the neck]) central venous catheter for a new 9.6 Fr. (French-size of catheter), single-lumen non-power Hickman catheter." Review of the Patient Care Timeline dated 02/16/2019 at 1520 revealed Patient #9 returned to the emergency department and report was given to RN #2. Review of the Patient Care Timeline revealed Patient #9 was sitting up and drinking Ginger ale on 02/16/2019 at 1633 and had friends at bedside at 1734. Review of an AVS (After Visit Summary) dated 02/16/2019 at 1842 revealed no instructions for wound/dressing care. Review of the medical record revealed Patient #9 signed receipt of the AVS on 02/16/2019 at 1852. Review of the record revealed Patient #9 was discharged from the facility on 02/16/2019 at 1900. Review of ED (Emergency Department) note dated 02/16/2019 at 1904 by RN #2 revealed "DC (discharge) instructions reviewed with pt (patient). Verbalized understanding. Denied questions."

Telephone interview on 03/20/2019 at 1305 with RN #2 revealed she was the primary nurse in the emergency department for Patient #9 after returning from IR (interventional radiology). Interview revealed RN #2 could not remember specifically but she (RN #2) would have reviewed what was in the AVS (After Visit Summary). Interview revealed RN #2 could not remember if there were instructions given regarding dressing. Interview revealed there were no wound care instructions provided in the discharge instructions.

2. Review of the medical record for Patient #19 on 03/20/2019 revealed a 59 year old female that presented to the ED on 02/05/2019 at 1108 with a complaint of "port will not dilate." Review the medical record revealed Patient #19 was escorted to the IR (Interventional Radiology) department from the ED on 02/05/2019 at 1516. Medical record review revealed Patient #19 had an exchange of the central venous access device performed in IR on 02/05/2019. Medical record review revealed on 02/05/2019 at 1726 Patient #19 returned to the ED to recover from the procedure. Review of the AVS (After Visit Summary) dated 02/05/2018 at 1918 revealed no instructions for wound/dressing care. Patient # 19 was discharged from the facility ED on 02/05/2019 at 1925.

Interview on 03/20/2019 at 1440 with Director of Emergency Department (ED) revealed the ED nurse should go over the reason for the ED visit and review the discharge instructions as selected by the provider. Interview revealed if the patient had a procedure like sutures in the ED, the ED nurse/team could give instructions for care. Interview revealed it was unclear who would give instructions about dressing care when a patient who had a procedure in another area discharged from the ED.



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B. Review of the "Positive Microbiology Culture Results in the Emergency Department" policy effective 06/05/2017 revealed "1. All positive microbiology culture results that are made known after the patient has been discharged from the Emergency Department (ED) are to be evaluated by the (name of facility) Resource Nurse in close collaboration with the EM (Emergency Management) Attending Physician, with clinical assessment of the patient's record to determine adequate treatment. ... General Procedure:
1. Identify a positive microbiology culture and review the patient's medical record and determine if the patient has received adequate treatment. 2. If patient has received appropriate treatment as per the current CDC (Center for Disease Control) Guidelines and or EM Attending Physician evaluation: a. Mail appropriate patient letter outlining individual results with appropriate follow up information with disease specific educational material. b. Mail communicable disease report card to appropriate health department if applicable. c. Attempt to contact the patient by phone to provide immediate alert to positive culture to allow the patient to take appropriate actions sooner i.e. if STD (sexually transmitted disease), inform sexual contact(s). ..."

Review on 03/19/2019 of Patient #2's ED record revealed a 28 year-old female that resented to the emergency department on 07/13/2018 at 0018 with a chief complaint of "Groin pain." Review of nursing triage notes at 0036 revealed the patient had been seen at an urgent care earlier in the day for a suspected urinary tract infection and was complaining of urinary frequency and incontinence starting on the day of arrival to the ED. Nursing notes recorded that the patient had started an antibiotic and "noticed a lesion in her vaginal area and has concerns for herpes." Review revealed a Physician's Assistant (PA) examination started at 0344 that revealed the patient had two small ulcerations at the entrance of the vagina. Review revealed a HSV (Herpes Simplex Virus) culture was ordered and collected at 0440. Review of the PA notes recorded a diagnosis of "vesicular lesion." Review revealed discharge instructions were provided that included medication for herpes simplex virus and instructions to obtain a follow up appointment in three days with a primary care provider. Review revealed the patient was provided information regarding Herpes Simplex that included "... Meaning of Test. Your caregiver will go over the test results with you and discuss the importance and meaning of your results, as well as treatment options and the need for additional tests if necessary. ..." Review revealed the patient signed the discharge instructions as reviewed and understood on 07/13/2018 at 0456. Review revealed the patient departed the ED on 0/13/2018 at 0532. Review of a HSV culture revealed the test was finalized and the result reported on 07/13/2018 at 1316 (7 hours and 44 minutes after the patient departed the ED). Review of nursing notes dated 07/13/2018 at 1502 recorded the patient received a prescription for the positive HSV culture. Review revealed no evidence the patient was notified via telephone or mail of a positive culture result.

Interview on 03/20/2019 at 1000 with RN #4 revealed she was the patient's primary nurse in the ED on 07/13/2018. The nurse stated the patient was given a dose of medication for HSV prior to departure and a prescription to take post discharge. Interview revealed the HSV was confirmed at 1316 after the patient had departed the ED. Interview revealed an ED resource nurse should communicate the results to the patient after the culture results are finalized. The nurse stated "The resource nurse should call her (Patient #2)."

Telephone interview on 03/20/2019 at 1315 with RN #5 revealed he was the resource nurse that reviewed and documented the resulted positive HSV culture for Patient #2. Interview revealed the nurse did not remember the patient and stated he documented the patient received appropriate treatment (prescription). Interview revealed there was no documentation that the patient was notified of the positive HSV culture. The nurse stated the normal procedure for a positive result would be to review the result with an ED physician for appropriate treatment and then to call and notify the patient. The nurse stated that would be followed with a letter that included a CDC fact sheet. The nurse stated he was new to the job at that time and he could not remember if he called the patient to notify her of the results. The nurse stated he should have documented if he had called the patient and sent her a letter with the results.

NC00148473; NC00148802; NC00147769