HospitalInspections.org

Based on interview and record review, the facility and nursing department failed to appropriately supervise the on-going care for 1 (Patient #4) of 10 sampled patients.

The findings included:

On 8/31/16, a record review of Patient #4's medical chart revealed he was admitted on 3/25/16, through the Emergency Department (ED). A cardiac alert was completed on his arrival to the ED. Registered Nurse, Staff H said she wrote the name of Patient #4's cardiologist on the form. She said that Patient #4 requested Staff C to be contacted, because he was under his care in the community.

On 10/6/16 at 9:45 a.m., the Risk Management and Patient Safety Director said she believes Patient #4 did give the name of his community cardiologist as Staff C. She said Staff C should have been the one notified from the ED. She said the patient should have the choice of which cardiologist to notify and that person should be called. She said Patient #4 probably did tell staff, the nurses, who he wanted for his cardiologist and Staff C wasn't called.

On 8/31/16, a review of the Emergency Service Back Up Physician Schedule documented Cardiologist, Staff B was listed as the "On Call Cardiologist" for 3/24/16 and 3/25/16.

On 8/31/16 a review of nursing progress notes dated 3/25/16 at 0702 (7:02 a.m.), Registered Nurse, Staff F documented "Advanced Registered Nurse Practitioner, Staff D noted Patient #4 with continued chest pain; stated she will notify Cardiologist Staff B." At 0757 (7:57 a.m.), Registered Nurse, Staff E documented "call placed to Cardiologist, Staff B to notify of Troponin level of 30.300, awaiting call back at this time." At 0818 (8:18 a.m.), Staff E documented "second call placed to Cardiologist, Staff B to notify of Troponin of 30.300 this a.m., still awaiting call back at this time."

On 8/31/16, a review of a physician order dated 3/25/16 at 0847 (8:47a.m.), for Patient #4 documented a consult was requested with Cardiologist, Staff C.

On 10/6/16, a review of the policy "Chain of Command" documented Policy II. Any ordering, attending/covering, or the consulting physician of the appropriate specialty, will be contacted whenever a patient's condition warrants or when there is a question that the change in condition could affect patient safety or an adverse outcome could occur. The Procedure documented (2) notify the charge and or lead clinician of the situation.