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Based on interview, record review and document review the facility failed to ensure medical staff followed established medical staff rules and regulations regarding attending physicians seeing and evaluating a new patient upon admission to the hospital within twelve hours after the patient had contact with the facility's emergency department physician for 2 of 23 sampled patients (Patient #7 and #23).

Findings include:

Hospital Medical Staff Rules and Regulations: Article II Admission and Discharge of Patients last revised 04/11 included the following:

2.1.4 - "The attending physician,with the exception of routinely laboring patients must see any admission within (12) hours after the practitioner has been contacted by the emergency room physician. Every patient admitted to the intensive care unit must be seen within (6) hours by the attending physician after the practitioner has been contacted by the emergency room physician. If a higher standard has been established by a clinical department, then the higher standard shall be applied."

Patient #7

Patient #7 reported being taken to taken to the emergency department on 12/17/11 by ambulance due to respiratory distress. The patient had a history of COPD (Chronic Obstructive Pulmonary Disease). The patient was transferred to a medical unit. Patient #7 reported the nursing staff failed to provide appropriate care and administer medication and breathing treatments according to physician orders. The patient reported no attending physician ever made contact or evaluated the patient for 17 hours. Due to neglect in care the patient was taken to another acute care facility the following morning by a family member.

A Physician Emergency Department Clinical record dated 12/17/11 at 4:59 PM included the following:

Patient #7 presented to the emergency department with a chief complaint of difficulty breathing. The patient had a history of COPD (Chronic Obstructive Pulmonary Disease) and had a cough productive of sputum. The patient was complaining of burning central chest pain. The patient's diagnoses included hypertension, COPD, coronary atherosclerosis, chest pain.

Clinical impression included acute exacerbation of COPD. The patient s chest x-ray showed mild bibasilar subsegmental atelectasis.

Physician Progress Notes included the following:

12/17/11 at 5:15 PM: The patient was administered intravenous Saline bolus of 1000 ml times one. The patient received Solumedrol 125 mg (milligrams) IV (intravenous), Aspirin 325 mg by mouth, Albuterol nebulizer treatment 10 mg continuous over one hour and Atrovent 0.5 mg unit dose nebulizer treatment. "Discussed case with hospitalist. Will admit. Reviewed test results. Agreed upon treatment plan. Health care provider will see patient in hospital. Patient counseled in person regarding the patient's stable condition, test results, diagnosis and need for admission. 12 lead EKG (electrocardiogram) performed."

The patient had been taking the following medications at home.

1. Albuterol Sulfate 2.5 mg every 4 hours.
2. Aspirin 81 mg daily by mouth.
3. Plavix 75 mg by mouth daily.
4. Xanax 1 mg two tablets by mouth at bedtime.
5. Synthroid 88 mcg (micrograms) by mouth daily.
6. Prednisone 10 mg by mouth daily.
7. Librium 5 mg by mouth as needed for depression.
8. Oxycodone 30 mg by mouth every 4 hours when needed for pain.

A review of Adult Emergency Department Covering Admission orders dated 12/17/11 at 6:30 PM documented the patient was admitted to the medical floor with a diagnosis of COPD and chest pain. The patient was prescribed the following medications until seen by admitting physician.

1. Albuterol 2.5 mg and Atrovent 0.5 mg nebulization every four hours around the clock and every one hour as needed for dyspnea and wheezing.
2. Nicotine patch 21 mg.

The patients nursing care plan listed altered respiratory status as a problem area.

A Nursing Admission Assessment dated 12/17/11 at indicated the patient breath sounds had rales and crackles.

On 12/27/11 at 2:00 PM, an interview was conducted with Employee #1 (Director of Quality) who reported that all patients transferred from the emergency department to a medical floor have temporary orders for treatment and medications written by the emergency department physician. According to medical staff rules and regulations the admitting physician has 12 hours from the time the patient is seen by the emergency department physician to see the patient and write admitting orders. Employee #1 confirmed Patient #7's admitting physician had not seen or written any admitting orders on the patient within the 12 hour hour limit or prior to the patient leaving the facility 17 hours after being seen by the emergency department physician. Employee #1 confirmed the patient's medication administration record revealed Patient #7 had not received any of the prescribed medication breathing treatments by nursing staff or respiratory therapy that were ordered by the emergency room physician.

The Physician Clinical Emergency Department record indicated the patient was seen and evaluated by the emergency department physician on 12/17/11 at 4:59 PM. The patient left AMA (Against Medical Advice) on 12/18/11 at 10:20 AM. The patients admitting physician arrived on the floor to see the patient on 12/18/11 at 10:45 AM (17 hours past without the patient being seen or evaluated by the admitting physician).


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Patient # 23

Patient #23 arrived to the emergency department on 12/21/11. Patient diagnoses included fall, pneumonia, lung cancer, rhabdomyolysis, arm abrasions, back sprain and leukocytosis.

A record review conducted on 12/28/11 revealed that the adult emergency department covering orders were dated and signed by the emergency room physician on 12/21/11 at 8:50 PM. It included an order that stated, "Covering orders are valid for up to...12 hours for general level of care. Contact admitting physician for admit orders, changes in patient status....or further orders."

Further record review on the same day revealed that admitting orders were written and signed by the admitting physician on 12/22/11 at 2:00 PM, 15 hours and 10 minutes after covering orders were provided.

Based on interview and record review, the facility did not adequately ensure the prevention of infection for 1 of 23 sampled patients (Patient #1).

Findings include:

Patient #1 was admitted to the facility 09/08/2011 with diagnoses that included intracerebral mass and mild hydrocephalus.

On 12/28/2011, Patient #1's clinical record was reviewed. The record stated that Patient #1 had a Foley catheter. Laboratory results indicated that urine cultures taken on 09/21/2011, 09/25/2011, 10/01/2011, 10/05/2011, were negative for bacterial colony count. On 10/08/2011, Patient #1's urine culture was positive for Pseudomonas aeruginosa and Enterococcus faecalis.

On 12/28/2011, at 10:05 AM, Employee #6, the facility's Infection Preventionist, was interviewed. She stated that Patient #1's bladder infection was facility acquired as indicated by the previous negative urine cultures and the subsequent positive urine culture.