HospitalInspections.org

Based on document review and interview, the facility failed to ensure that outpatient services met the needs of the patients, in accordance with acceptable standards of practice, by failing to have a medical staff member adhere to the Medical Staff Bylaws, Rules and Regulations, ensuring patients' rights requirements were met, ensuring the nursing staff followed the policies and procedures related to providing age appropriate care, ensuring care was received to patients of all ages who enter H # 1 (Urgent Care), and a patient assessment, from head to toe, was completed in one (1) patient care instance (Patient # 12). The nurse executive failed to ensure a nursing staff member at H # 1 maintained a current job description in one (1) instance. (NS # 2)

Findings include:

1. The hospital policy titled, "Expectations of the Medical Staff", policy number MS-07, issued date June 2007, indicated to "provide appropriate patient care which consistently meets or exceeds generally accepted clinical standards". This policy was last reviewed on 12/05/2017.

2. The hospital policy titled, "Standards of Care-Urgent Care", policy number EX-36, issued date June 2007, indicated that "patients that present" to H # 1 "can expect age appropriate care that will address their specific complaint". This policy was last revised in March 2018.

3. The hospital policy titled, "Scope of Care, Treatment and Services-Urgent Care", policy number EX-51, issued date December 2013, indicated H # 1 "offers services to patients of all ages" who "walk in to receive care". This policy was last revised in March 2018.

4. The hospital policy titled, "Pediatric Assessment in Urgent Care", policy number EX-26, issued date June 2007, indicated "to assess the sick or injured child" by completing an "examination from head to toes". This policy was last revised in September 2016.

5. The hospital policy titled, "Patients Rights and Responsibilities", policy number A-17, issued date June 2007, indicated "the patient has the right to impartial access to treatment". This policy was last reviewed in January 2019.

6. The hospital policy titled, "Registration Protocol-Urgent Care", policy number EX-49, issued date November 2013, "every time a patient comes to" H # 1 "they must fill out registration information". This policy was last reviewed in August 2016.

7. The hospital policy titled, "Urgent Care Employee Competence", policy number EX-13, issued June 2007, indicated H # 1 "is committed to having competent, knowledgeable employees capable of providing quality care and service". Employees will be "informed of the job expectations" and "each position will have a valid job description". The "job description", will include the "purpose of the position, the key processes of the job, qualifications necessary to hold the position", and will be "given to each applicant". This policy was last revised in September 2016.

8. The "Plan for Provision of Care", dated January 2016, page six (6), indicated "job descriptions along with policies and procedures provide written evidence that clearly identifies registered nurses' responsibility and accountability for ...coordinating all nursing care", page fifteen (15) "a registered nurse will assess each patient's need for nursing care in all settings in which nursing care is to be provided", page sixteen (16), indicated the "medical staff is responsible" for the medical plan of care and "has the responsibility to assess" and improve patient care for H # 1's patients. The "individuals with clinical privileges provide medical services in accordance with the Bylaws, Rules and Regulation of the Medical Staff".

9. The "Medical Staff Bylaws", page four (4), indicated the "purpose" of the medical staff were to "ensure all patients" admitted to "or treated" in any of the "facilities, departments", or services of the hospital "shall receive quality of care". The "responsibilities" of the medical staff included "an obligation upon appointment to the Medical Staff to provide continuous care and supervision to all patients", and on page fifteen (15) an agreement to "abide by all policies" of the hospital, including "all Bylaws, Rules and Regulations". The "Bylaws" were last amended on 11/13/2018.

10. The "Medical Staff Rules and Regulations", adopted by the "Board of Managers" 01/12/2009, page one (1), indicated the "patient has the right to impartial access to treatment". The "Rules and Regulations" were last amended on 11/13/2018.

11. The "Application for Medical Staff Appointment", dated and signed 05/13/2013, indicated MS # 1 (Physician) "have received and read the Medical Staff bylaws and rules and regulations. I agree to abide by the terms of the Medical Staff bylaws rules and regulations; policies and procedures". If appointed "I specifically agree to: Abide by generally recognized ethical principles applicable to my profession", and provide "care and supervision" to "all patients" within the hospital for "whom I have responsibility".

12. In interview on 01/09/2019 at approximately 2:00 pm with nursing staff member NS # 2 (Registered Nurse-RN), confirmed remembering "turning away" patient # 12. The patient "was never registered so there wasn't a chart" (medical record). The "patients can't get past registration" and "they" (physicians) get upset with us if we register the patient". That evening MS # 1 "just out right refused to see the patient, and I have been told it is up to the physician if they see the patient". MS # 1 "is uncomfortable seeing some certain age patients".

13. In interview on 01/09/2019 at approximately 2:58 pm with administrative staff member A # 1 (Attorney), confirmed "expecting the physician to see any patient that walked through" H # 1's "doors" even if the physician were going to send them to the Emergency Department. The physician "should document and assess them appropriately".

14. In interview on 01/10/2019 at approximately 3:20 pm with administrative staff member A # 1, confirmed the "Plan for Provision of Care" dated January 2016, was the most current updated version.

15. In interview on 01/11/2019 at approximately 12:15 pm with administrative staff member A # 4 (Chief Nursing Officer-COO/Chief Nursing Officer-CNO), confirmed the "medical staff are required to follow their Bylaws, Rules and Regulations" as well as "the nursing staff should be following our policies and procedures". At 12:40 pm confirmed the H # 1 "physician is expected to see the patient and assess them. It is just safe patient care".

16. In interview on 01/11/2019 at approximately 1:05 pm with administrative staff member A # 4, confirmed "the patient has the right to impartial access to treatment. It sounds like we" (H # 1) "are not following our policies and procedures. I would say that we infringed upon their rights".

17. In interview on 01/11/2019 at approximately 12:45 pm with administrative staff member A # 4, confirmed that NS # 2 "did not have a job description for H # 1 in his/her personnel file", and "yes" NS # 2 "should of had an updated one" (job description).