HospitalInspections.org

Based on record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to ensure patients received care in a safe setting as evidenced by failure to ensure S6MD, who was on call, responded to hospital staff and an accepting hospital's calls to ensure Patient #1, a critical patient, could be transferred as ordered for a higher level of care. The hospital staff failed to notify any other medical provider, administration or medical director that S6MD failed to answer calls related to timely transferring Patient #1 to a higher level of care, when a bed was available. Furthermore, on 03/16/2024 the hospital staff received notice of another available bed. The hospital staff attempted to call S6MD, the physician caring for Patient #1, who was not on call. The hospital staff failed to follow the appropriate process for after hours when there was no in-house physician on call. The hospital staff also failed to notify any other medical provider, administration or medical director of the available bed, resulting in the bed not being available and the patient not being transferred. (See findings under tag A-0144)

On 03/27/2024 at 3:18 p.m. an Immediate Jeopardy was called. The Immediate Jeopardy situation was a result of the hospital failing to take immediate action to prevent on call physicians from not responding to calls related to critical patients and not taking immediate action to prevent hospital staff from not notifying any other medical provider, administrator or medical director when an on call physician is not responding to calls related to a critical patient. This lack of action placed all current 68 patients and any other admitted patients at risk.

On 03/28/2024 at 9:34 a.m. S2Qual presented a plan for lifting the immediacy of the IJ situation and the plan included the following:
Actions:
ICU Staff: Immediate training started 3/27/24 at 4:45 pm with the current ICU staff on duty, and oncoming night shift. Training will continue at the change of shifts until all staff have been properly educated which includes:
1) Following the Chain of Command policy when there is not prompt management and resolution to a patient care concern.
2) This notification includes the use of eICU during 7P to 7A shift, as outlined in the policy, "SOS 01Steward eICU Program Scope of Services".
On 3/27/24 a.m. oncoming shift will be educated.
Education will include a manual read and sign. All new hires will receive this training and annual training will be assigned.
All staff: Immediate training started on 3/27/24 at 4:45 pm to current staff on the following:
3) Following the Chain of Command policy when there is not prompt management and resolution to a patient care concern.
Case Management:
CM initiated a search for transfer to a higher level of care. EMR review revealed the failure to document communication regarding the transfer to the attending and ICU team.
03/27/2024 PM met with CM weekday staff still in-house and re-educated of the requirements to document delays, obstacles to expected care plan progression. On 03/28/2024 AM will meet with CM weekday staff, and the Case Management Director will review with weekend staff on the next two weekends, in person, with scheduled weekend staff.
On 3/27/24 at 6:00 pm the Interim President sent a notice to all employees via email outlining the responsibilities to use the Chain of Command policy to get a more timely response to a patient transfer, despite the time of day and day of the week. Any communication problems, even with an on-call physician should be escalated as required. This includes using technology like eICU, the RL system (hospital's incident/accident system), our processes such as reports and huddle, and routine escalations to include House Supervisor, department leadership, Administration, CNO/CMO and Administrator on call.
The Interim President notified the board chairman 3/27/24 of the findings.
At Leadership Huddle on 3/28/24 and ongoing, the Case Management Director will inform the leaders of any pending transfers or barriers to patient care be communicated.

Call Schedule:
On 3/28/24, the Intensivist call schedule will be revised to provide additional clarification and was distributed to all on-call providers.
The CMO discussed on call responsibilities including responding to calls with the attending Intensivist on 3/27/24.
On call responsibility training will be sent to the Medical Staff beginning morning of 3/28/24:
The medical staff was notified of the chain of command policy regarding communication process between hospital staff and LIPs via email blast of our policy as well as a hard copy mailed to each active member of staff. Direct communication with ED medical director, hospitalists, and intensivists (inclusive of NP and PA LIP) will be carried out by the CMO and COS. The chain of command response will be communicated with Medical Executive Committee and department chairs by presentation at the Medical Executive Committee meeting as well as by email communication.

In an interview on 03/28/2024 at 10:20 a.m. S8RN, S9RN, S10RN, S11RN and S12RN were able to speak to the ICU Physician Call Schedule and the appropriate measures to take if a physician on call fails to answer.

On 03/28/2024 at 10:52 a.m. the Immediate Jeopardy situation was lifted.

Based on record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by failure to ensure S6MD, who was on call, responded to hospital staff and an accepting hospital's calls were answered to ensure Patient #1, a critical patient, could be transferred as ordered for a higher level of care. The hospital staff failed to notify any other medical provider, administration or medical director that S6MD failed to answer calls related to timely transferring Patient #1 to a higher level of care, when a bed was available. On 03/16/2024 the hospital staff received notice of another available bed. The hospital staff attempted to call S6MD, the physician caring for Patient #1, who was not on call. The hospital staff failed to follow the appropriate process for after hours when there was no in-house physician on call. The hospital staff also failed to notify any other medical provider, administration or medical director of the available bed, resulting the bed not being available and the patient not being transferred.

Findings:

A review of the hospital policy titled Admission, Transfer, and Discharge last revised 05/18/2021 revealed in part:
II. Transfer
A. Generally
Each Attending Practitioner must ensure timely, adequate professional care for his or her patients in the Hospital by being continuously available, or by transferring the care of the patient (temporarily or permanently) to a qualified Medical Staff Member with whom prior arrangements have been made. In the even urgent assistance is needed, Hospital personnel must be able to quickly and accurately identify the responsible Medical Staff Member.

F. Transfer to Another Medical Facility
Patients transfer to another medical facility must be discharged from the Hospital.
III. Discharge
B. No patient may be discharged without the agreement of the patient's Attending Practitioner, unless the patient request discharge against medical advice.

A review of the hospitals Rules and Regulations of the Medical Staff revealed in part: 1.5 Each Practitioner must assure timely, continuous, and professional care for his patients in the Hospital by being available himself or having available, through his office, an alternate Practitioner with whom prior arrangements have been made and who is a member in good standing on the Medical Staff. Failure of an attending Practitioner to meet these requirements could result in the loss of clinical privileges.

A review of the Glenwood Regional Medical Center MD Call schedule revealed S6MD scheduled 03/15/2024 from 7p-7a.

In an interview on 3/26/2024 at 3:40 p.m. S2Qual stated the intensivist covers the ICU and verified the Call scheduled above.

A review of Patient #1's Medical Record on 03/27/2024 with S17RN revealed in part:
A note dated 3/13/2024 at 3:33 p.m. dictated by S20NP- Plan: She has not been able to make decision about code status, thus remains full code. D/W S6MD. We will initiate transfer to Hospital "d" (pt. agreeable) for severe PHTN and worsening respiratory failure.

A Nurses Note dated 03/14/2024 at 8:43 p.m. S13RN documented a conversation with Hospital "c". Patient update given and Hospital "c" stated they were checking bed availability and will call back with information to move forward.
A Nurses Note dated 03/15/2024 at 00:26 a.m. S13RN documented Hospital "c" called stating they have an ICU bed available, but they were going to be sure Patient #1 meets Hospital "c" ICU criteria and call back.
A Nurses Note dated 03/15/2024 at 00:58 a.m. S13RN documented Hospital "c" transfer center calls back stating Hospital "c" ICU MD wants to speak with Glenwood Regional Medical Center ICU MD. S6MD cell phone number give. Hospital "c" states they will call S6MD and coordinate.
A Nurses Note dated 03/15/2024 at 1:45 a.m. S13RN documented Hospital "c" called and stated they attempted to call S6MD x 2 with no answer. Hospital "c" MD will not admit until he speaks with S6MD. I attempted to call x1 with no answer; message left with call back number to unit and Hospital "c" Transfer Center number.

A Nurses Note dated 3/16/2024 at 8:25 p.m. S13RN documented Hospital "a" transfer center called. Stated Hospital "a" still has no bed available, but Hospital "b" is able to take the patient.
8:45 p.m. Hospital "a" called back and stated Hospital "b" MD wants to speak with Glenwood Regional Medical Center Intensivist. Cell phone number given for S6MD.
9:00 p.m. Hospital "a" calls back and states they called S6MD multiple times with no answer, same as pervious nights attempts. Voicemail left. S13RN stated she will try to call from Glenwood Regional Medical Center and call back with any information. S13RN called S6MD x2 with no answer. Message left.

In an interview on 3/27/2024 at 10:30 a.m. S17RN, Case Management verified Patient #1's Medical Record Information.

Further review of Patient #1's Medical Record revealed:
Code Sheet 3/22/24-
CPR initiated 2213, PEA on monitor, CPR initiated
2214, 1 epi given
2219, pulse check, asystole---1 epi given
2221, pulse check, asystole---death pronounced
A Telemedicine Note dated 03/22/2024 at 10:23 p.m., Called to camera in room for code blue. CPR noted to be in progress. 2 cycles of CPR performed with resulting rhythm of PEA. Death pronounced.

In an interview on 3/27/2024 at 10:35 a.m. S19RN, Case Management verified S6MD was the MD making rounds on Friday 3/15/2024 morning and the staff nurse mentioned the phone calls and S6MD stated something to the effect that must have been the call I got around 1-1:30 a.m.

In an interview on 3/27/2024 at 10:54 a.m. S2Qual stated there is always a house supervisor, administrator always on call and staff should be aware of this.

In an interview on 3/27/2024 at 11:09 a.m. S3RN, Director Case Management stated he was made aware on the Friday after the first time S6MD did not answer. He was also made aware on Monday about the second time. S3RN denies being aware of anyone elevating this to other Medical Staff.

In an interview on 3/27/2024 at 11:30 p.m. S16MD, Chief Medical Officer and Hospitalist stated the staff should have called the eICU as they are on call after hours. He also stated he was familiar with Patient #1 but not aware of S6MD not answering the calls. S16MD verified S6MD was on call 3/15/2024 and should have answered the calls.

In an interview on 03/27/2027 at 12:05 p.m. S4RN stated there is no documentation showing staff are trained on the MD on Call schedule, eICU. She stated they should call the MD on the schedule, call the answering service, during the day use the unit secretary to find a MD, night and day time the house supervisor has availability for every phone number. S4RN stated she was made aware of S6MD not answering the phone several days after the incident. She questioned, if eICU did not want to transfer the patient. The incident was reported by S13RN. S13RN told her the accepting MD said they wanted to speak with the in-house intensivist, S6MD. She verified S6MD was on call the night of 3/15/2024. She also agreed that S6MD should have answered the call. S13RN told her that after S6MD did not answer she documented in the record and was hoping the bed would be available in morning because S6MD is in house between 7:00- 7:30 am; however, the bed was not available later. S4RN denied speaking with S6MD. S4RN stated she mentioned S6MD not answering call to S1Adm.

In an interview S1Adm stated he was made aware of the situation and agreed S6MD should have answered the call.

In an interview on 03/27/2024 at 1:07 p.m. S4RN verified there has not been any staff or MD training related to the on call issue.

In an interview on 03/27/2024 at 1:35 p.m. S6MD denied receiving a call on 03/15/2024 when he was on call. He reviewed the on call schedule and verified he was on call the night of 03/15/2024.

In an interview on 03/27/2024 at 2:05 p.m. S2Qual stated she reviewed Patient #1's medical record and did not see any documentation related to canceling the transfer order.

In an interview on 03/27/2024 at 2:35 p.m. S3RN stated he reviewed Patient #1's medical record and he failed to locate an order to cancel Patient #1's transfer.

In an interview on 03/28/2024 at 7:20 a.m. S13RN and S14RN verified the nurses note dated 03/14/ 2024 through 03/16 2024, noted above.

In an interview on 3/28/2024 at 8:26 a.m. S1Adm stated S15MD Steward's eICU Medical Director stated the eICU MDs are not credentialed to admit or discharge. In order to transfer a patient they must be discharged.

In an interview on 03/28/2024 at 9:30 a.m. S7TeleCom provided print out of an outgoing call from the ICU on 03/15/2024 at 1:27 a.m. to S6MD's cell phone number.

In an interview on 03/28/2024 at 11:10 a.m. S4RN, ICU Director verified S6MD's cell phone number on the print out of outgoing calls from the ICU on 03/15/2024 at 1:27 a.m.

In an interview on 03/28/2024 at 9:40 a.m. S1Adm stated that once he and other administration was made aware of the on call issues they failed to immediately implement measures to prevent the incident from happening again.