HospitalInspections.org

Based on interview and record review it was determined the facility failed to have an effective system in place to inform Patient #1 of the results of bacterial cultures in order for the patient to obtain the necessary treatment.

The findings include:

Review of the hospital's Discharge Summary revealed Patient #1 was hospitalized August 30th through September 02, 2010 with diagnoses which included recurrent Bilateral Pleural Effusion and Bloody Pleural Effusion.

Review of the Physician's Orders, dated 09/01/10, revealed an order to culture the drainage from both pleural drains.

Review of the microbiology report revealed a final report was generated on 09/04/10 at 9:22 AM. Per the report, the Pleural Fluid from the left lung had light growth of Staphylococcus Aureus.

Interviews, on 10/26/10 at 8:30 AM, with the hospital's Laboratory Manager, Out Patient Line Administrator and Microbiology Manager, revealed the facility's system could be accessed by the physicians when patients were admitted to the hospital. They explained after a patient was discharged the laboratory generated a "New Work Report" which is printed and placed in the physician's mailbox in medical records. They stated they have a system to track when the reports were printed and distributed to the physician.

The Laboratory Manager printed a "Status History" which documented the "New Work Report" for Patient #1 was generated on 09/05/10 at 12:09 AM and delivered to the physician's mailbox on 09/05/10 at 12:10 AM. Additional review of the "Status History" revealed Patient #1's attending physician was identified as having received the "New Work Report" on 09/05/10. However, the "Status Report" provided no documented evidence the attending physician received the "New Work Report". The Laboratory Manager stated they did not verify the physician had received the "New Work Report".

Interview, on 10/26/10 at 2:55 PM, with Patient #1's attending physician revealed he had not received the "New Work Report" with the results of the cultures on the pleural fluid. He explained as he did not receive the report he had no information to relay to the patient's Primary Care Physician, or the patient related to the possible need for treatment.

Interview, on 10/26/10 at 12:30 PM, with Physician #2 revealed he did not always get a copy of the "New Work Report" after his patients were discharged. Physician #2 stated when he did not get the "New Work Report", he would have to contact the hospital for the results when the patient came in for their follow-up visit. The physician explained that as a result treatments would be delayed and could be prolonged depending on the nature of the infection.

Review of the hospital's policy, "Distribution of Reference Laboratory Reports", revealed if a patient is discharged prior to laboratory results being finalized the reports are labeled with "MR" and distributed to the appropriate physician mailbox.