HospitalInspections.org

Based upon interview and record review, the facility failed to ensure services provided by the hospital in the off-campus outpatient Express Care location fulfilled acceptable standards of practice regarding establishing a process to assure that each patient or the patient's representative is given information on the patient's health status, diagnosis, and prognosis.
Findings include:
Per review of Patient #1's Medical Record, the patient visited the facility's outpatient 'Express Care' on 3/2/23 with complaints that included "Urinary frequency. Patient reports this has been worsening for the last week or so ...the urine does not show signs of urinary tract infection on urinalysis in clinic. We will send the urine to the lab for culture, which is the more definitive test". Further review reveals orders placed for 'Bacterial Culture-Urine' on 3/2/23, and results achieved the same day. The culture tests are documented as "Resulted 3/2/23, Abnormal".
Pt. #1's Medical Record records on 3/24/23 at 9:19 AM the patient called the facility and "she stated she had not heard from anyone on the Urine Culture results from 3/2/23. She is continuing to have symptoms and they are so bad that last night she could hardly pee. Please call." Further review reveals Nurse Practioner [NP] notes time-stamped 10 minutes later reporting "I called pt. and she said nobody ever called her for urine culture results and she is feeling unwell and having several urinary symptoms. I see there is a March 2 urine culture positive for strep urine infection. I recommend Ceftin [an antibiotic] for 5 days. Return precautions given." The NP notes include the diagnosis "Acute cystitis" [Cystitis is the medical term for inflammation of the bladder. Most of the time, cystitis happens when there's an infection caused by bacteria. This is called a urinary tract infection (UTI). Having a bladder infection can be painful and annoying. It can become a serious health problem if the infection spreads to your kidneys"]. (https://www.mayoclinic.org/diseases-conditions/cystitis/symptoms-causes/syc-20371306)
An interview was conducted with the Medical Director of Express Care on 5/31/23 at 10:50 AM.
The Medical Director stated that patients are telephoned if tests results are critical or positive, and test results are usually achieved within 24 to 48 hours. The Medical Director reported that the physician ordering the tests reviews results 2-3 times a week. The Medical Director reviewed Pt. #1's medical record and confirmed that tests dated 3/2/23 showed Pt.#1 was positive for a urinary tract infection [UTI]. The Medical Director also confirmed that Nurse Practioner notes dated over 3 weeks later on 3/24/23 document that the patient had not received any notification of having tested positive for a UTI, and was "feeling unwell and having several urinary symptoms" and required antibiotic treatment. Regarding Pt. #1's urinary infection, the Medical Director stated, "That is too long to wait to hear results".
An interview was conducted with the facility's Director of Primary Care Operations [DPCO] on 5/31/23. The DPCO reported that the facility has no written policy regarding patient notification but it is in the Physician's scope of practice and the Physician's responsibility to notify the patient of any diagnosis or critical or positive test results. The DPCO confirmed lab results for Pt. #1 dated 3/2/23 revealed positive results for a urinary tract infection and confirmed NP notes dated 3/24/23 recorded that Pt. #1 called the facility in search of test results from 3/2/23, that the results were available for 3 weeks but the patient was never notified of the positive urine cultures until the NP returned the patient's call on 3/24/23.