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1850 CHADWICK DR

JACKSON, MS 39204

CARE OF PATIENTS - RESPONSIBILITY FOR CARE

Tag No.: A0068

Based on staff interview, review of the cardiology on call schedule, review of the facility "Consult" policy and procedure, Medical Staff Rules and Regulations for "Patient Care Rounds," the facility failed to ensure a cardiology and pulmonology consult for Patient #1 and Patient #2 was made within 24 hours and for failure ensure a physician/designated alternate made rounds on Patient #1 at least daily for two (2) of three (3) medical records reviewed; Patient #1 and Patient #2.

Findings Include:

An interview with the Intensive Care Unit (ICU)/Telemetry Director, on 08/17/2023 at 10:45 a.m., confirmed cardiology/pulmonology physicians are to see patients within 24 hours. ICU/Telemetry Director confirmed that the consults were not performed in a timely manner.

An interview with Cardiologist #1, on 08/17/2023 at 11:37 a.m., confirmed he recalled the weekend consults were missed. Cardiologist #1 reported there was a computer glitch with the new system, and he did not receive all the patients he was expected to see on his list. Cardiologist #1 reported he does not recall the ED doctor calling and talking to him about patient #1.

During an interview with the RN Supervisor, on 08/17/2023 at 2:40 p.m., it was confirmed the RN Supervisor told RN #3 to keep notifying cardiology they had a consult for Patient #1. The RN Supervisor also confirmed the incident was not reported this Chief Nursing Officer or Director of Quality,

During an interview with the CNO, on 08/17/2023 at 3:40 p.m., it was confirmed based on facility protocol, Patient #1 was expected to receive a cardiology consult completed within 24 hours of the order.

An interview on 08/17/2023 at 4:15 p.m. with RN #1, confirmed RN #1 was not working with Patient #1, but RN #1 said she heard conversation from other nurses concerning the multiple times Cardiologist #1 was called about his consult.

A telephone interview on 08/17/2023 at 4:45 p.m. RN #3, confirmed the facility did have computer issues on the weekend of 07/21/2023 and further confirmed she called for cardiologist #1 multiple times, but was not able to document the calls because of the new system.

Review of the ED physician note for Patient #1 confirms Patient #1 was admitted to the telemetry unit on 07/21/2023 at 8:58 a.m. with a diagnosis of non-ST elevated myocardial infarction with a cardiologist was consulted. The ED physician note 07/21/2023 at 6:40 p.m. revealed the ED physician discussed results of test and assessment for Patient #1 with cardiologist #1, the cardiologist agreed to see Patient #1 in the a.m. (07/23/2023).

Review of Patient #1's in-patient medical record confirmed no cardiologist documentation for a consult on Patient #1 until 7/24/23 at 8:50 p.m.

Review of Patient #1's inpatient medical record physician document, confirms the patient was seen by Certified Nurse Practitioner (CNP) #1 on 07/23/2023 at 2:23 p.m. and a history and physical was completed, and further review confirms there is no documented evidence the patient was seen by a physician on 07/22/20233.

Review of Patient #1's medication record revealed that the patient was not started on his regular medications until 07/23/2023 after seeing the Nurse Practitioner at 2:23 p.m.

Review of the Patient #2's inpatient medical record reveals Patient was admitted to the facility on 07/22/2023 at 4:21 a.m. with a diagnosis of COPD exacerbation and received a history and physical exam by CNP #1 on 07/22/23 at 1:57 p.m. Documentation reveals CNP #1 ordered a pulmonary consult. Further review of the inpatient medical record for Patient #1 revealed no documented evidence of a Pulmonologist consult until 07/24/23 at 5:00 a.m.

Review of the Facility policy and procedure, "Consults," policy #1300, dated 2/2004, updated 2/2023), revealed " ...Physician orders for consults will be communicated to the physician at the time the order is written ...Consults that are urgent and/or emergent or consults that are ordered in the Emergency Department should be a physician to physician call ...In the event an inpatient consult is ordered, after hours, then the unit secretary or nurse will notify the consulting physician's office/answering service of the consult and document the time, date, and name of the person accepting consult. Exception: if the ordering physician specifically writes to consult in a.m., then notify the consultant the next morning ...Failure to respond to a consult and/or within a specified timeframe as indicated by the physician's order is indicative of behavior that undermines a culture of safety as defined by the medical staff bylaws; and should be reported: To the attending physician who ordered the consult ...In the Event Reporting System (ERS) ..."

Review of the Facility Medical Staff Rules and Regulations, Article #3 "General Conduct of Care," no date, revealed " ...3.8 "Patient Care Rounds" Hospitalized Patients shall be seen at least daily and more frequently if their status warrants by the Attending Physician or his/her designated alternate ..."

During exit conference on 08/17/2023 at 5:30 p.m. with the Chief Nursing Officer, Director of Quality, and Chief Administrative Officer, survey findings were discussed, and no further documentation was submitted for review.

PATIENT SAFETY

Tag No.: A0286

Based on staff interviews, medical record reviews, service failure log review, and policy and procedures review the facility failed to report, measure, analyze and track patient safety events and performance improvement activities for two (2) of three (3) medical records reviewed; Patient #1, and #2.

Findings Include:

An interview with the Director of the Emergency Department (ED), on 08/16/2023 at 3:30 p.m. confirmed the ED Staff are expected to follow the Facility's "Chest Pain Protocol." The ED Director also confirmed the documented times of staff interaction with Patient #1 ED medical record were correct and there was a delay in patient care from the arrival time until the chest pain protocol was initiated.

An interview with the Chief Nursing Officer (CNO), on 08/17/2023 at 10:00 a.m., confirmed the ED staff are expected to follow the Facility's "Chest Pain Protocol" when criteria are met.

An interview with the Intensive Care Unit (ICU)/Telemetry Director, on 08/17/2023 at 10:45 a.m., confirmed cardiology/pulmonology physicians are to see patients within 24 hours. ICU/Telemetry Director confirmed that the consults were not performed in a timely manner.

An interview with Cardiologist #1, on 08/17/2023 at 11:37 a.m., confirmed he recalled the weekend consults were missed. Cardiologist #1 reported there was a computer glitch with the new system, and he did not receive all the patients he was expected to see on his list. Cardiologist #1 reported he does not recall the ED doctor calling and talking to him about patient #1.

An interview with the Chief Nursing Officer (CNO), on 08/17/2023 at 2:00 p.m., confirmed there is no documented evidence of Quality Assurance Performance Improvement (QAPI), or Performance Improvement (PI) projects related to patients not receiving consults or a failure to be seen by a Provider based on the facility's policy and procedures and protocols.

An interview with Director of Quality (DOQ), on 08/17/2023 at 2:15 p.m., confirmed the missed consults for Patient #1 and Patient #2 were not reported to the Event Reporting System as required for tracking.

During an interview with the RN Supervisor, on 08/17/2023 at 02:40 p.m., it was confirmed the RN Supervisor told RN #3 to keep notifying cardiology they had a consult for Patient #1. The RN Supervisor also confirmed the incident was not reported this Chief Nursing Officer or Director of Quality.

During an interview with the DOQ on 08/17/2023 at 3:35 p.m., it was confirmed based on facility protocol, Patient #1 was expected to have a cardiology consult completed within 24 hours of the order.

During an interview with the CNO, on 08/17/2023 at 3:40 p.m., it was confirmed based on facility protocol, Patient #1 was expected to receive a cardiology consult completed within 24 hours of the order.

An interview on 08/17/2023 at 4:15 p.m. with, RN #1, confirmed RN #1 was not working with Patient #1, but overheard conversations from other nurses concerning the multiple times Cardiologist #1 was called about his consult.

A telephone interview on 08/17/2023 at 4:45 p.m. with RN #3, confirmed the facility did have computer issues on the weekend of 07/21/2023 and further confirmed she called for the cardiologist multiple times, but was not able to document the calls because of the new computer system.

During an interview with the Chief Administrator Officer (CAO), on 08/17/2023 at 5:15 p.m., it was confirmed ED staff are expected to follow the proper chest pain protocol and further confirmed a patient is to be seen by a hospitalist every day and have a cardiology consult completed within 24 hours.

Review of Patient #1's Emergency Department (ED) medical record revealed the patient arrived on 07/21/2023 at 4:32 p.m. with complaints of chest pain and was triaged at a documented acuity level of three (3) after waiting 52 minutes for triage at 5:53 p.m. Review of Patient #1's Medical Screening Exam (MSE) documentation revealed the patient waited one (1) hour and 11 minutes to receive an MSE at 5:53 p.m. Review of Patient #1's medical record test results confirm the first Electrocardiogram (EKG) was completed at 6:45 p.m. two (2) hours and 13 minutes after the patient's arrival and the second EKG was completed at 11:35 p.m. four (4) hours and 50 minutes after the first EKG with changes noted. Review of the ED laboratory results revealed patient #1's Troponin levels were not taken until 7:09 p.m. two (2) hours and seven (7) minutes after arrival. Laboratory results revealed Patient #1's Troponin levels were critically high at 111.2 and a second Troponin level was drawn on 07/21/2023 at 11:24 p.m. with indicating an increase to 120.7 critically high.

Review of the ED physician note for Patient #1 confirms Patient #1 was admitted to the telemetry unit on 07/21/2023 at 8:53 p.m. with a diagnosis of non-ST elevated myocardial infarction and a cardiologist was consulted. The ED physician note 07/21/2023 at 6:40 p.m. revealed the ED physician discussed Patient #1 with cardiologist #1, and the cardiologist agreed to see Patient #1 in the a.m. (07/23/2023).

Review of Patient #1's in-patient medical record confirmed no cardiologist documentation for a consult on Patient #1 until 7/24/23 at 8:50 p.m.

Review of Patient #1's inpatient medical record physician document, confirms the patient was seen by Certified Nurse Practitioner (CNP) # 1 on 07/23/2023 at 2:23 p.m. and a history and physical was completed, further review confirms no documented evidence the patient was seen by a physician on 07/22/20233.

Review of Patient #1's medication record revealed that the patient was not started on his regular medications until 07/23/2023 after seeing the Nurse Practitioner at 2:23 p.m.

Review of the Patient #2's inpatient medical record reveals Patient was admitted to the facility on 07/22/2023 at 4:21 a.m. with a diagnosis of COPD exacerbation and received a history and physical exam by CNP #1 on 07/22/2023 at 1:57 p.m. Documentation reveals CNP #1 ordered a pulmonary consult. Further review of the inpatient medical record for Patient #2 revealed no documented evidence of a Pulmonologist consult until 07/24/2023 at 5:00 a.m.

Review of the Facility's "Service Failure Log" for 2023 confirmed no reported incidents since 03/23/2023.

Review of the Facility's "Chest Pain Protocol," (effective date 07/2015) revealed patients with chest pain should be " ...immediate bed placement ...ECG within 5 minutes ...Interpretation within 10 minutes ...consult cardiology and admit to inpatient/hospitalist ...repeat troponin and EKG in 3 and 6 hours ...anticipate Cath lab transfer ..."

Review of the Facility's policy and procedure "Triage Assessment of the Patients by Emergency Severity Index," (effective date 09/2011) revealed " ...high risk situation ...chest pain ...level 2 acuity ..."

Review of the Facility policy and procedure, "Consults," policy #1300, dated 2/2004, updated 2/2023), revealed " ...Physician orders for consults will be communicated to the physician at the time the order is written ...Consults that are urgent and/or emergent or consults that are ordered in the Emergency Department should be a physician to physician call ...In the event an inpatient consult is ordered, after hours, then the unit secretary or nurse will notify the consulting physician's office/answering service of the consult and document the time, date, and name of the person accepting consult. Exception: if the ordering physician specifically writes to consult in a.m., then notify the consultant the next morning ...Failure to respond to a consult and/or within a specified timeframe as indicated by the physician's order is indicative of behavior that undermines a culture of safety as defined by the medical staff bylaws; and should be reported: To the attending physician who ordered the consult ...In the Event Reporting System (ERS) ..."

Review of the Facility Medical Staff Rules and Regulations, Article #3 "General Conduct of Care," no date, revealed " ...3.8 "Patient Care Rounds" Hospitalized Patients shall be seen at least daily and more frequently if their status warrants by the Attending Physician or his/her designated alternate ..."

During exit conference on 08/17/2023 at 5:30 p.m. with the Chief Nursing Officer, Director of Quality, and Chief Administrative Officer, survey findings were discussed, and no further documentation was submitted for review.

EMERGENCY SERVICES POLICIES

Tag No.: A1104

Based on staff interview, review of Emergency Department medical records (ED), and review of the facility policies and procedures (protocols) for Triage Assessment and Chest Pain the Facility ED staff failed to follow its policy and procedures (protocols) for one (1) of three (3) patient medical records reviewed; Patient #1.

Findings Include:

An interview with the Director of the Emergency Department (ED), on 08/16/2023 at 3:30 p.m. confirmed the ED Staff are expected to follow the Facility's "Chest Pain Protocol." The ED Director also confirmed the documented times of staff interaction with Patient #1 ED medical record were correct and there was a delay in patient care from the arrival time until the chest pain protocol was initiated.

An interview with the Chief Nursing Officer (CNO), on 08/17/2023 at 10:00 a.m., confirmed the ED staff are expected to follow the Facility's "Chest Pain Protocol" when criteria are met.

Review of Patient #1's Emergency Department (ED) medical record revealed the patient arrived on 07/21/2023 at 4:32 p.m. with complaints of chest pain and was triaged at 5:24 p.m. with a documented acuity level of three (3) after waiting 52 minutes for triage. Review of Patient #1's Medical Screening Exam (MSE) documentation revealed the patient waited one (1) hour and 11 minutes to receive an MSE at 5:53 p.m. Review of Patient #1's medical record test results confirm the first Electrocardiogram (EKG) was completed at 6:53 p.m. two (2) hours and 13 minutes after the patient's arrival and the second EKG was completed at 11:35 p.m. four (4) hours and 50 minutes after the first EKG with changes noted. Review of the ED laboratory results revealed patient #1's Troponin levels were not taken until 7:09 p.m. two (2) hours and seven (7) minutes after arrival. Laboratory results revealed Patient #1's Troponin levels were critically high at 111.2 and a second Troponin level was drawn on 07/21/2023 at 11:24 p.m. with indicating an increase to 120.7 critically high. The ED physician note 07/21/2023 at 6:40 p.m. revealed the ED physician discussed the results of tests and assessment for Patient #1 with cardiologist #1, the cardiologist agreed to see Patient #1 in the a.m. (07/22/2023).

Review of the Facility's "Chest Pain Protocol," (effective date 07/2015) revealed patients with chest pain should be " ...immediate bed placement ...ECG within 5 minutes ...Interpretation within 10 minutes ...consult cardiology and admit to inpatient/hospitalist ...repeat troponin and EKG in 3 and 6 hours ...anticipate Cath lab transfer ..."

Review of the Facility's policy and procedure "Triage Assessment of the Patients by Emergency Severity Index," policy # 1191-101, effective date 09/2011, revealed " ...high risk situation ...chest pain ...level 2 acuity ..."

During exit conference on 08/17/2023 at 5:30 p.m. with the Chief Nursing Officer, Director of Quality, and Chief Administrative Officer, survey findings were discussed, and no further documentation was submitted for review.