HospitalInspections.org

Based on record reviews and interviews the facility failed to ensure medical staff enforced their bylaws by:

Failing to ensure that, for 2 patients (#s 3 and 26), out 6 sampled emergency department (ED) patients, received a timely consultation per the ED physician's order. This failure had the potential to contribute to the worsening of the patient's medical condition from a delay in treatment. Findings;

Patient #3

Record review on 4/2-6/18 revealed Patient #3 entered the hospital's ED on 12/3/17 with a diagnosis of acute homicidal ideation.

Review of the ED physician's exam, dated 12/3/17 at 5:08 am, revealed "I spoke with [physician's name] psychiatry on call for the behavioral health unit. She will admit [Patient #3] on voluntary basis.

On 12/4/17, dictated at 2:09 pm, more than 24 hours after the initial request for consultation, the psychiatrist saw Patient #3. Review of the exam revealed "the patient does not meet criteria for an involuntary hold. The patients not currently interested in being admitted to the mental health unit for any reason. He/she is not suicidal. He/she is not homicidal." The patient was subsequently discharged home.

Patient #26

Record review conducted on 4/2-6/18 revealed Patient #26, presented to the facility's ED accompanied by his/her mother, on 3/18/18 with a chief complaint of anxiety and explosive, violent behaviors.

Review the physician orders revealed a Physician's order, dated 3/18/18 at 11:29 pm, "Routine psychiatric for assistance with psychiatric management."

Review of a ED Social Services note, dated 3/21/18 at 2:17 pm, revealed "Psych consult was ordered and [he/she] will fax results when available to both facilities when it is available."

During an interview with ED Physician #1 on 4/5/18 at 1:10 pm stated the ED physicians usually wait until morning to call the psychiatrists for a consult. Physician #1 stated it can take anywhere from 12-24 hours for the psychiatrist to provide the consult. When asked about pediatric psychiatric patients, the Physician stated there was no timeline for a psychiatric evaluation of a pediatric patient.

During the interview when asked about the physician's screening for suicidal and/or homicidal ideation and what level the level of risk was, the Physician #1 stated although the physicians occasionally used a standard screening tool, it was up to the ED providers clinical judgement.

During an interview on 4/6/18, when asked about the delay in psychiatric evaluations, the Chief Medical Officer (CMO) stated the ED physicians had not complained about the response times. The CMO stated only nurses had complained and they had filled out several "Verge" [facility's online incident tracking] reports.

Review of the "Bylaws of the Medical Staff of Fairbanks Memorial Hospital", last dated 12/20/17, revealed "Except for Honorary Medical Staff, the ongoing responsibilities of each member of the Medical Staff include...participating in emergency room coverable as determined by their department and approved by the Executive Committee and the Hospital Administrator...Any Staff on call for the Emergency Room or Labor and Delivery shall respond by telephone within (30) minutes of a call from the Emergency Room or Labor and Delivery. If requested by the Emergency Room Physician, the staff member will by physically present within forty five (45) minutes of the request..."


.

.
Based on observation, interview, and record review the facility failed to ensure physician orders for 1 patient (#30) out of 10 active inpatients reviewed. This failed practice placed the patient at risk for a delay in healing and potential unnecessary treatment. Findings:

Record review on 4/4-5/18 revealed Patient #30 was admitted to the facility on 4/3/18 following a surgical skin graft to a burn site on the leg with a diagnoses history that included coronary artery (blood vessels of heart) disease, heart failure, and diabetes.

During an observation on 4/4/18 at 12:25 pm, Licensed Nurse (LN) #1 performed a blood glucose (BG-sugar) check on Patient #30's finger. When the result was 163, the LN commented the BG was a little elevated.

The Patient was then provided with his meal tray, which contained juice, a slice of angel food cake, rice, and chicken. The diet slip on the tray, indicated the Patient was on a regular diet and the carbohydrate count of the meal was 69. LN #1 stated to the Patient, that seems like too many carbs so we'll just remove the juice.

During an interview, on 4/4/18 at 1:30 pm, LN #1 stated the BG had been running high and the Patient did not have an order for sliding scale insulin (to manage elevated BG). The LN stated she/he had placed a call into the Patient's physician.

Review of Patient #30's medical record on 4/5/18 of a "Consultation Preliminary Report", conducted 4/4/18, by internal medicine physician #2, revealed "Assessment and Plan: Diabetes Mellitus. blood sugars have been mildly elevated. We will continue his Lantus insulin correction dosing as well as add some carbohydrate coverage..."

Review of a written protocol order, signed by Patient #30's admitting physician, dated 4/4/18 at 4:42 pm, revealed "Intensive Subcutaneous Insulin Protocol...Pre-Meal BG Goal 120-180...Notify physician for BG [greater than] 300...Nutrition Services...Medium Carbohydrate Diet (45 grams/meal)...BG Correction Goal: 150 mg/dl...Low Dose Algorithm." The back of the protocol, provided information on how much insulin the Patient was to receive for elevated BGs.

Observation of Patient #30's noon meal tray on 4/5/18 at 12:20 PM revealed the Patient was provided with a regular diet, not the ordered Medium Carbohydrate Diet.

During an interview with on 4/5/18 at 12:30 PM, when asked about the regular tray, LN #2 stated only 1/2 the protocol order had been processed, the LN stated processing orders had been a challenge when managing both electronic and written orders.

Review of the medical record revealed Patient #30 had the following BG levels: 4/4/18 at 5:10 PM-218; 4/4/19 at 9:03 PM-238; and 4/5/18 at 7:39-150. All the BG levels were above normal parameters.

.

Based on record review, observation, and interviews the facility failed to integrate the discharge/transfer needs of 1 patient (#26) in the ED, out of 14 patients reviewed receiving outpatient services. The failure to provide and/or coordinate services utilizing impatient resources delayed the patients discharge/transfer and created emotional distress of the patients and a stretch of family resources due to a delay in treatment implementation. Findings:

Patient #26

Record review conducted on 4/2-6/18 revealed Patient #26, presented to the facility's ED accompanied by her mother, on 3/16/18 with a chief complaint of anxiety and explosive violent behaviors. The Patient was discharged home with her mother.

Patient #26 returned to the ED with his/her mother on 3/18/18 with the same chief complaint. Review of an ED report, dated 3/18/18, revealed "the mother does not feel safe taking the child home. She wishes to have further psychiatric consultation."

Review of the psychiatric consultation, conducted 3/21/18, revealed "The patient is awaiting transport to an inpatient psychiatric facility. There are presumably 2 facilities that are currently under consideration ...I agree that inpatient hospitalization would help the patient reestablish stability particularly for a violent outburst.

Observation of the video of the seclusion rooms, on 4/2/18 at 1:39 PM revealed Patient #26 was laying on the bed, next to a woman who was seated on a nearby chair. During the observation the Patient began kicking the woman seated next to him/her.

Staff #1, who was covering the monitors, called to nearby staff, "he/she's kicking his/her mom again."

Review of a "ED Social Services Note", dated 3/21/18, revealed "SW [Social Worker] was asked to assist w/ phone calls and faxing re: acute psychiatric hospitalization for the Pt. Pt cannot be admitted to either facility in the State of Alaska. Pt. has been added to the wait list for 2 of the facilities ...Fax confirmations and clinical info provided to Pt's. Nurse ...in the ER [ED]. She will resume trying to get Pt. for placement. Psych consult was ordered and she will fax results to both facilities when it is available. ER will continue trying to find appropriate placement for this Pt."

Review of a communication, dated 3/28/18, revealed Patient #26 had been accepted to a facility located out of the State.

During an interview on 4/5/18 at 1:30 pm, when asked about the support provided by the facility and how long they had been in the ED, Patient #26's mother stated she was staying with her daughter in the ED while waiting for the Patient's transfer. They had been waiting in the ED for 3 weeks (19 days). She stated they were waiting for Medicaid to authorize the travel so the Patient could be transferred. The Mother stated it was required she stay with her daughter in the ED. She stated the facility staff sometimes provided respite care so she could take a shower or get something to eat, but she hated to ask the nurse for anything because they were so busy. She stated her father came in to help on the weekends and her mother was watching her other 2 children. The Patient's mother stated she had to pull her other children out of school since her mother lived almost 100 miles away. She stated she was unable to take her daughter home and the Hospital was the only one that had helped her.

During an interview with PQR (Patient Quality Resources-derpment that assists with discharge planning) Staff #1 on 4/5/18 at 1:45 pm, when asked about the discharge process for patients, PQR Staff #1 stated facility staff would notify PQR Task Management. PQR Staff #1 stated her only involvement in this case was providing the ED with some forms that needed to be filled out for the Division of Behavior Health (DBH). When asked about PQR's further involvement with the case, the PRQ staff stated she had thought the Patient's family was going to take her home.

On 4/5/18 at 2:28 pm, the State Medicaid office stated they had not received any out of state travel requests for Patient #26.

During an interview on 4/5/18 at 3:35 pm, Charge Nurse (CN) #2 stated she had attempted to make multiple calls to the agency that works with out of state Medicaid. The CN stated she had even attempted to call from a cell phone thinking they were avoiding calls. The CN stated the ED had been working with DBH in an attempt to get help with the placement.

Review of the soft chart (paper record) kept in the ED, revealed several different nurses had communicated with the out of State staff responsible for coordination with the out of State Medicaid.

During an interview on 4/6/18 at 11:00 am, the PQR Manager stated there was no discharge planning staff or SW assigned to cover the ED since they did not do discharges. The PQR Manager stated the ED staff would call if they needed help with transfers and stated she remembered they had called for assistance on 3/21/18. The PQR Manager stated they had a mental health SW that worked on the inpatient unit and a clinical SW that worked in the PQR department that no longer functioned in that role.

.

Based on record review and interview the facility failed to ensure the director of respiratory services is a doctor of medicine (MD) or osteopathy (DO) with the knowledge, experience and capabilities to supervise and administer the service properly. This failed practice placed all patients receiving respiratory services in jeopardy of receiving less than optimal respiratory care and services. Findings:

Record review on 4/3/18 at 9:00 am of the hospital key facility personnel list provided by the facility revealed RT #1 was the listed as Respiratory Director. Further review of the personnel/employee health worksheet completed and returned to the surveyor by the facility listed RT #1 as a respiratory therapist, not a MD or DO.

During an interview on 4/5/18 at 1:30 pm when asked if he was an MD or DO, RT #1 revealed he was not and the department had been without a medical director for two years.

During an interview on 4/6/18 at 9:55 am when asked if a MD or DO was director of respiratory services the Chief Medical Officer revealed he was only made aware of the position lacking qualified personnel prior to a Joint Commission survey earlier (February) in this year.
.