HospitalInspections.org

Based on record review and interview, the facility failed to ensure patient's rights to considerate and respectful care in a safe setting for 1 of 10 patients (Patient #2), in that, Patient #2 was informed she would have a thoracentesis during her admission from 12/24/15 through 12/26/15 and the facility did not complete thoracentesis. It was not documented complete and Patient #2 was discharged home with instructions to set it up on an outpatient basis.

Findings included

Patient #2's 12/24/15 emergency room Physician documentation reflected, "SOB (shortness of breath)...Dyspnea on exertion...Large right pleural effusion. This has significantly increase compared to 12/3/15...Will admit for consultations and possible thoracentesis...Counseled patient/family re: diagnoses, lab results, imaging studies, need for admission..."

Patient #2's 12/25/15 oncology consultation report reflected, "Pleural effusion...symptomatic. We will get a thoracentesis arranged and send for cytology...Discuss the same with patient..."
Patient #2's signed 12/25/15 8:47 AM order reflected, "Obtain signature on Consent...thoracentesis...pleural effusion..."
There was no procedure note documented during the admission to reflect a thoracentesis was completed for the patient.
Patient #2's 12/26/15 discharge summary reflected, "...anticipation of thoracentesis...Plan was to have thoracentesis while in the hospital; however, due to Christmas holiday, this could not be arranged in interventional radiology. Credentialed Personnel #10's group was consulted. They could not get (to) the patient's bedside to accommodate exam due to the business of their service and patient really not needing thoracentesis on an emergency basis...Patient herself felt that she was ready to go home...The patient was discharged home in stable condition. Full discharge plan discussed with patient, husband and daughter who are at bedside..."
During electronic record review and interview on 8/23/15 ending at 3:20 PM, Personnel #1 was asked for the thoracentesis documentation. Personnel #1 navigated the record and displayed the above findings. Personnel #1 stated, "I don't see any."
The facility's 10/01/14 "Patient Rights" required, "right to receive considerate and respectful care...individualized care that fosters the patient's comfort and dignity..."

Based on record review and interview, the medical staff failed to enforce it's rules and regulation for consults to be completed within 24 hours for 1 of 10 patients (Patient #2), in that, Patient #2's pulmonary consultation was not documented complete within 24 hours and did not get completed prior to the patient being discharged.

Findings included

Patient #1's 12/24/15 emergency room Physician documentation reflected, "SOB (shortness of breath)...Dyspnea on exertion...Large right pleural effusion. This has significantly increase compared to 12/3/15...pulse Ox (oximeter) 97% on room air...Will admit for consultations and possible thoracentesis...Referral/consultation name (Credentialed Personnel #9)...consultant called: intensivist, pulmonologist...2215 (10:15 PM)...12/24/15...Call returned...2221 (10:22 PM)...12/24/15..."
There was no pulmonary consultation note documented during the admission to reflect a consultation had been done.
The 12/26/15 discharge summary reflected, "...Plan was to have thoracentesis while in the hospital; however, due to Christmas holiday, this could not be arranged in interventional radiology. (Credentialed Personnel #10) group was consulted. They could not get (to) the patient's bedside to accommodate exam due to the business of their service..."
During the electronic record review and interview on 8/23/16 ending at 3:20 PM, Personnel #1 directed the review and was asked for the pulmonary consultation documentation. Personnel #1 stated, "I don't see one." Personnel #1 was asked if the patient was discharged with out being see by pulmonary. Personnel #1 stated, "It looks that way."
The facility's November 2014 Medical Staff Rules and Regulations required, "Consultations should be done within 24 hours of physician to physician request..."