HospitalInspections.org

Based on interview and document review, the hospital failed to ensure physicians on the on-call list of hospital medical staff had privileges at the hospital for 1 of 5 medical staff credentials (Physician-H) reviewed.

Findings include:

On 5/30/19, at approximately 10:15 a.m. the list of on-call physicians was reviewed. At 10:20 a.m., a request was made to review the medical staff credential files for Physician-H. The administrator and credentialing specialists were in attendance of this review request. The administrator stated Physician-H only provided consultation the nurse practitioner who would call Physician-H. The administrator stated Physician-H did not come to the hospital. Per Credentialing Specialist I, there was no credentialing file for this physician, as he had no hospital privilege.

On 5/30/19, at 12:05 p.m. an interview as conducted with Physician-E. Physican-E said the hospital practice was that a physician be the back-up for mid level providers, and must be able to come to the hospital within 30 minutes. Physician-E was not aware Physician-H was on the on-call schedule.

Review of the hospital policy and procedure Emergency Medical Treatment and Active Labor Act last approved on 3/21/17, directed: VI. On-Call Response A. The hospital shall maintain a list of on-call physician and/or QMP (qualified medical provider) representing the medical speciality services available at the hospital to consult or provide treatment necessary to stabilize a patient with a EMC (emergency medical condition). The on-call physician and/or QMP is responsible to respond, examine, and treat emergency patients as defined in the hospital/s medical staff and regulations.

Review of the Fosston Medical Staff Rules and Regulations date unknown, directed: 7.8 Responsibilities of the On-Call Physician: Medical Staff Members who are officially on-call for patient care at the medical center are required to respond when: 1. called to evaluate a patient to determine if an emergency medical condition exists.....Initial response will be by telephone call to the individual who has called the on-call Medical Staff Member. The Medical Staff Member on call is required to respond by telephone within a reasonable time as outlines in this Section B.

Based on interview and documentation review, the hospital failed to maintain an accurate and complete central log for each individual who presented to the emergency department (ED) for 4 of 25 patients (P1, P13, P17, and P21) Findings include:

P1:
Review of the ED central log revealed P1 presented to the ED on 5/17/19, and the disposition was transfer.

Review of the medical record for P1 revealed P1 presented to the ED on 5/17/19. Per discharge notes of 5/20/19, the patient was observed in the hospital until discharge back to his home (assisted living facility) on 5/20/19.

P13:
Review of the obstetrics central log revealed P13 presented to the ED on 4/1/19 and the disposition was P13 was discharged.

Review of P13's medical record revealed P13 was admitted to the hospital on 4/1/19, for a cesarean section.

P17:
Review of the ED central log revealed P17 presented to the ED on 4/10/19, and the disposition noted P17 was transferred from the ED.

Review of P17's medical record revealed P17 eloped from the hospital on 4/10/19, after he was evaluated by the provider at 3:42 a.m.

P21:
Review of the ED central log revealed P21 presented to the unit on 5/8/19, and was discharged on 5/8/19.

Review of P21's medical record revealed P21 was admitted to the hospital on 5/8/19, due to contractions and membranes ruptured. P21 discharged from the hospital on 5/10/19.

Review of the policy and procedure Emergency Medical Treatment and Active Labor Act dated 3/21/17, directed: II. Central Log E. All logs must contain at minimum the following: 1. Name of the individual seeking medical treatment; and 2. Disposition: a. Refused treatment b. Was refused treatment c. Was transferred d. Was admitted e. Was transferred; or f. Was discharged.

On 5/30/19, at 2:30 p.m. the chief nursing officer (CNO)-B was interviewed. CNO-B verified the central log was incorrect for P1, P13, P17, and 21.