HospitalInspections.org

Based on document review, policy review, medical record review, and interview, the hospital failed to ensure Medical Staff Bylaws, Rules and Regulations and hospital policies regarding on-call physicians were followed by 1 of 1 (Hospitalists Group #1) hospitalists groups of physicians providing coverage for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital document titled, "Medical Staff Bylaws, Policies, and Rules and Regulations" revised 12/14/2022 revealed, "...Substantial Compliance While every effort will be made to comply with all provisions of these Bylaws, substantial compliance is required..."

Review of the hospital document titled, "Unified General Rules & Regulations" revealed, "...On Call Coverage A credentialed physician can provide on-call coverage (including hospital rounds) for a credentialed sub-specialist as long as the credentialed physician does not exceed his/her level of approved privileges. During the period in which the credentialed physician provides on-call coverage the credentialed sub-specialist must be available (immediately by phone and within 30 minutes to the applicable... location) to ensure appropriate subspecialty coverage if needed... Physician Response to Phone Calls/Pages Physicians are expected to return appropriately placed phone calls and pages from hospital personnel within 30 minutes of the time the call/page is made. Physicians in provider-based clinics shall address inquiries from patients seeking clinical advice within the guidelines established by the practice..."

Review of the hospital document titled, "Medical Staff/Allied Professional Code" signed by Physician #1 on 10/30/2024 and Physician #2 on 5/8/2024 revealed, "...The goal of the Medical Staff is to provide the highest quality of care to our patients... In an effort to accomplish this, the medical staff has articulated the generally accepted criteria, which govern the practice of medicine at our facility. Each member of the medical staff is expected to adhere to these principles as a member of a community of health care professionals engaged in the delivery of high quality medical care. These criteria are...Abide by the Bylaws, Rules, and Regulations and other policies and procedures, including the Standards of Conduct and all-applicable accreditation and regulatory requirements... Communicate timely and effectively with other members of the health care team including nurses, therapists, other physicians, and anyone involved in the safety and welfare of patients. This includes...Responding promptly to pages..."

2. Review of the hospital policy titled, "Chain of Command and Physician Notification Policy" revised 9/23/2024 revealed, "...Patient care requires communication between the team members responsible for providing that care. A provider should be accessible for communication with other team members regarding any aspects of patient care including, but not limited to: discussing change in status, patient/family requests, medication clarification, receive reports of lab/diagnostic values, or coordinate care plan with other team members including physicians, or concerns with the current plan of care. The provider should respond, after notification, as soon as possible, but not to exceed 30 minutes..."

Review of the hospital policy titled, "Pain Assessment Policy" revised 12/16/2024 revealed, "...All patients will be assessed for pain based upon their clinical presentation, services sought, and in accordance with the care, treatment, and services provided. When pain is identified, the patient is treated or referred for treatment... The identification of pain is an important part of the plan of care because unrelieved pain has adverse physical and psychological effects... Pain scales used... Numeric Rating Scale...0 (no pain) to 10 (worst pain)..."

3. Medical record review for Patient #1 revealed a 46 year old female admitted under the care of Physician #1 on 12/15/2024 with diagnoses which included Pleural Effusion (a buildup of fluid between the tissues that line the lungs and the chest), Metastatic Breast Cancer (the most advanced stage of breast cancer; occurs when cancer cells spread from the breast and nearby lymph nodes to other parts of the body, such as the brain, bones, liver, or lungs), Asthma and Acute Respiratory Failure with Hypoxia (a condition where the body is unable to adequately oxygenate the blood due to a sudden decline in lung function, resulting in low oxygen levels in the bloodstream and requiring immediate medical attention). Review of the History and Physical completed by Physician #1 on 12/15/2024 at 11:36 PM revealed, "...Plan: Admit to stepdown ER [emergency room]; called interventional radiology who would like patient to be admitted and they will evaluate in a.m. [morning] for therapeutic thoracentesis of the left side..." (Thoracentesis is a medical procedure that involves removing fluid or air from the pleural space, the space between the two layers of tissue that cover the lungs and line the chest wall.) "...Pain medication to be ordered for patient as patient is significantly uncomfortable...Restart selected home medications as medically prudent..." Patient #1's home medications used to treat pain were continued which included Flexeril 10 milligrams (mg) by mouth twice a day, Fentanyl Patch 25 micrograms per hour (mcg/hr) topically every 72 hours, and Percocet 10mg-325mg four times a day by mouth as needed for pain. (Flexeril is a muscle relaxant used to treat pain and stiffness caused by muscle spasms. A Fentanyl patch is an opioid medication applied to the skin for long-lasting pain relief. Percocet contains a combination of acetaminophen (Tylenol) and oxycodone which is an opioid medication use to treat pain.) The report indicated Patient #1's most recent dose of Flexeril had been taken on 12/14/2024; and the fentanyl patch in place upon arrival had been placed on 12/15/2024 at 5:00 PM. There was no documentation noted indicating the date and time of the last Percocet dose.

Review of the nursing documentation and medication administration records (MARs) for Patient #1 dated 12/16/2024 revealed the Patient complained of pain in the right side at a level of 7 on a scale of 0 - 10, with 10 being the worst, at 12:54 PM. Patient #1 was given 1 Percocet tablet to address the pain and was then transported to Interventional Radiology to undergo thoracentesis.

Review of the US (ultrasound) Guided Thoracentesis W (with) Image Guidance report dated 12/16/2024 at 3:28 PM revealed, "...Successful ultrasound-guided thoracentesis on the left with 1.2 liters of fluid removed..."

Review of the nursing documentation and MARs revealed Patient #1 complained of severe pain on the right side at a level of 10 on 12/16/2024 at 4:51 PM and was administered 0.5 mg of Dilaudid intravenously (IV) per physician's orders. (Dilaudid is an opioid medication used to treat moderate to severe pain.)

Continued review of the nursing documentation and MARs revealed Patient #1 rated her pain level as 10 on 12/16/2024 at 6:42 PM. Physician #4 was notified, and orders were received to increase the Dilaudid to 1 mg IV which was administered.

A nursing note written by RN #2 on 12/16/2024 at 7:39 PM revealed, "...Patient was in pain today, so I gave her oxycodone [Percocet]...After the patient got back [from thoracentesis procedure] I started doing routine vitals [vital signs]. Patient started complaining of pain, so I gave her 0.5mg of dilaudid and some heat packs. An houe [hour] later the patient and patient's family got irate and started yelling because she was in so much pain. I tried to call [Physician #1] and he did not answer so I also texted him. In the mean time [RN #1] was calling [Physician #2] pager line to get in touch with someone. [Physician #4] called back and gave me oral orders to discontinue the 0.5mg, add 1 mg Q [every] 4 hr [hours] for pain...[RN #1] gave the patient the 1mg of Dilaudid this evening..."

Review of the nursing documentation and MARs dated 12/16/2024 revealed the following:

At 8:10 PM Patient #1 complained of pain at a level of 10 and was given Percocet 10 mg per physician's orders.

At 8:42 PM, RN #1 documented she attempted to reach Physician #1 because Patient #1 was complaining of "excruciating pain" on the right side. The RN further documented she was "waiting on response" from Physician #1.

At 9:29 PM, RN #1 documented she paged Physician #1 again and was "waiting on response."

Review of a Care Plan Addendum written by RN #4 on 12/16/2024 at 10:15 PM revealed, "...Patient stated she is in agonizing pain. Pain is located on the patient's right side that radiates to the patient's back. She described the pain as cramping, squeezing and stabbing. She also stated that she has SOB [shortness of breath] along with the pain. O2 Sat [oxygen saturation] was 90% [percent]. Patient was put back on BNC at 2L [by nasal cannula at 2 liters (Oxygen)]. She stated that the oxygen relieved her SOB. HR is 113 Sinus Tach [tachycardia, or rapid heartbeat]. She refused a BP [blood pressure] check. Patient received 1mg of Dilaudid and 10mg of Roxicodone [Percocet] for the pain. She states that the Dilaudid made the pain worse, but the Roxicodone slightly relived [relieved] the pain. House Supervisor also spoke with patient and family per family request. The on-call for the provider has been paged twice. No response received at this time. Patient is currently sleeping..."

Review of a Significant Event note written by RN #3 on 12/16/2024 at 10:40 PM revealed, "...Called by house supervisor - Patient is having extreme pain on the right flank. Pt [patient] had thoracentesis today on the Left. Significant history includes BC [breast cancer] with mets [metastasis]. Patient has diminished breath sounds throughout left side, right side is clear. Chest x-ray ordered...[Pulmonary Group] NP [nurse practitioner] consulted for pain management. 1x [1 time] dose of Toradol ordered. Given to patient. Pt is resting on departure of MRT [medical response team]. Bedside RN updated..."

There was no documentation in Patient #1's medical record to indicate Physician #1 or Physician #2 ever responded to the phone calls and/or pages placed by the nursing staff.

4. During an interview on 1/7/2025, the Clinical Director for 3 West (CD3W) stated she recalled making rounds on Patient #1 and was informed by the Patient and her family Physician #1 and #2 didn't respond quick enough to address the Patient's pain on 12/16/2024. The CD3W continued and stated when she investigated the incident, she discovered nursing staff reached out to a different group of physicians (the Pulmonology Group) and obtained medication orders to address the Patient's pain after they were unable to reach the physicians from Hospitalists Group #1.

During an interview on 1/7/2025 at 11:51 AM, the Director of Quality (DQ) stated Physician #1 and Physician #2 worked for Hospitalists Group #1 and their on-call procedure was for hospital staff to call their office number call center. The call center would take the message and then notify the appropriate physician.

During an interview on 1/7/2025 at 12:20 PM, the Chief Medical Officer (CMO) stated on-call physicians were expected to return calls within "30 minutes" for life-threatening conditions and "in a timely manner" for all other calls.

During an interview on 1/8/2025 at 8:15 AM, the House Supervisor (HS) verified he responded to a call from Patient #1's family on the night of 12/16/2024. The HS continued and stated Patient #1's family member stated Patient #1 was in pain and staff hadn't been able to reach Physician #1 via phone or page. The HS stated he went to Patient #1's room and "she looked like she was in pain." The HS continued and stated Patient #1's nurse, RN #2 informed him she had called and/or paged Physician #1 three times attempting to get something else ordered to address the Patient's pain without success. The HS stated he called the Medical Response Team (MRT) for assistance who came and assessed the Patient, ordered a chest x-ray, and reached out to another physician's group (Pulmonology Group) and got something ordered to address the Patient's pain.

During an interview on 1/8/2025 at 1:30 PM the DQ stated Hospitalists Group #1 did not provide an official on-call list to the hospital. Hospital staff merely called the office and they in-turn routed the calls to the appropriate physician.

During an interview on 1/8/2025 at 2:30 PM, Physician #2 stated his group of physicians were available 24 hours a day, 7 days a week. When asked how staff could reach those physicians, Physician #2 stated staff should call the answering service and "a lot of the nurses have our personal cell phone numbers, but the default is to call our answering service." Physician #2 stated he was unaware staff were unable to reach Physician #1 regarding Patient #1's pain, "I don't think I got involved until around Christmas."

During a telephone interview on 1/8/2024 at 4:57 PM, RN #4 confirmed she was Patient #1's primary nurse during the evening/night shift on 12/16/2024. RN #4 stated Patient #1 was very anxious and complained of pain in her right side. RN #4 continued and stated Patient #1 had been given Dilaudid during the previous shift, but Patient #1 informed her it didn't help as much as the oxycodone did. RN #4 stated she attempted to reach Physician #1 by calling his office/answering service, but he did not respond. RN #4 stated she tried to call him again about 20 minutes after the first call, but he never responded. RN #4 stated she called the HS and informed him of the situation and the HS called the MRT who came and evaluated the Patient. The MRT was able to reach one of the nurse practitioners with the Pulmonology Group present in the hospital and got orders for a chest-ray and Toradol. RN #4 stated Patient #1 calmed down and "went to sleep" after receiving the Toradol.

During a telephone interview on 1/8/2025 at 9:55 PM, RN #3 stated she was the nurse on the MRT who responded to Patient #1 on 12/16/2024. The RN stated she had already gotten orders for a chest ray before she assessed Patient #1 who reported pain at a level of 10. The RN continued and stated Patient #1 had a Fentanyl patch in place and informed her the oral pain medication hadn't worked. RN #3 continued and stated Patient #1 refused to take any more Dilaudid. RN #3 stated she called the Pulmonology Group's nurse practitioner, who was present in the hospital and got orders to give the Patient a Toradol injection. The RN continued and stated she helped reposition Patient #1, administered the Toradol, and assisted the Patient with deep breathing and relaxation exercises. RN #3 stated she went back to check on Patient #1 about 1 and a half hours later, and the Patient was asleep. When asked if she was aware of any issues with Physicians #1 and #2's response times, the RN stated she didn't "believe so", but it was sometimes more difficult to reach them [Hospitalists Group #1] because they weren't on-site. RN #3 stated staff call the exchange service and "sometimes they call quickly, but sometimes, the nurse practitioner is on call and she's not real good at responding."

Hospitalists Group #1 failed to respond to calls from the nursing staff in a timely manner to address Patient #1's pain.