HospitalInspections.org

Based on record review, review of Medical Staff Rules and Regulations and staff interview, the facility failed to ensure that medical providers responded to the Emergency Department (ED) within 30 minutes of notification for 13 of 19 ED records (Patient's 25A, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51 and 52) reviewed. This failed practice has the potential to affect all ED patients. The facility had 2,214 ED visits for fiscal year 2022.

Findings are:

A. Review of Patient 25A's medical record revealed an ED visit on 9/26/23 with a check in time of 7:55 PM with main complaint of increased anxiety. The Physician Assistant (PA) on call was notified of patient in the ED at 8:15 PM. The PA arrived in the ED at 8:56 PM, 41 minutes after notification.

-Review of Patient 41's medical record revealed an ED visit on 9/3/23 with a check in time of 2:05 AM with main complaint of a fever. The Medical Doctor (MD) on call was notified of patient in the ED at 2:42 AM. The MD arrived in the ED at 3:33 AM, 51 minutes after notification.

-Review of Patient 42's medical record revealed an ED visit on 9/3/23 with a check in time of 8:33 PM with main complaint of deformity of right forearm. The MD on call was notified of patient in the ED at 8:42 PM. The MD arrived to the ED at 9:30 PM, 48 minutes after notification.

-Review of Patient 43's medical record revealed an ED visit on 9/9/23 with a check in time of 9:26 AM with main complaint of mental health concerns. The PA on call was notified of patient in the ED at 9:37 AM. The PA arrived in the ED at 10:11 AM, 34 minutes after notification.

-Review of Patient 44's medical record revealed an ED visit on 9/12/23 with a check in time of 1:12 AM with main complaint of nausea and vomiting. The PA on call was notified of patient in the ED at 1:24 AM. The PA arrived in the ED at 2:10 AM, 46 minutes after notification.

-Review of Patient 45's medical record revealed an ED visit on 9/12/23 with a check in time of 5:12 AM with main complaint of chest pain. The PA on call was notified of patient in the ED at 5:24 AM. The PA arrived in the ED at 6:10 AM, 46 minutes after notification.

-Review of Patient 46's medical record revealed an ED visit on 9/15/23 with a check in time of 5:38 AM with main complaint of not feeling well for the past 2 days. The PA on call was notified of patient in the ED at 5:57AM. The PA arrived at the ED at 6:34AM, 37 minutes after notification.

-Review of Patient 47's medical record revealed an ED visit on 9/22/23 with a check in time of 10:14 PM with main complaint of nausea and vomiting. The PA on call was notified of patient in the ED at 10:34 PM. The PA arrived in the ED at 11:15 PM, 41 minutes after notification.

-Review of Patient 48's medical record revealed an ED visit on 9/23/23 with a check in time of 7:15 AM with main complaint of vomiting for the past week. The PA on call was notified of patient in the ED at 7:35 AM. The PA arrived in the ED at 8:15 AM, 40 minutes after notification.

-Review of Patient 49's medical record revealed an ED visit on 9/23/23 with a check in time of 6:50 PM with main complaint of vomiting and diarrhea. The PA on call was notified of patient in the ED at 7:08 PM. The PA arrived in the ED at 7:55 PM, 47 minutes after notification.

-Review of Patient 50's medical record revealed an ED visit on 9/24/23 with a check in time of 7:22 PM with main complaint of increased nausea, vomiting, diarrhea and headache. The PA on call was notified of patient in the ED at 7:29 PM. The PA arrived in the ED at 8:17 PM, 48 minutes after notification.

-Review of Patient 51's medical record revealed an ED visit on 9/27/23 with a check in time of 3:30 AM with main complaint of sore throat. The PA on call was notified of patient in the ED at 3:41 AM. The PA arrived in the ED at 4:20 AM, 39 minutes after notification.

-Review of Patient 52's medical record revealed an ED visit on 10/3/23 with a check in time of 2:28 AM with main complaint of suicidal ideation and alcohol intoxication. The PA on call was notified of patient in the ED at 2:58 AM. The PA arrived in the ED at 3:33 AM, 35 minutes after notification.

B. Review of Medical Staff Rules and Regulations (Last Review/Revision 2020) stated "A member of the Active Medical Staff will be on call and immediately available by telephone or radio, and available on site within 30 minutes 24 hours a day."

C. Interview with ED Manager (10/5/23 at 10:00 AM) confirmed that the above medical records documentation revealed the providers did not arrive within the 30 minute time limit.




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