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Based on staff interview, clinical record and administrative document review, the hospital failed to ensure the medical staff was accountable to the governing body for the quality of care provided to all patients when the emergency physician (DO 2) did not ensure the quality of medical care provided to Patient 1 while under the care of Physician's Assistant (PA) 5 whom DO 2 supervised. DO 2 and PA 5 failed to abide by The MEDICAL STAFF RULES AND REGULATIONS when they did not communicate, collaborate and worked as an effective team while PA 5 provided medical services to Pt 1. (refer to A347)

The cumulative effect of these systemic practices resulted in the failure of the hospital to ensure the provision of quality of health care.

Based on staff interview, clinical record and administrative document review, the hospital failed to ensure the medical staff was accountable to the governing body for the quality of care provided to all patients when the emergency physician (DO 2) did not ensure the quality of medical care provided to Patient 1 while under the care of Physician's Assistant (PA) 5 whom DO 2 supervised. DO 2 and PA 5 failed to abide by The MEDICAL STAFF RULES AND REGULATIONS when they did not communicate, collaborate and work as an effective team while PA 5 provided medical services to Pt 1. These failures negatively impacted the quality of care delivered to Pt 1.

Findings:

The General Acute Care Hospital policies for credentialing and peer review, complete medical staff roster and the medical staff rules, regulations and bylaws were reviewed on 4/6/15 at 10:30 A.M. The hospital policy and procedure titled "Medical Staff Rules and Regulations" dated 1/30/12, indicated "O. Allied Health Professionals [AHP]: 4. Supervision: a. A physician member of the medical staff shall ultimately be responsible for the care of the patient and for any medical problem that may be present at the time of admission or that may arise during hospitalization. The supervising physician reviews, signs, and dates the medical record of every patient treated by the AHP within fourteen (14) days of the treatment. All Allied Health Professionals must be under the direction of a member of the Medical Staff of the facility, who possesses clinical privileges in the area in which the AHP will practice. Membership on the Allied Health Professionals is contingent upon the continued Medical Staff membership of the sponsoring physician.

Independent Classification: Independent AHPs function in a capacity where they use their own judgment in making patient care decisions, such as a clinical psychologist and Licensed Clinical Social Worker (LCSW). Since these healthcare professionals do many things that physicians do, these AHPs have clinical privileges, but are not members of the medical staff. Independent AHPs do not have admitting privileges.

Dependent Classification: Dependent AHPs are supervised by a member of the medical staff. Dependent AHPs do not have clinical privileges, but provide services under a position description or scope of service as well as by standardized procedures and protocols which have been approved by the Interdisciplinary Practice Committee. In many cases, dependent AHPs provide services similar or the same as services being provided by employees of the organization; they are not members of the medical staff.
b. Physician Assistants: 1. The supervising/responsible physician is responsible to review, countersign, time and date the verbal orders, within 48 hours. The parts of the medical record that are the responsibility of the MD (medical doctor)/DO (doctor of osteophathic medicine)/DPM (doctor of podiatry medicine) must be authenticated by this individual. When non¿ MD/DO/DPM's have been approved for such duties such as taking medical histories/physicals and/or documenting aspects of MD/DO/DPM examination, such information shall be appropriately authenticated by the responsible MD/DO/DPM. When the discharge summary and/or operative report/note is delegated to the allied health professional, the MD/DO/DPM responsible for the patient during his/her stay shall co¿ authenticate and date/time the discharge summary to verify its content. (Cross reference: Supervising Physician Agreement for Physician Assistants.)
(2) The supervising physician reviews, signs, and dates the medical record of every patient treated by the Physician Assistant within fourteen (14) days of the treatment.
(3) A physician assistant may only provide those medical services which he or she is competent to perform and which are consistent with the physician assistant's education, training, and experience, and which are delegated in writing by a supervising physician who is responsible for the patients cared for by that physician assistant.
(4) The supervising physician shall provide the Medical Staff Office with a written annual evaluation/review in the following six areas of competency: (1) Medical Knowledge; (2) Clinical Judgment; (3) Communication Skills; (4) Interpersonal Skills; (5) Professionalism; and (6) Overall Recommendation. (Cross reference: Supervising Physician Agreement for Physician Assistants.)

"Q. Code of Conduct: The Medical Executive Committee recognizes and acknowledges that providing high quality medical care depends, in large part, upon the ability of Practitioners and Allied Health Professionals (collectively, "Practitioners and AHPs") to communicate well, conduct themselves in a professional manner, collaborate effectively, be mutually supportive towards other Practitioners and AHPs and the hospital staff and work as an effective team within the hospital setting. To that end, the demonstrated ability to work collaboratively with others in the treatment team setting so as not to pose a threat to the quality of patient care is an existing criteria for Practitioner and AHP status, and failure to satisfy this requirement can result in corrective action under the Medical Staff Bylaws. In assessing whether particular circumstances jeopardize the ability of the treatment team to work together in the interests of patient care, the assessment need not be limited to care of specific patients, or to a direct impact on patient health. Rather, it is understood that quality patient care embraces - in addition to medical outcomes - matters such as professional and respectful treatment of all Practitioners and AHPs, staff, patients and families ("Persons"). In evaluating compliance with the existing criteria regarding Practitioner and AHP behavior, the Medical Executive Committee shall be guided by its professional judgment and the following Code of Conduct. ..."

The medical record for Pt 1 was reviewed on 4/6/15 at 10:30 A.M. as a part of the usual survey process. Pt 1 had initially been evaluated and treated in the emergency services department (ER) of the facility by MD 8 on 12/16/14 at approximately 4:44 A.M. for a 3 centimeter stab wound he had sustained to his left anterior lower leg while at work in a cattle processing plant. The medical record did not reflect any irrigation of the wound prior to suturing it closed. There is no record of Pt 1 receiving antibiotic therapy prior to discharge. The medical record shows he was treated and discharged on 12/16/14 at approximately 9 A.M. The medical record indicated Pt 1 had returned to the emergency services department of the facility for a second visit on 12/17/14 at approximately 4 A.M. complaining of left lower leg pain. During his return (2nd) visit to the ER he was seen and treated by PA 5. PA 5 noted (in the medical record) that Pt 1 had sustained a "laceration to the left lower leg that had a dressing on, dressing is not removed, it was put on 20 hours ago." PA 5 noted (in the medical record) that Pt 1 had "No erythema extending proximally or distally to dressing. Patient has decreased ROM of the lower leg secondary to pain." The medical record for Pt 1 shows PA 5 never removed the dressing from Pt 1's leg and never examined the direct site of the injury.

The medical record shows Pt 1 returned to the ER of the facility again on 12/17/14 at approximately 5 P.M. (for 3rd visit) once again complaining of pain in his left lower leg associated with the injury he had sustained on 12/16/14 and was evaluated by MD 3. The medical record shows the condition of the left lower leg (as assessed by MD 3) had worsened. Pt 1 was eventually taken to the operating theater of the facility shortly thereafter and underwent an amputation of his left leg above the knee joint. Pt 1 was discharged from the facility on 12/28/14 after having had an above the knee amputation of his left leg.

DO 2 was interviewed on 4/6/15 at 3 P.M. He stated his was the supervising physician for PA 5 who was a dependent allied health practitioner. He stated PA 5 never removed the dressing from Pt 1's left lower leg during Pt 1's second visit to the ER on 12/17/14. He stated PA 5 had never asked him for a consultation with regard to Pt 1's wound during Pt 1's second visit second visit to the ER on 12/17/14. He stated he did co-sign PA 5's note on 12/17/14 without having been consulted regarding Pt 1's wound and without having seen Pt 1's wound. He stated PA 5 should have removed the dressing on Pt 1's left lower leg on 12/17/14 during Pt 1's second visit to the ER and examined the wound directly. He stated PA 5 should have communicated with him as his supervising physician regarding Pt 1's care and treatment. He stated he was aware of the of the fact that Pt 1 had undergone an above the knee amputation of his left leg on 12/17/14.

PA 5 was interviewed on 4/7/15 at 11:03 A.M. He stated he was a dependent allied health practitioner. He stated DO 2 was his supervising physician. He stated he was the PA who had seen Pt 1 when he had returned to the rapid medical evaluation section of the ER for his second visit on 12/17/14. He stated he had examined Pt 1, however, he never removed the dressing form Pt 1's left lower leg and examined the wound directly. He stated he had never asked DO 2 for a consultation with regard to Pt 1's wound during his encounter with Pt 1 in the ER on 12/17/14. He stated he did write and sign a note on 12/17/14 without having consulted his supervising physician regarding Pt 1's left lower leg wound and without having seen Pt 1's wound. He stated he should have removed the dressing on Pt 1's left lower leg on 12/17/14 during Pt 1's second visit to the ER and examined the wound directly. He stated he should have communicated with his supervising physician (DO 2) regarding Pt 1's wound care and treatment. He stated he was aware of the of the fact that Pt 1 had undergone an above the knee amputation of his left leg on 12/17/14.

MD 3 was interviewed on 4/6/15 at 1:24 P.M. He stated he was the ER physician who saw and examined Pt 1 when he returned to the ER for his third visit on 12/17/15 at 3:24 P.M. He stated he carefully examined Pt 1's left lower leg wound. He stated his examination revealed a wound which had a foul smell, was swollen and showed signs of a serious, advanced infection. He stated he was aware of the of the fact that Pt 1 had undergone an above the knee amputation of his left leg on 12/17/14.

MD 4 was interviewed by phone on 4/7/15 at 9 A.M. He stated he was Medical Director of the ER. He stated he was familiar with the case of Pt 1. He stated PA 5 had failed to remove the dressing from the wound on Pt 1's left lower leg wound when he saw the patient in the ER on 12/17/14 at 4 A.M. He stated PA 5 should have removed the dressing and examined the wound directly. He stated PA 5 should have consulted with his supervising physician (DO 2) regarding Pt 1's wound care and treatment. He stated the supervising physician should had been asked to examine the wound. He stated he was aware of the of the fact that Pt 1 had undergone an above the knee amputation of his left leg on 12/17/14. He stated he was aware of the fact that both PA 5 and DO 2 had signed and cosigned a ER medical note, respectively without the benefit of any communication or collaboration regarding the quality or appropriateness of care Pt 1 received on 12/17/14. He stated the case was in the process of being peer reviewed.