HospitalInspections.org

Based on review of medical staff bylaws, rules, regulations, hospital documents, medical records and staff interviews, it was determined the governing body failed to ensure the quality of care provided by the medical staff as evidenced by:

1. failure to require documentation of evaluations of patients placed on a "sick call" log for 3 of 4 log entries (Pt #'s 2 and 22) and

2. failure to document a biopsy follow up regarding Pt # 19's emergency department visit on 12/04/14.

Findings include:

The Medical Staff Bylaws 2012-2014, required: "...The Responsibilities of the Medical Staff Shall Be...To maintain, administer, recommend amendments to and enforce these bylaws, supporting manuals and the Rules and Regulations of the Medical Staff and the relevant Policies and Procedures of the Hospital...."

The Medical Staff Rules and Regulations 2012-201/, required: "...Clinical Observations...Progress Notes...Pertinent progress notes shall be recorded in a timely manner, sufficient to permit continuity of care, documentation of treatment progress...."

1. The hospital policy titled Sick Call for Patients, required: "...To establish guidelines for reporting physically ill patients to the physician/medical provider...Procedure for Sick Call...Assess the patient as to the need to be examined by the physician and document that assessment including vital signs in the patient's health record...If the physician should see the patient the next administrative workday, complete the 'Patient Sick Call' form with the patient's name, the date, the time, and the patient complaint...."

The hospital policy titled Assessment of the Patient required: "...Responsible Person: Assigned Admitting Medical Physician and /or Assigned Physician's Assistant...Reexamination of the patient's physical status will be performed as follows: When the patient exhibits signs of illness...."

Review of the hospital's sick call log revealed the following entries:
01/15/14: "...Pt # 22...Redness accompanied w/itching on abdomen and chest...."
01/18/14: "...Pt # 2...Low grade fever...99.3...."
01/18/14: Pt # 22...Low grade fever...100.4...."

All of the sick call entries above contained the initials of Physician #2.

Review of Pt # 22's medical record revealed Physician # 2 wrote a progress note on 01/09/14, prior to the sick call log entries. No other notes were written by Physician # 2 through 01/27/14.

Review of Pt # 2's medical record revealed Physician #2 wrote a progress note on 01/15/14, prior to the sick log entry on 01/18/14. No other progress notes were written by Physician # 2 through 01/28/14.

Personnel # 19 confirmed on 01/30/14, that Physician # 2 initialed the sick call log book to indicate she had seen the patients and no progress notes were written. Personnel # 19 could not confirm the physician evaluated the patients.

2. The hospital policy titled Assessment of the Patient required: "...Responsible Person: Assigned Admitting Medical Physician and /or Assigned Physician's Assistant...Reexamination of the patient's physical status will be performed as follows: Within 24 hours upon return from inpatient or emergency department treatment provided by an outside medical facility...."

Pt # 19 was sent to the emergency department on 12/04/14 after swallowing a plastic bottle cap. Physician # 2 evaluated the patient after his return to the hospital on 12/04/14. The progress note included: "...Biopsy was done to eval H pylori and results pending at the time of discharge...." Review of the medical record through 01/29/14, revealed the results from the biopsy were not in the medical record, nor was there a progress note indicating follow up for the biopsy results. The Chief Medical Officer confirmed on 01/30/14, that the results were not in Pt # 19's medical record.

Based on hospital policies/procedures, hospital documents, medical record and interview it was determined the facility's policies and procedures failed to ensure that patients were provided the same level of care for urgent medical needs 24 hours a day, seven days a week.

Findings include:

Hospital policy titled "Patient Rights and Responsibilities" requires: "...All patients have the right...to receive treatment...suited to their preferences and needs...."

Hospital policy titled "Sick Call For Patients" requires: "...patients have their physical...needs met in a timely manner...All physicians...will review the Sick Call book each administrative work day (Monday-Friday)...Assess the patient...need to be examined by the physician...Nurse's opinion the physician should see the patient prior to the next administrative work day, the physician on call should be notified...."

Patient #15 was admitted to the facility on 03/09/09, with a diagnosis of Chronic Paranoid Schizophrenia/delusional. The patient was found non-restorable to competency. The patient has a medical history that includes: hypertension, asthma, status-post right partial lung resection and bronchitis. The patient is currently housed on the Desert Sage unit.

Review of the "Patient Sick Call" log book revealed: ten (10) horizontal lines, with the first line listing eight (8) vertical columns with the following headings: date and time; patient's name; chief complaint; for informational purposes; RN initials; date of RN progress note; MD/DO/PA initials; and date of MD/DO/PA progress note.

The sixth line of the Patient Sick log revealed the date 1/10/14; Patient #15's name; complaint of cough; 4th column was blank; initials U.F.(RN #15); RN progress note 1/10/14; MD initals H.L.(physician #2); and the 8th column was blank.


Physician Progress Notes dated 1/13/14 at 1226 hours revealed the patient was seen by Physician #2. The physician documented the patient had a "productive cough with yellow greenish sputum. Sometimes trace of blood in the sputum. Sore throat; lungs crackles no wheezing. Will empiric(sp) treat him with Azithromycin. He has biops(sp) proven Cocci. He did not need treatment per pulm(sp) at this time. Patient will go to the Pulm(sp) tomorrow".

Nursing Symptom Review and Physical Assessments dated 01/14/14 at 1413 hours revealed the patient had a productive cough and general malaise. The patient was assessed by Physician #5. The patient's chest X-ray was abnormal with infiltrates and suspected pneumonia. The patient was sent to a medical facility for treatment for respiratory distress, per Physician #5.

Patient #15 was discharged from the medical facility and returned to the Desert Sage unit on 01/21/14 with a diagnosis of eosinophilic pneumonitis.

The Chief Medical Officer confirmed during an interview conducted on 12/30/14 at 1300 hours, that it is the facility's practice for the physician to examine the patient's entered in the Sick Call log on the following administrative day, unless the nurse determines the patient's complaint as emergent. Administrative work days are not Saturdays or Sundays.

Based on hospital policies/procedures, medical record, review of Lippincott's Nursing Procedures and staff interviews it was determined the nursing staff failed to assess the patient before and after a respiratory treatment in 1 of 1 patients (Patient #15).

Findings include:

Hospital policy titled "Small Volume Nebulizer (SVN) Therapy Without Positive Pressure" requires: "...safe and effective administration of aerosolized medication...." The policy did not provide any assessment and re-assessment protocols.

Hospital policy titled "Assessment Of The Patient" requires: "coordinate the care, treatment and services provided to a patient...comprehensive assessment will be completed on each patient...Lippincott's "Nursing Procedures-Fifth Edition" reference book...should be utilized as the reference for any nursing procedures...."

Lippincott's Nursing Procedures Fifth Edition pg's 590-592 requires: "...Nebulizer Therapy...Implementation...take the patient's vital signs...auscultate his lung fields to establish a baseline...Remain with the patient during the treatment...take his vital signs to detect any adverse reaction to the medication...Auscultate the patient's lungs to evaluate the effectiveness of therapy...."

The Medication Administration Record (MAR) dated 1/10/14, revealed Patient #15 received a small volume nebulizer (SVN) treatment at 2115 hours for shortness of breath.

The Medication Administration Record (MAR) dated 1/11/14, revealed Patient #15 received an SVN treatment at 2330 hours for shortness of breath.
N's #14 and #15 confirmed during an interview conducted on 01/28/14 at 1530 hours, that the nursing staff does not do vital signs or listen to breath sounds on the patients before or after a respiratory (SVN) treatment.

The Chief Nursing Officer confirmed during an interview conducted on 01/30/14 that the facility follows the Lippincott's reference book for protocols regarding nursing treatments/procedures; and the nursing staff did not document vital signs or lung sounds before or after Patient #15's SVN treatment.