HospitalInspections.org

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.