HospitalInspections.org

Based on medical record review, interview and review of Medical Staff Rules and Regulations, the hospital failed to ensure a consultation was provided to Patient Identifier (PI) # 1, a patient who was admitted to the hospital with a diagnosis of opiate withdrawal. This affected PI # 1, one of ten sampled patients and had the potential to affect all patients served.


Findings include:

A review of PI # 1's History and Physical, documented by the attending physician on 10/18/17, revealed the patient was admitted on 10/18/17 with a chief complaint of opiate withdrawal (opiate: drugs that act on the nervous system to relieve pain. Continued use and abuse can lead to physical dependence and withdrawal symptoms, www.drugfreeworld.org).

History of present Illness: PI # 1 presents for treatment in the medical detoxification program. The patient reports a history that includes coronary artery disease and hypertension. Has taken opiate type pain medication daily for the past year. Acute Diagnosis: Opiate withdrawal.

On 10/18/17, the attending physician wrote an order for PI # 1 to be seen in consultation by the physician responsible for providing an evaluation of PI # 1's substance abuse history.

A review of PI # 1's medical record, revealed no consultation or any documentation regarding the patient by the consulting physician.

During an interview on 11/1/17 at 9:30 AM, Employee Identifier (EI # 1) verified there was no consultation or documentation regarding PI # 1 by the consulting physician in the medical record. The attending physician completes the History and Physical and orders a consultation by the physician who has expertise in medical detoxification from opiate drugs / medications.

A review of the Medical Staff Rules and Regulations, updated 2/15/16, revealed the following re consultations:

" 1. When Required. When the condition of the patient exceeds the privileges of the Practitioner, a consultation is required...

3. Compliance. ...the patient should be seen within 24 hours...

5. Consultation Examination and Opinion. A satisfactory consultation includes examination of the patient and the record. A written opinion signed by the consultant must be included in the patient's medical record..."

As a result of the deficient practice, it is not known if PI # 1 was physically assessed and or the medical record was reviewed by the consulting physician.