HospitalInspections.org

Based on medical record review, document review and staff interview, the medical staff did not ensure the general surgery consult ordered for Patient #1 was completed or discontinued prior to the patient's discharge. This has the potential to affect continuity of care.

Findings include:

Review of attending physician's orders dated 1/29/18 at 9:34 AM revealed order for general surgery consultation for evaluation of abdominal pain.

Review of medical record from date of admission on 1/28/18 through date of discharge 1/30/18 revealed no documentation of completion of general surgery consultation.

Review of Attending Physician progress note dated 1/30/18 at 3:31 PM revealed no documentation regarding whether there was a continued need for the general surgery consultation prior to the patient's discharge.

Review of facility Medical Staff Rules and Regulations revealed that consultations shall be performed no later than the next calendar day of being ordered or in accordance with other relevant hospital policies. To insure continuity of care, the consultant will communicate with the attending physician by written consultation note.

Telephone interview with Staff (A), Quality Manager on 6/13/18 at 1:30 PM verified that a general surgery consultation was ordered by admitting physician on 1/29/18 and was not completed. Staff (A) verified that there was no documentation by ordering physician regarding status or continued need for this consultation prior to discharge.

Based on medical record review, policy and procedure review and staff interview, nursing staff failed to supervise and evaluate the nursing care provided to Patient #1 in regards to oxygen therapy administration. This has the potential to negatively impact the continuity of patient care.

Findings include:

Review of Emergency Department (ED) Physician Documentation dated 1/28/18 at 3:04 PM revealed that Patient #1 presented to Emergency Department with complaint of abdominal swelling and pain, as well as, progressive shortness of breath. ED physician orders included order for oxygen at 2 liters nasal cannula. Patient #1 was admitted to hospital for continued evaluation and diagnostic testing and was transferred to a medical unit at 7:59 PM on 1/28/18.

Review of attending physician inpatient admitting orders dated 1/28/18 at 7:00 PM revealed no order to continue oxygen therapy.

Review of Nursing Vital Signs Documentation revealed 3 Liters of O2 via nasal cannula was documented as being administered on 1/29/18 at 12:00 AM, 4:00 AM and 8:00 AM. At 1:00 PM 2 Liters of O2 was documented as being administered.

Review of facility Policy and Procedure entitled "Clinical Application of Oxygen Therapy" effective 4/4/17 revealed that supplemental oxygen therapy requires a physician's order.

Interview with Staff (A), Quality Manager on 6/12/18 at 10:15 AM revealed Emergency Department (ED) physician orders end when the patient is admitted as an inpatient and leaving the ED. The admitting physician orders then become the current order set. Staff (A) verified that oxygen therapy was ordered while the patient was in the ED by the ED physician and was not ordered by the admitting physician. Staff (A) verified that the documentation by nursing revealing continued oxygen administration on admitting floor required a physician order by the admitting physician.