HospitalInspections.org

Based on document review, the facility failed to ensure physicians responded to pages for 1 of 5 patients (patient #4) with critical lab values delaying treatment for the critical lab values for over 4 hours.

Findings include:

1. Review of patient #4 medical record indicated the following:
(A) The patient had labs drawn at 5:30 a.m. on 4/19/10. He/she had a critical high CK of 877 (normal low at 38 and high at 174) and critical high CKMB of 7.6 (normal low at .30 and high at 4.0). The results were called to the nurse at 6:42 a.m. Narrative nurses notes indicated that the physician (M.D. #2) was paged at 7:00 a.m., 7:30 a.m., 9:30 a.m. and 10:30 a.m. with no response. The physician (M.D. #2) was not reached until 11:30 a.m. concerning the critical high lab results.
(B) The notes indicated that M.D. #3 was also paged at 9:30 a.m. and 10:30 a.m. with no response.

2. Facility policy titled "PHYSICIAN COVERAGE FOR EMERGENCIES" last reviewed/revised 7/09 does not address what a timely response is for a physician to return pages.

Based on document review and staff interview, the facility failed to complete an incident report per policy for 1 of 5 patients (patient #1).

Findings include:

1. Review of patient #1 medical record indicated the following:
(A) Per narrative nurses notes, the patient received a superficial skin tear to his/her forearm on 2/7/09 requiring an opsite to be applied "to hold the skin in place and reduce bleeding".

2. Review of incident reports for 2/09- present indicated the following:
(A) There were no incident reports for patient #1.
(B) There were incident reports for other patients that included skin tears.

3. Facility policy titled "Event Reporting Process" last reviewed/revised 7/09 states under policy statement on page 1: "An event is any event, happening or occurrence which is not consistent with the routine operation of (facility #1) or the routine care of a patient......" and "B. Any person who discovers or has knowledge of an event will report it to his/her immediate supervisor in addition to completing the appropriate Event Report."

4. Staff member #3 indicated the following in interview at 5:15 p.m.:
(A) He/she verified that there were no incident reports completed for patient #1.

Based on document review and staff interview, a registered nurse failed to ensure timely reporting to physicians of critical lab values for 1 of 5 patients (patient #4).

Findings include:

1. Review of patient #4 medical record indicated the following:
(A) The patient had labs drawn at 5:30 a.m. on 4/19/10. He/she had a critical high CK of 877 (normal low at 38 and high at 174) and critical high CKMB of 7.6 (normal low at .30 and high at 4.0). The results were called to the nurse at 6:42 a.m. Narrative nurses notes indicated that the physician (M.D. #2) was paged at 7:00 a.m., 7:30 a.m., 9:30 a.m. and 10:30 a.m. with no response. The physician (M.D. #2) was not reached until 11:30 a.m. concerning the critical high lab results. The notes indicated that M.D. #3 was also paged at 9:30 a.m. and 10:30 a.m. with no response.
(B) The medical record lacked evidence that other measures were taken when M.D. #2 or M.D. #3 failed to return repeated pages.