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YAVAPAI REGIONAL MEDICAL CENTER
MEDICAL STAFF - ACCOUNTABILITY
Tag No.: A0049
Based on the review of Medical Staff Rules and Regulations, medical record, and interview, it was determined the Governing Body failed to require that Physician #1 and Physician #2, had documented clinical reasoning for changing treatments on Patient #1.
Findings include:
The Medical Staff Rules and Regulations require: "...Progress Notes: Pertinent progress notes shall be recorded at the time of observation, sufficient to permit continuity of care...Wherever possible, each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders...."
Patient #1, was admitted on 08/10/10, with a complaint that the "J tube" (jejunostomy tube) was leaking. The patient had cellulitis and leukocytosis at the J- tube site.
On 12/22/11, the Director of Quality confirmed Patient #1's attending was Physician #1, and Physician #2, was covering on 08/17/10.
On 12/08/11, Physician #1, verified with the Director of Quality, that on 08/16/10, he had ordered Patient #1's intravenous (IV) fluid, to be increased to "200 cubic centimeters (cc)/hr." He was concerned for the patient's hydration, due to the patient's diarrhea and malfunctioning of the J-tube.
On 12/22/11, the Director of Quality confirmed Physician #1 did not document in the medical record, why the IV fluids were increased on 08/16/10.
On 12/05/11, Physician #2, verified with the Director of Quality, that on 08/17/10, he ordered the IV fluids to be stopped immediately after being notified by the nurse, that Patient #1's condition had changed. The nurse had reported Patient #1's lung sounds were coarse, the oxygen saturations (O2 sats) were 85% on 2 liters (L) of O2, and periorbital edema was noted. Along with discontinuing the patient's IV fluids, Physician #2 had ordered an increase of oxygen from 2L to 4L, and the O2 sats improved to 91-93%.
On 12/22/11, the Director of Quality confirmed neither Physician #1, nor Physician #2, had documented why the IV fluids were discontinued on 08/17/10.
There is no evidence Physician #1 had documented why the IV fluids were increased on 08/16/10, and neither Physician #1, nor Physician #2 had documented why the IV fluids were discontinued on 08/17/10.