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WINCHESTER HOSPITAL
MEDICAL STAFF
Tag No.: A0338
The Hospital was out of compliance for the Medical Staff Condition of Participation.
Findings include:
The Medical Staff failed to ensure Patient #1 received a prompt assessment by a credentialed provider after a change in condition.
Refer to TAG: A0347
MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY
Tag No.: A0347
Based on record review and interview for one (Patient #1) of ten medical records reviewed the medical staff failed to ensure an appropriate assessment/examination was performed by a credentialed practitioner after the patient developed a change in condition and were accountable to the governing body for quality medical (surgical) care.
The Medical By-Laws Rules and Regulations, dated 3/27/20, indicated that a prompt assessment must be performed as soon as possible in a time dictated by the acuity of their illness of the unstable patient.
A surgical progress note, at 10:38 P.M. on 9/28/20, indicated a computerize tomography (CT scan) imaging study indicated acute appendicitis, but no obvious perforation or abscess. The plan included pain medication, antibiotics and intravenous hydration and a laparoscopic appendectomy on 9/28/20.
A nursing flow sheet, at 6:04 A.M. dated 9/29/20, indicated Patient #1 was having a significant amount of pain, worst in the right lower quadrant of his/her abdomen (possible sign of a change in condition requiring further assessment by a credentialed and privileged provider).
The Surveyor interviewed the Attending Surgeon at 2:30 P.M. on 10/15/20. The Attending Surgeon said she was aware of Patient #1's increased pain. The Attending Surgeon said she did not evaluate Patient #1, however, Patient #1 was evaluated during morning rounds on 9/29/20. The Attending Surgeon said at no time did she need to take Patient #1 emergently to the operating room.
The medical record indicated no documentation of Patient #1's change in condition was evaluated by a credentialed and privileged provider to determine the stability of Patient #1's condition.
A Nursing Progress Note, at 10:39 P.M. dated 9/29/20 indicated Patient #1 was sent to the Operating Room for surgery.
The Operative Note, at 12:15 A.M. dated 9/30/20, indicated Patient #1 had a perforated appendix with purulent fluid in the pelvis and in the space between the colon and abdominal wall.