HospitalInspections.org

Based on record review and interview, the hospital failed to ensure its medical staff was organized and provided the care and services that the physician had attested to providing for one of one (Physician #2) physicians who attested to providing care for Patient #1 but was off work the day the physician had attested to providing the care.


The findings include:

1. Review of the "Medical Staff By Laws and Rules and Regulations: with an updated date of "June 27, 2019" revealed, " ...Each member of the medical staff shall...provide his patients with care at the generally recognized professional level of quality and efficiency...prepare, complete, in timely fashion, the medical records for all patients the physician admits or in any way provides care in the facility...abide by the ethical principles of his profession...".

Review of the National Library of Medicine, Fundamentals of Medical Record Documentation, published online 2004 revealed, "...Documentation is regarded as an essential element...Failure to document relevant data is itself considered a significant breach of and deviation from the standards of care...The patient's record provides the only enduring version of the care as it evolves over time...".

2. Patient #1 presented to the Emergency Room (ER) on 3/18/22 with a chief complaint of not being able to detect a fetal heartbeat.

Review of Attending Physician #2's Attestation statement dated 3/18/22 revealed, "...I had face-to face time with this patient which included an examination..."

Review of Physician #2's schedule revealed the Physician did not work on 3/18/22.

In an interview on 6/7/2022 beginning at 11:30 AM in the board room, the Chief Nursing Officer (CNO) was asked to review the Attending Physician #2's Attestation statement for Patient #1 and asked was the physician working at the hospital on that day. The CNO stated, "...Well we have a problem...Let me check and see for sure [that Physician #2 was working]...I have checked and [Physician #2] was not here at the time but when [PA #1] sees a patient it automatically defaults to [Physician #2] unless [PA #1] changes the default and puts in the correct physician...".

In an telephone interview on 6/7/2022 beginning at 3:21 PM, Physician Assistant (PA) #1 stated, "...[Physician #2] is automatically my default physician so it automatically goes to him unless I change it...I guess I overlooked changing it on the particular patient..."

In an telephone interview on 6/8/2022 beginning at 1:22 PM, Physician #2 was asked about the Attestation statement which he had signed on 3/18/2022 for Patient #1 and he stated, "...I must have just missed that, an oversight on my part..."

Refer to A347

Based on review of the hospital By-laws, standards of practice review, medical record review and interview, the hospital failed to ensure each physican provided the services that the physican attested to providing for one of one (Physican #2) physicans who signed an attestation that he had performed an examination of a patient when the physican was not working on that day.

The findings include:

1. Review of the "Medical Staff By Laws and Rules and Regulations: with an updated date of "June 27, 2019" revealed, " ...Each member of the medical staff shall...provide his patients with care at the generally recognized professional level of quality and efficiency...prepare, complete, in timely fashion, the medical records for all patients the physican admits or in any way provides care in the facilty...abide by the ethical principles of his profession...".

Review of the National Library of Medicine, Fundamentals of Medical Record Documentation, published online 2004 revealed, "...Documentation is regarded as an essential element...Failure to document relevant data is itself considered a significant breach of and deviation from the standards of care...The patient's record provides the only enduring version of the care as it evolves over time...".

2. Medical record review revealed Patient #1 presented to the Emergency Room (ER) on 3/18/2022 with a chief complaint that she was unable to detect a fetal heartbeat and had not felt the fetus moving that day.

Review of an Attending Physician #2's Attestation statement dated 3/18/202 revealed, "...I reviewed the PA [Physician Assistant] documentation, treatment plan, and medical decision making. I had face-to face time with this patient which included an examination: 29-year-old pregnant female for evaluation..."

In an interview on 6/7/2022 beginning at 11:30 AM in the board room, the Chief Nursing Officer (CNO) was asked to review the Attending Physician #2's Attestation statement for Patient #1 and asked was the physician working at the hospital on that day. The CNO stated, "...Well we have a problem...Let me check and see for sure [that Physician #2 was working]...I have checked and [Physician #2] was not here at the time but when [PA #1] sees a patient it automatically defaults to [Physician #2] unless [PA #1] changes the default and puts in the correct physician..."

In an telephone interview on 6/7/2022 beginning at 3:21 PM, Physician Assistant (PA) stated, "...There is a doctor assigned to the patient from the very beginning of their admission to the emergency room...they [physicians] either come in at the beginning or the end to the visit".
PA #1 was asked how could Physician #2 sign as the attending physician attestation statement if he did not see the patient and PA #1 stated, "...[Physician #2] is automatically my default physician so it automatically goes to him unless I change it".
PA #1 stated, "...I guess I overlooked changing it on the particular patient..."

In an telephone interview on 6/8/2022 beginning at 1:22 PM, Physician #2 was asked about the Attending Attestation statement for Patient #1 which he had signed on 3/18/2022 and the Physician stated, "...I must have just missed that, an oversight on my part. I sign off on his patients after I look at the documentation and medical decision making but I do not sign that I have seen the patient if I have not. I must have just missed that one, so sorry..."

Based on medical record review, facility policy review and interview, the facility failed to ensure adequate emergency services were available to provide appropriate services and the facility failed to ensure Qualified Registered Nurses (RN) performed and documented their assessment in the medical record for one of three (Patient #1) obstetrical (OB) patients reviewed.

The findings include:

1. Review of the facility's "Emergency Medical Screening" policy with an revised date of "01/2017" revealed, "...Every individual who presents to [Named Hospital] #1 will receive an appropriate medical screening examination...An emergency room physician , PAC [physician assistant - certified], or FNP [Family Nurse Practitioner] will perform the medical screening examination with in the capability of the hospital's Emergency Department. Pregnant patients presenting with obstetrical complaints may receive their medical screening examination by a Registered Nurse who has been specifically trained and formerly qualified by medical staff to perform those screenings...

Review of the facility's "Medical Screening of Obstetrical Patients" policy with a revised date of "05/2021" revealed, "...To provide for the antepartal patient that is 20 weeks gestation or greater a safe, comfortable environment that promotes rest and relaxation...Qualified Evaluators are Registered Nurses who have demonstrated competence in performing all duties and responsibilities as demonstrated by completed checklist signed by the Chief of OB [Obstetrical] and the OB Nurse Leader. These RNs [Registered Nurses] are then approved by the Medical Staff and Board of Trustees and are deemed competent to perform a medical screening exam (MSE) after having competed the following: Minimum of 90 days orientation in labor and delivery or a minimum of one year prior L [labor] and D [delivery] experience....The electronic version of this document is considered to be the controlled version. Printed copies are considered uncontrolled documents. Before using a printed copy, verify that it is the current version..."

2. Medical record review revealed Patient #1 presented to the Emergency Room (ER) on 3/18/2022 with the chief complaint that she was unable to detect a fetal heartbeat and she had not felt the fetus moving today. The patient was 16 weeks gestation.

Review of the emergency room medical record revealed no documentation of a thorough health history as well as a comprehensive assessment.

Patient #1's medical record revealed RN #2 assessed the patient and the patient's fetal heart tones. There was no documentation of Board or medical staff approval for RN #2 to assess OB patients.

Patient #1 remained in the hospital's ER for approximately two (2) hours. Patient #1 called a high risk Obstetrician and drove herself to Hospital #2.

Review of Patient #1's medical record at Hospital #2 revealed an ultrasound was performed and the fetus was pronounced deceased.

In a interview on 6/7/2022 beginning at 11:30 AM in the board room with Hospital #1's Chief Nursing Officer (CNO), the CNO was asked should there have been a thorough health history as well as a comprehensive assessment completed for Patient #1. CNO stated, "...Yes."

In an interview on 5/31/2022 at 1:49 PM with Hospital #1's Chief of Nursing (CON), the CON was asked what kind of training was provided to the Emergency Room (ER) staff for Obstetrical patients and the CON stated, "...Our ER staff do not get any training/competency in Obstetrical Patients. We call our OB nurses to come take care of them".
The CON was asked was there someone on call at the hospital to perform ultrasounds after 4:00 PM and the CON stated, "...Not just anybody in the hospital can do an ultrasounds after 4:00 PM... we do have someone on call most of the time for ER ... The ultrasound would be as the physician deems important. The ER physician would have to feel that it was an emergency to call someone back in..."

In an interview on 5/31/2022 beginning at 2:47 PM Hospital #1's RN #2, " ...I've been a RN for 15 or 16 years ...I've worked in the ER".
RN #2 was asked who assessed pregnant patients in the ER and RN #2 stated, " ...I take them back and then I call OB [Labor and Delivery unit] to come and assess them. If the patient is under 16 weeks, we usually can't find a fetal heart tone with our Doppler, OB will bring a different type".

In an telephone interview on 6/2/2022 beginning at 3:38 PM with RN #1, the RN was asked what was their process when a OB patient is instructed to go to the ER to be monitored? RN#1 stated," ...They come to admitting and admitting will call us and tell us we have a patient that was told to come here (admitting) and be monitored. First our hospital policy stated that they have to be 20 weeks to be monitored in Labor and Delivery or we have to have a doctor's order. All pregnant patients have to go to the emergency room first before they are admitted to Labor and Delivery. Patient #1 did not have an doctor's order to come to our floor to be monitored...It is hard to get a 16 weeker heart rate on a Doppler ...without an ultrasound you really can't tell..."
RN #1 was asked if Patient #1 should have had an ultrasound and the RN stated, "...Well yes but I'm trying to explain why they did not have one...they do not always do a ultrasound if they can't find a heartbeat if the patient is not in a life threatening situation. This hospital had one person for fetal ultrasounds, they work Monday though Friday from 8:00 AM to 4:00 PM and they are not on call after 4:00 PM".

In an interview on 6/7/2022 at 11:30 AM, Hospital #1's Chief Nursing Officer (CNO) was asked should there had been a thorough health history as well as a comprehensive assessment completed for Patient #1 and the CNO stated,
"...Yes."