HospitalInspections.org

Based on record review and interview, the hospital failed to ensure consideration of medical staff recommendation by the governing body for one (Memorial Hospital) of one hospitals reviewed.

Review of credentialling records did not show documentation of appointment recommendation by the medical staff to the governing body and did not show governing body approval. Specifically:

1. The Appointment Page of the medical staff appointment application for Staff N read in part, "DATE: 6-20-23 CHIEF OF STAFF: [signed name withheld]," and appointment recommended was not marked and appointment not recommended was not marked.
2. The Appointment Page continued to read in part, "DATE: 5-1-24 CHAIRMAN, GOVERNING BOARD [signed name withheld]," and approved was not marked and disapproved was not marked.

On 05/22/25 at 2:11 PM, Staff D reviewed the credentialing records and stated:

1. The medical staff recommendation was not marked and should have been.
2. The governing board approval or disapproval was not marked and should have been.

Based on record review and interview, the hospital failed to ensure medical-surgical care was not provided by non-clinical staff for one (Patient #5) of five patient records reviewed.

Review of a document titled "HOSPITAL-ADMISSIONS CLERK JOB DESCRIPTION" did not show needle decompression as a job responsibility.

Patient #5

Review of the Emergency Physician Report signed 04/08/25 at 7:54 PM read in part, "Chest Tube Placement ...completed without complication."

On 05/22/25 from 12:27 PM to 12:40 PM, Staff M stated:

1. They assisted the physician in a chest tube placement by inserting a needle into the patient's chest.
2. They were not a nurse or in nursing or medical school.
3. Placing needles in patients was not part of their job description.
4. They thought they should not do it, but did because they were intrigued.

On 05/22/25 from 12:51 PM to 1:10 PM, Staff K stated:

1. Having a non-healthcare associate participate in a procedure was not allowed and not appropriate.
2. There was nothing in print that said it was allowed and nothing that said it was not allowed.
3. The hospital was not a teaching hospital.

On 05/22/25 at 3:56 PM, Staff B reviewed the job description for Staff M and stated needle decompression was not listed in the job duties.

Based on record review and interview, the hospital failed to ensure grievance process for two (Staff J and Staff L) of seven staff reviewed for grievance.

Review of a policy titled "Complaint/Grievance Policy" with a revision date of December 2024 read in part, "The Complaint and Grievance Policy will provide ...employees a mechanism to voice complaints and/or grievances concerning activities within the facility ...The following are automatically considered patient grievances ...3 ...safety of patient."

On 05/22/25 from 11:28 AM to 11:39 AM, Staff L stated:

1. A physician let an ED clerk do a needle decompression on a patient.
2. They notified administration of the occurrence.

On 05/22/25 at 11:47 AM, Staff J stated they notified administration of the occurrence.

On 05/22/25 at 12:41 PM, Staff M stated no follow-up conversation took place.

On 05/22/25 at 12:51 PM, Staff K stated:

1. Administration was going to follow up on what occurred.
2. They were waiting to see what administration's results were going to be.

On 05/22/25 from 1:46 PM to 1:53 PM, Staff D stated medical staff was to review and investigate what occurred and then administration and the governing board would review and decide the result.

Based on record review and interview, the hospital failed to ensure medical staff recommendation to governing body for one (Memorial Hospital) of one hospitals reviewed.

Review of credentialling records did not show appointment recommendation by the medical staff to the governing body. Specifically:

1. The Appointment Page of the medical staff appointment application for Staff N read in part, "DATE: 6-20-23 CHIEF OF STAFF: [signed name withheld]," and appointment recommended was not marked and appointment not recommended was not marked.

On 05/22/25 at 10:34 AM, Staff E reviewed the credentialing records and stated:
1. Medical staff did not mark appointment recommendation.
2. They should have marked recommended or not recommended.

Based on record review and interview, the hospital failed to ensure:

1. Patient assessment for one (Patient #3) of five patient records reviewed.
2. Timely intervention for one (Patient #3) of five patient records reviewed.


Patient #3 - Assessment

Review of the medical record showed no assessment for allergies or date of last dialysis. Specifically:

1. The Emergency Triage Note dated 03/26/25 at 3:58 AM read in part, "pt havig [sic] shortness of breath. audible breath sounds ...pt has hemodialysis ...ALLERGIES No Allergy Assessment."
2. The Emergency Nursing ED Assessment dated 03/26/25 at 4:00 AM read in part, "CARDIOVASCULAR ...NARRATIVE: htn noted ...GENITOURINARY Exam deferred."

On 05/21/25 at 2:05 PM, Staff C reviewed the medical record and stated:

1. The medical record did not show allergies were assessed by nursing.
2. All patients should be assessed for allergies.
3. The risk to the patient was receiving the wrong medications and death.
4. The nurse did not chart when the patient last received dialysis and should have.

On 05/22/25 at approximately 2:44 PM, Staff F reviewed the medical record and stated nursing was to assess patients for allergies and the risk to the patient was a compounded problem of stridor and breathing.


Patient #3 - Intervention

Review of the medical record showed no documentation of physician notification of elevated blood pressure and showed delayed intervention. Specifically:

1. The Vitals Summary read in part:
a. "03/26/2025 3:54 am ...Blood Pressure: 239/92"
b. "03/26/2025 5:00 am ...Blood Pressure: 253/112"
c. "03/26/2025 5:50 am ...Blood Pressure: 211/103"

2. The Emergency Department Drug Administration Form dated 03/26/25 at 6:21 AM read in part, "0619 [6:19 AM] - hydralazine 20mg ivp." (2 hours 25 minutes after initial blood pressure reading)

3. The Orders Summary read in part, "03/26/2025 06:20 New Order entered by ...(ED NURSE) ...hydrALAZINE HCL 20mg ...IV NOW."

On 05/21/25 from 1:00 PM to 2:34 PM, Staff C reviewed the medical record and stated the patient's blood pressure was 239/92 at 3:54 AM and the nurse put in the order for hydralazine at 6:20 AM.

Based on record review and interview, the hospital failed to ensure policy was followed for one (Patient #3) of five patient records reviewed.

Patient #3

Review of the medical record showed an oxygen rate adjustment by nursing and showed no order for oxygen. Specifically:

1. The Emergency Nursing ED Assessment addendum dated 03/26/25 at 6:05 AM read in part, "0550 [5:50 AM] ...pt o2 sats 98-100 on room air. pt is asking for oxygen."
2. The Emergency Nursing ED Assessment addendum dated 03/26/25 at 9:14 AM read in part, "at 0630 [6:30 AM] ...89o2 sat on 2lpm bumped pt to 4lpm and came up to 92%."

Review of a policy titled "Oxygen Therapy" effective date November 2010 read in part, "Oxygen ...may be considered medically necessary for appropriately selected patients in cases when a physician prescribes oxygen."

On 05/21/25 at 1:53 PM, Staff C reviewed the medical record and stated there was no order for oxygen.

On 05/21/25 at 1:56 PM, Staff B reviewed the policy and stated:
1. There were no standing orders for oxygen in the ED.
2. A physician order was required for oxygen.
3. If a patient's oxygen dropped below 90%, nurses were to call the physician and obtain an order for oxygen.