The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|RIVERVIEW REGIONAL MEDICAL CENTER||600 SOUTH THIRD STREET GADSDEN, AL 35901||Nov. 1, 2017|
|VIOLATION: MEDICAL STAFF - ACCOUNTABILITY||Tag No: A0049|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, interview and review of Medical Staff Rules and Regulations, the hospital failed to ensure a consultation was provided to Patient Identifier (PI) # 1, a patient who was admitted to the hospital with a diagnosis of opiate withdrawal. This affected PI # 1, one of ten sampled patients and had the potential to affect all patients served.
A review of PI # 1's History and Physical, documented by the attending physician on 10/18/17, revealed the patient was admitted on [DATE] with a chief complaint of opiate withdrawal (opiate: drugs that act on the nervous system to relieve pain. Continued use and abuse can lead to physical dependence and withdrawal symptoms, www.drugfreeworld.org).
History of present Illness: PI # 1 presents for treatment in the medical detoxification program. The patient reports a history that includes coronary artery disease and hypertension. Has taken opiate type pain medication daily for the past year. Acute Diagnosis: Opiate withdrawal.
On 10/18/17, the attending physician wrote an order for PI # 1 to be seen in consultation by the physician responsible for providing an evaluation of PI # 1's substance abuse history.
A review of PI # 1's medical record, revealed no consultation or any documentation regarding the patient by the consulting physician.
During an interview on 11/1/17 at 9:30 AM, Employee Identifier (EI # 1) verified there was no consultation or documentation regarding PI # 1 by the consulting physician in the medical record. The attending physician completes the History and Physical and orders a consultation by the physician who has expertise in medical detoxification from opiate drugs / medications.
A review of the Medical Staff Rules and Regulations, updated 2/15/16, revealed the following re consultations:
" 1. When Required. When the condition of the patient exceeds the privileges of the Practitioner, a consultation is required...
3. Compliance. ...the patient should be seen within 24 hours...
5. Consultation Examination and Opinion. A satisfactory consultation includes examination of the patient and the record. A written opinion signed by the consultant must be included in the patient's medical record..."
As a result of the deficient practice, it is not known if PI # 1 was physically assessed and or the medical record was reviewed by the consulting physician.