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CHRIST HOSPITAL 2139 AUBURN AVENUE CINCINNATI, OH 45219 April 27, 2017
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure emergency department staff followed the current facility policy related to contacting the physician on call. This affected one patient of 10 medical records reviewed. (Patient #2)

Findings include:

The medical record of Patient #2 was reviewed on 04/27/17 at 11:45 AM. Patient #2 (MDS) dated [DATE] at 06:05 PM with complaints of vaginal bleeding and pelvic cramping. The obstetric physician's History and Physical documented the patient was status post dilation and curettage (surgical procedure in which the cervix is dilated so that the uterine lining can be scraped with a curette to remove abnormal tissue) a week prior, on 11/23/16, after a miscarriage at approximate 8 weeks gestational age. The patient reported increased bleeding for the past two days. The patient's vital signs were noted to be within normal limits at 104/62 (blood pressure), 80 beats per minute (heart rate), 98.2 degrees Fahrenheit (temperature), and 18 (respiratory rate).

On exam by an emergency department physician, it was noted the patient had no significant bleeding, CBC (complete blood count) was normal with an unchanged hemoglobin from the day of the D&C. The patient's hemoglobin and hematocrit were 12.9 and 38.2. The patient's obstetric physician was called at 7:39 PM and he/she returned the call at 8:18 PM. The physician was updated by emergency department staff. It was noted the physician ordered that the patient be discharged home. The patient was discharged home hemodynamically stable at 8:49 PM.

The patient again presented to the emergency department four hours later at 1:43 AM with complaints of increased vaginal bleeding. The patient's blood pressure at 1:56 AM was 97/64 and heart rate was 74. A peripheral intravenous (IV) catheter was placed by emergency department staff at 1:59 AM. The patient's Hemoglobin and Hematocrit at 2:05 AM were 12.5 and 37.3. Normal saline was infusing through the patient's IV at 2:07 AM. The medical record documented the patient's obstetric physician was called at 2:17 AM. There was no returned phone call. The patient's blood pressure at 2:29 AM was 92/50. An emergency department nurse practitioner was noted to be at the bedside of the patient to assess the patient at 2:21 AM. A Nursing Note at 2:27 AM documented the patient continued to bleed heavily. The patient's blood pressure at 2:40 AM was 72/36. Emergency department staff placed a second IV catheter in the patient. At 2:41 AM the patient's blood pressure was 65/29. A note written by the emergency department nurse practitioner documented the patient was now complaining of dizziness and feeling bad. The patient had a liter of normal saline infusing through both IVs.

A second call was made to the obstetric physician at 2:42 AM. There was no returned call. The medical record lacked documentation another obstetric physician was called. An obstetric resident was called and noted to be at the bedside of the patient at 2:53 AM.

The obstetric physician was called again at 3:19 AM. There was no returned call. A Nursing Note at 4:22 AM documented the facility laboratory called to notify emergency department staff of the patient's critical Hemoglobin and Hematocrit (H&H). The patient's H&H was 9.3 and 27.5.

A fourth attempt to reach the obstetric physician was made at 4:26 AM. There was no returned call. The nurse practitioner's progress note documented the obstetric resident was updated and the resident reported the patient would be taken to the operating room later in the morning for a D&C.

The medical record lacked documentation the in house obstetric attending physician was updated of the patient's status. The emergency department nurse practitioner revealed he/she made another attempt to call the patient's obstetric physician at 6:45 AM. There was not a returned phone call.

The patient's obstetric physician documented in a progress note at 9:58 AM that he/she had not received any phone calls during the evening as the ringer on his/her phone had been inadvertently turned off. An operative note revealed an emergent D&C was performed at 10:49 AM.

Staff A, the Manager of the Emergency Department, was interviewed on 04/27/17 at 3:30 PM. According to Staff A after two attempts to call a physician with no response, staff are required to call the operator and obtain an alternate number to reach the physician.

The facility policy titled "ER Paging Procedure" was reviewed on 04/27/17 at 3:45 PM. According to the policy staff are instructed to call the physician every 15 minutes and after 45 minutes have elapsed, staff should call the operator for an alternate phone number. It was confirmed that the medical record lacked documentation the operator was called after 45 minutes. It was further confirmed the obstetric physician was called from 2:17 AM to 6:45 AM, more than four hours, with no response.

Staff C, the Director of Obstetrics, was interviewed on 04/27/17 at 04:00 PM. According to Staff C even if staff had called the operator, as required by facility policy, it was discovered recently that the operator did not have an alternate number for the physician. Staff C reported that an alternate number for the obstetric physician has now been given to the operator. The Director of Obstetrics revealed it is policy for obstetric residents to consult the in house attending obstetric physician about all patients that present to the emergency department.