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.
| MEMORIAL HERMANN HOSPITAL SYSTEM | 1635 NORTH LOOP WEST HOUSTON, TX 77008 | Jan. 21, 2011 |
| VIOLATION: ON CALL PHYSICIANS | Tag No: A2404 | |
| Based on record review, and interview, a Surgeon on call at the hospital failed to come to the emergency room (ER) eight (8) hours after he was called by the ER Physician to see a patient with a leaking Abdominal Aortic Aneurism. Citing one of one on-call surgeon. Findings: Review of clinical record for Patient # 1 revealed the following information: Review of emergency room (ER) Nurses ' notes for Patient # 1 revealed the following information: On December 10, 2008 at 9 pm sixty- one (61) year old Patient walked into the emergency room unaided, accompanied by his wife. His chief complaint was abdominal pain since 3-4 days ago. Review of triage nursing notes revealed the patient was triaged at 9:06 pm and was assigned an Acuity Level 3(Urgent). At the time of triage vital sign was as follows: Blood Pressure (B/P) 116/71, Pulse 60, Respiration 18, and Temperature 98 degrees. Pain severity was assessed at 9/10. Patient # 1 was moved to a room. Review of Nursing Assessment notes dated 12/10/08 at 9: 40 pm documented Patient # 1 was having abdominal pain and passing dark urine for the past 2-3 days. His abdomen was obese and he complained of nausea and vomiting. The patient gave history that he was not taking any medication. On examination his abdomen was soft and tender on palpation. The pain was located in the right and left lower quadrant. Intra Venous (IV) access was started. Review of Physician ' s notes dated 12/10/08 revealed the patient had a medical screen examination at 9: 27 pm conducted by ER Physician B. The physician described the pain as severe, getting worse, abdomen tender. The patient had history of Hypertension and recent illness of URI. (Upper Respiratory Infection). Oxygen saturation was 96% on room air. There was documentation that blood and urine was ordered for analysis at 9:46 pm. Morphine for pain was ordered and Zofran for nausea. Review of ER Nurses notes dated 12/10/08 documented that patient # 1 was given Morphine and zoflan IV push, at 9:41 pm. Blood pressure at 10:15 pm was 90/68, pulse 91 and respiration 18. Review of Nurses notes dated 12/10/08 revealed that at 10:50 pm the patient complained that his pain had increased, it was a sharp pain in his groin area. At 11:08 pm another dose of Morphine and Zofran was administered IV push. At 11:14 pm there was an order for Computerized Tomography (CT) with contrast. The procedure was conducted at 00:45 and the result of Abdominal Aortic Aneurysm was called to Physician B. Further review of the nurses notes revealed on 12/11/08 at 00:53 am Patient # 1 complains of pain the left groin area, left femoral area, left inguinal area and left iliac crest. The patient was conscious, awake and alert. B/P 122/71, pulse 95 and respiration 18, pain was 8/10. The patient was given Morphine for pain at 1:10 am. Review of the physician ' s notes revealed The Physician documented that the case was discussed with Dr. C (Vascular Surgeon on Call) on 12/11/08 at 1:00 am and the patient and family was counseled. ER physician B documented the disposition as the patient was admitted . There was an admission order faxed at 01:08 for admission to the Medical Surgical unit to Dr. C, the order was signed by Dr. B ER physician. On 12/11/08 the admission order was upgraded for the patient to be admitted to the Intensive Care Unit (ICU). The order was faxed to the Intensive Care Unit at 2:17 am, with additional order to type and cross match 6 units of blood in addition to monitoring the patient ' s Complete Blood Count (CBC). During an interview on 1/19/11 at 10:30 am at the facility Staff # 50 stated the patient remained in the ER because there were no available ICU beds. Review of the ER Nurse ' s assessment notes dated 12/11/08 documented at 4:06 am the patient ' s blood pressure was dropping, B/P 75/57, pulse 102. ER Physician B was notified but did not make an order. At 4:43 am Physician B ordered a stat CBC due to decreasing blood pressure. Intra Venous Normal Saline 0.9% 1000 ml. at 250 milliliter an hour was started at 4:42 am. Up to this point in the patient ' s care there was no indication that Dr. C; on-call Surgeon came to see the patient. The Nurses did not mention in their notes that the Surgeon called or came to see the patient. Review of Physician ' s progress notes dated 12/11/08 at 10:00 am revealed the following information: The On- coming emergency room (ER) Physician Dr. J, documented that " Patient signed out awaiting transfer to ICU at 6:30 am. Per Dr. B, (out- going ER Physician) patient had a leaking AAA (abdominal aortic aneurysm) and admitted to Dr. C (On-Call Surgeon). Per Dr. B, he spoke with Dr. C, x 2 and stated he would do surgery " . Review of nursing documentation revealed Dr. C; On-Call physician arrived in the ER at 9: 00 am on 12/11/08( eight hours after he was called to see the patient). Review of physician ' s notes dated 12/11/08 at 9:00 am revealed Dr. C wrote that he was " called at 8:26 am and told that Patient # 1 was in the ER with AAA. He came to see the patient and found he was fairly stable with history of back and abdominal pain. Abdomen is diffusely tender, palpable bilateral femoral pulses " . The doctor wrote that he " had no recollection of phone calls during the night about this patient " . There was documentation that he reviewed the CT scan report, and the patient had Intrareneal Abdominal Aortic Aneurysm with retroperitoneal hematoma. Further review of physician ' s progress notes dated 12/11/08 at 9:00 am revealed Dr. C, documented that " based on the fact that I had been up and working for 24 hours. I do not feel in physical and mental condition to take this patient with such a critical problem " . Further review revealed Dr. C, wrote he discussed the case with Dr. J, and decided he would transfer the patient to another facility for surgical intervention.( The patient's care was further delayed.) Review of the facility ' s On-Call Log dated 12/10/08 documented that Dr .C was scheduled to be on call from 7am-7am at Hospital Q, effective 12/10/08. Review of Physician call log for the emergency room dated 12/10/08 revealed information that Dr. B, ER physician placed a call to Dr. C, On- Call Surgeon at 0110 hours regarding Patient # 1, and that Dr. C returned the call at 0113hrs. Review of transfer records revealed the initial call to a hospital was placed at 9:14 am with a response from that hospital at 9:34 am accepting the patient for surgery. There was documentation that Life Flight was at the hospital by 9:46 am. Review of Nurses notes dated 12/11/08 revealed that at 9:40 am the nurse documented she returned to the patient ' s room and informed him that Life Flight would be there in five (5) minutes. Patient # 1 was sitting up in bed; he went to lie down then suddenly complained of a sharp pain in his abdomen while holding his right side of abdomen tight. He started having signs of a seizure. Dr. C and ER Staff were called for help to assess patient stat. Chest compression was started and code team was called. The patient coded. Cardio Pulmonary Resuscitation (CPR) procedure was performed from 09:45 am to 10:15 am when the patient expired.(Nine hours after he was diagnosed and awaiting surgical intervention). Review of the facility's Medical Staff Bylaws General Rules dated June 2008 titled Patient Management Emergency Center section 2. documented the following information: " Physicians on the emergency room call list are obligated to respond. Failure to do so will result in corrective action and/or dismissal from the Medical Staff. Any failure to comply will be reported to the Chairman of the Section of Emergency Medicine. If an individual physician does not want to take call, he/she is responsible for reaching an agreement with his/her section regarding the ongoing duty to take emergency room call, or on an individual event basis, he/she is responsible for finding a substitute". |
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| VIOLATION: STABILIZING TREATMENT | Tag No: A2407 | |
| Based on record review, and interview, the facility failed to have systems in place to ensure On-call physicians came to the hospital when called by the ER physician to provide stabilizing treatment for patients with emergency medical condition. The facility ' s ER Physicians failed to transfer a patient with an emergency medical condition for stabilizing treatment when the on- call physician failed to come and treat the patient. This failure resulted in the patient's death in the emergency room . Citing one (1) of three (3) patients named in a complaint. Findings: Review of emergency room (ER) Nurses ' notes for Patient # 1 revealed the following information: On December 10, 2008 at 9 pm sixty- one (61) year old Patient walked into the emergency room unaided, accompanied by his wife. His chief complaint was abdominal pain since 3-4 days ago. Review of triage nursing notes revealed the patient was triaged at 9:06 pm and was assigned an Acuity Level 3(Urgent). At the time of triage vital sign was as follows: Blood Pressure (B/P) 116/71, Pulse 60, Respiration 18, and Temperature 98 degrees. Pain severity was assessed at 9/10. Patient # 1 was moved to a room. Review of Nursing Assessment notes dated 12/10/08 at 9: 40 pm documented Patient # 1 was having abdominal pain and passing dark urine for the past 2-3 days. His abdomen was obese and he complained of nausea and vomiting. The patient gave history that he was not taking any medication. On examination his abdomen was soft and tender on palpation. The pain was located in the right and left lower quadrant. IV access was started. Review of Physician ' s notes dated 12/10/08 revealed the patient had a medical screen examination at 9: 27 pm conducted by ER Physician B. The physician described the pain as severe, getting worse, abdomen tender. The patient had history of Hypertension and recent illness of URI. (Upper Respiratory Infection). Oxygen saturation was 96% on room air. There was documentation that blood and urine was ordered for analysis at 9:46 pm. Morphine for pain was ordered and Zofran for nausea. Review of ER Nurses notes dated 12/10/08 documented that patient # 1 was given Morphine and zoflan IV push, at 9:41 pm. Blood pressure at 10:15 pm was 90/68, pulse 91 and respiration 18. Review of Nurses notes dated 12/10/08 revealed that at 10:50 pm the patient complained that his pain had increased, it was a sharp pain in his groin area. At 11:08 pm another dose of Morphine and Zofran was administered IV push. At 11:14 pm there was an order for Computerized Tomography (CT) with contrast. The procedure was conducted at 00:45 and the result of Abdominal Aortic Aneurysm was called to Physician B. Further review of the nurses notes revealed on 12/11/08 at 00:53 am Patient # 1 complains of pain the left groin area, left femoral area, left inguinal area and left iliac crest. The patient was conscious, awake and alert. B/P 122/71, pulse 95 and respiration 18, pain was 8/10. The patient was given Morphine for pain at 1:10 am. Review of the physician ' s notes revealed The Physician documented that the case was discussed with Dr. C (Vascular Surgeon on Call) on 12/11/08 at 1:00 am and the patient and family was counseled. ER physician B documented the disposition as the patient was admitted . There was an admission order faxed at 01:08 for admission to the Medical Surgical unit to Dr. C, the order was signed by Dr. B ER physician. On 12/11/08 the admission order was upgraded for the patient to be admitted to the Intensive Care Unit (ICU). The order was faxed to the Intensive Care Unit at 2:17 am, with additional order to type and cross match 6 units of blood in addition to monitoring the patient ' s Complete Blood Count (CBC). During an interview on 1/19/11 at 10:30 am at the facility Staff # 50 stated the patient remained in the ER because there were no available ICU beds. Review of the ER Nurse ' s assessment notes dated 12/11/08 documented at 4:06 am the patient ' s blood pressure was dropping, B/P 75/57, pulse 102. ER Physician B was notified but did not make an order. At 4:43 am Physician B ordered a stat CBC due to decreasing blood pressure. Intra Venous Normal Saline 0.9% 1000 ml. at 250 milliliter an hour was started at 4:42 am. Up to this point in the patient ' s care there was no indication that Dr. C; on-call Surgeon came to see the patient. There was no documentation that ER physician Dr. B, called the on call Surgeon again regarding the patient ' s care. The Nurses did not mention in their notes that they had concerns that the Surgeon never called or came to see the patient. Review of Nurses notes dated 12/11/08 documented that at 5:46 am the patient was placed on oxygen 2liters via nasal canula. Physician B was informed of the patient ' s blood pressure and Mean Arterial Pressure (MAP) of 123, however, no orders were made. The nurses documented that at 6:53 am, patient was assessed and there were no deficits. Review of Physician ' s progress notes dated 12/11/08 at 10:00 am revealed the following information: The On- coming emergency room (ER) Physician Dr. J, documented that " Patient signed out awaiting transfer to ICU at 6:30am. Per Dr. B, (out going ER Physician) patient had a leaking AAA (abdominal aortic aneurysm) and admitted to Dr. C (On-Call Surgeon). Per Dr. B, he spoke with Dr. C, x 2 and stated he would do surgery " . This documentation indicated that Dr. J was aware of the patient ' s diagnosis at 6:30 am on 12/11/08. There was no documentation that Dr. J, on-coming ER physician evaluated the patient ' s condition when he took over at 6:30 am, Dr. J did not develop a treatment plan for the patient and did not seek stabilizing treatment for the patient. Review of nursing documentation dated 12/11/08 revealed the first transfer call was made at 9:14 am almost three (3) hours after Patient # 1 was handed over to Physician J. Review of nursing documentation revealed Dr. C; On-Call physician arrived in the ER at 9: 00 am on 12/11/08. Review of physician ' s notes dated 12/11/08 at 9:00 am revealed Dr. C wrote that he was " called at 8:26 am and told that Patient # 1 was in the ER with AAA. He came to see the patient and found he was fairly stable with history of back and abdominal pain. Abdomen is diffusely tender, palpable bilateral femoral pulses " . The doctor wrote that he " had no recollection of phone calls during the night about this patient " . There was documentation that he reviewed the CT scan report, and the patient had Intrareneal Abdominal Aortic Aneurysm with retroperitoneal hematoma. Review of call log for the emergency room dated 12/10/08 revealed information that Dr. B, ER physician placed a call to Dr. C, On- Call Surgeon at 0110 hours regarding Patient # 1, and that Dr. C returned the call at 0113hrs. Further review of physician ' s progress notes dated 12/11/08 at 9:00 am revealed Dr. C, documented that " based on the fact that I had been up and working for 24 hours. I do not feel in physical and mental condition to take this patient with such a critical problem " . Further review revealed Dr. C, wrote he discussed the case with Dr. J, and decided he would transfer the patient to another facility for surgical intervention. Review of the facility ' s On-Call Log dated 12/10/08 documented that Dr .C was scheduled to be on call from 7am-7am at Hospital Q, effective 12/10/08. Review of transfer records revealed the initial call to a hospital was placed at 9:14 am with a response from that hospital at 9:34 am accepting the patient for surgery. There was documentation that Life Flight was at the hospital by 9:46 am. (The transfer process was completed including acceptance and transportation within thirty minutes). Review of Nurses notes dated 12/11/08 revealed that at 9:40 am the nurse documented she returned to the patient ' s room and informed him that Life Flight would be there in five (5) minutes. Patient # 1 was sitting up in bed; he went to lie down then suddenly complained of a sharp pain in his abdomen while holding his right side of abdomen tight. He started having signs of a seizure. Dr. C and ER Staff were called for help to assess patient stat. Chest compression was started and code team was called. The patient coded. Cardio Pulmonary Resuscitation (CPR) procedure was performed from 09:45 am to 10:15 am when the patient expired. Review of the facility's Emergency Services and Patient Transfer Policy revised 7/21/10 documented the following information: " The hospital recognizes the right of an individual to receive, within the capabilities of the hospital's staff and facilities: An appropriate medical screening examination; Necessary stabilizing treatment ( including treatment for an unborn child) and; If necessary, an appropriate transfer to another facility even if the individual cannot pay,does not have medical insurance, or is not entitled to Medicare or Medicaid. 2. No delay for Injury: A medical screening examination, stabilizing treatment, or appropriate transfer will not be delayed to inquire about the individual's method of payment or insurance status. 4. If a patient at the Hospital has an emergency medical condition that has not been stabilized, or when stabilization of the patient's vital signs is not possible because the Hospital does not have the appropriate equipment or personnel to correct the underlying process, evaluation and treatment should be performed and transfer should be carried out as quickly as possible." |
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