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.

Based on policy review, staff interviews, and medical record review the facility did not ensure the staff was able to consistently honor the right of the patient to notify their private physician of admission to the hospital for three (#2, #3, #4) of six sampled patients.

Findings included:

A review of the policy "Primary Care Physician Notifications of Admission/ER Visit" #BC-CBO-248, Issue date 3/28/16 revealed the registrar was responsible for obtaining the name of the patient's personal physician and entering the information in the registration software.
If the patient's personal physician was a member of the medical staff, the policy indicated the patient's physician would be automatically notified using a proprietary software application. The policy failed to identify the methods to be used or who would be responsible for notification if the patient's personal physician if he or she was not a member of the medical staff.

An interview was conducted with the Manager of Registration on 7/17/18 at 2:00 PM. She indicated the registrar was required to enter the name of the patient's personal physician in the registration software system. She stated she was not a clinical person so she did not know if a nurse on a clinical unit was able to view that information. She indicated the physicians on staff would receive an internal notification if they had registered with the system to provide that service. She indicated she did not know what the process was to notify a patient's personal physician if the physician was not on staff. She indicated the registrar's responsibility ended with entering the name of the patient's personal physician.

Interviews with Registered Nurse (RN) C, D, E and F on 7/17/18 between 3:20 PM and 3:35 PM regarding the hospital's process for notification of patient family and private physician of the hospital admission, when requested by the patient. RN C indicated that on the initial assessment patients were asked if they would like family notified of their admission. RN C stated there was no place on the assessment to ask about the patient's primary physician. RN D indicated that on the initial assessment she can inquire about family notification but not physician notification. RN E indicated she did not know of anywhere in the patient's record she could find information regarding the patient's personal physician. RN F indicated she did not know anything about the process and would refer the patient's request to her charge nurse or manager.

An interview was conducted with the Director of Quality, on 7/17/18 at 3:40 PM, who confirmed the finding that the facility policy did not address the process for notifying patients' personal physicians who are not members of the facility medical staff.

A review of the records for Patient #2, #3, and #4 failed to reveal evidence that these patients were asked about notification of their personal physician upon their admission to the hospital.