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.

FAXTON-ST LUKE'S HEALTHCARE 1656 CHAMPLIN AVENUE UTICA, NY 13503 July 3, 2018
VIOLATION: MEDICAL STAFF Tag No: A0338
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record (MR) review, document review and interview, the hospital failed to ensure an urgent consult was completed in a timely manner. Specifically, in 1 (Patient #1) of 13 MRs an urgent neurology consult for a patient with altered mental status was not completed until 72 hours after it was ordered because the hospital did not have a system in place to ensure follow up of ordered consults. This could lead to patients not receiving appropriate specialized care and untoward outcomes.

Findings include:

-- Per MR review, Patient #1, a [AGE]-year-old female, presented to the emergency department (ED) on 1/12/18 at 9:06 am, with altered mental status. Patient #1's admitting diagnosis was acute [DIAGNOSES REDACTED] (alteration in brain function). Admission orders were done at 12:16 pm. Patient #1 remained in the ED for monitoring until an intensive care unit (ICU) bed was available. At 5:29 pm additional orders were placed that included urgent (within 8 hours) neurology consult. Documentation by Staff A, ED Secretary indicated the neurology answering service was contacted at 6:00 pm (no coverage was available). Patient #1 was transferred to ICU at 7:00 pm. On 1/15/18 at 5:27 pm, Staff C, Neurologist performed a neurology consult (72 hours after initial order was placed for an urgent consult).

There is no documentation in the MR that referenced any delay of the urgent neurology consult.

-- Review of the hospital's "Medical Staff Bylaws," last revised 1/25/18, indicated the attending physician is responsible for obtaining consultation from an appropriately privileged provider. The consult order should include the degree of urgency, Emergent/STAT (right away), Urgent, or Routine (within 24 hours, same day if possible).

-- During interview of Staff A on 7/3/18 at 12:25 pm, he/she had called the neurology service regarding the consult ordered for Patient #1 and was told there was no on-call coverage available. Staff A then entered the information into the MR. He/she stated when the patient was admitted to the floor, staff should have reviewed all orders and seen the consult was not done. Staff A does not alert anyone else regarding lack of specialty service.

-- During interview of Staff D, ED Secretary on 7/3/18 at 12:35 pm, he/she indicated, if a patient is being admitted and is waiting in the ED, he/she will call the specific answering service for the ordered consultations and document it in the MR. If coverage is not available, sometimes he/she tells the nurse, but does not contact the ordering physician. When the patient is transferred to the floor they should check all the orders for completion.

-- Per interview of Staff C on 7/2/18 at 12:55 pm, he/she became aware of Patient #1's neurology consult on Monday (1/15/18). It was not called as STAT. He/she did the consultation.

-- During interview of Staff F, Medical Director on 7/3/18 at 8:50 am, he/she acknowledged the above findings.

-- Review of the hospital's on-call schedule indicated Staff G, Neurologist was listed as the neurologist on-call 1/12/18.

-- Per interview of Staff G, Neurologist (on call on 1/12/18) on 7/2/18 at 1:35 pm, he/she was only on-call until 5:00 pm. He/she called the ED after being notified to inform them of this and instructed them to contact the stroke coverage person. Staff G stated that after this happened he was contacted by the Medical Director about the on-call schedule and his responsibilities.

-- Per interview of Staff F, Medical Director on 7/3/18 at 8:50 am, he/she spoke with the Staff G and explained he/she was on-call until 8:00 am Saturday (1/13/18). Call is for 24 hours, it does not end at 5:00 pm. He/she further stated that the expectation for consults is that the ordering physician signs off to the on-coming provider if a consult had not been obtained. Consults are time limited, if the service is not available and a patient requires specialized services they should be transferred.

-- Review of the hospital's P&P titled "Specialists Consultations for admitted Patients in the Emergency Department," last revised 12/28/17, indicated when a consult is ordered, the secretary or tech will use the on-call schedule to call the specialty group and then document in the MR who they spoke to, the time and the reason. When the on-call provider returns the call it should be documented in the MR. The nurse then calls the floor the patient is being admitted to and states the report is in the MR. The P&P does not instruct staff of the procedure to follow when the specialty service is not available or may be delayed. It does not identify who should be notified if this issue occurs.

-- During interview of Staff H, Director of Quality Management on 7/3/18 at 11:45 am, he/she acknowledged the above finding.