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HCA HOUSTON HEALTHCARE WEST 12141 RICHMOND AVE HOUSTON, TX 77082 Aug. 14, 2018
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the governing body failed to ensure the facility followed its Policy and Procedures, Medical Staff Bylaws and Rules and Regulations.

The facility failed to treat 1 of 15 the patient (Patient ID #22) with respect and dignity and to respond in a prompt and reasonable time for requested service.

Findings:

Review of current Rules, Bylaws & Policy and Procedures:

Review on August 14, 2018 at 2:30 p.m. of the facility's " 2015 Medical Staff Rules and Regulations" Last revision January 2014 read in part ...B. Enforcement and Discipline: The Rules and Regulations are intended to be the policy of the Medical Staff as proposed and approved by the Departments, the Medical Executive Committee and the Board of Trustees. The Medical Executive Committee shall have the authority to ensure that the Rules and Regulations are enforced in the best interest of the patient. F. 8) Each member of the staff shall name another member of the staff as an alternate to be called to attend his patients in an emergency when the attending practitioner is not available or until the attending practitioner can be present. In case of a medical emergency the designated alternate shall be called. In case the alternate is not available, the CEO (or designee) or the Chief of Staff shall have the authority to call any other member of the Staff to attend to the patient.

Review on August 14, 2018 at 2:30 p.m. of the current faculty's Bylaws of the Medical Staff 2014. 1.3 Purpose and responsibilities of the Medical Staff are: 1.3.1 To provide a formal organizational structure through which the Medical Staff shall carry out it responsibilities and govern the professional activities of its members .....to provide mechanisms for accountability of the Medical Staff. 2.2.6 Be available on a continuous basis, either personally or by arranging appropriate coverage to respond to the needs of inpatients and Emergency Department patients in a prompt, efficient and conscientious manner. (("Appropriate coverage" means coverage by another member of the Medical Staff with specialty-specific privileges equivalent to the Practitioner for whom he or she is providing coverage.) The Practitioner must document that he or she is willing and able to: 2.2.61. Respond within 15 minutes, via phone, to STAT pages from the Hospital and respond within 30 minutes, via phone, to all other pages; 2.2.6.2 Appear in person to attend patient within 30 minutes when requested to do so by the Practitioner caring for the patient at the Hospital.

Review on August 14, 2018 at 2:30 p.m. of the current Policy and Procedure titled "Patient Rights", Policy ID: 23, Last Revised: 06/2016 reads in part ...Patient Rights: (facility) respects the dignity and pride of each individual we serve. Every patient has the right to have his/her rights respected ...Considerate and Respectful Care: To receive ethical, high-quality, safe and professional care without discrimination. To be free from all forms of abuse and harassment. To be treated with consideration, respect ...Decision Making and Notification: To request or refuse treatment. To a prompt and reasonable response to ...requests for service. Protective Services: To expect emergency procedures to be carried out without unnecessary delay...."

Review on August 14, 2018 at 2:30 p.m. of the current facility's Policy and Procedure titled "Scope of Service - Emergency Services", PolicyStat ID: 63, Last Approved 08/2016 reads in part .... Policy: The Emergency Service Plan for the Provision of Patient Care Services has been designated to support and promote improvements and innovation in the delivery of care to patients in accordance with the Hospital Plan for the Provision of Patient Care Services. Types of Services: Activities and services provided by the Emergency Services included but are not limited to ....5. Consideration shall be given to the psychological and social needs of the patients in a crisis situation. 7. Consideration shall be given to the patient's family in a crisis situation.

Review on August 14, 2918 at 2:30 p.m. of the current facility's Policy and Procedure titled, "Chain of Command for Register and Licensed Practitioners", - Conflict Resolution - Admission, Treatment or discharge of a Patient". PolicyStat ID: 55, Last Revised: 03/2015 states in part .... Purpose; 1. To provide guidelines for registered or licensed practitioners should a conflict arise in the admission, treatment or discharge of a patient. 2. To provide Guidelines for register or licensed practitioners to request intervention or consultation regarding physician orders or patient care. Procedure: 1. At all times during the resolution process, care will be provided to the patient following appropriate and uncontested physician orders and standards of care. Procedure: V. If the concern is still not resolved, the House Supervisor/Leadership will notify the Chief Nursing Officer (CNO), or in his/her absence, the Administrator on-call. The CNO or Administrator on-call will contact the ordering physician to resolve the concern. VI. If the concern remains unresolved, the CNO or Administrator on-call will notify the Chief of Staff/Department Chairman for the ordering physician/Medical Director for the Unit regarding the unsolved situation. Risk Management is available for consult upon request

Patient # 21

Complaint # TX 488 reads in part ....... "when the dead fetus was delivered at home, the parents returned to the ED (emergency department) for the mom to lay on a gurney in the ED for 7 hours with a dead baby between her legs. The mom begged to have the cord cut, but the ER MD wouldn't and the OB MD couldn't be reached."

Record review of medical records for admitted [DATE] reviewed on 08/13/2018 reads in part ....

ER Visit 6/15/18 - Arrival Time: 8:49 a.m. brought by HFD (Houston fire department) for abdominal pain and vaginal bleeding, was told she had a miscarriage last night in ER. On arrival, Pt noted to have delivered fetus with moderate amount of bleeding. Physician ID #74 made aware. Pain 7/10.

Physician Note - Emergency Department: 6/15/2018 (Physician ID#74) - 32 y/o 13 weeks pregnant, presents to ED with c/o vaginal bleeding that began this morning at 8:15 a.m. Patient states she went to the restroom this morning and a gush of fluid and bright red blood came out of her vagina. Reports she partially delivered the fetus and had 2 episodes of vaginal discharge in route to ED. Note she was here yesterday and advised she may have a miscarriage and saw her OB, Physician ID #70 four days ago.
Partial delivered fetus, however, cord is still intact internally.
deceased fetus present and umbilical cord still attached internally.
Primary Impression - incomplete miscarriage
Disposition Decision - admit Physician ID #70, OB/GYN, request time 6/15/18 @ 0906. Admission Accepts - Yes 6/15/2018 at 0920. Called Physician ID #70 information given, will see patient. Advised to give patient: l liter NS (normal Saline (0920), Zofran (0910), Hemabate (used to treat bleeding after childbirth and cramping (0921), Lomotil (drug used to treat diarrhea) (0929), Tylenol (0921), Hemabate 2nd dose (1459)
10:05 am - Patient having more pain so will give her stronger pain meds. Tylenol is not helping. Morphine 4 mg IV
Disposition: Admit 6th floor, Room 612

ER Nurse notes: 6/15/2018 Arrival time 8:49 am discharged ED Department 3:30 p.m.
10:08 a.m. - (Employee ID # 75 Charge RN) "Per L&D nurse, Physician ID #70 wants patient admitted to 5th floor/medsurg.
11:30 a.m. - (Employee ID #76 RN ER primary nurse) "Physician ID #70 called at this time in regards to when he will come to see the patient as patient and family are concerned and upset. Physician ID #70 is currently in emergency surgery as well as a procedure scheduled. Charge Nurse Employee ID #75 and ER Physician ID #74 notified of patient's concerns. Awaiting physician at this time."
1:16 p.m. - (Employee RN ID #76) "Family still concerned at this time. They want the baby and placenta removed from the room, but placenta is still intact. Physician ID #70 to remove, discussed with family, awaiting Physician ID #70 at this time."
1:56 p.m. - (Employee RN ID #76) "Physician ID #70 at bedside at this time."
2:45 p.m. - (Employee RN ID #76) "Fetus sent to pathology at this time."
2:57 p.m. - (Employee RN ID #76) "Report faxed to 6th floor at this time, Russel confirmed."
3:40 p.m. - (Employee RN ID #76) "Patient transferred to 6th floor via stretcher, IV, tech and RN."

OB/GYN Physician ID #70 notes:
6/15/18 at 2:29 p.m. - [AGE]-year-old presented to the ER for the second time in 24 hours for complaints of cramping and pelvic pressure. Patient passed the fetus in the ER and I was called while in surgery. Order given for Hemabate IM q 4 hrs. After surgery I went down to see patient. Placenta still in place but protruding 1 cm thru os. Patient otherwise appears stable. Patient has been afebrile on all readings in the ER. Plan - Reviewed findings and associated risk of expectant management vs suction D & C. Patient voiced understanding and wishes to continue with Hemabate every 4 hours for now.

Interview with Emergency Physician Employee ID #74 on 8/14/18 at 1:20 p.m. stated he personally called and spoke with OB/GYN Physician ID #70 and told him of the incomplete miscarriage with everything still connected and need evacuation. Physician ID #70 did not tell me he was delayed; said he was coming. Physician #70 did not tell me he was in surgery and did not come in for a long time. The patient and husband was very upset about the delay. I went back and talked to husband and he wanted a different OB doctor. Patient wanted a different OB. Physician ID #70 does not have cross cover with any MD practice. The OB doctors do not cover each other's patients. Patients usually go up to L & D for delivery of placenta, never seen a delay like this, the patients are usually seen within one hour. Physician ID #74 was asked why the ER doctor did not cut cord on the fetus. Physician ID #74 replied that he had never done an aborted fetus like that and stated if it was a live birth we cut the cord, but a partial abortion we do not cut the cord. When asked what he would have done different Physician ID #74 stated, looking back I would have expedited the case with the house supervisor, better communication and have doctor cross coverage information.

Interview on 8/13/2018 at 4:25 p.m. OB/GYN Physician Employee ID #70 regarding 32-year-old, Patient ID #22 admitted on [DATE], who was 13 weeks pregnant and presented to the ED with vaginal bleeding and a partial delivered fetus. He stated "ER doctor should have cut the cord." I was in surgery for four hours. The family was very upset the placenta was still inside of her and the fetus was still attached for four hours. The cord was clamped. The placenta was delivered and I sent her home the next day. Physician ID #70 was asked if he would do anything different and he stated "The ER doctor should have cut the cord instead of leaving it there for 4 hours. I was in surgery."

Interview on 8/13/2018 at 4:40 p.m. with OB/GYN Division Medical Director Doctor Employee ID #57 was asked if he was aware of the Patient's ID #22 complaint about lying on a gurney with a dead fetus still attached to her placenta for over 5 hours. Employee ID #57 stated that should have never happened, the ER physician could have cut the cord a long time before that. Employee ID #57 stated they could of called someone else.

Interview on 8/9/18 at 2:10 p.m. Employee ID #54 CNO (Chief Nursing Officer) revealed:
Concerning fetal demise, incomplete abortion or miscarriage we do not put those patients that have lost a baby on the labor and delivery unit with other crying babies or active L&D patients. Those patients go to medical/surgical floor and stay in a different area rather than L & D. OB/GYN Physician ID #70 had requested patient be admitted to 5th floor med/surg unit. There were no beds on the 5th floor so she was admitted to 6th floor medical surgical unit. The staff were not really familiar with post-partum delivery of a placenta and were afraid it was a large clot and called for a rapid response for a physician to come evaluate the patient.
Employee ID #54 confirmed the staff should have expedited the delay of the physician arrival with patient ID #22 with the hospital supervisor and up to administration. It was wrong of them to leave her miscarried fetus in bed with her for over 5 hours. She stated that should of never happened. CNO stated that patient ID #22 was not treated with respect and dignity nor compassion. CNO stated that both Physician #70 and #74 had been reported and the case has gone to the peer review committee.

CNO Employee ID #54 stated that emergency room RN Employee ID #76 was the patient's primary nurse. Employee ID #76 had escalated the issues to both ER Physician ID #74 and ER Charge Nurse Employee ID#75 who notified the Administrator on call at the time. Employee ID #77 was the night shift manager on duty when the patient was transferred to the 6th floor. He spoke to the Administrator on Call about the issue and was told that the Administrator had spoken to OB/GYN Physician #70 personally about the issue.