HospitalInspections.org

Based on review of facility documents, review of medical records (MR) and interview with staff (EMP), it was determined that the facility failed to notify a patient's physician regarding a change in a condition for one of one applicable medical record reviewed (MR1).

Findings include:

A review conducted on August 10, 2010, of Shamokin Area Community Hospital "Physician Notification policy," last reviewed July 19, 2010, revealed "... The R.N. is responsible to call the attending, on-call, or consulting physician with change in patient's condition."

A review conducted on August 10, 2010, of Shamokin Area Community Hospital "Registered Nurse job description," no revision date, revealed "Purpose of Job: Coordinates total nursing care for the patients, utilizing the nursing process; participates in patient and family teaching, and provides leadership by working cooperatively with ancillary nursing and other patient team personnel in maintaining standards for professional nursing practices in the clinical setting. Essential Job Functions: ... 7. Identify, report and document any critical data or change in patient's condition (such as labs, vital signs, rhythm changes, change in neuro status, or deterioration in patient's condition) to physician and to Nurse Manager."

1) A medical record review on August 10, 2010, of MR1 revealed nursing documentation on July 25, 2010, at 6:15 PM that MR1 had positive gross hematuria (blood in the urine) while voiding and that MR1's physician would be made aware in the morning.

An interview with EMP1 on August 10, 2010, at 1:15 PM confirmed that nursing staff documented that MR1 had positive gross hematuria and that MR1's physician was not notified until the next day. Further interview with EMP1 revealed that MR1's physician should have been notified at the time the hematuria was identified because it was a change in MR1's condition.