HospitalInspections.org

Based on document review, medical record review, and staff interview, the facility failed to provide a Urology Consult and documentation within twenty-four (24) hours of notification according to the Medical Staff Bylaws 2024; affecting one (1) of six (6) patients (#1) with a Urology Consult order. This failure has the potential to affect all patients who seek urology care at the facility.

Findings include:

A review of the "Medical Staff Bylaws, Rules and Regulations", dated 04/26/24, was completed and stated in part, "Consultation Reports: Requests for a consultative evaluation and recommendations shall be provided upon a specific order in the patient's medical record from the attending physician or admitting service. Physicians or services being consulted shall be personally notified verbally or through secure text from the physician ordering the consult. The consultative evaluation and report shall be completed as soon as practicable for emergency or urgent requests, but within twenty-four (24) hours for all consultations." And:
"Medical Records: ...medical records shall be completed within the following time frames unless a shorter time frame is required by applicable laws, rules or regulations: ...Consultation Reports- by the end of the day that service is provided ..."

A review was conducted of the medical records for patient #1, date of admission 06/04/25 to 06/13/25, with a diagnosis of sepsis secondary to urinary tract infection (UTI). Patient #1 was admitted to the clinical observation unit (COU), then transferred to 2 East Bed Tower room 2956 on 06/07/25, and ultimately discharged on 06/13/25. The history and physical notes were reviewed, and stated in part, "There is concern for a false urethral tract and [family member] notes during [his/her] most recent exchange, it took several attempts to exchange the Foley catheter and the urologist had to use the camera/scope to place the Foley." A Urology consult was ordered on 06/05/25 at 00:43 a.m., and staff #10 was notified via Halo, and acknowledged acceptance on 06/05/25 at 1:05 a.m. There was no documented evidence of multiple attempts to contact staff #10. A Progress Note-Nurse signed by staff #23, dated 06/06/25 at 12:55 p.m. stated, "[staff #10] exchanged pts [patient's] foley catheter." A Hospitalist Progress Note signed by staff #16, dated 06/06/25 at 1:47 p.m. stated, "Foley exchanged at bedside per [staff #10]." There was no documentation of a progress note regarding the Foley catheter exchange from staff #10. There was a Urology consultation note dated 06/09/25, and subsequent daily notes, signed by staff #13.

An interview was conducted on 07/08/25 at 12:30 p.m. with staff #3 who confirmed that the Medical Staff Bylaws state that all consults are to be seen within twenty-four (24) hours of notification; and the Cerner documentation system states that routine consults are to be seen within forty-eight (48) hours. Staff #3 confirmed that the Bylaws were changed in 2024, but information technology (IT) had not changed the Cerner program yet, and the Bylaws should be followed.

An interview was conducted on 07/08/25 at 1:30 p.m. with staff #2 regarding staff #10 and patient #1. Staff #2 stated, "[Staff #10] was on call on 06/05/25 and received the consult after midnight. It would be expected that [he/she] would see the patient, even though the call schedule changed at 8:00 a.m. that morning. You either see the patient or hand it off. [He/she] did not hand it off or see the patient within twenty-four (24) hours. There is definitely a problem with [staff #10] not documenting the procedure. [He/she] tried to explain that a simple procedure like a catheter change does not need to be documented, but [he/she] is wrong." Regarding the Medical Staff Bylaws, staff #2 stated, "The medical staff review the Medical Staff Bylaws and sign off on it upon hire. The medical staff committee reviews the Medical Staff Bylaws and makes changes. Any changes or addendums are emailed to the medical staff. We do not have any sign off sheets for that. We did make the changes in the 2024 Bylaws to have routine consults see the patients within twenty-four (24) hours. It used to be forty-eight (48). IT has not changed it in Cerner yet."