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Based on record review, and interview, the hospital failed to ensure that the registered nurse (RN), supervised and evaluated the nursing care for 1 of 10 patients (Patient #1), in that, after Patient #1 experienced a change in condition, she: A) did not notify the physician on call of Patient #1's change in condition after the patient's physician failed to respond to four phone calls from the nurse.

Findings included:

A) Patient #1 was admitted to the hospital at 9:00 PM on 10/05/12 from a facility in a different city with diagnoses of Pneumonia, Pleural Effusion, Oropharyngeal dysphagia, uncontrolled Hypertension, Diabetes Mellitus II, Coronary Artery disease, Severe Hypothyroidism, Leukocytosis and Delirium. Patient #1 recently underwent a CABG (Cardiac Arterial Bypass Graft) along with replacement of 2 heart valves. Patient #1's condition was stable but very guarded. Patient #1 was receiving an antibiotic Levaquin for Pneumonia upon her admission to the hospital on 10/05/12 at 9:00 PM.

During an interview 10/31/13 at 10:25 AM with LVN (Licensed Vocational Nurse) Personnel #5 she said on the morning of 10/08/12 she received report from Personnel
#19. Personnel #19 said she had left a couple of messages with Physician #8 that morning asking him to return her calls regarding Patient #1. Patient #1's fever was 104, and the patient was a little short of breath. RN (Registered Nurse) Personnel #18 attempted to call Physician #8, 2 or 3 times and he didn't call back. Permission was obtained from Personnel #2 to transfer Patient #1 to ICU (Intensive Care Unit) for her fever and SOB. Personnel #5 said the patient was SOB, pale and had fever of 104 degrees.

During an interview on 10/31/13 at 12:30 PM with Personnel #2 she said on the morning of 10/08/12 several calls had been made by staff to Physician #8 regarding Patient #1. Physician #8 didn't respond to staff phone calls until around 9:30 AM. By that time Personnel #2 said she instructed the nurse to take Patient #1 to ICU for observation due to the patient's high fever.

Review of Patient #1's medical record revealed on the morning of 10/08/12 Patient #1 began to deteriorate and was taken to ICU due to a fever of 104 degrees Fahrenheit and shortness of breath (SOB). Physician #8 did not respond to phone calls from the hospital staff at 7:15 AM, 7:35 AM, 8:00 AM and at 8:20 AM on the morning of 10/08/12. At 8:40 AM Personnel #2 instructed the staff to transfer the patient to ICU for closer monitoring. Physician #8 didn't return staff phone calls until approximately 9:30 AM on 10/08/12. There was no documentation that the physician on call or any other physician was contacted regarding Patient #1 after there was no return contact received from Physician #8, and/or was seen by any physican before being transferred to ICU.