HospitalInspections.org

Based on interview and record review the facility failed to ensure medical staff accountability for the provision of quality care to 1 of 10 patients ( patient #10)

Physician # 59 failed to respond in a timely manner to a critical change in condition.

Findings Include:
Tx00270533

Record review of complaint intake Tx00270533 revealed allegation that physician #59 failed to respond several times to telephone calls from ICU nurse that involved Patient #10.

Review of Patient #10 History & Physical revealed he was a 59 year-old male status-post fall who was re-admitted with SOB, fever and chills.
Patinet #10 became unresposive and required resusitation efforts. Patient #10 expired, cause of death, hemorrhage and collapsed lung. Further review of Patient's #10 clinical record revealed his condition was declining on 1/18/17 as evidenced by worsening arterial blood gases results, and chest X-ray.
Communication portion of patient #10"s record showed Physician #59 was telephoned on 1/18/17 at 9:15 PM. It was noted "no orders received".

Record review of ICU physican call log revealed the following:
1/19/17 5:30 PM Physician #59 called, "no call back"
1/19/17 5:35 PM Physician #59 called, "no call back"

Record review of contract titled: " Intensive Care Unit on-call Services agreement dated 6/29/17, read:"...12. When not present on site, return high urgency calls/pages within 5 minutes...".

Interview on 10/19/17 at 1:35 PM with ICU Director #63, stated," this meant the physician did not call back".

Interview on 10/19/17 between 9:30 AM and 10:45 AM in ICU revealed two (2) of 4 Registered Nurses (RN) interviewed RN#54, RN#55 said there were issues with late response time specific to physician #59.

Interview on 10/19/17 at 4:00 PM by telephone with physician #58 Director of Physician Group revealed he expected the physicans to respond to calls from ICU within a 5-10 minute time frame. He went on to say he was unaware of a problem with response time by physician #59.