HospitalInspections.org

Based on record review and interview the governing body failed to:
1) Failed to ensure that 4 of 10 patients reviewed were evaluated by a physician within 24 hours of admission per the hospital Bylaws. (Patient ID's 1, 3, 4 and 5)
2) Failed to ensure that the primary physician of Patient ID# 1 coordinated the care of the patient (the primary physician never saw the patient during his 6 day stay in the hospital)
3) Failed to ensure that the primary physician of Patient ID# 1 ordered Consults (the physician's assistant ordered all Consults)

Findings include:

A complaint was made to the Texas Department of State Health services by the wife of patient ID# 1. The wife stated that her husband was admitted to the hospital 3/6/13 and signed out against medical advice on 3/11/13. The wife alleged that her husband was never seen by the primary physician (ID# 53) during his six day stay in the hospital.

Interview 5/23/13 at 8:30 a.m. with the Chief Executive Officer (CEO) revealed:
The hospital investigated the complaint and found that the primary physician (ID# 53) did not come see the patient within 24 hours according to the requirements in the hospital Bylaws. The primary physician's nurse practitioner did see the patient every day while in the hospital and several other physician consultants visited the patient. The hospital has sent the primary physician case to Medical Staff Peer Review for not following the hospitals Bylaws and seeing the patient within 24 hours. The hospital held an immediate meeting concerning this case with the Chief of Medical Staff and found that physician ID# 53's actions were not acceptable. The hospital is currently monitoring to ensure physicians evaluate their patients within 24 hours of admission.

Record review of Medical Staff Bylaws, Rules and Regulations dated 2012 stated:

" A. Admission and Discharge of Patients: 1. A patient may be admitted to the Hospital only by a practitioner approved by the Medical Staff in accordance with the Medical Staff Bylaws. The practitioner shall be responsible for providing an admitting diagnosis upon admission of the patient. All practitioners shall be governed by the admission policies of the hospital. "

" B. Medical Records: 2. A complete medical history and physical examination shall, in all cases, be dictated or entered into the record by the responsible practitioner and available on the chart no more than 24 hours after admission of the patient. "

Record review of medical record for patient ID# 1 revealed that Physician ID# 53 was the admitting physician. The admitting physician failed to evaluate the patient during the patient's stay from 3/6/13 to 3/11/13.

A History and Physical dictated 3/6/13 by a Nurse Practitioner ID# 56) stated:
" Reason for admission: Chronic right foot diabetic wound osteomyelitis. The patient is here for prolonged IV antibiotics. History: The patient is a 58-year-old Indian male patient, who has a history of chronic right foot osteomyelitis and abscess. Past medical history: Hypertension, Diabetes, Hyperlipidemia, Chronic foot wound, Seizure disorder, reflux, and Dementia with altered mental status."

The medical record reflected that a physician assistant (ID# 56) coordinated the care of patient ID# 1. The physician assistant consulted a Podiatrist, an Infectious Disease Doctor, and a Gastroenterologist.

A form titled " Statement of Patient Leaving Against Medical Advice " dated 3/11/13 revealed patient ID# 1's wife had her husband signed out of the hospital. The wife had written on the form as follows: " I, wife of patient ID# 1 is take my husband because no Doctor visit him within 5 day period except wound specialist and his staff. My Husband is not treated good at all. I did complain about Kindred how they treated their patient. "

Record review of current patients revealed the following:

The following patients were not evaluated by a physician within 24 hours of admission.

Patient ID# 3 was admitted on 5/11/13 by Dr. ID# 53. The History and Physical was completed by his physician assistant, (ID# 57) on 5/11/13. The first note by the primary physician was noted on 5/19/13. (8 days after admission)

Patient ID# 4 was admitted on 10/8/12 by Dr. ID# 53. The History and Physical was completed by his physician assistant, (ID# 56) on 10/9/12. The first physician progress note was dated 10/24/12. (16 days after admission)

Patient ID #5 was admitted on 5/3/13 by Dr. ID# 53. The History and Physical was completed by his physician assistant, ID# 58) on 5/4/13. The first note by the primary physician was noted on 5/5/13. (2 days after admission)


Record review of a letter dated 5/13/13 from Kindred hospital addressed to Dr. ID # 53 stated:

" When a complaint is received from a patient or a family member regarding a physician, these concerns are routinely forwarded to the Medical Staff Quality Sub-Committee for physician review. The committee has reviewed a complaint from the wife of patient ID# 1 and would like to receive a written response to the committee. This patient was admitted on March 6, 2013 under your service and left AMA on March 11, 2013.

In review of the record, the committee noted several issues in this case. The first issue brought forth was the lack of an H&P documented by the attending physician. While the H&P was performed by a nurse practitioner the current Bylaws, Rules and Regulations require the H&P to be completed specifically by an attending Physician within 24 hours of admission. Additionally, the patient had evidence of worsening renal failure without intervention by the attending physician. It appears no attending every saw this patient during his entire stay in the hospital. "

The committee also noted that all of the consultations were ordered by the Nurse Practitioner or the Physician Assistant. The Bylaws, Rules and Regulations were ordered by the Nurse Practitioner or the Physician Assistant. The Bylaws, Rules and Regulations clearly state that " The attending physician is responsible to request consultation when the situation indicates. "