St James Hospital

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 49420 Based on policy review, document review, medical record review, and interview, in 1 of 12 medical records reviewed, it was determined that the medical staff failed to properly consult the general surgery service for Patient #1. Patient #1 never received a general surgery consult to assess the need for an endoscopy (medical procedure that using a long, flexible tube with a camera to examine the upper digestive tract). Reference: 482.22(b) Standard: Medical Staff Organization and Accountability”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 49420 Based on policy review, document review, medical record review, and interview, in 1of 12 medical records reviewed, it was determined that the medical staff failed to properly consult the general surgery service for Patient #1. Patient #1 never received a general surgery consult to assess the need for an endoscopy (medical procedure that using a long, flexible tube with a camera to examine the upper digestive tract). Findings include: Review on 02/06/25 of “Physician Consultations Policy”, last revised 01/10/22, revealed “a consultation is generally at the request from one provider to another to assist in the diagnosis or management of a patient. The purpose for consultation may include advice on diagnostic problems, management issues, confirmation of the current plan, surgical risk assessment, approval for anesthesia or approval for surgery. Physician consultations should only be requested by the patient’s attending physician, or other health care practitioner who has been given that authority by the physician. In the latter situation, the attending physician must be notified, and a note must be entered in the record to explain specifically what is expected of the consultant. The requesting provider is expected to verbally communicate the consult request, including two forms of patient identification, and details to the consulting service. The consulting provider is expected to inform the requesting provider if an order is needed. Consultations should be done as soon as possible, unless otherwise directed by the requesting health care provider.” Review of “Medical Record Content and Documentation Policy”, last revised on March 2023, revealed the documentation requirement for provider consult notes “will specify the reason for the consult, provider requesting the consult, a review of the relevant history and data, pertinent findings on examination, and the consultant’s opinion and recommendation. Other required documentation includes that progress notes should document the course of treatment, response to treatment, changes in patient condition, diagnosis or prognosis, and plans for expected discharge. All health care practitioners must document their participation in, and when appropriate supervision of, relevant aspects of the patient’s care.” Review of the document “St. James Hospital Emergency Department On-Call Schedule” for October 2024, revealed on Sunday, 10/20/24 the general surgery on-call service was with a regional hospital with which St. James Hospital has a contract. Review of the medical record for Patient #1 revealed the following: On 10/20/24: -At 07:41 AM, an emergency department provider note by Staff (J), Physician, revealed Patient #1 presented to the hospital after a recent hospitalization for diverticulitis (disease of the intestinal tract) from the inpatient rehabilitation facility with abdominal pain, diarrhea, dark bloody stool, and nausea. Patient #1 was a do not resuscitate (do not perform chest compressions if a patient’s breathing or heart stops) and do not intubate (do not insert a breathing tube) and did not want any heroic measures. A guaiac stool sample (stool sample that is tested for hidden blood using a chemical) was collected and found to be positive with melanotic blood (having or characterized by black pigmentation). Patient #1 had a gastrointestinal bleed and a transfusion of two units of blood was ordered. This was discussed with Patient #1 and Patient #1 consented to the blood transfusion. Patient #1 reconfirmed they would not want any significant heroic interventions and prefer to be admitted locally. Patient #1 was clinically stable and was admitted to the hospital for gastrointestinal bleed and diverticulitis. While Patient #1 was in the emergency department they had a few maroon-colored bowel movements. -At 08:00 AM, a lab report revealed Patient #1’s hemoglobin was 7.6 grams per deciliter (g/dL) (an iron-rich protein in red blood cells that carries oxygen from the lungs to the body’s tissues and organs, normal level 9.9-12.4 g/dL). -At 04:04 PM, the history and physical provider note by Staff (L), Nurse Practitioner, revealed Patient #1 was admitted for gastrointestinal bleed and diverticulitis. Antibiotics (medication to treat infections) were ordered for the diverticulitis. Saff (L) “spoke to the general surgery physician assistant and they stated they would consult on Patient #1 in the morning for a possible endoscopy.” Patient #1 was unable to have a colonoscopy (a procedure internally examining the large intestine via a small camera) due to active diverticulitis. Patient #1 was nothing by mouth for possible endoscopy on 10/21/24. Patient #1 was placed on pantoprazole (medication to help prevent or treat stomach ulcers) twice a day, and they would trend (review fluctuations) the hemoglobin. -At 08:44 PM, a lab report revealed Patient #1’s hemoglobin was 9.6 g/dL. On 10/21/24: -At 04:18 AM, a lab report revealed Patient #1’s hemoglobin was 9.1 g/dL. -At 09:03 AM, the hospital internal medicine progress note by Staff (I), Physician, revealed Patient #1 was pending an endoscopy, and colonoscopy and was deferred due to concurrent diverticulitis. -At 03:28 PM, a lab report revealed Patient #1’s hemoglobin was 7.6 g/dL. -At 03:34 PM, an addition to the hospital internal medicine progress note by Staff (I), Physician, revealed Patient #1 was seen and examined at bedside and was a bit disappointed they were nothing by mouth for most of the day and they were not going to surgery yet. Patient #1 continued to have bowel movements that were bloody. Patient #1 denied abdominal pain or nausea. The plan was to monitor the hemoglobin and to transfuse for a hemoglobin less than 7.0 g/dL. -At 04:19 PM, an operating room case request (a request for the operating room to hold a time slot on the schedule in case the procedure needs to be completed) was entered by Staff (M), Physician Assistant, for an endoscopy. -At 07:11 PM, a blood bank order by Staff (L), Nurse Practitioner, revealed one unit of packed red blood cells was ordered to be transfused for Patient #1 due to “significant drop in hemoglobin from 9.6 to 7.4 g/dL with an active gastrointestinal bleed, plan for operating room 10/22/24.” On 10/22/24: -At 04:06 AM, a lab report revealed Patient #1’s hemoglobin was 7.3 g/dL. -At 08:34 AM, a lab report revealed Patient #1’s hemoglobin was 7.6 g/dL. -At 01:56 PM, the hospital internal medicine progress note by Staff (I), Physician, revealed “Patient #1 had multiple bloody bowel movements overnight and a hemoglobin of 7.6 g/dL. Staff (I) was called to evaluate Patient #1 urgently around 8:45AM due to unresponsiveness. On arrival Patient #1’s, blood pressure was unobtainable using the monitor, and manual blood pressure (normal systolic pressure (top number) of less than 120 mmHg and a normal diastolic pressure (bottom number) of less than 80 mmHg) was attempted (which was low 70’s over 50’s.) At that time Patient #1 was placed in reverse Trendelenburg position (patient positioning technique where the patient’s head is higher than their feet), two liters of intravenous fluids were initiated wide open (the highest possible flow of fluids being administered through an IV (intravenous) (allowing the fluid to rapidly enter the bloodstream), and Levophed (medication used to treat life-threatening low blood pressure) was also initiated. Patient #1’s blood glucose (amount of sugar in the blood) was 51 mg/DL (normal range 70 to 99) and an ampule injection of dextrose (provides extra water and carbohydrates) was administered. Patient #1 woke up intermittently and inquired of the time of day. Patient #1’s blood pressure stabilized with the systolic in low 100’s. A Peripherally Inserted Central Catheter line (thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) was placed due to poor peripheral access. Towards the end of Peripherally Inserted Central Catheter line placement, Patient #1 was noted to be unresponsive and bradycardic (low heart rate below 50 beats per minute) with heart rates in the low 30’s and numerous medications were administered during this time. Multiple attempts were made to contact Patient # ‘s son and when Staff (I) was able to speak to the family member they decided to transfer Patient #1 to a higher level of care. The transfer center was notified, and a regional hospital accepted Patient #1. While waiting for the ambulance to arrive, Patient #1 became unresponsive and bradycardic again. At that point, Patient #1’s family member had arrived, and the decision was made to make Patient #1 comfortable. Patient #1 expired with family and staff present.” (There was no documentation in the record that a general surgery consult was completed) Interview on 02/05/25 at 10:30 AM with Staff (F), Physician, revealed they work in the emergency department. If a patient presents to the emergency room with a surgical need, they will evaluate the patient and then decide if the patient will stay at the hospital to be admitted or if the patient would need to be transferred to another hospital for a higher level of care. If the patient is appropriate to stay at the hospital, they will use the on-call schedule to request a surgical consult. Interview on 02/05/25 at 12:05 PM with Staff (K), Surgeon, revealed that they are the only full-time general surgeon at the hospital, and they do not remember Patient #1. If a patient needs a surgical consult, the on-call schedule should be utilized. The surgical team at the hospital is only on-call Monday through Friday from 08:00 AM until 04:00 PM. After this time there is an outside hospital in the region that is on-call. Staff (K) stated if they were consulted for a patient they would assess the patient that day or the next morning, depending on the time of day the consult is requested. Staff (K) would speak (either in-person or over the phone) to the requesting provider, to get a report of the patient’s condition. If the patient were to need a procedure Staff (K) would place an order for the procedure. Interview on 02/05/25 at 12:40 PM with Staff (C), Executive Vice President, revealed that providers are to always use the on-call schedule if they need a consult. Interview on 02/05/25 at 02:00 PM with Staff (H), Physician, revealed that they are a hospitalist and if a patient needed a general surgical consult while in the hospital, they would call the general surgeon at the hospital to discuss why the consult is needed and would document in the medical record. They would also order a consult in the medical record. If a patient needed a consult for a service not available at the hospital, they would call the transfer center or the on-call provider to speak to them. If a patient needed a consult on the weekend or after hours, they would contact the resource listed on the on-call schedule or call the transfer center. Interview on 02/05/25 at 02:15 PM with Staff (L), Nurse Practitioner, revealed that they work for the hospitalist group and remembered Patient #1 as they admitted Patient #1 during their second admission on 10/20/24. Patient #1 was stable and admitted with diverticulitis and gastrointestinal bleed. Staff (L) spoke to Staff (M), Physician Assistant for general surgery regarding Patient #1 and the need for an endoscopy. Staff (M) was not on-call that day and Staff (L) stated they did not use the on-call schedule to know who to call for a general surgery consult. Interview on 02/05/25 at 03:05 PM with Staff (M), Physician Assistant, revealed that they work with the general surgical team at the hospital and remembered Patient #1. On Sunday, 10/20/24 they were working for the hospitalist group (not general surgery). Staff (M) was about to be finished with their shift, Staff (J), Emergency Department Physician, told them Patient #1 needed to be admitted for a gastrointestinal bleed. Staff (M) said they would tell Staff (L), Nurse Practitioner, as they were coming on shift. While giving shift report, Staff (L) asked Staff (M) if they thought Patient #1 would need an endoscopy. Staff (M) stated they did not know as they had not assessed Patient #1, and they were not on-call for surgery. Staff (M) told Staff (L) they would need to call the on-call surgeon. If a patient needed an endoscopy they would need to see and assess the patient before that would be decided. Staff (M) told Staff (L) to communicate with them on Monday to advise how Patient #1 was doing. On Monday, 10/21/24 the operating room was very busy, and they did not hear from the hospitalist until late in the afternoon. At that time, they put in a case request for an endoscopy for Patient #1, to hold a spot on the schedule for 10/22/24, but the final decision would be made after the surgeon assesses the patient. On 10/22/24 they were told that Patient #1 was becoming unstable when they went to the unit to assess Patient #1. Upon arriving at Patient #1’s bedside, the hospitalist was in the process of facilitating a transfer to another hospital for a higher level of care. If a surgical consult is needed for a patient, the requesting provider would call with the reason the consult is needed. Staff (M) would then evaluate the patient as soon as possible and document a formal consult note in the medical record. If the operating room was needed for an inpatient, they would bump an elective procedure (a medical procedure that is scheduled in advance and is not an emergency) if needed. Interview on 02/05/25 at 03:45 PM with Staff (I), Physician, revealed that they work for the hospitalist group and remembered Patient #1 as they were the primary physician for Patient #1’s 10/20/24 admission. During the 10/20/24 admission Patient #1 had diverticulitis and a gastrointestinal bleed. When Staff (I) evaluated Patient #1 on the morning of 10/21/24, Patient #1 was stable, and Staff (I) did not see any active bleeding. Patient #1 received a blood transfusion the night before. There was a question of whether Patient #1 needed an endoscopy or not. Staff (I) was told that surgery could not do the procedure on 10/21/24 due to the operating room being too busy and that surgery would need to see the patient. Staff (I) spoke to Staff (M), Physician Assistant, with general surgery and explained that it was ok to wait until 10/22/24 to do the endoscopy. Staff (I) did not think Patient #1’s bleed was an upper gastrointestinal bleed and did not think another hospital would accept Patient #1 due to this. Patient #1 was told by Staff (M) that they were not getting the endoscopy on 10/21/24. On 10/22/24 Patient #1 became unresponsive and hypotensive, but they never lost a pulse. When Patient #1 became unstable, Staff (I) started the transfer process to a higher level of care as the hospital does not have an intensive care unit. Staff (I) updated Patient #1’s health care proxy on Patient #1’s condition and discussed the course of treatment going forward. Patient #1’s health care proxy made the decision to make no further resuscitative efforts and make Patient #1 comfortable. Interview on 02/05/25 at 04:30 PM with Staff (B), Chief Medical Officer, revealed that if a patient needed an in-house consult there would be documentation in the medical record about the conversation from the requesting provider. If a routine consult is needed it should be completed within 24 hours and if an emergent consult is needed it would be completed as quickly as possible. If a consult is needed from another hospital for a service not provided at the hospital, they requesting provider would call the transfer center. The requesting provider would document the consulting providers recommendations. If a consult is needed for general surgery, the requesting provider would need to use the on-call schedule to contact the appropriate provider.”

“STANDARD TAG FOR OUTPATIENT SERVICES CFR(s): 482.54 Standard-level Tag for §482.54 Condition of Participation: Outpatient Services If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with acceptable standards of practice. This Standard is not met as evidenced by: 34528 Based on policy review, observation, and interview, the facility failed to remove expired medication from the medication room for four of four epinephrine pens. Findings include: Review of the policy “Unstable and Outdated Drugs,” last reviewed November 2023 revealed that all outdated drugs shall be returned to the pharmacy department for proper disposal. Nursing or other staff approved by licensure to administer medications, will contact the Pharmacy Department if outdated drugs are discovered. The nursing or other licensed staff member will place the unusable medication in an area away from usable medications and label it to return to the pharmacy. Observation on 03/11/24 at 01:15 PM in the Urgent Care Unit medication room drawer revealed two Epinephrine Auto Injectors 0.15 mg with an expiration date of August 2023. There were two Epinephrine Auto Injectors 0.3mg with an expiration date of October 2023. Interview on 03/12/24 at 02:45 PM with Staff (O) Chief Nursing Officer, revealed that a nurse should have recognized the expired medication and removed them.”