In July 2013, a patient was diagnosed with rectal cancer with metastasis to the liver.  He was treated with chemotherapy.  His course was complicated by colovesical fistula and scrotal abscess.

On 2/4/2014, the patient underwent a laparoscopic diverting colostomy.  He had further chemotherapy after this operation.

On 7/7/2014, the patient went to Internist A’s office.  At that time, the patient’s medication regimen included a fentanyl patch, hydrocodone-acetaminophen, hydromorphone, valium, zolpidem, and oxycodone-acetaminophen.  Adderall was not listed as a prescribed medication in the patient’s medical records.

On 7/22/2014, the patient was admitted to the medical center after a fall at home.  The accompanying diagnosis included syncope, dehydration, volume depletion, generalized weakness, and perineal wound.  During that hospital stay, the patient was found to have streptococcal bacteremia, for which he was treated with intravenous antibiotics.  In the emergency department’s record from the medical center, Adderall was listed in his prior to admission medication list.  It was continued in the inpatient setting and carried over with his discharge orders at the time of transfer to a skilled nursing facility. Internist A did not perform a medication reconciliation when the patient’s care was transitioned.

On 8/2/2014, the patient was discharged from the hospital.  At that time, his medication regimen was as follows:  Adderall 20 mg daily; zolpidem 10 mg at bedtime; fentanyl patch 25 mcg every 72 hours; oxycodone 10-20 mg every 4 hours as needed; and diazepam 5 mg daily as needed.  Based on the patient’s wife’s concern, the physician covering for Internist A discontinued the Adderall and the fentanyl patch.  However, the discharge summary makes no mention of discharge medications.  The patient was transitioned to a skilled nursing facility for continuation of intravenous antibiotics.  He received physical therapy/occupational therapy there and intravenous antibiotics.  He subsequently developed a fever.

On 9/18/2014, the patient was transferred back to the emergency department for tachycardia and was admitted to the hospital.

On 9/25/2014, the patient was discharged home with his spouse under hospice care.  On 10/1/2014, the patient expired at home.

While at the skilled nursing facility, the patient’s wife was concerned that the patient was on too many medications, that he was not required to ambulate, and that is dentures were lost, which impaired his oral intake.  During this period of time, the patient’s wife made multiple phone calls to Internist A, attempting to express her concerns about the care provided to her husband, but was unable to speak to Internist A.  Internist A failed to communicate with the wife regarding her husband’s condition.

The Board felt that Internist A had practiced below the standard of care given failure to perform medication reconciliation at transitions of care.  He failed to fulfill his responsibility as a treating clinician to update the patient’s wife.  He failed to maintain accurate and adequate medical records.  The patient’s perineal wound was not mentioned in his admissions notes or in subsequent follow-up notes.

The Board issued a reprimand against Internist A.  He was ordered to comply with attending a course in medical record keeping.

State: California

Date: February 2017

Specialty: Internal Medicine, Hospitalist

Symptom: Weakness/Fatigue, Fever

Diagnosis: Sepsis, Colon Cancer

Medical Error: Failure of communication with patient or patient relations, Improper medication management, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 1

Link to Original Case File: Download PDF