HospitalInspections.org

Based on interview and document review, it was determined that the hospital failed ensure that patients in the Bariatric Surgery Service, or patients who weighed greater than 500 pounds, were provided with care in a safe setting.

The hospital's failure to do so placed all patients in the Bariatric Surgery Service, or those patients who weighed greater than 500 pounds, at risk for unsafe, inconsistent or inappropriate care and services.

Bariatric Patients and/or Patients Who Weighed Over 500 Pounds

The Vice President for Patient Care Services (VPPCS), and the Nursing Director for Radiology, Operating Room/Recover Room, Minor Procedures, PICC Team and Out-Patient Infusion Services, were interviewed on 6/23/2010. The Nursing Director was identified by the VPPCS as leading the Bariatric Surgery Services Program.

The VPPCS stated that the hospital had 2 surgeons who performed bariatric surgeries, and Nursing Director stated on 6/25/2010 that the surgeons had been performing bariatric surgeries for about 5 years. The VPPCS stated that the hospital did approximately 3 bariatric surgeries each week.

Both the VPPCS and the Nursing Director stated that the following elements of the Bariatric Surgery Service program had not been completed:

-Staff training
-Centralized equipment list
-Policies and procedures for in-house transfers
-Transfer agreement with another hospital and radiology facility
-Evacuation plan for bariatric patients
-A third "HoverMat" [used to transfer patients]
-Re-training on how to use equipment
-Transporter training
-Algorithm for equipment ordering
-Identification of all portions of the hospital where structural modifications might be needed
-"manuals" had not been developed
-Policy and procedure for discharge planning specific to patients in the Bariatric Surgery Service

The VPPCS and the Nursing Director also stated that a definition of "bariatric" patients had not been developed, so that it was not possible to consistently identify which patients might need specialized care and services.

The hospital's failure to fully develop a program for the care of Bariatric Surgery Services patients, or those patients who weighed greater than 500 pounds, placed those patients at risk for unidentified and unmet care needs, as well as unsafe care by untrained care providers and/or a lack of appropriate equipment and physical facilities.

Based on interview and review of hospital documents, it was determined that the hospital failed to adopt, implement, review and revise patient care policies and procedures designed to guide staff regarding patient safety measures.

Findings include:

Patient Falls

On 6/18/2010, the Vice President for Patient Care Services (VPPCS) was asked to provide documentation of all falls that had occurred in the hospital from December, 2009 through May, 2010. Twenty-one reports were identified by the hospital.

The VPPCS and the Director of Risk Management/Quality Improvement (DRMQI) were interviewed regarding the hospital's process for evaluation of incidents. The VPPCS stated that there was not currently a procedure in place to notify her/him of incidents that resulted in patient injury.

The VPPCS and the DRMQI acknowledged that there had not been a complete evaluation of the "why and how" of any of the incidents under review, and that there was not a process in place to ensure that each incident was evaluated and analyzed, with the appropriate subsequent policies and procedures and staff trainings.

-Eleven (11) of the 21 patient falls involved patients who had been provided with bed alarms. While some incidents had been addressed on an individual basis, there had not been a documented, comprehensive evaluation as to why bed alarms were not preventing patient falls.

-One patient who fell had been moved from the bed to a chair for a meal, but had not been provided with a chair alarm. At the time, there was not a policy in place to ensure that all patients who were determined to be fall risks and required a bed alarm would also be provided with a chair alarm.

-Three patients who fell had been accompanied by a Certified Nursing Assistant (CNA) when they fell. No evaluation as to "why and how" the patients fell, while accompanied, had been performed. There was no evaluation of the CNA skills related to stand-by assistance, use of gait belts, understanding of how to assist a patient who might have an impaired extremity, etc.

-One sedated patient had fallen from a procedure table to the floor during a procedure. The sedated patient had fallen to the floor in the presence of 4 hospital employees and a physician. It had been determined that the patient had been transferred from the gurney to the procedure table via a sliding transfer pad, and the slippery sliding transfer pad and lack of use of restraining straps on the procedure table precipitated the patient's fall.

That information was not communicated to other patient areas where patients were also transferred from gurneys to procedure tables. At the time of the initiation of the investigation, communications to patient care areas had not been made regarding those safety issues, nor had the requirement to always use safety straps on procedure tables, including in the Operating Rooms.

-One patient who was approximately 5'1" tall and weighed 278 pounds was dropped to the curb as s/he was being transferred from a wheelchair to a private vehicle. The patient had been escorted by a nursing assistant who was unable to safely assist the patient into the car, and the patient slid to the curb and had to be taken back to the hospital to await an ambulance for safe discharge.

The documentation regarding patient incidents was reviewed with the VPPCS, who acknowledged that there was inconsistent documentation of a nursing assessment of patients, including evaluation of vital signs, post-incident.

The hospital's "Year 2010 Performance Improvement - Patient Safety Plan" stated:
"All incidents, particularly clinical errors, are to be reported immediately, once the patient is stabilized and/or no longer at risk...There may be multiple staff who are in some fashion party to an incident, and a separate report is required from each one..."

The VPPCS reviewed the documentation for each incident and acknowledged that the requirement that each person who was "party to an incident" file a separate report had not been followed for any incident under review.

The hospital's failure to thoroughly investigate the causes of falls, how the falls occurred and why, and to implement changes to practice based on that investigation, placed all patients in the hospital at risk for injury.