HospitalInspections.org

Based on staff interviews, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to ensure patient safety was met regarding allergies, for one (1) of eight (8) patients in the survey sample (Patient #6).

Patient #6 was assessed as having a seafood allergy, however while in the Emergency Department, Patient #6 was served fish which required medication intervention.

The findings included:

On 5/18/21 at 3:40 p.m. Patient #6's clinical record was reviewed with the assistance of the ED Director (Staff #6). Patient #6 was not in the hospital during the survey. The clinical record revealed the following ED visit dates in 2020 and 2021: 6/16/20, 11/19/20, 11/30/20, 12/21/20, 2/19/21, 3/9/21, and 3/27/21. All visits resulted in a transfer to another facility as planned, except for 2/19/21 in which Patient #6 left against medical advice.

Review of Patient #6's clinical record revealed the following documentation written by Registered Nurse (RN) Staff #10: "12/21 (2020) 18:00 (6:00 p.m.) gave patient a piece of fish that she thought was chicken, moved to room 16 and placed on monitor. patient vomited the fish and no obvious swelling noted or hives noted."

The Respiratory Therapist (RT) documented on 12/21 at 19:47 (7:47 p.m.) "Respiratory: Breath sounds are clear bilaterally. Initial nebulizer treatment given as ordered Patient was instructed on Method of Teaching: discussion, Patient's behavior during the teaching process was cooperative, Teaching done by respiratory therapist. Understanding level: Patient verbalized understanding of the teaching provided. The following documentation by the RT: read: "12/21 19:58 Respiratory: Breath sounds are clear bilaterally."

The Nurse Practitioner (NP) documented on 12/21 at 20:30 (8:30 p.m.) "ED course: Nursing staff reported to me that patient may be having an allergic reaction to ingestion of seafood with her dinner meal. On assessment, patient is resting quietly with respirations are regular and nonlabored, no hypoxia, no tachycardia, no tachypnea. Patient denies any sensation of mouth or tongue or throat swelling or itching. On auscultation of breath sounds, there is bilateral upper lobe expiratory wheezing appreciated. No signs of respiratory distress, no accessory muscles use, no retractions, no nasal flaring. Medications were administered and her wheezing has resolved. Patient reports she feels better and denies any other further symptoms of allergic reaction. Continuing to monitor patient closely. 12/21 at 23:00 (11:00 p.m.) NP documented "Response to treatment: the patient's symptoms have markedly improved after treatment."

Further review of the clinical record revealed documentation that an on 12/21/20 at 19:10 (7:10 p.m.) an IV was inserted into Patient #6's right antecubital area, and famotidine (Pepcid) 20 milligrams was infused as ordered at 19:34 (7:34 p.m.). Other medications given at the time of the famotidine were Solu-Medrol 60 mg IVP (push), and diphenhydramine 12.5 mg IVP. Albuterol 3 milliliter inhalation was documented as administered at 21:00 (9:00 p.m.).

On 5/18/21 at 3:40 p.m. an interview was conducted with the Emergency Department Director, Staff #6. Patient #6's clinical record was reviewed with Staff #6. When asked the process of documenting allergies, Staff #6 stated "If someone has an allergy, it's put into the computer system." Staff #6 stated "We put in a generic order for a meal tray." Staff #6 explained that once the diet is ordered by the physician, it is put into the system; it will say on the print-out (diet slip) any allergies.

On 5/19/21 at 9:45 a.m., the hospital menu for 12/20/20 through 12/22/20 was received and reviewed with Staff #6. Dinner on 12/21/20 included "Herb Baked Fish." Although "Historical Allergies" which included seafood were entered into the clinical record on 12/21 at 13:04 (1:04 p.m.), review of Patient #6's diet order revealed the diet was not ordered by the physician until 12/22/20 at 6:37 a.m. Contained on the "Order Sheet" was "Allergies: prednisone cream, seafood, nuts." Staff # 6 stated "I know they called down for a safe tray "(tray with contents used for patients who presented to the ED for assessment of suicidal ideation; no knives, etc.).

On 5/19/21 at 10:40 a.m., an interview was conducted with Registered Nurse, Staff #10. When asked to describe the circumstances regarding Patient #6, Staff #10 explained that safety trays came for the psych patients. There were 3 patients in the 15 area (hallway). Staff #10 stated she gave the tray to Patient #6 and a patient in room 15. Staff #10 stated "The patient in room 15 stated "Mmm this is good fish," and when I walked out of the room patient (Name) was spitting out fish and stated "I'm allergic to fish". Staff #10 stated room #16 was cleaned out and Patient #6 was moved into the room to monitor vitals and O2 sat, and the physician was notified of what happened. When asked how Patient #6 presented after eating the fish, Staff #10 stated she vomited a chunk of fish. Staff #10 stated the patient was hooked up to cardiac leads, O2 sensor and blood pressure cuff and stated "I don't recall any other symptoms besides vomiting fish." When asked how report is given to the oncoming shift, Staff #10 stated her shift ended at 7 p.m. and at change of shift she brought the oncoming nurse into the room and explained what happened.

The above noted findings document that Patient #6 required medical intervention due to ingesting a portion of a fish served by the facility staff despite a known seafood allergy. The facility failed to ensure Patient #6's safety while in the Emergency Department.

Based on observations, staff interviews, clinical record review, facility documentation review, and in the course of a complaint investigations, the facility staff failed to ensure an interdisciplinary plan of care was fully developed and implemented in regard to allergies, for one (1) of eight (8) patients in the survey sample (Patient #6).

Patient #6 was assessed to have a seafood allergy, however the dietary department was not informed of the allergy timely resulting in Patient #6 receiving a dinner tray with fish. Patient #6 ate some of the fish and subsequently required medical intervention.

The findings included:

On 5/18/21 at 3:40 p.m. Patient #6's clinical record was reviewed with the assistance of the ED Director (Staff #6). Patient #6 was not in the hospital during the survey. The clinical record revealed the following ED visit dates in 2020 and 2021: 6/16/20, 11/19/20, 11/30/20, 12/21/20, 2/19/21, 3/9/21, and 3/27/21. All visits resulted in a transfer to another facility except for 2/19/21 in which Patient #6 left against medical advice.

Review of the clinical record revealed the following documentation written by Registered Nurse (RN) Staff #10: "12/21 (2020) 18:00 (6:00 p.m.) gave patient a piece of fish that she thought was chicken, moved to room 16 and placed on monitor. patient vomited the fish and no obvious swelling noted or hives noted."

The Respiratory Therapist (RT) documented on 12/21 at 19:47 (7:47 p.m.) "Respiratory: Breath sounds are clear bilaterally. Initial nebulizer treatment given as ordered Patient was instructed on Method of Teaching: discussion, Patient's behavior during the teaching process was cooperative, Teaching done by respiratory therapist. Understanding level: Patient verbalized understanding of the teaching provided. The following documentation by the RT: read: "12/21 19:58 Respiratory: Breath sounds are clear bilaterally."

The Nurse Practitioner (NP) documented on 12/21 at 20:30 (8:30 p.m.) "ED course: Nursing staff reported to me that patient may be having an allergic reaction to ingestion of seafood with her dinner meal. On assessment, patient is resting quietly with respirations are regular and nonlabored, no hypoxia, no tachycardia, no tachypnea. Patient denies any sensation of mouth or tongue or throat swelling or itching. On auscultation of breath sounds, there is bilateral upper lobe expiratory wheezing appreciated. No signs of respiratory distress, no accessory muscles use, no retractions, no nasal flaring. Medications were administered and her wheezing has resolved. Patient reports she feels better and denies any other further symptoms of allergic reaction. Continuing to monitor patient closely. 12/21 at 23:00 (11:00 p.m.) NP documented "Response to treatment: the patient's symptoms have markedly improved after treatment."

Further review of the clinical record revealed documentation that an on 12/21/20 at 19:10 (7:10 p.m.) an IV was inserted into Patient #6's right antecubital area, and famotidine (Pepcid) 20 milligrams was infused as ordered at 19:34 (7:34 p.m.). Other medications given at the time of the famotidine were Solu-Medrol 60 mg IVP (push), and diphenhydramine 12.5 mg IVP. Albuterol 3 milliliter inhalation was documented as administered at 21:00 (9:00 p.m.).

On 5/18/21 at 3:40 p.m. an interview was conducted with the Emergency Department Director, Staff #6. Patient #6's clinical record was reviewed with Staff #6. When asked the process of documenting allergies, Staff #6 stated "If someone has an allergy, it's put into the computer system." Staff #6 stated "We put in a generic order for a meal tray." Staff #6 explained that once the diet is ordered by the physician, it is put into the system; it will say on the print-out (diet slip) any allergies.

On 5/19/21 at 9:45 a.m., the hospital menu for 12/20/20 through 12/22/20 was received and reviewed with Staff #6. Dinner on 12/21/20 included "Herb Baked Fish." Although "Historical Allergies" which included seafood was entered into the clinical record on 12/21 at 13:04 (1:04 p.m.), review of Patient #6's diet order revealed the diet was not ordered by the physician until 12/22/20 at 6:37 a.m. Contained on the "Order Sheet" was "Allergies: prednisone cream, seafood, nuts." Staff # 6 stated "I know they called down for a safe tray (tray with contents used for patients who presented to the ED for assessment of suicidal ideation; no knives, etc.).

On 5/19/21 at 10:40 a.m., an interview was conducted with Registered Nurse, Staff #10. When asked to describe the circumstances regarding Patient #6, Staff #10 explained that safety trays came for the psych patients. There were 3 patients in the 15 area (hallway). Staff #10 stated she gave the tray to Patient #6 and a patient in room 15. Staff #10 stated "The patient in room 15 stated "Mmm this is good fish," and when I walked out of the room patient (Name) was spitting out fish and stated "I'm allergic to fish". Staff #10 stated room #16 was cleaned out and the (Patient #6) was moved into the room to monitor vitals and O2 sat, and the physician was notified of what happened. When asked how Patient #6 presented after eating the fish, Staff #10 stated she vomited a chunk of fish. Staff #10 stated the patient was hooked up to cardiac leads, O2 sensor and blood pressure cuff and stated "I don't recall any other symptoms besides vomiting fish." When asked how report is given to the oncoming shift, Staff #10 stated her shift ended at 7 p.m. and at change of shift she brought the oncoming nurse into the room and explained what happened.

The above noted findings regarding the delayed diet order by physician and subsequently delayed notification of the dietary department of Patient #6's allergy status resulted in serving Patient #6 a dinner tray with fish. Patient #6 ate some of the fish and subsequently required medical intervention.