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Based on interview and record review the Hospital failed to follow hospital approved policies and procedures while caring for two (Patient #4 and Patient #5) out of 11 sampled patients.

Findings include:

1. For Patient #4, the Hospital failed to follow their policy for documentation in the Patient's medical record.

The Hospital policy titled, Documentation, effective November 2016, indicated that documentation should be entered into the medical record as needed. This includes, but is not limited to the following situations:
iv. LIP (Licensed Independent Practitioner) notification related to a patient situation, e.g., critical lab value and provider response, such as no new orders, continue to monitor, new orders/treatment.
v. The transfer of patient care, e.g., acute care to Intensive Care Unit (ICU) or vice versa.

Patient #4 was admitted to the Hospital on 2/10/19 with diagnoses of hip fracture and non-ST-elevation myocardial infarction (heart attack).

On 2/14/19, Patient #4 was transferred from 3-West (the Medical-Surgical / Cardiology Department) to the ICU for change in condition. Patient #4's medical record did not indicate the reason for transfer to a higher level of care in the nursing documentation.

The Surveyor interviewed the Regulatory Program Manager at 7:20 A.M. on 5/14/19. The Regulatory Program Manager said that the nurses rely more on the physician progress notes and they do their vitals and document that in the medical record.

The Surveyor interviewed the 3-West Nurse Manager at 9:50 A.M. on 5/14/19. The 3-West Manager said the nurse caring for Patient #4 on 2/14/19 should have written a transfer note and she would speak with her about this lack of documentation.


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2. The Hospital policy titled, Triage and Treatment of Medical Emergencies, effective October, 12, 2017, indicated that at all campuses, aUniversity of Massachusetts Memorial Medical Center (UMMMC) Resuscitation Report will be completed for each cardiopulmonary arrest event.

Patient #5 was admitted to the Hospital on 3/22/19 for a scheduled surgical repair of his/her shoulder. The procedure was completed at 7:00 P.M. and Patient #5 was transferred to the Post Anesthesia Care Unit (PACU). Upon arrival at the PACU, Patient #5 was apneic (not breathing) and became pulseless after arrival. A medical code was called and cardiopulmonary resuscitation (CPR) was performed. At 7:17 P.M. Patient #5 had a return of spontaneous circulation and was transferred to the Intensive Care Unit (ICU).

Review of PACU Nurse #1's nursing note and electronic code document, indicated that medication doses and cardioversion joule's (delivery of an external electrical shock in an effort to convert the heartbeat into a viable rhythm) were not recorded and documentation was inconsistent. PACU Nurse #1's nursing notes indicated that three doses of Epinephrine were administered while the Electronic Code Documentation indicated that two doses of Epinephrine were administered.

The Surveyors interviewed PACU Nurse #1 on 5/15/19, at 10:00 A.M. PACU Nurse #1 said that she participated in Patient # 5's code and after Patient #5 was transferred to the ICU she then documented the medications administered during Patient #5's code in her nurse's note and into the electronic code document. PACU Nurse #1 said she did not fill out a UMMMC Resuscitation Report.

Based on record review and interview the Hospital failed for one patient (Patient #3) of 11 patients sampled to have a completed and documented history and physical (H&P) in the patient's electronic health record 30 days prior to Patient #3's two surgical procedures that were performed five months apart.

Findings include:

The Medical Staff Bylaws dated June 2018, and the Rules and Regulations dated August 2018, indicated that a medical history and physical examination may be performed up to 30 days prior to admission and when not performed on the day of admission, the Attending Physician or designee shall write a note documenting a reassessment of any pertinent portions of the history and physical examination.

The History and Physical (H&P) Update Note for Patient #3, dated 10/19/18 at 12:45 P.M., indicated Attending Surgeon #1 electronically signed that she reviewed the H&P examination performed by a nurse practitioner on 9/14/18 and that she performed a pertinent physical examination on Patient #3 and attested that no changes had occurred. However, the H&P was performed greater than 30 days prior to Patient #3's surgery on 10/19/18.

The H&P Update Note for Patient #3, dated 3/13/19 at 2:40 P.M., indicated that Attending Surgeon #1 reviewed an H&P that was dated 3/12/19 at 12:52 P.M. and performed at a follow up clinic visit. Attending Surgeon #1 attested she performed a pertinent physical examination on Patient #3 and that no changes were identified. However, the electronic documentation on the follow up clinic visit record did not include a medical physical examination.

Based on record review and interview the Hospital failed twice for one patient (Patient #3) of 11 patients sampled to have either a brief operative report immediately written after surgery and an operative report documented with 48 hours after surgery.

The Medical Staff Bylaws, dated June 2018, and the Rules and Regulations dated August 2018, indicated that when a complete operative or procedure note cannot be immediately placed in the chart, a brief operative or procedure progress note detailing the names of the surgeon(s), surgical techniques, findings and outcome should be written in the patients record immediately after surgery or procedure. A complete operative or procedure report detailing at a minimum name of the surgeon(s), techniques, findings, tissues removed or altered, blood loss and complications shall be written or dictated within 48 hours and signed for inpatients and ambulatory patients by the time of medical record completion.

The Brief Operative Note, dated 10/19/18 at 1:43 P.M., indicated Attending Surgeon #1 documented the note; however, according to the perioperative record dated 10/19/18, Patient #3's surgery ended one hour later at 2:31 P.M. The note was filed by Attending Surgeon at 8:02 A.M. on 10/22/18 which was three days after Patient #3's surgery.

The Operative Note, dated 10/19/18 for Patient #3, indicated the Operative Note time was 1:43 P.M.; however, Patient #3's surgery ended at 2:31 P.M. The Operative Note was filed at 8:03 A.M. on 10/22/18, three days after Patient #3's surgery.

The Surveyor interviewed the Regulatory Project Manager at 8:50 A.M. on 5/13/19. The Regulatory Project Manager said the time stamped on Patient #3's Brief Operative Note dated 10/19/18 was a default time for surgery.

The Surveyor interviewed Attending Surgeon #1 at 12:15 P.M. on 5/14/19. Attending Surgeon #1 said she usually has the medical resident write the Brief Operative Note and she usually dictates the Operative Report right after a patient's surgery.

Based on record review and interview the Hospital failed, for one (Patient #5) patient of 11 sampled patients, to follow hospital policy and established standards of care and monitor a patient who received general anesthesia

Review of the policy titled A3001 Intraoperative Monitoring, indicated that the Hospital follows the American Society of Anesthesiologists standard for basic anesthesia monitoring which states that "during all anesthetics, the patient's oxygenation, ventilation, circulation and temperature shall be continually evaluated."

Review of Patient #5's medical record indicated that, on 3/22/19, Patient #5 underwent corrective surgery on his/her right arm due to chronic shoulder pain. Patient #5's surgery ended at 6:54 P.M. and he/she was extubated at 6:59 P.M. Patient #5's vital sign monitoring ended at 7:00 P.M. Patient #5 was receiving Remifentanil (a potent, short-acting synthetic opioid analgesic drug indicated as an adjunct for the induction and maintenance of general anesthesia) intravenously during the procedure. An additional 40 mcg of Remifentanil was administered rapid push intravenously at 7:00 P.M. by Certified Nurse Anesthetist (CRNA) #1. Patient #5 was then transferred to the Post Anesthesia Unit (PACU) without an oral airway or being placed on a monitor. When Patient #5 arrived in the PACU, he/she was apneic (not breathing) and had no pulse. A Code (Emergency Response) was called, Cardiopulmonary Resuscitation (CPR) was started and Patient #5 was cardioverted (sending electric shocks to your heart through electrodes placed on your chest) three times. Patient #5's pulse returned (time not recorded) and he/she was transferred to the Intensive Care Unit (ICU). Patient #5 remained critically ill until 3/29/19 when he/she was transferred to a tertiary facility and died on the same day.

The Surveyors interviewed PACU Nurse #1 on 5/15/19 at 10:00 A.M. PACU Nurse #1 said that Patient #5 arrived to the PACU and was not breathing and was not on a monitor during transport. PACU Nurse #1 said that Patient #5 was placed on a monitor and there was no pulse. PACU Nurse #1 said that a code was called and an airway was placed. PACU Nurse #1 said that Patient #5's pulse returned approximately 20 minutes into the code and he/she was then transferred to the ICU.

Surveyors interviewed the Anesthesia Department's Director of Quality and Patient Safety at 12:05 P.M. on 5/15/19 The Director of Quality and Patient Safety said that he reviewed Patient #5's case and that the Remifentanil should not have been given post surgery without Patient #5 being on a monitor and that a different medication would have been indicated. The Director of Quality and Patient Safety said as a result of this incident the CRNA was counseled. The Director of Quality and Patient Safety said that he sent an email to all anesthesia staff with the Hospital's expectations on the administration of Remifentanil but could not verify who received the information or read the email. The Director of Quality and Patient Safety acknowledged that the Hospital failed to determine who, if any of the anesthesia staff, were aware of the Hospital's expectations of Remifentanil as a result of this incident. The Director of Quality and Patient Safety said that the Hospital intended on reviewing this case in Mortality and Morbidity rounds and conduct audits on the use of Remifentanil as an analgesic but had not implement either prior to the start of the Survey.