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Based on medical record review, document review and staff interviews, the medical staff was not accountable for the quality of the medical care provided to Patient #1 relative to the initiation of the sepsis protocol. This has the potential to affect patient outcome and care provided.

Findings include:

Review of facility Policy and Procedure entitled "Adult Sepsis Protocol" issued 7/5/16 revealed the following:
(A) SIRS (systemic inflammatory response syndrome): the body's response to an infection or noninfectious insult:
-Tachycardia greater than 90 beats per minute
-Leukocytosis (greater than 12,000) or greater than 10% bands
(B) Sepsis: SIRS that is secondary to infection that has been diagnosed clinically.
(C) Severe Sepsis: Sepsis plus at least one sign of tissue hypo perfusion or organ dysfunction:
-Lactate greater than 18.0 mg/dL (2 mmol/L)

Actions to be completed within three hours of recognition of sepsis include the following:
-Measure lactate level
-Obtain blood cultures prior to administration of antibiotics
-Administer broad spectrum antibiotics
-Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L

Review of Provider Notification in medical record dated 7/24/17 at 07:00 AM revealed SIRS Alert based on SIRS Criteria: Heart Rate=108 (greater than or equal to 96). Bands 29.0% (greater than or equal to 10.1). WBC 20.0 (greater than or equal to 12.1). Glucose 149 mg/dL (greater than or equal to 141 or less than 200). Lactate 3.3 (greater than or equal to 2.1).

Review of medical provider progress note dated 7/24/17 at 08:05 AM revealed sepsis secondary to acute diverticulitis, as evidenced by leukocytosis, fever, tachycardia and elevated lactate with acute kidney injury. Possible micro-perforations sigmoid colon on CT scan, complicated by severe constipation. Plan: Continue IV Ceftriaxone and Flagyl antibiotics. Continue IV fluids and trend lactate. Serial abdominal exams and pain control. Follow CBC and temperature trend. There is no evidence to indicate the sepsis protocol and order set were initiated.

Review of Nursing Medication Administration Record dated 7/24/17 revealed the 8:00 AM dose of Ceftriaxone 1 Gm IV and Flagyl 500 mg IV were not given due to patient being without IV access. Central line was inserted at 3:39 PM and Ceftriaxone was administered at 5:19 PM and Flagyl at 5:51 PM.
Continuous infusion order for Sodium Chloride IV 0.9%, 100 ml/hour was interrupted from 7/23/17 until 7/24/17 when IV access was re-established with central line at 3:39 PM. There is no nursing documentation found on 7/23/17 describing reason or time IV was discontinued.

Interview with Staff (D) Nursing Director ED and Staff (J) Pharmacy Manager on 3/1/18 at 10:00 AM verified that Patient #1 was without IV access on 7/23/17 at 7:00 PM until central line insertion on 7/24/17 at 3:39 PM delaying administration of 8:00 AM doses of Ceftriaxone and Flagyl IV antibiotics on 7/24/17 until 5:17 PM (Ceftriaxone) and 5:50 PM (Flagyl).

Interview with Staff (K), Hospitalist, on 3/1/18 at 11:35 AM verified the sepsis protocol was not initiated on 7/24/17 at 7:00 AM when SIRS criteria was met and medical provider documented in progress note that Patient #1 had sepsis secondary to acute diverticulitis and acute kidney injury. There was no IV access at this time and antibiotics were not administered.

Based on medical record review and document review, the medical staff did not adhere to bylaws related to supervision of Physician Assistants (PA's) in the care of Patient #1. This has the potential affect patient outcome.

Findings include:

Review of facility Bylaws dated 8/15/17 on 3/8/17 revealed that no Advanced Practice Provider shall be permitted to perform patient care services without supervision in the Hospital except as authorized by the Advanced Practice Provider Policy.

Review of the Advanced Practice Provider Policy dated 5/2017 revealed under Core Scope of Practice that physician assistants practice medicine with supervision or direction by licensed physicians. Competencies of physician assistants included the following:
- Order and interpret appropriate diagnostic/laboratory tests within protocol guidelines which must be reviewed and countersigned by the supervising physician.

Review of physician progress notes in medical record on 7/24/17, 7/25/17 and 7/26/17 revealed documented patient encounters including full examination, assessment and plan by physician assistant which include ordering and interpreting diagnostic and laboratory tests. No physician review or countersignature found in progress notes for these dates.

Based on medical record review, document review and interview, nursing staff did not notify the provider regarding lack of IV access for Patient #1 in accordance with facility protocol. This has the potential to result in delay in treatment.

Findings include:

Review of facility policy entitled " IV Care and maintenance-Adult" revised 4/13/17 revealed that IV fluids infused and/or discontinued must be documented with time and the medical provider must be notified to obtain further orders.

Review of physician orders dated 7/23/17 at 4:06 AM revealed continuous IV order for 0.9% 1,000 mL Sodium Chloride, 100 mL/hr.
Review of Intake and Output Record revealed total IV intake on 7/23/17 from 4:00 PM until 12:00 AM was 300 ml. and total IV intake on 7/24/17 from 12:00 AM until 4:00 PM was 0 ml. No nursing documentation was found in medical record on 7/23/17 or 7/24/17 regarding time or reason for discontinuation of IV.

Review of Nursing Medication Administration Record on 7/24/17 revealed 8:00 AM doses of Ceftriaxone 1 Gm IV and Flagyl 500 mg IV were not given due to patient being without IV access. Ceftriaxone administered at 5:19 PM and Flagyl administered at 5:51 PM after central line insertion.

Interview with Staff (D), Nursing Director and Staff (J), Pharmacy Manager verified that Patient #1 was without IV access on 7/23/17 at 7:00 PM until central line insertion on 7/24/17 at 3:39 PM delaying administration of 8:00 AM doses of Ceftriaxone and Flagyl until 5:17 PM and 5:50 PM respectively.

Telephone interview with Staff (F), Manager QI, on 3/15/18 at 8:50 AM verified that there was no documentation found in the nursing notes of the medical record regarding reason for discontinuation of IV or provider notification.