HospitalInspections.org

Based on medical record review, document review and interview, the Quality Assessment and Performance Improvement department did not ensure all patient deaths are identified and reviewed in accordance with facility policy and New York State Title 10 Codes, Rules and Regulations, Section 405.6 in 1 of 3 medical records reviewed.

Findings Include:

Review of the anesthesia record for Patient #1 dated 02/16/15 revealed the patient expired in the operating room at the completion of an emergent resection and reanastomosis of the bowel.

Review of New York State Title 10 Codes, Rules and Regulations Section 405.6 Quality assurance program revealed: (b) The activities of the quality assurance committee shall involve all patient care services and shall include, as a minimum: (2) review of mortalities.
Review of facility policy and procedure titled " Occurrence Reporting, " last revised 04/14 revealed the following:

- " It is the policy to document and report all unusual occurrences as defined in the guidelines set forth in this policy. This policy shall, at all times comply with federal, state and local regulations in addition to those applicable standards set forth by the Joint Commission and the New York State Department of Health. "
- Guidelines: " An occurrence that resulted in a near-death event (e.g. anaphylaxis, cardiac arrest). An occurrence that resulted in unexpected patient death. "

Review of facility policy and procedure titled " Quality & Patient Safety Peer Review Program, " last revised 12/14 stated the following:

- " Cases for potential Peer Review as delineated by the 2805j code (New York State Public Health Law) may be collected from but not limited to the following sources: Significant Event Process, CHS Occurrence reports. The Quality & Patient Safety Staff will review the case against established criteria. The cases will be placed into the peer review process for review by the Department Chair/Designee/Department Committee or Service Line. "

Interview with Staff #13 and Staff #14 on 11/18/15 at 10:30am confirmed in accordance with review of medical record that Patient #1 coded and died in the operating room on 02/16/15 at 2:07pm. Staff #14 stated that no documentation of occurrence reporting or Quality & Patient Safety Peer Review of this case could be found. Staff #13 and 14 stated that this case required occurrence reporting and peer review according to hospital policy and procedure.

Based on medical record and document review the nursing staff did not notify the medical staff of a change in wound appearance in accordance with hospital policy in 1 of 5 medical records reviewed.

Findings include:

Review of Nursing Documentation in Patient #1's medical record dated 02/14/15 at 8:00am under Integumentary assessment revealed the following:

- Incision Review: " mid abd staples intact, lower portion of incision with scant green drainage, scabbed area. "
- Surgical Incision Care: Incision Drainage: " Green, Yellow. " Incision Dressing: " no action indicated at this time. "
- Previous wound assessments noted serous drainage.

Review of facility policy and procedure titled " Wound Management and Treatment Policy, " last revised 05/14 directed nursing staff to " perform a wound culture when signs of infection are present (Attachment A). A provider ' s order is required. " Attachment A: " Signs and symptoms of local infection include: Change in wound bed color (yellow green, dullness, unhealthy coloration). "

There is no evidence to indicate the physician was notified of the change in Patient #1's wound drainage prior to the patient's discharge to home on 02/14/15.