HospitalInspections.org

Based on document review and interview, it was determined for 1 of 10 (Pt. #1) records reviewed, that the Hospital failed to ensure that the patient's rights were protected. This potentially affects current and future patients admitted to the Hospital. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure a Sentinel Event was completed for the incident to ensure safety for future patients experiencing similar circumstances. See deficiency cited at A-144.

Based on document review and interview, it was determined for 1 of 7 (Pt #6) patients records reviewed who transferred to another hospital for a higher level of care, the Hospital failed to ensure patients signed a consent prior to the transfer to another facility per policy. This has the potential to affect all patients who are transferred to another hospital for a higher level of care

Findings include:

1. The policy titled "Consent, Informed" (revised 5/13/21) was reviewed on 9/1/22 at approximately 9:00 AM. The policy noted "III. Signed consent shall be procured from patient or patient representative... 4. Consent for transportation to another facility..."

2. Pt #6 Date of Service (DOS): 6/27/22
Diagnosis: Dizziness. The record was reviewed on 9/1/22 at approximately 10:30 AM. The record noted Pt #6 was transferred to another hospital on 7/1/22 for a higher level of care. The record lacked documentation of the signed consent form for the transfer.

3. During an interview conducted on 9/1/22 at approximately 11:15 AM, the Risk Manager (E#2) verbally agreed the record lacked documentation of a signed consent for the transfer to another hospital and one should have been completed.

Based on document review and interview, it was determined for 1 of 1 Patient (Pt #1) who experienced a Sentinel Event, the Hospital failed to ensure the Sentinel Event was reported and investigated to ensure safety for future patients experiencing similar circumstances. This has the potential to affect all patients who receive outpatient and inpatient care by the hospital with a current census of 109 patients.

Findings include:

1. The policy titled "Sentinel Event Reporting and Investigation" (reviewed/revised on 2/17/21) was reviewed on 9/1/22. The policy noted "Sentinel Event: A patient safety event... that reaches the patient and results in any of the following: ... C. Severe temporary harm... requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for a life-threatening condition... treatment to resolve the condition... occurrence that are a sentinel event and are subject to review... II. Sentinel Event Follow-up A. All sentinel events will be reviewed by the hospital... 1... discloses the event to the patient and family... 2. Notification of hospital leadership. 3. Immediate investigation..."

2. Pt #1 Date of Service (DOS): 7/12/22
Diagnoses: COVID-19, chest pain and shortness of breath. The record was reviewed throughout the survey on 8/31/22 to 9/1/22. The following was noted:

- On 7/26/2022 at 2:30 PM, Pt#1 had a condition change, "Patient complaining of dizziness and not feeling well. Pt #1 presenting with new purple discoloration/bruising around mouth. Documentation by Registered Nurse (E#4) on 7/27/2022 at 8:01 AM, stated "Patient has bruising on left side of her face, under eye, mouth, cheek and neck. Patient mouth on inside of left cheek is grossly edematous with severe bruising.

- The Laboratory Review Flowsheets noted a normal reference range for a White Blood Cell (WBC) count was 3.60 to 11.00 10*3/uL (measurement used for WBC counts). The Lab Flowsheet noted the following: 7/22/22, WBC 22.78 (H) (high). Pt#1's labs were not addressed again until 7/27/22 at 11:14 AM when Pt#1's WBC were critical at 47.97 (H); 7/27/22 at 10:53 PM 51.17 (HH)(Extremely High); and 7/28/22 at (no time) 58.82 (HH).

- Pt #1 was transferred to the Intensive Care Unit. The Intensivist Consult Note dated 7/28/22 at 12:36 AM noted "... developed progressive swallowing difficulty managing (her/his) own secretions and required suction .... The record noted Pt #1 was intubated/ventilated due to concern for airway compromise due to increased swelling into the neck area, IV vasopressors were required to maintain blood pressure, a critical White Blood Cell count, which indicated sepsis (body's response to infection, life threatening), and Pt #1 was transferred to another hospital for higher level of care.


3. The Adverse Event log/ Sentinel Event log was reviewed on 9/1/22. The log lacked documentation of any Adverse Event related to Pt #1.


4. During an interview on 9/1/22 at approximately 2:00 PM, the Risk Manager (E#2) stated "We (hospital leadership) knew nothing about this incident until you guys came on Monday. I have been reviewing the record and there were many missed opportunities of reporting. There were so many people involved from CNA's (Certified Nurse Aides), to Nurses, Physicians to unit Managers. Someone should have reported this so the incident could have been investigated. I agree this is a Sentinel Event." E#2 verbally agreed Pt #1 was not monitored for sepsis and repeat CBC's should have been ordered and monitored; the patient had an adverse event that required an unplanned transfer and the family was not notified of the change in condition and should have been.

Based on document review and interview, it was determined for 1 of 10 (Pt#1) patient records reviewed, the hospital failed to ensure nursing services updated the physician on patient condition changes and abnormal laboratory values. This has the potential to affect all patients who receive outpatient and inpatient care by the hospital.

Findings include:

1. Pt #1's record was reviewed throughout the survey. Pt #1 was admitted on 07/12/2022 with diagnoses of "COVID-19, chest pain and shortness of breath." The record noted the following condition changes:

-On 7/26/2022 at 2:30 PM, Registered Nurse (E #8)'s "Flowsheet Note" documented, "Patient complaining of dizziness and not feeling well. Patient presenting with new purple discoloration/bruising around mouth." There is no documentation E #8 called a condition change/update to the physician.

-On 7/26/2022 at 7:42 PM, Registered Nurse (E#9), documented "Patient has a swollen left upper lip with bruising on the left side of her chin that was not there when I left shift this AM." The record lacked documentation the physician was notified and the record lacked documentation of a physician's note."

-On 7/22/2022 the laboratory results for Pt#1 indicated a elevated white blood count (WBC) of 22.78 (on 07/16/2022 WBC was 5.54) indicating infection. There was no documentation in the record the nurse advised the physician of the elevated white count.

2. An interview was conducted on 9/1/2022 at approximately 10:00 AM with Risk Manager (E#2). E#2 reviewed Pt #1's record and stated, "the nurse is responsible to notify the physician's of any changes related to a patient condition and abnormal lab work immediately. This was not done in this case and should have been."