HospitalInspections.org

Based on medical record review, document review and interview, in one (1) of 16 medical records (MR) reviewed, it was determined the medical staff failed to implement its bylaws for timely consultations with specialist physicians to ensure that a patient with abnormal heart rate and blood pressure received appropriate care that meets the patient care needs (Patient #1).

These failures may have placed patients at risk for serious harm or death.

Findings include:

Review of the medical record for Patient #1 identified the following: Patient is a 24-year-old female who was admitted to a medical-surgical unit on 5/2/2020 for Sepsis, Pneumonia and Acute Kidney Injury after delivery of her second child on 4/14/2020 (3 weeks post partum). During this hospitalization, the patient's heart rate and blood pressure (B/P) on 5/5/20 was stable with the heart rate at 86 per minute, B/P - 117/75 and on 5/8/20 heart rate was 73 per minute (min) and the B/P 146/83 (Normal: 90-130/50-90 Hg).

Documentation on 5/2/20 at 1:49 PM, noted that the patient's electrocardiogram (ECG) was "borderline." The ECG on 5/2/20 at 10:39 PM revealed it could not be analyzed and the heart rate was 174.

On 5/3/20, cardiac monitoring between 3:10 AM and 3:44 AM revealed there was ventricular fibrillation/tachycardia, multiform, premature ventricular contractions, and a missed beat.

There was no evidence in the medical record that a cardiology consultation was done.

On 5/8/20, the patient was transferred to the Behavioral Health Unit (BHU) for Post-Partum Depression and Psychosis. Upon arrival to the unit at 11:35 PM, the patient was lethargic and non-verbal with temperature -99.6 F (normal range 97F to 99F), heart rate 93 per minute, respiration 16/min (normal 12-16) and B/P 130/101. Patient had a previous history of Post-Partum Depression after the birth of her first child for which she was treated with electro-convulsive therapy and currently she had also been diagnosed with Chronic Anemia and Thrombocytosis (excessive number of platelets in the blood).

There was no physician intervention for this elevated blood pressure.

On 5/9/20 at 2:37 PM a psychiatrist ordered vital signs to be done daily. Documentation in the MR identified the patient had fluctuating blood pressure readings and heart rates. For example:
On 5/9/20 at 7:04 AM: heart rate - 114 per minute (normal 60-100)) and B/P -137/60.
5/10/20 at 6:43 AM: heart rate -115/min and B/P - 139/93
The patient refused vital signs check on 5/10, 5/11 and 5/12/20.
5/13/20 at 6:43 AM: heart rate - 99/min and B/P - 136/93

A comprehensive metabolic profile on 5/14/20 was normal.

On 5/15/20 at 6:53 AM: heart rate -100/min and B/P -143/100

On 5/15/20 a consultation was performed for a groin rash and foul-smelling urine. The consultant concluded the patient most likely had a fungal infection and treatment was prescribed.

The patient's heart rate was persistently elevated from 5/16/20 to 5/20/20.
5/16/20 at 11:03 AM: heart rate - 108/min and B/P -148/90
5/16/20 at 5:53 PM: heart rate - 171/min and B/P - 153/116
5/18/20 at 8:58 PM: heart rate - 128/min and B/P - 126/109
5/19/20 at 10:44 PM: heart rate -137/min and B/P - 135/99
5/20/20 and 5/24/20: the patient's vital signs were not done.

All vital signs were reviewed by physicians.

A comprehensive metabolic profile on 5/20/20 was normal and the excessive platelet was noted to be resolving on 5/21/20 at 481 (normal 140-440) down from 533 the day before.

On 5/24/20 an internal medicine consultant noted "earlier in the daytime the patient was noted to have right facial swelling and lip swelling. Currently no evidence of swelling on patient's face or lips. Continue to monitor."

From 5/25/20 to 5/26/20, the patient's heart rate and B/P were documented as follows:
On 5/25/20 at 5:45 PM: heart rate - 99/min and B/P -154/108.
5/26/20 at 10:20 AM: heart rate -110/min and B/P -159/118
5/26/20 at 10:23 AM: HR - 127/min & B/P - 145/109.
5/26/20 at 10:23 AM: heart rate -127/min and B/P -145/109.

On 5/26/2020, a hospitalist that was consulted on the medical care of the patient noted that the patient was "persistently hypertensive since admission and differential diagnoses were broad and may include Neuroleptic Malignant Syndrome which can be a fatal condition and Post-Partum Hypertension. The latter diagnosis does not explain the patient's rapid heart rate." Labetalol 100 mg tablet was prescribed twice per day.

A creatinine phosphokinase (CPK) test for muscle damage performed on 5/26/20 was normal.

On 5/28/20 at 6:59 AM, heart rate - 111/min and B/P -135/84.
On 5/28/20 at 12:09 PM, the internal medicine consultant documented that the patient had reactive tachycardia and blood pressure controlled. "Medicine will sign-off."
On 5/29/20 at 5:32 AM: heart rate -123/min and B/P -138/91.

The psychiatrist documented the patient's behavior and mental state was improving, and possible discharge plans were contemplated for the week of 6/1/2020.

The last vital signs documented on 5/30/20 at 9:39 PM, were heart rate -136/min and B/P -141/107.

On 5/30/2020 at 11:23 PM, a nurse documented the patient's behavior and mental state. A doctor was notified, and Ativan 2 mg IM was prescribed and given at 11:41 PM. The nurse directed the patient to her bed at 12:36 AM on 5/31/20 and the staff checked the patient's room throughout the night at 10-20 minute intervals until 4:57 AM that morning.

On 5/31/2020, a nurse documented the patient was found unresponsive and in cardio-pulmonary arrest at 5:17 AM that morning in a prone position in her bed.
A doctor documented that during resuscitation of the patient, she could not be intubated because she had developed rigor mortis. She was pronounced dead at 5:47 AM on 5/31/2020.

There was no documented evidence that the patient was referred for cardiology consultation based on the abnormal electrocardiograms, persistent tachycardia or abnormal vital signs. A repeat electrocardiogram was not performed in the psychiatric unit from 5/8/2020 to 5/31/2020 when the patient expired.

The patient was transferred to a psychiatric unit on 5/8/20 where vital signs were taken daily. The frequency of vital signs monitoring was inadequate for a patient with abnormal blood pressure and heart rate.

The patient was persistently tachycardic during her admission to the psychiatric unit from 5/8/2020 to 5/31/2020. The consultation with the hospitalist on 5/26/20 for evaluation of the patient's elevated heart rate and blood pressure was not performed in a timely manner.

The facility's Medical Staff Bylaws state, "the Attending Practitioner is responsible for requesting consultations when indicated ...When the special expertise of the consultant is no longer required, the consultant should sign-off the case."
The internal medicine consultant signed off the case on 5/28/20 and noted that the patient had reactive tachycardia and blood pressure controlled.

There was no referral for further evaluation and treatment of the patient's tachycardia. The documentation in the MR noted the patient's heart rate and blood pressure remained unstable. No further diagnostic tests were ordered or performed.

During an interview with Staff B, Chief Hospitalist which was conducted on 8/9/2021 at 3:00 PM, he stated the following: A medical consultation could have been requested and performed earlier in the patient's hospitalization. An EKG should have been done when the patient was in the BHU. Based on the medications the patient was receiving and the patient's symptoms, she could have died from Q-T prolongation which is a fatal heart rhythm.

These findings were shared with the Chief Compliance Officer on 8/11/2021 at 3:05 PM.