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Based on review of the clinical record, review of hospital policies and procedures, review of hospital documentation and interviews with hospital personnel for one pediatric patient (Patient #1) who's condition became unstable, the hospital's medical staff failed to ensure comprehensive medical oversight of the patient's care.

1. Patient #1 was admitted to the hospital on 4/7/10 with diagnoses that included pneumonia and gastroenteritis. Review of the clinical record and interviews with hospital personnel identified that the patient's condition changed on 4/9/10: Patient #1 had complained of abdominal pain during the night, vomited, became acidotic, tachycardic and hypotensive. Documentation and interviews failed to reflect that medical interventions and resuscitative efforts were implemented in a timely manner, consistent with the acuity of the patient's condition. (see A 0347)

Based on review of the clinical record, review of hospital policies and procedures, review of hospital documentation and interviews with hospital personnel for one pediatric patient (Patient #1) with a change in condition, the medical staff failed to ensure comprehensive medical oversight of the patient's care. The findings include:

1. Patient #1 was admitted to the hospital on 4/7/10 with diagnoses that included pneumonia and gastroenteritis. Review of the Discharge Summary (no date, scanned into hospital computer system 5/11/10) by the attending pediatrician, MD #1 indicated that the patient experienced fever (102.7), sore throat, cough and nasal congestion between 3/26/10 through 3/31/10. On 4/4/10, Patient #1 developed abdominal pain with vomiting every 3 hours. Admission blood work (4/7/10) identified a marked leukocytosis, white blood cells (WBC) 29,100 (normal 4.0-13.5) with a left shift, marked dehydration and hypokalemia (potassium = 3.0 mEq/L, normal = 3.5-5.5.0 mEq/L). Urinalysis identified 1+ proteinuria and leukocytosis with 23 WBCs. The chest x-ray dated 4/7/10 demonstrated a small lingular infiltrate and bowel distention consistent with an ileus. The patient was admitted to the pediatric unit 5.4 on 4/7/10 at 5:49 PM and received intravenous (IV) fluids and antibiotics from 4/7/10 through 4/9/10. Physician Progress Notes and interview with MD #1 on 7/15/10 failed to reflect abdominal assessments on 4/8/10. Review of the record and interview with MD #1 identified that on 4/9/10, the patient had a change in condition: Patient #1 had complained of abdominal pain during the night and vomited 300 cc dark liquid (positive for blood) at 8:30 AM. Blood work at 10:40 AM reflected hemoconcentration (dehydration) with a hematocrit (HCT) of 46.4 (normal 35-45), WBC 9600 with a massive left shift, acidosis with a serum CO2 of 18.8 (normal 23.0-31.0) and an anion gap of 15 (normal 5-12). Although MD #1 was notified about the patient's vomiting at 8:40 AM, MD #1 did not see the patient until 11:45 AM. Upon patient examination at 11:45 AM, MD #1 identified that he believed that Patient #1 had a "surgical abdomen" and he ordered a "stat" surgical consult, as well as "stat" flat and erect abdomen and chest x-rays . The patient's abdomen was more distended, diffusely tender with minimal bowel sounds. Upon inquiry, MD #1 did not know if the patient was making urine at that time. Although MD #1 indicated, upon interview, that the patient's breathing was "okay" at noon, interview with the patient's family member on 6/11/10 identified that the patient was "panting" at noon and that MD #1 responded with, "I think it's fluid in her belly". Despite the changes in Patient #1's condition and the assessed need for a stat surgical consult, MD #1 returned to his office. After the patient's condition changed throughout the morning, the clinical record and interviews with hospital staff failed to reflect a patient reassessment that included vital signs (VS) and monitoring of intake and output (I & O) for hemodynamic instability and fluid and electrolyte imbalance. Physician Orders failed to direct VS frequency, I & O and patient activity orders. The "stat" surgical consult was not performed until 2 hours later at 1:45 PM. Interview with the surgeon, MD #2 on 6/30/10 identified that he/she conversed with MD #1 between 12:30 and 1:00 p.m. on 4/9/10 but that MD #1 conveyed no immediacy to assess the patient and/or that the consult was considered to be "stat."

Although MD #2 indicated upon interview that his examination of the patient included abdominal inspection, auscultation, palpation and percussion, peritoneal signs were not identified upon the patient's physical examination. MD #2 stated that he did not review the stat abdominal and chest films that were completed at 1:17 PM. The surgeon, MD #2 did not believe Patient #1 had a "surgical abdomen" and ordered a CT scan. MD #2 returned to his office. Documentation and interviews failed to reflect medical and/or nursing reassessment between 1:45 PM - 4 PM. The patient was finally reassessed at 4 PM by nursing staff and was found to be tachypneic (respirations 30, normal 12-20) and hypotensive (blood pressure 89/56, normal 120/80). Despite unstable vital signs, Patient #1 was transported to CT scan at 4:12 PM without the benefit of medical or nursing supervision. The CT scan (completed at 4:29 PM) reflected small bowel loops with thickened wall suggestive of inflammatory bowel disease, moderate to large amount of ascites, a distended lobulated thick-walled bladder and small bilateral pleural effusions. MD #1, MD #2 and the radiologist, MD #3, reviewed the CT scan together in the radiology department (time unclear). Patient reassessment and monitoring by medical and/or nursing staff was not performed until 6:18 PM (two hours since last assessment), at which time the patient's clinical status had clearly deteriorated. Patient #1 was more tachycardic (HR 200s) and hypotensive (66/54). Although MD #1 and MD #2 identified that the anesthesia department was called to evaluate the patient for intubation (prior to resuscitation), documentation and interview with the anesthesiologist, MD #5 failed to reflect a physical assessment of the patient, any interventions provided and/or consultation with attending medical staff. Review of the Cardiopulmonary Resuscitation (CPR) Record dated 4/9/10 identified that the hospital wide resuscitation team was activated at 6:20 PM. Patient #1 was subsequently asystolic and compressions were started at 6:22 PM and another anesthesiologist (MD #6) intubated the patient at 6:25 PM. CPR was performed for 49 minutes. Interview with MD #1 on 7/15/10 indicated that he pronounced Patient #1 dead at 7:11 PM. Review of the Post Mortem Records (dated 4/15/10 and 6/2/10) identified that the cause of death was related to a ruptured appendix with massive peritonitis.

Review of the Rules and Regulations of the Medical Staff (Appendix B, 5 Attending Physician) identified that every member of the medical staff agrees to provide continuum of care to his patients. Review of the Assessment and Reassessment of Patients Policy identified that assessment of the patient's need for care or treatment begins at the time of initial presentation within the organization. The assessment process would determine the need for care and/or treatment, the type of care to be provided and needs throughout the continuum of care. The policy also identified that the assessment/reassessment process included the collection and analysis of relevant physical data regarding each patient and this process involved continuous, collaborative effort among a multidisciplinary team. Documentation and interviews with MD #1, MD #2 and MD #5 failed to reflect comprehensive medical oversight and supervision that included patient assessments, reassessments and patient monitoring for hemodynamic instability, as well as fluid and electrolyte imbalance after Patient #1 had a change in condition (had complained of abdominal pain, had vomited, was acidotic and dehydrated) on the morning of 4/9/10.



2. Patient #1 was admitted to the hospital on 4/7/10 with diagnoses that included pneumonia and gastroenteritis. Review of the clinical record and interview with MD #1 on 7/15/10 reflected that he examined Patient #1 on 4/9/10 at 11:45 AM and the patient's abdomen was more distended and tender. MD #1 believed the patient had a "surgical abdomen" and the Physician Progress Note dated 4/9/10 by MD #1 identified that a "stat" surgical consult was initiated. However, the Physician Order dated 4/9/10 at 12:15 PM failed to reflect "stat" . Interview with MD #2 on 6/30/10 indicated that he was notified (by written memo) on 4/9/10 of the consultation request while in the operating room and that it was not communicated to him as "stat" . MD #2 went to his office after surgery and called MD #1 between 12:30 -1 PM. Review of the Surgical Consultation dated 4/9/10 and interview with MD #2 identified that no peritoneal signs were present upon the patient's physical examination. Interview with MD #2 indicated that the patient was tachypneic on exam. However, MD #2 did not believe Patient #1 had a "surgical abdomen" , believed that it was a viral syndrome with an abdominal component and ordered a CT scan (order communicated as "urgent" not "stat" ). The CT scan (abdomen and pelvis with contrast) identified that the appendix was not definitely seen. After reviewing the CT scan with MD #1 and the radiologist, MD #3 between 5-5:30 PM, MD #2 indicated that upon returning to the patient's room (? time), the patient was tachycardic. MD #2 instructed the nurses to call anesthesia because he thought the patient would require intubation. Patient #1 arrested on 4/9/10 at 6:22 PM and was pronounced dead at 7:11 PM. Review of the Post Mortem Records indicated that the cause of death was related to a ruptured appendix with massive peritonitis. Review of the Medical Staff On-Call Policy identified that when a house physician requests an on-call physician, it was the expectation of the Medical Staff that the on-call physician would respond within 45 minutes. Furthermore, the on-call physician was not required to interrupt surgery, but was responsible to designate another physician to evaluate the patient. MD #2 examined the patient 2 hours after the stat surgical consult was initiated. Documentation and interviews failed to reflect that the surgeon responded within 45 minutes as per hospital policy.


3. Patient #1 was admitted on 4/7/10 with diagnoses that included pneumonia and gastroenteritis. Interviews with MD #1 on 7/15/10 and MD #2 on 6/30/10 identified that anesthesia was called on 4/9/10 (prior to CPR) to evaluate the patient for intubation. Interview with the anesthesiologist, MD #5 on 7/21/10 identified that he could not recall what time he had evaluated Patient #1, whether it was morning or afternoon and that "they" told him that the patient was not acidotic. Upon inquiry, MD #5 could not identify who "they" were. MD #5 recalled the patient's HR was 180 because the patient was on a monitor and that the patient did not need to be intubated because there was no physical evidence of respiratory distress. MD #5 indicated that there was a lot of confusion and that the Medical Emergency Team (MET) code may have been activated. Review of the MET policy identified that the MET was a rapid response team of clinicians who brought critical care expertise to the patient bedside or wherever it was needed. The goal of the team was to improve patient outcomes by enhancing the ability to intervene when patients first show signs of medical deterioration. Interviews with the nursing staff identified that the MET team was not utilized in the pediatric department and that the MET code was not activated. Upon inquiry, MD #5 was not sure if he had reviewed the arterial blood gases (ABGs) completed at 6:03 PM and identified that the ABGs were an acidotic blood gas. ABGs on 15 L O2 rebreather mask: pH 7.41 (7.35-7.45), pCO2 20 (35-45), HCO3 12.8 (22-28), pO2 319 (80-100). Documentation and interview with MD #5 failed to reflect a physical assessment of the patient, any interventions provided and/or consultation with attending medical staff. when the patient demonstrated a change in condition.

Based on review of the clinical record, review of hospital documentation, review of hospital policies and interviews with hospital personnel for one pediatric patient (Patient #1) admitted with the complaint of abdominal pain and a subsequent change in condition, nursing staff failed to complete assessments, monitor and intervene in a timely manner when Patient #1's clinical status deteriorated. (see A 0395)

Based on review of the clinical record, review of hospital documentation, review of hospital policies and interviews with hospital personnel for one pediatric patient (Patient #1) admitted with the complaint of abdominal pain and a subsequent change in condition, nursing staff failed to complete comprehensive patient assessments, reassessments and monitoring as per hospital policy. The findings include:

1. Patient #1 was admitted to the 5.4 pediatric unit on 4/7/10 at 5:49 PM with diagnoses that included pneumonia and gastroenteritis. Review of the Pediatric Functional Assessment Form dated 4/7/10 completed on admission at 6:30 PM identified that the patient was experiencing abdominal pain described as constant and at a level 4 (pain scale 0-10, 10 worst). Review of the Interdisciplinary Care Plan dated 4/8/10 reflected pain as a problem. Review of the 24 Hour Pediatric Flowsheet dated 4/8/10 failed to reflect a pain level assessment between 3 PM - 11:30 PM. Interview with RN #4 on 7/1/10 identified that she did not specifically ask the patient about abdominal pain, severity or location, but pain in general. RN #4 indicated that Patient #1 had "vague abdominal discomfort". Review of the Pain Management, Infants and Children policy indicated that the RN would document the pain level on the 24 hour flow sheet every 8 hours and with each reassessment. Documentation failed to reflect the pain assessment and reassessment on 4/8/10 between 3:00 PM-11:30 AM as per hospital policy.

2. Patient #1 was admitted to the 5.4 pediatric unit on 4/7/10 with diagnoses that included pneumonia and gastroenteritis. Review of the Pediatric Functional Assessment Form dated 4/7/10 completed on admission at 6:30 PM identified that the patient was experiencing abdominal pain described as constant and at a level 4 (pain scale 0-10, 10 worst). A Physician Progress Note dated 4/9/10 at 12:15 PM identified that Patient #1 had complained of abdominal pain during the night. However, review of the nursing documentation failed to reflect the complaint of abdominal pain between 12 AM - 8 AM on 4/9/10 and indicated that the patient's pain level was 0/10 (pain scale 0-10, 10 worst). Interview with RN #5 on 7/1/10 identified that Patient #1 actually did complain of abdominal pain during the night of 4/9/10 and that it was not sharp pain. RN #5 was not sure if the complaint was at 3:30 AM or between 4-5 AM. RN #5 identified that the patient also communicated the need to defecate and was nauseous. Review of the 24 Pediatric Flowsheet dated 4/9/10 and interview with RN #5 indicated that the patient's abdomen was soft with bowel sounds. RN #5 assisted the patient to the bathroom and believed the abdominal discomfort was "gas". RN #5 identified that she reported the patient's pain and nausea to the oncoming shift. Interview with RN #2 (4/9/10 on-coming, day shift nurse) on 6/7/10 recalled the shift report and that the patient had a "fussy night" and had "dry heaves". Review of the Pain Management, Infants and Children policy indicated that the RN would document the pain level on the 24 hour flow sheet every 8 hours and with each reassessment. Documentation failed to reflect Patient #1's complaint of pain and pain reassessment during the night on 4/9/10 as per hospital policy.

3. Review of the intake and output (I & O) sections of the 24 Hour Pediatric Flowsheets dated 4/7/10, 4/8/10 and 4/9/10 reflected incomplete documentation in the the "end of shift" and twenty-four hour totals were blank. No urine output was noted on 4/7/10. On 4/8/10, Patient #1's urine output was 300 cc for 24 hours. On 4/9/10, no output was noted on the night shift. The day shift noted "voided x 3 per patient" (with no amount or time noted). Interview with RN #2 reported that the patient "missed the hat" in the bathroom. Documentation for the 3 days indicated the patient's urine output was 300+ cc. Review of the 2010 Lippincott Intake and Output assessment procedure utilized by the hospital identified that I & O may be recorded hourly or at the end of each shift and that total I & O should be calculated at the end of 24 hours and recorded according to the facility's policy. The hospital lacked an I & O policy. Documentation and interviews with nursing staff failed to reflect that Patient #1's hydration status was monitored in order to assess for hemodynamic instability, as well as fluid and electrolyte imbalance.

4. Review of a Nurse's Note dated 4/9/10 at 8:40 AM and interview with RN #2 on 6/7/10 identified that Patient #1 complained of epigastric discomfort, was pale and vomited 300 cc dark liquid (positive for blood) at 8:30 AM on 4/9/10. VS reflected: temperature 37 degrees Celsius, HR 120, RR 20, BP 132/82. RN #2 notified MD #1 and the physician directed nothing by mouth (NPO). Review of the 24 Hour Pediatric Flowsheets dated 4/9/10, 7 AM- 3 PM and interview with RN #2 failed to reflect bowel sound assessment. Blood work obtained at 10:40 AM reflected WBC 9.6 (4.0-13.5), hematocrit 48.8 (35-45), CO2 18.8 (23.0-31.0) and anion gap 15 (5-12). RN #2 reviewed VS and blood work with the pediatric APRN (APRN #1). Although an interview on 6/11/10 with family members present with the patient on 4/9/10, identified that the patient was "panting", Interviews with APRN #1 on 6/3/10 & 7/21/10 identified that she reviewed VS and labs with RN #2 on 4/9/10, that she hung an IV at approximately noon, but did not assess the patient. Interview with NM #1 on 7/1/10 identified that she would have expected APRN #1 to complete a patient assessment. Patient #1 vomited again at 2 PM (300 cc emesis, positive for blood). Although interview with RN #2 identified that she (RN #2) was "nervous" about the patient's condition on 4/9/10 and believed that she obtained the patient's VS at noon, documentation failed to reflect VS after 8:30 AM or a reassessment until 4 PM which identified the patient was hypotensive (BP 89/56) and tachypneic (RR 30). Review of the Assessment and Reassessment of Patients policy identified that reassessment was to be ongoing and would be related to a significant change in the patient's condition. Documentation and interviews failed to reflect that the patient was monitored or assessed according to hospital policy.

5. Review of the 24 Hour Pediatric Flowsheets dated 4/9/10, 3 PM- 11 PM indicated that the patient's abdomen was soft, non-distended and non-tender, however, failed to reflect bowel sound assessment. Interview with RN #3 on 6/7/10 identified that she thought the patient had hypoactive bowel sounds. The patient was hypotensive (BP 89/56) at 4 PM prior to CT scan. Review of hospital documentation and interview with the Manager of Patient Support Services on 6/8/10 identified that Patient #1's transport from the pediatric unit to CT scan was completed at 4:12 PM. Likewise, transport from CT scan to the pediatric unit was completed at 4:58 PM. However, review of the clinical record and interviews with RN #1 and RN #3 failed to reflect the time when the patient returned to the pediatric unit from radiology and failed to reflect a patient assessment upon return from radiology. Patient reassessment was completed over 2 hours later at 6:20 PM and noted that the patient had deteriorated: BP 66/54, HR 200's, RR 44. Review of the Medical Emergency Team (MET) policy identified that the MET was a rapid response team of clinicians who brought critical care expertise to the patient bedside or wherever it was needed. The goal of the team was to improve patient outcomes by enhancing the ability to intervene when patients first show signs of medical deterioration. Interview with the Clinical Coordinator, RN #1 on 6/7/10 identified that MET was not activated for Patient #1. Interview with NM #1 on 6/7/10 identified that the MET was not utilized for pediatric patients and that pediatric patients were not admitted to ICU, but were transferred out to other hospitals. Review of the Cardiopulmonary Resuscitation (CPR) Record dated 4/9/10 identified that the hospital wide resuscitation team was activated at 6:20 PM. Patient #1 was pronounced dead at 7:11 PM on 4/9/10. Review of the Assessment and Reassessment of Patients Policy identified that assessment of the patient's need for care or treatment begins at the time of initial presentation and continues throughout the patient's contact within the organization. The assessment process would determine the need for care and/or treatment, the type of care to be provided and the needs throughout the continuum of care. The policy also identified that the assessment/reassessment process included the collection and analysis of relevant physical data regarding each patient and this process involved continuous, collaborative effort among a multidisciplinary team. Documentation and interviews with hospital staff failed to reflect that the hospital staff assessed, reassessed, monitored and intervened in a timely manner when Patient #1's clinical status deteriorated.


Based on review of the clinical record, review of hospital documentation, review of hospital policies and interviews with hospital personnel for one pediatric patient (Patient #1) who became hypotensive, nursing staff failed to notify the physician regarding the patient's change in condition as per hospital policy. The findings include:

1. The Physician Progress Note dated 4/9/10 at 12:15 PM indicated that the patient's abdomen became more distended, diffusely tender with minimal bowel sounds and a stat surgical consult was noted. Surgical consultation was completed at 2 PM and a CT scan was ordered. At 4 PM, the patient was tachypneic (RR 30) and hypotensive (BP 89/56) prior to the CT scan. Review of the record and interview with RN #3 on 6/7/10 identified that she reported the VS to the Clinical Coordinator, RN #1 not to the physician. Review of hospital documentation and interview with the Director of Risk Management indicated that RN #3 and RN #1 had discussed the 4 PM VS and decided that the patient needed the CT scan before the patient was transferred to another hospital. Review of the Timely Physician Notification policy identified that in the event of a deterioration in the patient's condition, the nurse would notify the physician immediately. Interview with the Pediatric Nurse Manager, NM #1 identified that she would expect the 4 PM vital signs to have been communicated to the physician.




Based on review of the clinical record, review of hospital documentation, review of hospital policies and interviews with hospital personnel for one pediatric patient (Patient #1) with a change in condition, nursing staff failed to follow physician orders. The findings include:

1. Physician Orders dated 4/9/10 at 12:15 PM directed to hang D5NS/4 (D5 1/4NS) with 20 mEq when available. Review of the 24 Hour Pediatric Flowsheet dated 4/9/10 reflected IV fluid D5NS with 30 mEq potassium infused at 100cc per hour from 8 AM-11 AM and D51/4NS infused at 100cc per hour from 11 AM-5 PM. Review of the Documentation Tool for Central and Peripheral Vascular Access was blank. Review of the record and interview with RN #2 on 6/7/10 failed to reflect the IV with potassium was hung as per physician order.



Based on review of the clinical records, review of hospital documentation, review of hospital policies and interviews with hospital personnel for 9 of 10 pediatric patients (Patients #1, #2, #3, #4, #6, #7, #8, #9,#10), documentation failed to reflect that patients were routinely monitored to ensure patient safety. The findings include:

1. Patient #1 was admitted to the hospital on 4/7/10 with diagnoses that included pneumonia and gastroenteritis. Review of the 24 Hour Pediatric Flowsheets dated 4/7/10 through 4/9/10 identified that the pediatric patient was to be monitored hourly for safety. Review of the "hourly rounding logs" dated 4/8/10 and 4/9/10 (no log for 4/7/10) identified that hourly rounds were completed for 7 hours of the 49 hours during Patient #1's hospitalization.

2. Patient #2 was admitted to the hospital with abdominal pain and vomiting on 4/11/10 at 3:20 PM. Review of the clinical record indicated that the pediatric patient was diagnosed with appendicitis, underwent an appendectomy on 4/11/10 at 4:10 PM and was discharged on 4/13/10 at 11 AM. Although a review of the 24 Hour Pediatric Flowsheet dated 4/11/10 indicated hourly rounds, review of the "hourly rounding logs" failed to reflect that hourly rounds were completed (upon return from the operating room) on 4/11/10 from 7 PM to 12 AM.

3. Patient #3 was admitted to the hospital with right middle lobe pneumonia and asthma on 4/20/10 at 11 PM. Review of the clinical record indicated that the pediatric patient was discharged on 4/21/10 at 2 PM. Review of the 24 Hour Pediatric Flowsheets dated 4/20/10 through 4/21/10 identified that the patient was on hourly rounding for safety. Documentation and interviews failed to reflect that hourly rounding was performed during the patient's hospitalization.

4. Patient #4 was admitted to the hospital with acute appendicitis on 4/26/10, underwent a laparoscopic appendectomy and was discharged on 4/27/10. Review of the record failed to reflect that hourly rounds were completed postoperatively between 8:30 PM and 12 AM on 4/26/10.

5. Patient #6 was admitted to the hospital on 4/24/10 with asthma exacerbation and discharged on 4/25/10. Review of the "hourly rounding log" failed to reflect that hourly rounds were completed on 4/24/10.

6. Patient #7 was admitted to the hospital on 4/20/10 with a peritonsilar abcess. Review of the record identified that an urgent tonsillectomy with an incision and drainage of the abcess was performed and the patient was discharged on 4/21/10 at 11:30 AM. Review of the clinical record failed to reflect that hourly rounds were completed postoperatively on 4/20/10 from 7:45 PM to midnight.

7. Patient #8 was admitted to the hospital on 4/16/10 at 3:50 AM with diagnoses that included asthma and right upper lobe pneumonia. Review of the record identified that the patient was discharged on 4/19/10 at 11:48 AM. Review of the "hourly rounding logs" identified that hourly rounds were completed for only 12 hours of the patient's hospitalization.

8. Patient #9 was admitted to the hospital on 4/13/10 at 1:25 PM with asthma and pneumonia and discharged on 4/15/10 at 11:20 AM. Review of the "hourly rounding logs" indicated that rounds were not completed for 23 hours of the hospitalization.

9. Patient #10 was admitted on 4/13/10 at 4:32 PM with asthma and discharged on 4/14/10 at 5:16 PM. Review of the "hourly rounding logs" indicated that rounds were not completed for the evening shift on 4/13/10.

Review of the log sheets and interviews with the Director of Education and Pediatric Nurse Manager, NM #1 identified that, although the hospital lacked a policy to reflect "hourly rounds", hourly rounds were conducted for all pediatric patients with the intent to review toileting, pain, positioning, as well as an environmental assessment for safety. Documentation and interviews failed to reflect that hourly rounds were completed to ensure patient safety.

Surveyor: Hubbard, Dawn
Based on review of the clinical record and interviews with hospital staff for one pediatric patient (Patient #1) who expired, the medical record reflected discrepancies. The findings include:

1. Review of the clinical record and interviews with hospital personnel identified that Patient #1 expired on 4/9/10 at 7:11 PM. Review of the Death Certificate dated 4/9/10 indicated that the patient's immediate cause of death was gastrointestinal hemorrhage due to enterocolitis due to pneumonia. An autopsy of the chest and abdomen was completed on 4/10/10 at 12:45 PM. The Post Mortem Record dated 4/10/10 noted the Provisional Anatomical Diagnoses as ruptured appendix with massive peritonitis. The second Post Mortem Record dated 6/2/10 noted the Final Anatomical Diagnoses as ruptured appendix with massive peritonitis. Interview with MD #1 on 7/15/10 indicated that he completed the Death Certificate immediately after death and that he did not know if the Death Certificate would be amended. Review of the General Statutes of Connecticut Section 19a-41-10. Death records: Amending cause of death information identified that when existing language on a standard death certificate (VS-4) required amendment due to a change in the original cause-of-death diagnosis, the practitioner who provided the original medical certification shall submit a letter to the local registrar of the town where the death occurred, indicating the correct cause of death.