HospitalInspections.org

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the medical/surgical team failed to notify a patient's family regarding a decline in a patient's medical condition and transfer to a higher level of care for one of ten medical records reviewed (MR1).

Findings include:

Review on June 3, 2103, of the facility's "Family Notification for Patient Change in Status" policy, last reviewed/revised August 23, 2012, revealed "Purpose: The purpose of the Family Notification for Patient Change in Status policy is to ensure communication occurs at [sic] with the family at key times during a patients [sic] hospitalization. Policy: family notification should occur in a timely manner whenever there is an unexpected deterioration in patient status and/or the patient is transferred to a higher level of care. The family member identified as the family representative in the medical record should be notified by phone of the event that occurred, the status of the patient and in the event of patient transfer, where the patient was transferred. The conversation, and with whom it occurred, should be recorded in the EMR [Electronic Medical Record] (dated and timed). Notification is the responsibility of the patient's primary medical/surgical team (physician/advanced practitioners). In the unusual case when a primary team does not have an in-house physician or advanced practitioner, the receiving team should notify the primary team of the patient's transfer and provide that primary team with the option to notify the family or establish that the receiving team will notify the family. In any case, the responsibility for documentation the family notification resides with whomever [sic] made the family notification."

Review of MR1 on May 30, 2013, revealed nursing documentation dated May 26, 2103, at 9:30 AM that MR1 was in severe pain, clutching the abdomen. MR1's pulse measured 128 beats per minute. The patient's temperature was 103.1 degrees Fahrenheit. The respirations measured 26 per minute. Oxygen saturation was 88 percent on 2 liters of oxygen. The RRT [Rapid Response Team] was called.

Review of MR1 on May 30, 2013, revealed physician documentation dated May 26, 2013, that General Surgery transferred MR1 from the special care unit to the critical care unit. The sending and receiving teams were aware of MR1's transfer. The reason for transfer was suspected abdominal sepsis. Further review revealed physician documentation that MR1 was in pulmonary edema (an abnormal buildup of fluid in the air sacs of the lungs) and was treated with Lasix (a drug used to treat excessive fluid accumulation).

There was no documentation MR1's family was notified regarding this patient's change in condition or transfer from the special care unit to the critical care unit.

Interview with EMP1, EMP2, EMP3, EMP4 and EMP5 on May 30, 2013, at approximately 4:45 PM confirmed the facility did not notify MR1's family regarding the decline in medical status or MR1's transfer from the special care unit to the critical care unit. Further interview with EMP5 revealed it is the expectation the family is notified whenever there is a change in a patient's status and when a patient is transferred to a higher level of care.