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Based on observation, interview, and record review, the hospital failed to follow its policy and procedure (P&P) titled, "Advance Health Care Directives [legal document indicating person's preference for end-of-life treatment decisions]" for three of four sampled patients (Patient 1, Patient 2, and Patient 3). This failure resulted in the hospital to be unaware of patients end-of-life care wishes and had the potential for patients' health care decisions to not be honored.

Findings:

During a concurrent observation, interview, and record review on 8/20/24 at 9:57 a.m. with Patient Access clerk (PA) 1, in the Pre-Admission Testing registration area, PA 1 registered Patient 1 for an out-patient procedure. PA 1 asked Patient 1 if she had an advance directive and Patient 1 stated she did not have one. On the "Conditions of Admission" form subsection "Compliance with Advance Directive Policies" dated 8/20/24, PA 1 checked the box indicating, "The Patient does not have a written advance directive about health care decisions and." PA 1 did not ask Patient 1 any other questions about advance directives. PA 1 then checked the box indicating "Does not want further information now." PA 1 stated, "I did not ask her [Patient 1]" if she wanted more information about advance directives.

During a concurrent observation, interview, and record review on 8/20/24 at 10:08 a.m. with PA 2, in the Pre-Admission Testing registration area, PA 2 registered Patient 2 for an out-patient procedure. PA 2 asked Patient 2 if he had an advance directive and Patient 2 stated he did not have one. On the "Conditions of Admission" form subsection "Compliance with Advance Directive Policies" dated 8/20/24, PA 2 checked the box indicating, "The Patient does not have a written advance directive about health care decisions and." PA 2 did not ask Patient 2 any other questions about advance directives. PA 2 then checked the box indicating "Does not want further information now." PA 2 stated, "I did not ask this time" if Patient 2 wanted more information about advance directives.

During a concurrent observation, interview, and record review on 8/20/24 at 10:35 a.m. with PA 3, in the Emergency Department (ED) registration area, PA 3 registered Patient 3 to be seen in the ED. PA 3 asked Patient 3 if he had an advance directive and Patient 3 stated he did not have one. On the "Conditions of Admission" form subsection "Compliance with Advance Directive Policies" dated 8/20/24 at 10:42 a.m. PA 3 checked the box indicating, "The Patient does not have a written advance directive about health care decisions and." PA 3 did not ask Patient 3 any other questions about advance directives. PA 3 then checked the box indicating "Does not want further information now." PA 3 stated she bypassed that question because it seemed liked the wife [of Patient 3] knew about advance directives.

During an interview on 8/20/24 at 10:50 a.m. with Patient Access Supervisor (PAS), PAS stated Patient Access clerks should be asking all patients who do not already have an advance directive for health care, if they want more information about one. PAS stated that information (advance directive for health care) was available at all registration areas.

During a review of the hospital's P&P titled, "Patient Rights," dated 2/28/24, the P&P indicated, "All employees of [the Hospital] are responsible for assuring that patient rights are protected. . . Patients have the right to. . . 10. Formulate advance directives. This includes designating a decision maker if you become incapable of understanding a proposed treatment or become unable to communicate your wishes regarding care. Hospital staff and practitioners who provide care in the hospital shall comply with these directives. All patients' rights apply to the person who has legal responsibility to make decisions regarding medical care on your behalf."

During a review of the hospital's P&P titled, "Advanced Healthcare Directives" dated 7/28/21, the P&P indicated, "Policy: [The Hospital] is committed to creating a health care environment that promotes health care decision-making as an ongoing collaborative process between patients or their surrogate decision-makers, medical and other clinical staff, and that is consistent with Patient Care Policies and the [Hospital Corporation's values]. [The Hospital] respects the right of patients to accept or refuse any treatment options offered or to request withdrawal of any treatment that has already been initiated regarding their treatment options. . . Procedure: 1. Responsibilities of Admitting [Department] a. For Adult Inpatients, ER [ED], and Outpatient Surgery/Procedures Admissions: 1) Provide patient with brochure entitled "Your right to make Decisions about Medical Treatment". 2) Verify whether patient has executed an Advance Health Care Directive and document in the medical record. 3) Inquire if patient desires assistance in completing an Advance Health Care Directive during this hospitalization and make appropriate referral to Spiritual Care Services in HER [electronic health record]."

Based on interview and record review, the hospital failed to ensure two of three sampled patients' (Patient 7 and Patient 8) deaths while in restraints were reported per hospital policy. This failure resulted in the deaths of Patient 7 and Patient 8 not being reported to the regulatory agency as required.

Findings:

During a concurrent interview and record review on 8/21/24 at 10:44 a.m. with Quality Patient Safety Director (QPSD), an untitled log indicating deaths associated with restraints (undated) was reviewed. The log indicated Patient 7's date of death was 4/14/24 while restrained with "Side rails X 4 Soft Limbs [all four bed rails were up and all limbs restrained]." The log indicated Patient 8's date of death was 4/12/24 while restrained with "Side rails X 4 Soft Limbs." QPSD stated side four side rails up with limb restraints would be reportable deaths.

During a concurrent interview and record review on 8/21/24 at 10:45 a.m. with QPSD, the hospital's policy and procedure (P&P) titled, "Use of Clinical Restraints," dated 10/27/21 was reviewed. The P&P indicated, "Reporting. . . Deaths associated with the use of restraints will be reported to CMS [Centers for Medicare and Medicaid Services] as required by regulation by the Quality/Risk Department." QPSD stated the two deaths should have been reported, and, "it was a miss."

Based on interview and record review, the facility failed to ensure two of three sampled patients' (Patient 5 and Patient 6) care plans were updated when Patient 5 and Patient 6 were placed in clinical restraints (used to limit a patient's movement in order to keep them safe and prevent harm to themselves or others). This failure had the potential for unmet care needs for Patient 5 and Patient 6.

Findings:

During a concurrent interview and record review on 8/20/24 at 10:02 a.m. with Quality Patient Safety Program Manager (QPSPM) 2, Patient 5's "Care Plan (CP)," dated 8/17/24-8/20/24 was reviewed. The CP indicated, "Suggested Care Plan" for restraints. QPSPM 2 stated the electronic healthcare system would suggest care plans, and if a restraint care plan had been initiated the CP would indicate "activated care plan." The "Suggested Care Plan" did not indicate "activated care plan." QPSPM 2 stated Patient 5 had been in restraints since 8/17/24.

During a concurrent interview and record review on 8/20/24 at 10:21 a.m. with QPSPM 2, Patient 6's CP dated 8/18/24-8/20/24 was reviewed. The CP indicated, "Suggested Care Plan" for restraints. The "Suggested Care Plan" did not indicate "activated care plan." QPSPM 2 stated Patient 6 had been in restraints since 8/18/24 and the restraint care plan should have been initiated.

During an interview on 8/20/24 at 10:42 a.m. with Director of Adult Critical Care (DACC), DACC stated it was his expectation that nursing staff initiated the restraint care plan when restraints were activated.

During a review of the hospital's policy and procedure (P&P) titled, "Use of Clinical Restraints," dated 10/27/21, the P&P indicated, "The use of restraints must be documented in the medical record, and must include the following information. . . Revisions to the plan of care."

Based on interview and record review, the hospital failed to follow its policy and procedure (P&P) titled, "Plan for the Provision of Patient Care for the Emergency Department [ED]" dated 1/26/22, for one of three sampled patients (Patient 4). This failure resulted in Patient 4 not being adequately nourished or hydrated during his ED stay.

Findings:

During a review of Patient 4's medical record (MR), the following was noted:

Facesheet indicated Patient 4 arrived at the hospital's ED on 6/23/24 at 12:42 p.m.

"ED Documentation" dated 6/23/24 at 12:43 p.m. indicated Patient 4 arrived from an out-of-town skilled nursing facility (SNF) due to "G-tube [gastrostomy tube - device used to give fluid, nutrition, and medication when the patient is unable to take anything by mouth] became slightly dislodged, not out all the way, but [SNF] staff unable to use [G-tube] at this time."

"ED Documentation" dated 6/23/24 at 12:43 p.m. indicated, "Problems/(Active) . . . Difficulty swallowing. . . Dysphagia [difficulty with or inability to swallow] . . . Esophageal cancer [cancer of the tube that runs from the throat to the stomach].

"ED Documentation-MD [sub-section] History of Present Illness" dated 6/23/24 at 2:19 p.m. indicated, "Patient [4] is an 83-year-old male resident of a local nursing facility who has a history of esophageal adenocarcinoma [cancer in gland tissue]. Patient apparently was in a [out of town] skilled facility [and his] newly place G-tube became dislodged and staff [at skilled nursing facility] was unable to use it . . . [Patient 4's] g-tube apparently did not fall out[.] I [Physician 2] was able to retrieve it on the patient's skin."

"General Information Textual Results" dated 6/23/24 at 4:21 p.m. indicated, "[Physician 4] made aware that GT [G-tube] site is leaking moments after Medication was administered."

"General Information Textual Results" dated 6/24/24 at 12 a.m. indicated, "G-tube is leaking around site. Chux [absorbent pad] pad placed and more gauze added around site."

"General Information Textual Results" dated 6/24/24 at 7:50 a.m. indicated, "Dressing changed to [G-tube] site. [Cleansed] skin around [G-tube] site with normal saline. Skin is red and excoriated [scratched or rubbed off]."
"General Information Textual Results" dated 6/24/24 at 8:22 a.m. indicated, "Notified MD that [G-tube is leaking at site."

"ED Documentation-MD" dated 6/24/24 at 10:15 a.m. indicated, "I [Physician 1] was told by nursing staff that the [Patient 4] continues to have leakage around the gastrostomy tube. I reviewed the patient's previous note, the gastronomy tube had already been replaced and the gastronomy tube injection x-ray already performed showing appropriate placement." There was no documentation that Physician 1 assessed Patient 4's G-tube site.

"ED Documentation-MD Reexamination/Reevaluation" dated 6/24/24 at 10:19 a.m. indicated, "I [Physician 2] was able to easily replace the G-tube unfortunately [the hospital did not have the correct sized supplies.] We are currently pending G-tube evaluation."

"General Information Textual Results" dated 6/24/24 at 2:58 p.m. indicated, "MD aware [G-tube] malfunctioning. Unable to safely give medication."

"General Information Textual Results" dated 6/24/24 at 7:57 p.m. indicated, "[Per Physician 3] began feeding with [liquid nourishment] 40 ml [milliliters-unit of measure equals about 1.35 ounces] at this time [,] [Patient 4] tolerated well[.]"

"General Information Textual Results" dated 6/24/24 at 8:03 p.m. indicated, "[Patient 4] provided oral care at this time for dry mouth as reported by patient."

"ED Documentation-MD" dated 10/24/24 at 11:08 p.m. indicated, "I [Physician 3] was asked to evaluate G-tube. . . Apparently [it] is still leaking around the tube when they [nursing staff] instill fluid. I examined it and . . . it was not placed properly, and it was not pushed all the way against the abdomen. Patient [4] has some surrounding erythemia [sic] [redness of the skin] that looks to be a yeast infection [fungal infection caused when the skin is overly moist] with possible cellulitis [bacterial skin infection] . . . Patient [4] was given a trial of feeding through the G-tube and fluid was not leaking out after I fixed [the problem]. Patient stable for discharge."

"Orders" dated 6/24/24 at 10:42 p.m. indicated, "Discharge" to "home or self care."

"Admit, Discharge, Transfer Forms" dated 6/24/24 at 11:37 p.m. indicated Patient 4 was discharged from the ED and was transported to "Home" via medical transport.

During a concurrent interview and record review on 8/21/24 at 9:15 a.m. with Patient Safety Program Manager (QPSPM) 1, Patient 4's medical record was reviewed. QPSPM 1 stated there was no order for intravenous (IV-given through a vein) fluids to be given.

During a concurrent interview and record review on 8/21/24 at 9:37 a.m. with Emergency Department Nurse Manager (EDNM) and QPSPM 1, QPSPM 1 stated there was no documented oral intake. EDNM stated there were no nurses' notes indicating Patient 4 could not take anything by mouth. EDNM stated Patient 4 was in the ED for around 36 hours. QPSPM 1 stated there were no nurses' notes requesting IV fluids for Patient 4. EDNM stated there was no intake (any fluid or liquid nourishment taken in) or output (urine, vomiting, and liquid stools) documented for 6/23/24. The "Intake and Output" dated 6/24/24 at 6 a.m. to 6/25/24 at 6 p.m. indicated Patient 4 had a total of 50 milliliters (ml-fluid unit of measurement) intake and 450 ml of urine output, resulting in a negative fluid balance of 400 ml (total intake should be nearly equal to total output every day).

During an interview on 6/21/24 at 3:15 p.m. with Physician 2, Physician 2 stated he would have expected to be notified if a patient was unable to take anything by mouth, the patient's G-tube was not working properly, and the patient was not receiving IV fluids. Physician 2 stated 50 ml of intake in a 36-hour period in not sufficient.

During a review of the hospital's P&P titled, "Plan for Provision of Patient Care for the Emergency Department" dated 1/26/22, the P&P indicated, "The hospital's plan for the provision of patient care serves to identify patient care delivery processes which ensure that all relevant patient care needs are met during their stay in the Emergency Department . . . 3. Scope and Complexity of the Patient Care Needs: The Emergency Department staff assesse3s each individual patient's care needs, develops a plan for provision of this care . . . 4. Methods Used to Assess and Meet Patients' Care Needs . . . All members of the healthcare team continuously reassess the patient's response to care and treatment and revise the plan of care accordingly."

Based on observation, interview, and record review, the facility failed to ensure one of two sampled Computerized Tomography (CT - x-ray machine that takes detailed pictures of the inside of the body) technicians (CT 1) was wearing a dosimeter badge (badge that measures radiation exposure). This failure resulted in CT 1 being exposed to an unknown amount of radiation.

Findings:

During a concurrent observation and interview on 8/19/24 at 11:21 a.m. with CT 1 and Director of Imaging (DI), in the CT suite, CT 1 was not wearing a dosimeter badge. CT 1 stated she would go look for the dosimeter badge.

During an interview on 8/19/24 at 11:42 a.m. with DI, DI stated it was his expectation for CT staff to wear their dosimeter badges at all times.

During a review of the hospital's policy and procedure (P&P) titled, "Radiation Safety: Personnel Radiation Monitoring," dated 10/25/23, the P&P indicated, "The film badge [dosimeter badge] shall be worn at all times while working in an area of possible radiation exposure."