HospitalInspections.org

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Based on documents review and interviews, in 13 of 20 incidents reviewed, it was determined the facility failed to develop an effective Quality Assessment and Performance Improvement Program to track, trend, analyze and develop plans to improve patient care outcome. Specifically, the Quality Assessment and Performance Improvement Committee minutes from September 2020 to April 2021 showed no evidence that issues that impacted patient care were reviewed.

Finding Include:

Review of a sample of the facility's Incidence/Occurrence Report from 10/2020 to 4/2021 showed multiple documentation of various incidents that were not investigated and included in the (QPIC) minutes from September 2020 to April 2021. In addition, other areas such as patient grievance and complaints were not reviewed or addressed. For example:

* Adverse Drug Reaction
1. Patient states that she was allergic to contrast dye, it was not listed in her allergy file. Patient was given contrast dye at 1:33AM. When she returned to her room she complained about not feeling well and was having a hard time breathing. The patient became unresponsive, CPR (Cardiopulmonary Resuscitation) was started at 1:50AM and the patient was intubated.

2. On 3/4/21, a physician ordered Nacan for a lethargic patient who was noted to react poorly to Narcotics and who had last received Morphine (narcotic agent for pain relief) on 3/2/21 and Fentanyl (Opioid drug used for treatment of severe pain) in the OR on 3/1/21.

*Restraints Injury
3. A patient was restrained on a stretcher with both arms tied tightly across the chest. The report noted "Patient fingers and hands were purple and cold to touch. Restraints were removed immediately and the color returned, however the ring and middle finger on the right hand appeared to be broken. Patient was transferred on sedation and not moving her extremities at this time."

*Injury Potential
4. "Patient was ordered 1,000mg CALCIUM CHLORIDE (mineral supplement and medication) IV X2 DOSES. When the nurse checked she found 1 GM CALCIUM GLUCONATE (where) with the pharmacy printed label saying 1,000MG CALCIUM."


* Medication Errors.
5. A patient's weight was documented as 118 kg but the correct patient was 118 lbs. The patient's Heparin (anti-clotting medication) bolus was based on weight. The patient received more than double the required dose of heparin bolus.

6. A patient was restarted on Heparin "not using normalized weight of 95 kg, 136.3 used."

7. A patient was "running IV Cardene (medication for short-term treatment of high blood pressure) at 5 cc/hr, which was suppose to be 50 cc/hr."

8. An incident report indicated before a meal, a patient was given Insulin sliding scale of 8 units instead of the 4 units which was ordered.

*Rapid Response Events
9. RN entered a patient's room and found the patient's breathing shallow and agonal (an abnormal breathing pattern). The Rapid Response Team (RRT) was called. The patient was no longer breathing but was still in sinus hymn with palpable pulse. The Patient was pronounced dead at 7:10AM.

10. "Patient found unresponsive with a pulse but he had VTach (A heart rhythm disorder) with a pulse. The patient was transferred to TCU."

11. "Patient found to be unresponsive, was in VTach. CPR was initiated."

12. "Patient was found lying in bed unresponsive and diaphoretic. A rapid response called."

13. "An 87 year old patient with past COVID history was admitted with Implantable Cardioverter-defibrilator (ICD) shock for Vtach, was found in a chair unresponsive. A rapid response team (RRT) was called and telemetry showed Torsades (life-threatening heart rhythm disturbances). A Lidocaine (medication used for treating abnormal heart rhythms) drip was started. Patient does not have advance directive. The family was called, the patient was made comfortable and the drip was stopped."

There was no documented evidence that the facility investigate all of these incidents to determine the impact on patient care and for quality improvement. There was no documented evidence that data from incidents was aggregated and analyzed to determine the scope of the various problems and develop plans for improvement.

The facility Quality and Patient Safety Plan for 2021 listed "significant medication errors and adverse drug reaction."
as one of the indicator to be monitored. The plan also described a "just culture" that utilizes a robust quality data management to track, trend and identify opportunities.

There was no documented evidence that significant medication errors and adverse drug reaction were investigated and opportunities for improvement identified.

During interview on 5/12/2021 at 12:40 PM, the Director of Critical Care and Cardiology (Staff B) acknowledged the findings and stated that the Incident reports and Adverse events are sometimes investigated and reported by the Manager and their Associates but it was not always documented.

During interview on 5/12/2021 at 2:45PM, The Director of Quality (Staff A) acknowledged the findings and stated that incidence/occurrence reports are reviewed in the Quality Performance meeting once a year but are looked at everyday.
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Based on the document review and interview the facility failed to take action to focus on high risk problem prone areas. Specifically, the Quality and Performance Improvement Committee (QPIC) Minutes from 10/2020 to 4/2021 showed no documented evidence that known deficiencies were addressed to identify opportunities for improvement in the management of patients.

Findings include:

This Facility is part of a Network of six (6) hospitals.
Review of the Quality and Performance Improvement Committee Meeting for 4/21/2021 showed an undated CMS Report indicating that this facility had the lowest rating of the 6 hospitals in the Network along with the reasons for this finding. The rating for this facility was listed as 2 of 5 Stars.
The document listed the following deficiencies:
-Re-admission was worst than the National average.
-Performance worst than the National average in 4 of 11 measures
-Failures: Excess days for Pneumonia; COPD 30 days re-admission.

-Patient experience worst than National average
-Performance worst than National average in 2 of 8 measures.
-Responsiveness of hospital staff to cleanliness and quietness of hospital environment.

-3 of 10 measures were worst than the National average.
-Abdominal CT use of contrast material.
-ED median arrive-departure time for admitted patients.
-ED median arrive-departure time for discharged patients.

The QPIC minutes had no documented evidence that the team discussed the data to determine actions for improvement.

During interview on 5/13/2021 at 2:30PM, the Chief Quality Officer for all six (6) Networks (Staff C) acknowledged the findings and stated that the data is old. The facility is improving, they went from one Star to two Stars.