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Based on medical record review, physician and staff interview, PGY1 Resident did not follow Hospital Policy and evaluate one of one Patients, Patient #1, in a timely manner after the PACU Registered Nurses reported bleeding at the donor site following a skin graft surgery on 01/20/12. The PACU Registered Nurses did not follow the chain of command and promptly notify a nursing supervisor that the surgical residents did not come to evaluate Patient #1 after multiple text messages were sent.

Findings include:

Refer to A-0347

Review of the Hospital's Policy for Department of General Surgery Supervision indicated that all PGY1 residents should be in direct communication with the next most senior resident to obtain consultation regarding any clinical changes in a patient's status.

Review of the Archived Messages placed by the nursing staff from PACU to the PGY1 Resident indicated that the PACU RN sent a text message on 01/21/12 at 4:58 A.M., 5:44 A.M., 7:30 A.M, 7:40 A.M. and 9:00 A.M. to request that PGY1 Resident evaluate Patient #1.

PGY1 Resident failed to evaluate Patient #1 in the PACU after nursing staff reported post-surgical bleeding. PGY1 Resident did not follow Hospital Policy and contact a senior resident for consultation.

Chief Resident #2 was interviewed in person on 03/05/12 from 12:50 P.M. to 1:10 P.M.. Chief Resident #2 said that Patient #1 was evaluated by PGY1 Resident at 7:10 A. M and the dressing was reinforced. However, there was no documented evidence that the PGY1 Resident evaluated Patient #1. Chief Resident #2 was informed by the Surveyor that the nursing staff reported that multiple calls were placed and the PGY1 Resident did not come to evaluate Patient #1. Chief Resident #2 said the PGY1 Resident should have gone to PACU to evaluate Patient #1.

The PACU Registered Nurses did not follow the chain of command and notify a nursing supervisor that Patient #1 was not evaluated for bleeding after multiple text messages were sent to the surgical residents and no one responded.

Based on medical record review and physician interview, the resident physicians did not evaluate one of one Patients, Patient #1, who was bleeding at the surgical donor site harvested from the left thigh following a skin graft procedure on 01/20/12.

Findings include:

Background Information:
Review of the Operative Record indicated that Patient #1 was scheduled for a split thickness skin graft harvested from the donor site of the left anterior thigh to cover an open wound on the right lower leg. Patient #1 had an excision of a malignant melanoma located on the right lower leg on 12/30/11. There were two separate skin grafts taken covering the wound on the right lower leg. The donor site was covered with an (clear) Opsite dressing. Surgeon #1 indicated there were no operative complications.

The Surgeon was interviewed in person on 03/05/12 from 10:20 A.M. to 11:00 A.M. The Surgeon said Patient #1 had a non-specific bleeding disorder. The Surgeon said the Operating Room (OR) Nurse said that Patient #1's family said DDAVP should be administered to Patient #1 prior to surgery. DDAVP is a medication administered to patients who have certain bleeding disorders to prevent bleeding. The Surgeon said he made a professional judgment not to administer the DDAVP medication because the surgery was expected to be superficial without compromising any major blood vessels and done under local anesthesia. The Surgeon never ordered the medication DDAVP to be administered. The Surgeon said that there was no spontaneous bleeding during the surgery and it was surprising that Patient #1 started to bleed twelve hours after the surgery. The Surgeon said that Patient #1's bleeding disorder was not well characterized. The Surgeon acknowledged that retrospectively, the DDAVP should have been administered. The Surgeon said the treatment for bleeding is to apply a compression dressing, but skin grafts do not bleed. However, Patient #1 had bleeding at the donor site.

Review of the Archived Messages placed by the nursing staff from PACU to the PGY1 Resident indicated that the PACU RN sent a text message on 01/21/12 at 4:58 A.M., 5:44 A.M., 7:30 A.M, 7:40 A.M. and 9:00 A.M. to request that PGY1 Resident evaluate Patient #1.

PGY1 Resident was interviewed in person on 03/05/12 from 11:44 A.M. to 12:10 P.M. PGY1 Resident said that he was called by the nursing staff in PACU on 01/21/12 between 5 A.M. and 6 A.M. and he was informed there was oozing at the donor site. PGY1 Resident said he informed the nursing staff that he would be over to see Patient #1. However, PGY1 Resident never came to the PACU to evaluate Patient #1 for bleeding at the operative site.

Review of the Senior Resident Progress Note dated 01/21/12 at 9:30 A.M. indicated that the left thigh dressing had 300 to 400 cc's of blood and a clot. The Senior Resident indicated the dressing was removed and there was oozing from several points in the wound. A pressure dressing was applied.

Review of the Rapid Response Code Form dated 01/21/12 at 9:20 A.M. indicated Patient #1 became unresponsive with a sudden drop in blood pressure. Patient #1 responded to two chest compression and the administration of Neo-Synephrine drip to stabilize the blood pressure. Patient #1 was transferred into the Intensive Care Unit.