HospitalInspections.org

Based on facility bylaws, record review and interviews, the facility's medical staff failed to provide adequate quality of care and treatment to 2 (Patient 1 and Patient 2) of 6 patients reviewed. Failure of responsibility to provide adequate quality of care caused a delay in treatment and transfer to a higher level of care resulting in death.

Findings included:

Review of facility bylaws revealed reassessments across all disciplines is ongoing and occurs at designated intervals during the patient's stay/treatment to determine the response to and effectiveness of certain care, treatment and services received. When there is a significant change in the patient's condition, a full reassessment is performed.

Review of Patient #1's medical record revealed on 09/19/2024 patient was experiencing shortness of breath, elevated heart rate and low blood pressure. At 11:00 AM Staff J, ARNP (Advanced Registered Nurse Practitioner) notified Staff K, MD (Medical Doctor) with concerns of the change in patient status and the need to transfer to an ER (Emergency Room). There is no documentation Staff K, MD assessed the patient until 5 hours later just prior to the patient transferring to the ER.

Review of Patient #1's medical record on 09/19/2024 from Lakeland Regional Hospital revealed patient was transferred there from Encompass Rehab for shortness of breath that started earlier that morning. At 5:20 PM ER MD ordered D Dimer (D-dimer test is a blood test that checks for blood-clotting problems. It measures the amount of D-dimer, a protein your body makes to break down blood clots. A positive test means the D-dimer level in your body is higher than normal. It suggests you might have a blood clot or blood clotting problems.) and CTA (Computed Tomography Angiography scan that uses 3D images to diagnose pulmonary embolism). D Dimer resulted 1136 (normal 0-243) and CTA was not performed due to patient going unresponsive. CRP was started (cardiopulmonary resuscitation) and patient expired at 7:17 PM.

Review of Patient #2's medical record revealed on 09/18/2024 the patient had a vasovagal event (a type of fainting that occurs when the body overreacts to certain triggers, causing a sudden drop in blood pressure and heart rate) and change in mental status. At 1:00pm Staff M, ARNP notified Staff L, MD with concerns of the change in condition and needed to be transferred to the ER. Then at 5:02pm Staff L, MD documented the staff and wife are concerned about the change of mental status. I anticipate discharge in 10days. No documentation supports Staff L, MD addressed the change in condition. At 6:50 PM the patient was transferred to Lakeland Regional Hopsital and expired in route with EMS (Emergency Medical Services)

During an interview on 10/01/2024 at 11:05 AM, Staff J, ARNP stated around 9:00 AM I went to see Patient #1 immediately and saw his heart rate was 115-120's [beats per minute](normal is 60-100 beats per minute) and his O2 (oxygen level) saturation was in the low 90's (normal is 95-100%). Around 11:00 AM I called Staff K, MD right after I assessed the patient and said I'm concerned about him; I think he may be experiencing a PE (Pulmonary Embolism. A pulmonary embolism is a serious condition that occurs when a blood clot blocks an artery in the lungs, preventing blood flow.) and he needs to be transferred to the ER. Staff K, MD gave me push back about transferring the patient to the ER and wanted to wait.

During an interview on 10/01/2024 at 2:52 PM, Staff K, MD stated I rounded on Patient #1, and it was reported to me that his blood pressure was running low. I thought since the patient was in bed for a long time that was the reason for his low blood pressure. Then around 4:00 PM, Staff J, ARNP called me stating the patient was not doing well and he needed to be transferred out. I then went to see the patient and he had O2 2L (2 Liters) on and his saturation was 94%. I said ok, lets send him out. I did not reassess the patient prior to 4:00 PM.

During an interview on 09/30/2024 at 12:00 PM Staff A, Risk Manager stated per protocol the physician should have seen Patient #2 after Staff M, ARNP reported the change in condition. There is no documentation supporting Staff L, MD went to reassess the patient; only documentation noted from Staff L, MD is 4 hours later.

During a discussion on 10/01/2024 at 3:30 PM Staff B, CEO asked, even if a patient is a DNR (Do Not Resusitate), we should still transfer the patient out?

During an interview on 10/01/2024 at 10:24 AM Staff L, MD after long pause and sigh stated "Yes, administration does have an influence on my judgement when it comes to transferring patients out to the ER; the ACT (Acute Care Transfers) rates are really high right now and they want us to really try to utilize all the resources here to make sure the transfer is really necessary.