HospitalInspections.org

Based on hospital policy review, grievance review, incident report review, medical record review, and staff interviews the hospital failed to ensure tracking of patient safety events by failing to document and complete an incident report for 1 of 1 sampled patient. (Patient #2)

Review on 06/28/2023 of the hospital policy Quality Assessment Report, last revised 08/29/2022 revealed " ...I. SCOPE/PURPOSE This policy/procedure describes the process to report incidents involving patients, visitors, and vendors, which occur in any (named) entity. It is the responsibility of all team members including medical staff to report incidents in the electronic incident reporting system (e-RL). Incidents include actual events that reach a patient, as well as near-miss events. II. Policy ...Any unexpected incident should be reported to the chain of command. If the incident meets the criteria a Quality Assessment Report is completed. III. QUALIFIED PERSONNEL All team members ...V. PROCEDURE A. General Guidelines. Incidents are to be entered into the electronic reporting system (e-RL) within 24 hours of occurrence or when a team member becomes aware of the event ...VII. DEFINITIONS Incident- Any happening that is not consistent with the routine care of a particular patient or an event that is not consistent with the normal operations of the organization ..."

Review of the grievance on 06/28/23 submitted by Patient #2 on 12/22/2022: "...Before drawing blood nurse (Named RN) used a tourniquet to tie off his arm, then drew blood ...and gave steroids (medication for allergic reaction) and Benadryl (medication for allergic reaction) ...After being brought to radiology Patient and team member noticed tourniquet was still on. Patient was not checked for hours after CT ... and his hand was still discolored, has pain in his left arm. [sic] Follow up heart vascular who stated he now has some blood clots in his left arm, and it was recommended he take aspirin long-term ..." [sic] Follow up actions: By MD #1: "...patient had extensive testing including ultrasounds, CT scans to evaluate blood clots. The patient did have a small superficial blood clot near his ankle. He reported bleeding ulcers, we spent a long-time discussing risks, benefits, and alternatives. I personally consulted the vascular cardiologist on call who recommended only warm compresses with no NSAIDS (anti-inflammatory) or blood thinners...Before leaving the room I said 'Are we good? And the Patient replied pristine' ...finally I arranged for the Charge Nurse (named) to speak to the patient about his nursing concerns..." Follow up Actions by the ED Charge Nurse, RN #6: "...the patient realized the tourniquet was still tied on his left upper bicep. The patient said this was witnessed by the transporter and his wife. Also took a photo, it was obvious that something was tight had been on the arm due to the red mark around the bicep ...." Follow up action by ED Nurse Manager, RN #7: Interview with RN #2 revealed he was "methodical and communicated every step he took with the patient including everything he did involving the IV and IV medications ...(Named RN #2) says he did not leave the tourniquet on the patient, however the transport team member mentioned to his manager that he did remember a tourniquet present on the patient ..." 1/13/2023 "Sub-type: Inconclusive: could not substantiate or unsubstantiate."

Request on 06/28/2023 to review the incident report for events on 12/17/2023 relayed by Patient #2 revealed there was not one.

Closed medical record review on 06/27/2023 revealed Patient #2, a 43-year-old-male patient who presented to the emergency department (ED) on 12/17/2022 at 0832 for Right Leg Pain. Review of the ED Provider Notes 12/17/2022 at 0902 by Medical Doctor (MD) #1 included a " ...history of a clotting disorder* ...", allergy to contrast (iodinated diagnostic agents) causing hives (rash) and complained with pain and tenderness along a right lower leg/ankle superficial vein that started the day before, a headache and chest pains. At 0915 a CT (Computed Tomography Scan) of Angio Chest (2-dimensional imaging requiring IV (intravenous) contrast to rule out a pulmonary embolus-blood clot in the lung) was ordered by MD #1. At 0941 a peripheral intravenous (IV) was started in the left antecubital (inside arm at the elbow) by Registered Nurse (RN) #3 without complications. Patient #2 was treated and monitored awaiting the Scan. At 1132 RN #2 was assigned to Patient #2. At 1357 RN #2 drew the 3rd troponin (lab test to show heart muscle damage) and at 1358 gave Patient #2 medications Solu-Cortef (steroid-can be used to lesson allergic reaction) 200 milligrams (mg) and Benadryl (antihistamine-can be used to lesson allergic reaction) 50 mg, both intravenously per order via MD #1. At 1442 Patient #2 was transported to radiology for the scan by Transporter #5. At 1449 the CT Angio Chest began and was completed at 1518. At 1519 Patient #2 arrived back to the ED. At 1520 RN #2 ended IV fluids bolus and was marked completed and at 1537 CT Angio Chest resulted as negative for Pulmonary Embolus. At 1551 Patient #2 had a reassessment by RN #2 with vital signs: heart rate 78, Respirations 20, blood pressure 141/78 and oxygen at 98% on room air, pain score 0. At 1643 Disposition was set to discharge by MD #1. Review of the ED Patient Care Timeline revealed 1657 through 1751 MD #1 was at the bedside with Patient #2. At 1909 on 12/17/2022 Patient #2 was discharged home with family. Review of the medical record failed to reveal an incident with Patient #2's tourniquet in the ED on 12/17/2022.

Interview on 06/28/2023 at 1400 with ED Charge Nurse, RN #6 " ...I just remember being asked to take the patient's statement. I just listened to his concerns, apologized for what they felt had happened ...and told them (named ED Nurse Manager, RN #7) would follow up with them ...This should have been an incident report ..." Interview revealed RN #6 should have completed an incident report after learning Patient #2 concerns. Interview revealed hospital policy was not followed for completing an incident report for Patient #2.

Telephone interview on 06/28/2023 at 1525 with Transporter #5 revealed " ...I knocked on the door 'transport' and I went to scan his wrist band and the patient noticed a band on his arm, a tourniquet-beige color, the patient removed it. I asked him if he wanted me to get the nurse and he said 'no'. When I returned the patient to his room, I told the nurse the patient was not happy, and about the situation and he said 'ok, thank you' ...My supervisor did call me and ask me about it, and I told him ..." Transporter #5 alerted the nurse on his return with the patient to the unit however could not identify who he spoke too. Interview revealed Transporter #5 did not complete an incident report. Interview revealed hospital policy was not followed for completing an incident report for Patient #2.

Interview on 06/29/2023 at 1406 with Chief Nursing Officer, RN #9 revealed the expectation for completing an incident report was to follow the policy. " ...Any unusual occurrence. An e-RL was not punitive, but open and welcome to complete. We talk about it every-day ..." The ED Charge Nurse, RN #6 "could have completed the e-RL for Patient #2's unusual finding and escalated up to her supervisor ..." Interview revealed hospital policy was not followed for completing an incident report for Patient #2.

NC 00197548