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Based on record review and staff interview, the Hospital failed to ensure the Registered Nurse supervised and evaluated the nursing care for each patient as evidenced by:
1) Failing to notify the physician of the patient's refusal of sliding scale insulin and administration of the insulin dose requested by the patient for 1 of 1 (#3) sampled patients reviewed for sliding scale insulin administration out of a total sample of 5 (#1-#5), and;
2) Failing to obtain physician orders for arterial blood gas analysis for 1 of 1 (#3) sampled patients reviewed for post-operative complications out of a total sample of 5 (#1-#5).

Findings:

1) Failing to notify the physician of the patient's refusal of sliding scale insulin and administration of the insulin dose requested by the patient:

Review of the Hospital policy titled, Medication Administration, policy number MM-070, revealed in part the following:
6. Always give the exact dosage ordered; if the nurse feels that the patient may achieve the same benefit from a reduced dose of the medication, the nurse must consult the physician and obtain a new order prior to administration.

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 65 year old admitted to the hospital on 11/22/16 for a Laparoscopic Gastric Sleeve procedure. The record revealed the patient was transferred to a higher level of care on 11/23/16 at 9:00 p.m. for pulmonology evaluation.

Review of the physician orders dated 11/22/16 at 11:57 a.m. revealed a Sliding Scale Insulin administration was ordered for the patient every 6 hours.

Review of the nurse's notes dated 11/22/16 at 6:39 p.m., documented by S9RN, revealed the following: Accucheck is 256. Per protocol, patient to have 6 units of regular insulin. Per patient request, patient given 3 units. Further review of the record revealed no documented evidence that the physician was notified of the patient's refusal of the prescribed dose of insulin, nor was the physician informed of the administration of a dose less than prescribed.

In an interview on 12/05/16 at 4:17 p.m., S1DON stated she spoke with S9RN and S9RN confirmed she did not notify the physician of the patient ' s refusal of the insulin sliding scale. S1DON stated S9RN indicated the patient refused the full dose because she was on liquids. S1DON confirmed the sliding scale insulin was ordered for 6 units to be administered for an Accucheck blood sugar of 256.


2) Failing to obtain physician orders for arterial blood gas analysis:
Patient #3
Review of the medical record for Patient #3 revealed the patient was a 65 year old admitted to the hospital on 11/22/16 for a Laparoscopic Gastric Sleeve procedure. The record revealed the patient was transferred to a higher level of care on 11/23/16 at 9:00 p.m. for pulmonology evaluation.
Review of the medical record revealed arterial blood gas results dated 11/23/16 at 5:46 p.m. Further review of the physician orders revealed no documented evidence of a physician's order for the blood gases.

In an interview on 12/07/16 at 10:28 a.m., S5RN stated she remembered Patient #3 and she was assigned to the patient on the day the patient was transferred. S5RN stated she was worried about the patient. S5RN stated the patient was very active in the early part of day, but became weaker and she had to stimulate the patient to follow commands. S5RN stated she then obtained arterial blood gases. When asked if the blood gases were ordered by the physician, she stated S10MD had told the nursing staff that if they were concerned about the patient's condition they can draw blood gases or do Accuchecks. S5RN confirmed she had not obtained a physician's order for the blood gases. S5RN stated she called S6MD (Surgeon) with the results of the arterial blood gases and stated he asked her to call nephrology. She stated she then called the nephrologist and reported the patient's lethargy and blood gas results.

Based on record review and staff interview, the Hospital failed to ensure the medical record contained information to support the patient's progress and response to medications and services as evidenced by failing to document physician progress notes when the patient's condition declined and required transfer to a higher level of care, and failing to update the discharge summary after the patient was transferred for 1 (#3) of 2 (#1, #2) sampled patients reviewed for transfers out of a total sample of 5 (#1-#5). Findings:

Review of the Hospital's Medical Staff Rules and Regulations dated 09/12/16 revealed in part the following:
Inpatient Medical Records shall include the following....progress notes made by the Medical Staff and other personnel authorized to make entries into the patient's medical record, clinical observations, including the result of therapy, consultation reports, conclusions at termination of hospitalization, clinical resumes and discharge summaries....
7. Progress Notes: Pertinent progress notes sufficient to permit continuity of care and transferability shall be authored or countersigned by a member of the Medical Staff....Pertinent progress notes shall be written at least daily on all patients, more frequently as dictated by clinical course and should include subjective complaints, objective findings, clinical assessment and therapeutic plans.
9. Consults: Consultations shall show evidence of a review of the patient's record by the consultant, pertinent findings on examination of the patient, the consultant's opinion and recommendations. This report shall be made a part of the patient's record....
12. Discharge Summary: A discharge summary (clinical resume) shall be recorded or dictated on all medical records and concisely recapitulate the reason for the hospitalization....condition on discharge and final diagnosis....

Review of the Hospital policy titled, Emergency Medical Transfer, policy number PC-540, revealed in part the following: The transferring physician and nurse will complete documentation of the medical record.


Patient #3
Review of the medical record for Patient #3 revealed the patient was a 65 year old admitted to the hospital on 11/22/16 for a Laparoscopic Gastric Sleeve procedure. The record revealed the patient was transferred to a higher level of care on 11/23/16 at 9:00 p.m. for pulmonology evaluation.

Review of the Stabilize and Transfer Assessment form revealed the reason for transfer was documented as, "Need for Pulmonology" and the benefits of transfer were, "Higher Level of Care." Review of the form revealed the form was documented and signed by S5RN and S11RN.


Review of the physician orders dated 11/23/16 at 5:30 p.m. revealed, "Transfer patient to Hospital "A" ICU per verbal order S6MD/S10MD/S4RN. Diagnosis: Metabolic Acidosis, Acute Renal Failure accepting physician S12MD, verbal order S10MD/S4RN."


Review of the nursing documentation by S5RN revealed the following:
11/23/16 at 11:00 a.m. - Creatinine and Potassium: S6MD (Surgeon) aware of Creatinine and Potassium. Medical management consulted-S10MD (Hospitalist) ordered 60 Grams of Kayexalate PO and consulted Nephrology. S8MD (Nephrologist) aware and ordered for patient to receive potassium shifting regimen. Calcium gluconate not available at this time but should be received in approximately 1 hour.
11/23/16 at 11:30 a.m. - Foley: order for Foley obtained from S6MD as patient has not yet voided and her creatinine and potassium are elevated.
11/23/16 at 5:30 p.m. - ABG results/transfer: S6MD aware that patient is becoming confused and is becoming lethargic. Aware of ABG results. S8MD also aware and Bicarb Drip ordered. Decision made to transfer patient to a different hospital due to decreasing pH with the potential to need a higher level of care and possible intubation for unstable pH (No pulmonologist available at this hospital).


Review of the nephrology consult documented by S8MD revealed the following:
11/23/16 at 3:00 p.m. - Renal Consult:
Patient #3 is a 65 year old female with Stage V CKD who had a gastric sleeve, am labs showed worsening kidney function, hyperkalemia, acidosis. Had been getting LR. Foley placed - made 300 cc urine.
1) AKI, Stage V CKD
2) Hyperkalemia
3) Metabolic Acidosis
4) Urinary Retention
Plan:
Stop LR. Will medically manage K (Kayexalate, insulin/D50, NS @ 75 cc/hr) - no calcium gluconate available in pharmacy.
Check BMP 4 hours and am
With Foley; strict I & O
If no improvement in labs in am will begin dialysis - if requires dialysis, will be ESRD
No NSAIDS/IV contrast
Needs telemetry - on remote telemetry.

Review of the Discharge Summary dated 11/23/16 at 6:50 a.m., and signed by S6MD revealed the following:
Clinical course/findings: Doing well, tolerating PO well, ambulating minimally - poor effort (Unfortunately not unexpected), understands home needs, ok for discharge home today if urinating well, may need discharge home with Foley and leg bag. Will need sliding scale at home, discussed.
Discharge date: 11/23/16.
Condition at Discharge: Stable.
Review of the discharge summary revealed the only laboratory test included in the summary was the results of a CBC dated 11/23/16 at 4:30 a.m.

There was no documented evidence in the progress notes of the need to transfer the patient.
There was no documented evidence of a consult done by S10MD (Hospitalist).
The discharge summary/progress notes were not updated with the patient's change in condition requiring transfer to a higher level of care.

In an interview on 12/06/16 at 9:50 a.m., S2RM reviewed the electronic medical record and stated S10MD gave a couple of telephone orders for Patient #3 but never saw the patient. She confirmed there was no documented evidence of a consult or progress note documented by S10MD.

In an interview on 12/06/16 at 10:12 a.m., S1DON confirmed the discharge summary was dictated by S6MD the morning the patient was transferred and prior to receiving of the patient's BMP lab results. She confirmed she did not see another discharge summary in the EMR and confirmed the one in the record was inaccurate. S1DON stated S10MD was consulted at 12:12 p.m. as per verbal order from S6MD. She stated S6MD and S10MD gave verbal orders to transfer the patient. S1DON stated S10MD was their hospitalist and managed medical problems of the patients. S1DON confirmed no physician came in and evaluated Patient #3 prior to the transfer. S1DON confirmed the only notes documented by the physicians post-operatively on the patient's record were the operative note, the discharge summary, and the nephrology consult. S1DON confirmed there was no physician documentation in the patient's record regarding the decline in the patient's condition that warranted transfer to a higher level of care.

On 12/06/16 at 10:49 a.m. a telephone interview was conducted with S6MD. S6MD confirmed he remembered Patient #3 and confirmed he had documented the discharge summary when he made rounds on 11/23/16. S6MD confirmed he had not documented a progress not or revised the discharge summary and stated he was in the process of doing that.

Based on record review and staff interview, the Hospital failed to ensure a completed medical history and physical examination was documented and placed in the patient's medical record no more than 30 days before admission and prior to surgery as evidenced by failing to include the patient's Chronic Kidney Disease in the patient's history and physical (H&P) for 1 (#3) of 5 (#1-#5) sampled patients.
Findings:

Review of the Medical Staff Rules and Regulations, dated 09/12/16 revealed in part the following: An adequate and legible history and physical exam shall be completed and recorded prior to any surgery or procedure requiring anesthesia or moderate sedation but in all events within twenty-four (24) hours after a patient is admitted or registered for inpatient care. The minimum components of the H&P shall be chief complaint, history of present illness, past medical history, past surgical history, allergies, review of systems, medications, physical exam and plan of care.


Review of the Hospital's policy titled, History and Physical, policy number IM-040, revealed in part the following: An adequate and legible History and Physical examination (H&P) will be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services....The minimum components of the H&P shall be chief complaint, history of present illness, past medical history, past surgical history, review of systems, medications, physical exam and plan of care.

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 65 year old admitted to the hospital on 11/22/16 for a Laparoscopic Gastric Sleeve procedure. The record revealed the patient was transferred to a higher level of care on 11/23/16 at 9:00 p.m. for pulmonology evaluation.

Review of the patient's record revealed an H&P dated 11/16/16 at 1:00 p.m. that included a faxed date/time of 11/16/16 at 2:02 p.m. from S6MD's office. The H&P revealed the patient was seen by S6MD on 11/16/16. Review of the H&P revealed the patient's "Significant Medical History" included only the following: Hypertension, Gastro-Esophageal Reflux Disease, and Type II Diabetes with Neuropathy. There was no documented evidence that the patient had Chronic Kidney Disease and was currently being followed by a nephrologist. Further review of the medical record revealed laboratory results were faxed from the office of S6MD on the same date/time as the H&P. Review of the faxed laboratory results revealed the following results dated 10/03/16:
BUN (Blood Urea Nitrogen-evaluates kidney function) - 72, normal range is 7-18 mg/dl.
Creatinine (Evaluates kidney function) - 3.40, normal range is 0.60-1.20 mg/dl.
Estimated GFR (Glomerular Filtration Rate-evaluates how well kidneys are filtering) - 14, normal range is 60-120 ml/min.

Review of the Registered Dietician notes faxed from the office of S6MD revealed a note dated 05/09/16 that revealed the patient had a diagnosis of Chronic Renal Disease and was on renal vitamins. The note also revealed the patient was unable to take Ibuprofen and Naproxen because of her kidney problems.

In an interview on 12/05/16 at 2:40 p.m., S1DON confirmed the dietary notes from the physician's office indicated the patient had Chronic Renal Insufficiency and the patient was on renal vitamins. S1DON stated one of the notes indicated the patient did not take Ibuprofen because of kidney problems. S1DON stated she had reviewed the patient's record because the patient was a transfer for a higher level of care. S1DON confirmed the patient's renal disease was not included in the H&P.

In a telephone interview on 12/06/16 at 10:49 a.m., S6MD stated he remembered Patient #3. S6MD stated the patient was followed by a nephrologist and had a Primary Care Physician (PCP). S6MD stated he spoke with one of her physicians about her kidney disease but he did not remember which one. He confirmed he had not documented the patient's kidney disease in his H&P. He stated he believed he had consulted the patient's nephrologist but it may have been the patient's PCP. S6MD stated he could have done a better job of documentation on the H&P to include the patient's renal disease. S6MD stated the patients kidney disease was certainly part of her medical history. He stated the patient's nephrologist or primary care physician had indicated dialysis was impending for the patient.

Based on record reviews and interviews, the hospital failed to ensure medical records included a properly executed informed consent for surgical procedures as evidenced by:
1) Failing to include the patient's Chronic Kidney Disease and the material risks a surgical procedure may pose to that condition for 1 (#3) of 4 (#2-#5) sampled patient records reviewed for surgical consents out of a total sample of 5 (#1-#5), and;
2) Failing to include the type of anesthesia and the risks/complications related to that type of anesthesia on the anesthesia consent for 1 (#2) of 4 (#2-#5) patients reviewed for consents out of a total sample of 5 (#1-#5).

Findings:

1) Failing to include the patient's Chronic Kidney Disease and the material risks a surgical procedure may pose to that condition:

Review of the Hospital policy titled, Consent and Disclosure, policy number RI-020, revealed in part the following:
It is the responsibility of the physician/performing healthcare provider actually performing the procedure to obtain the patient's informed consent to the procedure. The physician/performing healthcare provider is required to inform the patient of the nature and purpose of the procedure, the material risks associated with the procedure, any reasonable alternative to the procedure, and the risks associated with such alternatives.
A properly executed informed consent form contains at least the following: Risks....

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 65 year old admitted to the hospital on 11/22/16 for a Laparoscopic Gastric Sleeve procedure.
Review of the medical record revealed the patient required a nephrology consult on 11/23/16 after the patient's laboratory test results on 11/23/16 revealed the patient had a BUN of 57, Creatinine of 6.40, and a Potassium level of 6.3.
Review of the nephrology consult dated 11/23/16 at 3:00 p.m. revealed the following: Patient #3 is a 65 year old with Stage V CKD....AM labs showed worsening kidney function, hyperkalemia (elevated potassium), and acidosis....If no improvement in labs in AM, will begin dialysis-if requires dialysis with be ESRD (End Stage Renal Disease)....
The record revealed the patient was transferred to a higher level of care on 11/23/16 at 9:00 p.m. for pulmonology evaluation.

Further review of the patient's record revealed the pre-operative laboratory results and the pre-operative dietary notes revealed the patient had a diagnosis of Chronic Renal Disease.

Review of the Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information dated 11/16/16 revealed no documented evidence that the patient's kidney disease or the risk of worsening kidney disease and dialysis was included in the informed consent.

In a telephone interview on 12/06/16 at 10:49 a.m. S6MD (Surgeon) confirmed he remembered Patient #3. He stated the patient was followed by a nephrologist and had a PCP. He stated he spoke with one of her physicians about her kidney disease but he did not remember which one. He confirmed he had not documented the patient ' s kidney disease in his H&P. He stated he believed he had consulted the patient ' s nephrologist but it may have been the patient ' s PCP. S6MD stated the patients CKD was certainly part of her medical history. He stated her nephrologist/PCP had indicated dialysis was impending for the patient. He stated he had discussed the risks with the patient ' s physician and with the patient and the patient agreed to the procedure.

In an interview on 12/07/16 at 12:45 p.m., S2RM reviewed the patient ' s consent for surgery and confirmed there was no documentation in the consent that indicated the patient had renal disease or the risks surgery could pose related to her renal disease including worsening of that condition.


2) Failing to include the type of anesthesia and the risks/complications related to that type of anesthesia on the anesthesia consent:

Review of the Hospital policy titled, Consent and Disclosure, policy number RI-020, revealed in part the following:
Instances requiring informed consent include but are not limited to:...Anesthesia.
K. Anesthesia Consent:
1. The physician/performing healthcare provider remains obligated and responsible to obtain an informed consent for anesthesia....
2. Material risks for anesthesia should be disclosed.


Patient #2
Review of the medical record for Patient #2 revealed the patient was a 37 year old admitted on 11/22/16 for a Laparoscopic Gastric Sleeve procedure. The record revealed the patient was discharged on 11/23/16 at 10:12 a.m. to home.
Review of the Anesthesia Consent dated 11/22/16 revealed no documented evidence of the type of anesthesia that was going to be used and there were no risks for the specific type of anesthesia was not documented.

Review of the Anesthesia Record dated 11/22/16 revealed the patient received general anesthesia.

In an interview on 12/06/16 at 2:30 p.m., S1DON reviewed the patient's medical record and confirmed the anesthetist failed to indicate the type of anesthesia or the risks and complications of the anesthesia. She stated the anesthesiologist or anesthetist usually circle the type of anesthesia which includes the specific risks associated with that type of anesthesia.

Based on record review and staff interview, the Hospital failed to ensure a post-anesthesia evaluation was completed and documented by a practitioner qualified to administer anesthesia that included an assessment of respiratory function, cardiovascular function, mental status, temperature, pain, nausea and vomiting and postoperative hydration for 2 (#2, #3) of 4 (#2-#5) sampled patients that received general anesthesia out of a total sample of 5 (#1-#5).

Findings:

Review of the Medical Staff Rules and Regulations, dated 09/12/16, revealed in part the following: 4. Anesthesia: The anesthesiologist or the anesthetist shall maintain a complete anesthesia record to include evidence of pre-anesthetic evaluation and post-anesthetic follow-up of the patient's condition.

Review of the Hospital's Anesthesia policies and procedures revealed no documented evidence of any provisions for the post-anesthesia evaluation performed by the anesthesiologist or the anesthetist.

Patient #2
Review of the medical record for Patient #2 revealed the patient was a 37 year old admitted on 11/22/16 for a Laparoscopic Gastric Sleeve procedure. The record revealed the patient was discharged on 11/23/16 at 10:12 a.m. to home.

Review of the anesthesia record revealed the only documentation by the anesthesiologist post anesthesia was as follows:
Recovery 11/22/16 at 9:35 a.m. - "Patient released from recovery" was checked.
Postoperative 11/22/16 at 10:40 a.m. - "No apparent anesthetic complications by patient or surgeon" was checked. There was no documented evidence of any other post anesthesia evaluation documented by the anesthesiologist. Review of the anesthesia record revealed the above sections were signed by S7MD (Anesthesiologist).
Further review of the anesthesia record revealed the section titled, "Recovery" included a check box for, "Patient sufficiently recovered from anesthesia. Respiratory Function, Cardiovascular Function, Mental Status, Temperature, Pain, Nausea & Vomiting, Post-Operative Hydration evaluated." This section was not checked by the anesthesiologist.

In an interview on 12/06/16 at 2:30 p.m., S1DON reviewed the anesthesia record for Patient #2 and confirmed the anesthesiologist had not documented a post-anesthesia assessment of the patient's respiratory function, cardiovascular function, mental status, temperature, pain, nausea and vomiting or postoperative hydration.


Patient #3
Review of the medical record for Patient #3 revealed the patient was a 65 year old admitted to the hospital on 11/22/16 for a Laparoscopic Gastric Sleeve procedure. The record revealed the patient was transferred to a higher level of care on 11/23/16 at 9:00 p.m. for pulmonology evaluation.

Review of the anesthesia record revealed the only documentation by the anesthesiologist post-anesthesia was as follows:
Recovery 11/22/16 at 1:20 p.m. - "Patient released from recovery" was checked.
Postoperative 11/22/16 at 5:00 p.m. - "No apparent anesthetic complications by patient or surgeon" was checked. There was no documented evidence of any other post anesthesia evaluation documented by the anesthesiologist. Review of the anesthesia record revealed the above sections were signed by S7MD (Anesthesiologist).
Further review of the anesthesia record revealed the section titled, "Recovery" included a check box for, "Patient sufficiently recovered from anesthesia. Respiratory Function, Cardiovascular Function, Mental Status, Temperature, Pain, Nausea & Vomiting, Post-Operative Hydration evaluated." This section was not checked by the anesthesiologist.

In an interview on 12/07/16 at 9:20 a.m., S7MD (Anesthesiologist) reviewed the medical record for Patient #3 and confirmed he had only checked the boxes indicating, "Patient released from recovery, and No apparent anesthetic complications by patient or surgeon." When asked about an assessment of the patient's Respiratory Function, Cardiovascular Function, Mental Status, Temperature, Pain, Nausea & Vomiting, and Post-Operative Hydration, he stated if the nurse's report nausea or vomiting, pain, or respiratory problem, he addressed the problem. S7MD confirmed he had not documented any other post-anesthesia evaluation of the patient.

In an interview on 12/07/16 at 11:07 a.m., S1DON stated they added the section for the anesthesiologist to check off the post-anesthesia evaluation on the form to make it easier for the physicians. She confirmed S7MD did not use the check off or document a post-anesthesia evaluation of the patient anywhere else in the record. She stated she spoke with him about this and informed him it was required. S1DON also confirmed the Hospital's policies and procedures did not include provisions for the post-anesthesia evaluation of the patient by the anesthesiologist or anesthetist.