HospitalInspections.org

Based on medical record review and interview, in one (1) of six (6) medical records reviewed, it was determined the medical staff failed to diagnose and treat the cause of a patient's low platelet count. This was evident for Patient #1.

Findings include:

Review of medical record for Patient #1 identified the following: The patient was a 32-year-old patient who had a bone biopsy done in February of 2017 for low platelet count which was inadequate for bone marrow testing. The patient had a previous medical history of End Stage Renal Disease, Hypertension, Anemia and low levels of all types of blood cells. The patient received hemodialysis three (3) times each week and throughout the year, the patient continued to have low platelet counts (Thrombocytopenia). For example, on 7/19/17 the platelet count was 29 (normal range is 132 - 337).

On 11/3/17 the patient was admitted to the facility for hemodialysis and he reported fatigue, nausea and generalized body aches. The patient's platelet count was 35. The patient was dialyzed and at the end of the treatment at 2:36 PM, the Blood Pressure was 89/49 (normal blood pressure less than 120/80) and he was still lethargic. Fifteen minutes after the treatment the Blood Pressure was 91/44 but the patient signed out of the facility against medical advice at 3:30 PM that day.

The patient returned to the facility on 11/3/17 at 11:59 PM, with generalized fatigue and hypotension and he was admitted to the facility with a diagnosis of septic shock. Throughout the course of this hospitalization the patient's platelet count was as follows:
On 11/4/17 - platelet count was 53
On 11/7/17 - platelet count was 56
On 11/11/17 - platelet count was 35 and the patient was discharged home that day.

The patient returned to the facility on 11/12/17 and he stated, " I have been getting weaker for the past eight (8) months, I have no mobility, cannot get up and ambulate, they're carrying me everywhere."
On 11/12/17 - platelet count was 39,
On 11/13/17 - platelet count was 40,
On 11/20/17 - platelet count was 46.
The patient was discharged home at 2:52 PM on 11/24/17

There was no documented evidence that the patient was diagnosed and treated for low platelet count when it was noted on 7/19/17 and during inpatient admissions on 11/3/17 and 11/24/17.

On 11/24/17 at 4:40 PM, the patient returned to the facility with a complaint of bilateral hip and leg pain. He was diagnosed with a fracture of the right iliac bone. On 11/25/17 blood sample collected at 6:47 AM revealed: Platelet count - 58; Hemoglobin - 4.6 (normal range 13.3 - 17.0); Hematocrit - 15.2 (normal range 40.3 - 50.3). At 5:42 PM that day the platelet count was 45.

The hematology consult was ordered on 11/27/17 at 1:00 PM and performed on 11/27/17 at 3:19 PM.
At this time, the patient's family requested supportive care only due to the patient's deteriorating medical condition. The patient was pronounced dead at 6:15 PM on 11/28/17.

There was no documented evidence that the patient received timely diagnoses and treatment of his low platelet count.

During interview on 11/9/18 at 11:35 AM, Staff #A, Hematologist/Oncologist stated that he performed consultations on the patient on two (2) occasions, in February 2017 and on 11/27/17. He added that the bone biopsy that was done in February 2017 was unsuccessful. He acknowledged that he did not see the patient again until another consultation was requested on 11/27/17.

Based on document review and interview, it was determined that the hospital did not fully investigate all grievances received and did not ensure that the written responses addressed the outcome of the allegations.
This finding was evident in two (2) of three (3) grievance files reviewed. (Patient #2 & #3).

Findings include:

Review of hospital grievance files showed that on 1/27/18 the hospital received a letter from the wife of Patient #1, alleging several patient's rights violations. On 2/9/18, 2/15/18 & on 2/26/18, the hospital responded to the complainant; they thanked the patient's wife for her letter and apologized for not meeting her expectations.

There was no documented evidence the grievance filed by the patient's wife was investigated and the outcome of the investigation reported to the complainant.

Patient #3 wrote a letter to the hospital on 5/29/18 with allegations about the care she received during a visit on 5/22/18. On 6/4 and 6/12/18, the hospital acknowledged receipt of the letter and apologized for any miscommunication the patient received regarding her discharge instructions.

The record showed no evidence that the patient's allegations were investigated by the hospital and the outcome of the investigation reported to the patient.

The hospital policy and procedure titled "Patient Complaint and Grievances," last updated 11/16, states: " The written response to patient would include steps taken to investigate the complaint, the results of the process and the date of completion of the process."

During interview on 11/8/18 at 10:15AM, Staff D, Patient Advocate, confirmed findings. When she was asked about the outcome of the hospital investigation of complaints related to Patient #s 1 and 3, she stated that she did not know.

Based on document review and interview, the facility did not use the data it collected to identify opportunities to improve the quality of care and possible reduce the number of patients readmitted to the hospital.

Findings include:

Review of the hospital's performance improvement data for 2018 showed no documentation that re-admissions were reviewed and analyzed. The hospital recorded the number of re-admissions each month but did not present documented evidence that this information was reviewed or analyzed to identify areas for improvement.

Example:
The hospital established a goal of less than 10% for patient re-admission rate. Review of the data showed that the hospital's actual re-admission rate from October 2017 to July 2018 was between 11.6% to 12.3%.

There was no evidence that this data was reviewed or that a plan was developed to address the failure to decrease the facility's readmission rates.

During an interview on 11/09/18 at 1:35 PM, Staff C, Director of Case Management acknowledged findings.

Based on medical record review and interview, in one (1) of 10 medical records reviewed, it was determined the facility failed to develop an appropriate and safe discharge plan to address a patient's functional needs post discharge. This was evident for Patient #1.

Findings include:

Review of medical record #1 identified the following: The patient was admitted to the facility with complaints of generalized fatigue and hypotension on 11/4/17 and was diagnosed with septic shock. The patient had limited movement of his lower extremities, generalized weakness, generalized edema, 2+ edema (swelling) to his lower extremities and his speech was garbled on 11/11/17. The nursing staff was unable to assess the patient's gait throughout his hospitalization. At 7:41 AM that morning the patient required "maximum assistance, patient does 25 - 49 % with mobility." The patient was discharged home that day.

There was no evidence that assistive devices were arranged or provided to the patient when he was discharged on 11/11/17.

The patient returned to the facility on 11/12/17 and he "stated getting weaker for the past eight (8) months, has no mobility, cannot get up and ambulate, they're carrying me everywhere."

A Case Manager documented on 11/16/17, "12 steps to his room - live on first floor. Hospital bed, commode and rolling walker." Throughout the patient's hospitalization, the staff documented that the patient required assistance with mobilization and that the patient used a rolling walker.

Documentation on 11/23/17 at 8:04 AM revealed the patient was at a high risk for fall with a score of 60 on the Morse Fall risk scale (high risk is greater than or equal to 45). Patient required contact guard assist and steadying assist, and that the patient used a front wheel walker for mobilization. This assessment also noted the patient had limited movement in his lower extremities. At 2:52 PM on 11/24/17 the patient was discharged home.

There was no documented evidence that the patient received a safe discharge including the provision of assistive devices which were necessary for mobilization before he was discharged home on 11/24/17.

The patient returned to the hospital approximately two (2) hours after his discharge and was diagnosed with a fractured hip after he had fallen while attempting to get into his home.

These findings were shared with Staff B, the Director of Accreditation & Regulatory Compliance Quality Services on 11/9/18 at 3:30 PM.