HospitalInspections.org

Based on interview and record review, the facility failed to inform 2 (P-1, P-3) of 3 patients or patient representatives/durable power of attorney (DPOA) of 1) findings on a computerized tomography scan (CT scan) and 2) an incident resulting in denial of the patient/patient representative's right to be informed of changes and make decisions in the patient's plan of care. Findings include:

1) On 4/23/2024 at 1241, review of the medical record for P-1 revealed she was a 72-year-old female who presented to the Emergency Department (ED) on 8/5/2023 at 0735 after being hit in the head by the trunk of her car the day before. She denied loss of consciousness and denied being on blood thinners. A CT of the head without contrast was obtained. Radiologist Staff P read the scan as being negative. The negative findings were communicated to the patient by the ED physician and she was discharged home.

Further review of the medical record revealed P-1 returned to the ED on 10/26/2023 at 1304 with a chief complaint of left forehead numbness, headache, and left eye tingling for the past 3 days. The patient stated she had increased stress at work that ended with termination the day before. A CT of the head and neck with contrast was ordered. Results indicated there was an "extra-axial lesion overlying the right frontal convexities measuring up to 1.2 cm (centimeters) most likely a meningioma (a usually non-cancerous tumor that arises from the membranes surrounding the brain and spinal cord) not significantly changed from 8/5/2023."

ED physician notes dated 10/26/2023 stated, "I discussed her imaging with her particularly emphasized the meningioma. Patient states that she was not made aware that she had a meningioma on imaging back in August."

On 4/24/2024 at 0923, Radiologist Staff P, who read the CT on 8/5/2023, stated during interview he had the opportunity to look at the CT imaging from both 8/5/2023 and 10/26/2023 and stated he agreed with both reports. Staff P explained that a CT of the head without contrast was the most common CT that was done, and its purpose was a "stat study." Approximately 1000 images were obtained during the scan. The purpose was to look for major concerns such a bleeding, fractures, or trauma - anything that would require immediate surgical intervention. The images were read and reported quickly, in this case, within 10 minutes of the scan being done.

Staff P further explained that the study on 10/26/2023 was a different study with a completely different reason. He stated there were approximately 5000 images obtained with this study and the contrast helped to clarify the images causing the sensitivity to be higher for picking up lesions that may be present. In this case, there was a "very tiny" 1.2 cm lesion along the skull. Staff P stated it was normally very difficult to identify abnormalities close to the skull; however, once identified, he went back and looked at the 8/5/2023 CT images without contrast and was able to see that it was present.


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2) On 4/23/2024 at 1500 an interview was conducted with staff V, resident of internal medicine. Staff V was queried if he had been the staff member to inform the family of the incident of the fall. Staff V stated, "I'm not sure if I was the first person to let them know... they (family) acted as though they were already told ...I ' m not sure."

On 4/23/2024 at 1545 an interview was conducted with staff W, attending of internal medicine. Staff W was queried if she had been the staff member to inform the family of the incident of the fall. Staff W responded, "No... I think they already were aware of the fall. We receive report in the morning from the night shift physician ' s. I am not sure if they called the family or not."

On 4/24/2024 at 1340 an interview was conducted with staff KK, Internal Medicine resident who was working the night of P-3 fall. Staff KK was queried if she was the physician who was stated to be responsible for calling the family of P-3 to inform the family of P-3 fall. Staff KK stated that it was the attending who was supposed to call the family.

Staff LL, attending physician on the night of 12/19/2023 was unable to be reached for interview prior to the end of survey on 4/24/2024.

Staff Y, the house supervisor on the night of 12/19/2023 was unable to be reached for interview prior to the end of survey on 4/24/2024.

Record review occurred on 4/23/2024 of the policy titled, "Disclosure of Unanticipated Events," dated 9/28/2021, policy number 9930892. The policy states, "When a serious unanticipated outcome occurs, including one that may be caused by system(s) failures(s), the patient and, as appropriate, the family will receive timely, transparent, and clear communication concerning what is known about the event... Any care provider in any setting, including but not limited to staff physicians, house officers, and nurses, will disclose any unanticipated event when an explanation of any change in treatment is indicated."

Record review of P-3 medical record failed to show contact with P-3 guardian. Documentation on 12/20/2023 at 0605 stated the following under the title of "Assessment and Plan" subtitle "Traumatic fall", "She experienced a traumatic fall while being transported from the stretcher to the MRI machine. This occurred on 12/19 ...patient not complaining of any pain beside her baseline body aches ...had with family and notified them of this unfortunate event.[SIC]" Review of documentation on 12/19/2023 failed to have any documentation of the event or notification to the family at the time of the occurrence.

Based on interview and record review the facility failed to ensure nursing documented daily dietary intake in one of three (P-3) patients reviewed for dietary intake, resulting in the potential for poor patient outcomes. Findings include:

On 4/24/2024 at 1130 an interview was conducted with staff E, the Chief Nursing Officer of the facility. Staff E was queried who is responsible for the recording of meal consumption for a patient. Staff E responded, "It is ultimately the responsibility of the nurse although nursing assistants will sometimes record meals as well." Staff E was then asked if a meal was not consumed would documentation be left blank. Staff E stated, "No... a percentage is to be recorded not left blank."

Record review occurred of the policy titled, "Tier 1: IPD Nursing Document: Nursing Process," policy number 9533165, dated 2/18/2022. According to the policy it states, "The Registered Nurse (RN) will document all phases of the nursing process in the Electronic Record. Care of the patient is the priority of the healthcare team, and the nursing care will be rendered prior to the documentation in the EHR (Electronic Health Record)."

Record review of P-3's orders revealed "I/O," (Intake and Output) entered on 12/12/2023.

Record review of the Record review of P-3 medical record from 12/13/2024 to time of discharge on 12/29/2024 at 1655, for dietary consumption of meals. P-3 was deemed as a total feed related to her vision impairment. The following was revealed:

12/29: 100% breakfast, No lunch documentation
12/28: 50% breakfast, 50% lunch, 50% dinner
12/27: 100% breakfast, No lunch or dinner documentation
12/26: No documentation for breakfast, lunch, or dinner
12/25: 75% breakfast, 75% dinner, No lunch documentation
12/24: 25% breakfast, 75% dinner, No lunch documentation
12/23: No documentation for breakfast, lunch, or dinner
12/22: No documentation for breakfast, lunch, or dinner
12/21: 100% breakfast, No lunch documentation, No dinner documentation
12/20: 25% breakfast, 25% lunch, No dinner documentation
12/19: breakfast 100%, lunch 100%, No dinner documentation
12/18: dinner 25%, No breakfast documentation, No lunch documentation
12/17: breakfast 75%, lunch 50%, No dinner documentation
12/16: breakfast 50%, lunch 75%, No dinner documentation
12/15: lunch 100%, dinner 100%, No lunch documentation
12/14: breakfast 50%, dinner 25%, No lunch documentation
12/13: dinner 25%, No breakfast documentation, No lunch documentation (date of admission to inpatient and arrived on the inpatient unit after breakfast and lunch meals)

Record review of a dietary consult on 12/21/2023 stated, "Follow-Up High Risk
Monitoring and Evaluation: Goal is >75% meals eaten through follow up, Goal is 1 supplement(s) accepted daily through f/u (follow-up). Diagnosis: Increased protein needs (moderate) related to increased demand as evidenced by wounds, chronic hypoalbunimia [SIC] (hypoalbuminemia - when the body fails to produce enough albumin protein, or when the body loses too much albumin urine or stool). Diet/Oral Nutrition Supplements/Nutrition Support: Diet Regular; Thin Liquids; Regular texture, Diet/Feeding Assistance: total feed, Average: 61.5% average for 13 meals documented in the past 8 days. (12/13/2023 - 12/20/2023)"