HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure the patient's right to care in a safe setting for 1 of 6 patients receiving care in the Emergency department (ID# 3).

Findings include:

Review of facility policy titled "Patient's Rights and Responsibilities," dated 2/21/2023 showed the following:
Procedure:

2. Patient's Rights:
-Receive considerate and respectful care provided in a safe environment, free from all forms of abuse, neglect, harassment or exploitation.

Observation in the Emergency Department (ED) Disposition area on 4/3/2025 at 11:15 AM showed a patient restroom with no working call light and a rusty metal toilet, 6 patient care areas (recliners) with no call lights available, and a nurses' station behind partial wall/glass enclosure and not all patient care areas were visible. When surveyor tried to get the attention verbally of survey team and administrative staff behind the glass enclosure, the surveyor could not be seen or heard.

Interview with staff #ID 56 on 4/3/25 at 10:30 stated that the ED disposition area is not always in use. It is used for lower acuity patients (with ESI 4 or 5) on days when staffing allows.

Interview with facility CNO #ID 55 on 4/3/25 at 11:20 stated that the area would not be utilized until patient safety issues were addressed.

Based on document review and interview, the facility failed to ensure the medical staff followed the bylaws/rules and regulations of the medical staff, which included ensuring an order for specialty consultation was placed in the medical record and ensuring documentation of the consultation occurred in 1 of 5 patient records reviewed (Patient ID #11).

Findings Included:

Record review of medical record for Patient ID #11 for date of service 10/25/24 until 11/1/24. Critical care progress note written by Staff Physician ID #87 stated "It was at this time that vascular surgery was as the bedside in which the decision was made to transfer the patient to the Cath lab emergently for re-evaluation and exploration ..." . Cath lab procedure note 10/28/24 stated "Primary surgeon: (Redacted)/Vascular surgeon Staff ID #76).

Record review of facility "General Rules of the Medical Staff", last approved 07/27/2020, stated "CONSULTATIONS: A. General 1. It is the responsibility of the Department Chairman to see that the members of his department call consultants as needed. The call for a consultant must be either physician to physician, or physician's office to physician's office. The consultant must be appropriately delineated and qualified to give an opinion in the field in which consultation is sought. 2. As soon as possible, the referring physician will document in the orders or the progress notes the date and time the consult was requested ... 5. For emergency consultations requested by services other than the Emergency Department, residents or fellows may respond to the request for consultation and prepare the consultant note. However, the consultation must be reviewed and confirmed within two hours in person or by telephone with the attending physician. The consultation should be documented in the medical record and counter-signed by the attending physician. 6. Consultants will not postpone their initial evaluation of the patient pending the ordering or obtaining test results. 7. An acceptable consultation includes the examination of the patient and the record, and a written opinion signed by the consultant. When invasive procedures are involved, the consultation report shall be documented prior to the procedure."

Interview with Staff Informaticist ID # 77 on 4/4/24 at 10:25 am. She confirmed there was no evidence of an order placed for Cardiothoracic vascular surgery staff ID # 76, no evidence of progress note or consultation note by Staff ID #76. She stated there had been no chart entries by Physician Staff ID #76 placed in Patient ID #11 medical record which she could locate.

Interview with CNO Staff ID #55 on 4/4/24 at 10:30 am. She confirmed that she would expect an order to be placed for consultation for physician consultation/engagement in medical record. She confirmed she would expect any physician who had performed an evaluation and/or procedure on a patient to document their encounter in the medical record per policy.

Based on interview and record review, the facility failed to ensure nursing assessed, documented and acted on the rapidly changing needs of a patient who was receiving care at the facility in 1 of 13 sampled patients (Patient #11). The facility failed to ensure:

1)Nurses accurately assessed and acted on vital sign changes for Patient ID #11 in the post-cath lab procedure area (Patient ID #11).

2)Failed to activate the rapid response team in a timely manner for Patient ID #11 who displayed signs of hemorrhagic shock post-invasive cath lab procedure (Patient ID #11).

Findings Included:

Record review of Patient ID #11 medical record with Nurse Informaticist Staff ID # 77 on 4/4/24 at 10:25 am. Medical Record entry placed by Staff RN ID # 75 on 10/28/24 at 09:15 am "heart rate 100," 09:45 Vascular access site "Hematoma" 10:15 am stated "heart rate 116 ..." at 10:30 am stated "heart rate 118 and blood pressure 89/45." 10:45 am stated "heart rate 102. Charge nurse contacted MD. Recheck 78/61. Fluids & trendelenberg." 11:00 "heart rate 118". 11:15 am "heart rate 118". 12:30 BP 91/43, HR 101, RR 31, 02 sat 98% on 4L. Pt BP cont. to drop. Pt breathing has become labored. Contacted MD again." 12:40 "RRT called. BP 65/51, HR 98, RR 30, 02 sat 99% on 10L."

Record review of facility policy titled, "Patient Assessment, Reassessment and Documentation of Care", last revised 08/15/2023, stated "Policy: Patients are assessed on admission and at a minimum each shift to determine care, treatment and services that will meet the patient's initial and continuing needs. The process of assessment includes: 1. Collecting information about the patient's health history as well as physical, functional, and psychosocial status. 2. Analyzing the information in order to understand the patient's needs for care, treatment and services. 3. Making care, treatment, and services decision based on analysis of information collected. Depth and frequency of reassessment is dictated by patient's needs, program goals and the care, treatment and services provided .... C. Reassessments are performed and documented in the medical record as necessary based on patient's plan of care or changes in the patient's condition."

Record review of facility policy titled, "Rapid Response Team", last revised 07/18/23, stated "Policy: Rapid Response Team is to improve patient care and outcomes through response to early warning signs of clinical instability.
Procedure: 1. A staff member, patient or family may call the team to address a change in a patient's condition. 2. Triggers for a call to RRT may include but are not limited to: a. Significant change in heart rate b. Change in systolic blood pressure (systolic BP less than 90 mm Hg, SBP 30 mmHg below usual, systolic BP over 200 mmHg) c. Change in respiratory rate to
( less than 8 or greater than 30), or respiratory distress, or change in respiratory pattern (dyspnea) ... h. Acute bleed ..."

Interview with CNO Staff ID #55 on 4/4/25 at 10:40 am. She confirmed she would expect nursing staff to act on vital sign changes which are > 10% from patient's baseline, taking into account patient assessment and situation. She confirmed that the acquisition of a groin hematoma on assessment, heart rate elevations and blood pressure decreasing could be signs of hemorrhage. She confirmed that she would expect rapid response team to be initiated in the post-cath lab procedure area per policy to assist with timely patient care and intervention.