HospitalInspections.org

Based on interviews and record review, the Hospital failed to respond to Patient #1's four (4) phone calls and three (3) letters. The hospital is required to respond to complaints and grievances promptly and evaluate the process. The findings are:

A. On 04/26/2017 at 11:00 am during interview, the Director of Quality was asked to produce the responses and investigation to Patient #1's complaints and grievances. She stated, "We are only aware of a phone call from the spouse who wanted to speak to our attorney."

B. On 04/27/2017 at 1:45 pm during interview, Patient #1 stated, "My husband has called four (4) times and sent three (3) letters. We have not heard anything from the hospital. We only wanted to meet with the hospital. We we told the girl who handled that was out sick."

C. 04/26/2017 at 11:00 am during interview, the staff were asked to produce a list of hospital admission dates for Patient #1. They were not aware of the Emergency Department revisit and readmission on 09/16/2016. The Director of Quality also confirmed the hospital had received one (1) phone call when Patient #1's spouse articulated a complaint, but the hospital did not respond.

B. [Hospital's name] Policy/Procedure: The Patient Complaint/Grievance approved 10/22/2015 and reviewed 10/22/2016 revealed the following:
A. "Purpose: To provide a timely mechanism for receiving, responding to, resolving, and documenting the outcome of patient concerns and grievances that is in compliance with current Centers for Medicare & Medicaid Services (CMS) Patient Rights."
B. "Procedure: 2. Complaints-a. complaints solicited though surveys, suggestions cards or received through other avenues should be forwarded to Customer Relations Department where the data will be compiled for trending in an Excel spreadsheet. b. Any complaint that cannot be resolved at the time by staff present, is postponed or referred to other staff for further action, additional investigation, or late resolution, must be considered a grievance and handled accordingly. c. Documented resolution is not required for complaints. 3. Grievances: a. The timeframe for investigating, resolving, and communicating the outcome to the patient or his/her representative for a grievance, normally, is seven (7) days. If investigation and resolution cannot be accomplished within this timeframe, an acknowledgement letter must be sent to the patient or his/her representative specifying the current status and a date when the final resolution/response letter can be expected. The final resolution/response letter will be sent no greater than 30 days from the initial grievance reporting."

C. Record review of Patient #1's second hospitalization and readmission on 09/17/2016 revealed the following: Patient #1 returned to the [Hospital's name] Emergency Department (ED) the same day as her discharge 09/16/2016. She was short of breath and could not fill her prescription for medication for the two anticoagulants, Eliquis and Coumadin . The reason for the two anticoagulants was her diagnosis of a pulmonary embolism. The Eliquis would cover her needs until the Coumadin took effect, approximately 3 days. At discharge the team had scheduled the blood draw for 3 days hence. She also had a low red blood cell count. Review of her labs indicated she started the day of the surgery with a hemoglobin of 12 grams/deciliter and on the morning of discharge she was down to 8.1. (Normal hemoglobin is between 12.5 g/dL and 15.5 g/dL.) By that evening she was in the low 7's. They decided to readmit her and give her two units of blood. The ED notes also identified a blister on her knee adjacent to the staples in the wound. She was admitted to the General Surgery floor just after midnight from the ED, early on the morning of 09/17/2016.

D. Record review of the Discharge Summary for Patient #1's third hospitalization on 10/18/2016 and surgery indicated the following:
"Reason for admission: Wound dehiscence [opened] adjacent to recent total knee replacement. Hospital Course: Patient #1 is a [age] female who in mid September approximately 3 to 4 weeks ago had a right total knee replacement. Postoperatively, the patient developed a pulmonary embolism and has been on Eliquis since that time. She presented to the orthopedic clinic approximately 2 to 3 weeks ago with a thermal burn, which we determined that had been secondary to improper application of the Cryo/Cuff [cooling pad] directly onto the skin, which subsequently developed into an open wound. She was being treated initially at the wound care center; however, the wound care center sent her to the hospital for evaluation after it was determined that the patient's wound was getting worse and an ultrasound revealed her to have a small hematoma [a blood clot] associated with the area of the wound dehiscence [opened]. She was admitted by my partner on call on the 19th, was evaluated by myself, her surgeon for the total knee replacement and was taken for an irrigation and debridement [removal of dead tissue] of her wound. Postoperatively, her wound does look well. She has been on IV antibiotics, which were broad-spectrum in nature, although on postoperative day #3, her cultures have returned having grown Enterobacter cloacae complex and Enterococcus faecium [bacteria]. Sensitivities have been provided. On postoperative day #3, she is eating and excreting well. tolerating oral pain medications and is aware of how to perform dressing changes." Date of discharge 10/21/2016.
Note: Physician #1 signed the discharge summary on 01/18/2017, well past the 30 day limits for physicians.

Based on interviews and record review, the Hospital failed to track 1 day readmissions and evaluate the quality of the services the hospital delivered. 62 patients returned to the hospital with complaints that required readmission between 09/16/2016 and 03/17/2017. Patient #1 (P#1) had to return for care later on the day of her first discharge and was admitted two more times. One admission was for wound debridement (removal of dead tissue) and another was to close the surgical wound. The findings are:

A. On 04/26/2017 at 1:45 pm during interview, the Director of Quality was asked to explain the list she had presented of 62 patients who had to be readmitted between 09/16/2016 and 03/17/2017. She stated,"We have not looked at these yet. We track readmissions but I need to drill down on these to find out more." She also confirmed that discharge planning had not been addressed in regards to the readmissions.

B. Record review of the Hospital's several Quality Council Agendas for meetings held 04/06/2017 and 05/04/2017 revealed no discussions of the 62 readmissions to the hospital within a day of discharge between 09/16/2016 and 03/17/2017.
No analysis was performed on the data and no process improvement project was instituted to address the readmissions within one day after discharge issues.

C. Record review of Patient #1's second hospitalization and readmission on 09/17/2016 revealed the following: Patient #1 returned to the Hospital's ED the same day as her discharge 09/16/2016. She was short of breath and could not fill her prescription for medication for the two anticoagulants, Eliquis and Coumadin. The reason for the two anticoagulants was her diagnosis of a pulmonary embolism, a clot in the lung. The Eliquis would cover her needs until the Coumadin took effect, approximately 3 days, according to the physician. At discharge the team had scheduled the blood draw for 3 days after her discharge. She also had a low red blood cell count.

D. Review of P#1 labs indicated she started the day of the surgery with a hemoglobin [oxygen transporting molecule in blood] of 12 g/dL [concentration] and on the morning of discharge she was down to 8.1 g/dL, [normal is above 12 g/dL]. By that evening she was in the low 7's. They decided to readmit her and give her two units of blood. The Emergency Department notes also identify a blister on her knee adjacent to the staples in the wound. She was admitted to the General Surgery floor just after midnight from the ED, early on the morning of 09/17/2016.

Based on interview and record review, the Hospital Nursing staff responsible for the safe application and monitoring of a cooling pad failed to protect Patient #1 from a cold "burn."
This failed practice has delayed the healing process, may have contributed to a wound infection, and likely necessitated the hospitalization of Patient #1 two (2) more times after the original surgery. The findings are:

A. On 04/27/2017 at 2:00 pm during interview, Patient #1 stated the following: "I believe my recovery was hurt by the burn I received from the ice machine. My doctor told me that on one of my follow-up visits. I had to go back to the hospital several times. I am still in physical therapy and my knee is very stiff."

B. Record review of the Discharge Summary for Patient #1's third hospitalization on 10/18/2016 and surgery indicated the following:
"Reason for admission: Wound dehiscence (Wound dehiscence is a surgical complication in which a wound ruptures along a surgical incision) adjacent to recent total knee replacement.
Hospital Course: [Patient #1] is a [age]"-year-old female who in mid September approximately 3 to 4 weeks ago had a right total knee replacement. Postoperatively, the patient developed a pulmonary embolism and has been on Eliquis [anticoagulant] since that time. She presented to the orthopedic clinic approximately 2 to 3 weeks ago with a thermal burn, which we determined that had been secondary to improper application of the Cryo/Cuff [cooling pad] directly onto the skin, which subsequently developed into an open wound. She was being treated initially at the wound care center; however, the wound care center sent her to the hospital for evaluation after it was determined that the patient's wound was getting worse and an ultrasound revealed her to have a small hematoma [blood clot] associated with the area of dehiscence. She was admitted by my partner on call on the 19th, was evaluated by myself, her surgeon for the total knee replacement and was taken for an irrigation and debridement of her wound. Postoperatively, her wound does look well. She has been on IV antibiotics, which were broad-spectrum in nature, although on postoperative day #3, her cultures have returned having grown Enterobacter cloacae complex and Enterococcus faecium (bacteria). Sensitivities have been provided. On postoperative day #3, she is eating and excreting well. Tolerating oral pain medications and is aware of how to perform dressing changes." Date of discharge 10/21/2016.

C. Time line:
09/06/2016 Pre procedure evaluations
09/07/2016 Consent for Knee Surgery
09/12/2016 History and Physical completed with consent
09/13/2016 Surgery
09/16/2016 Discharge to home
09/16/2016 Patient returns to the ED
09/17/2016 Readmission
10/18/2016 Date of 3rd admission
10/21/2016 Date of 3rd discharge

D. Record review of the manufacturer's directions for use for the DJ Global "Iceman Classic"or Cryo/Cuff [cooling pad] revealed the following:
A. "Important: Water temperature is indicated by the red line on the thermometer. (The range of the thermometer is in both Fahrenheit and Celsius; from 32 degrees to 100 degrees F and from 0 to 40 degrees Celsius".)
B. "Warning (in red): This product can be cold enough to cause serious injury."
C. "Warning! This device can be cold enough to cause serious injury, including tissue necrosis [dead]. You must be able to check your skin condition under the cold pad. DO NOT use if you cannot check your skin condition frequently (at least every hour). Check for increased pain, burning, numbness, tingling, increased redness, discoloration itching, increased swelling, blisters, irritation or other changes in skin condition under the cold pad or around the treatment area. If you experience any of these conditions, immediately discontinue use of this device and contact your physician."

E. Record review of Patient #1's second hospitalization and readmission on 09/17/2016 revealed the following: Patient #1 returned to the hospital Emergency Department (ED) the same day as her discharge 09/16/2016. She was short of breath and could not fill her prescription for medication for the two anticoagulants, Eliquis and Coumadin. The reason for the two anticoagulants was her diagnosis of a pulmonary embolism. The Eliquis would cover her needs until the Coumadin took effect, approximately 3 days. At discharge the team had scheduled the blood draw for 3 days post-discharge. She also had a low red blood cell count.

Review of her labs indicated she started the day of the surgery with a hemoglobin of 12 g/dL [oxyegen carrying molecule in blood] and on the morning of discharge she down to 8.1. By that evening she was in the low 7's, normal is above 12 g/dL. They decided to readmit her and give her two units of blood.

The ED notes also identified a blister on her knee adjacent to the staples in the wound. She was admitted to the General Surgery floor early on the morning of 09/17/2016 from the ED.

F. Record review of the hospital's training policy for nurses and aides requires all nurses and aides to complete training for the cooling pad. Nurses and aides are allowed to apply the cooling pad to a patient after training.

G. Review of the nursing notes for Patient #1's stay revealed no issues with the wound, the cooling pad or concerns voiced by the patient. It was unclear from the patient's record who applied the cooling pad the day of the surgery after returning to the medical surgery unit.

Based on interview and record reviews, the hospital failed to review the discharge planning process on an ongoing basis or review readmissions within one day between 09/16/2016 and 03/17/2017. This failed practice kept the hospital from identifying problems with discharges that had to be remedied by readmission. The findings are:

A. On 04/26/17 at 1:30 pm during interview, the Director of Quality confirmed that the hospital had not reviewed the 62 readmissions within one day between 09/16/2016 and 03/17/2017 for reasons why the patients required readmission. She confirmed that the hospital had not analyzed this data or created a process improvement project to address it. She also confirmed that discharge planning had not been addressed in regards to the readmissions.

B. Record review of Patient #1's second hospitalization and readmission on 09/17/2016 revealed the following: Patient #1 returned to the hospital Emergency Department (ED) the same day as her discharge 09/16/2016. She was short of breath and could not fill her prescription for medication for the two anticoagulants, Eliquis and Coumadin. The reason for the two anticoagulants was her diagnosis of a pulmonary embolism. The Eliquis would cover her needs until the Coumadin took effect, approximately 3 days. At discharge the team had scheduled the blood draw for 3 days post-discharge to see if the Coumadin was within therapeutic range.
She also had a low red blood cell count.
Review of her labs indicated she started the day of the surgery with a hemoglobin of 12 g/dL and on the morning of discharge she down to 8.1. By that evening she was in the low 7's. They decided to readmit her and give her two units of blood.
The ED notes also identified a blister on her knee adjacent to the staples in the wound. She was admitted to the General Surgery floor just after midnight from the ED, early on the morning of 09/17/2016,

C. Record review of the Discharge Summary for Patient #1's third hospitalization on 10/18/2016 and surgery indicated the following:
"Reason for admission: Wound dehiscence adjacent to recent total knee replacement.
Hospital Course: Patient #1 is a [age]-year-old female who in mid September approximately 3 to 4 weeks ago had a right total knee replacement. Postoperatively, the patient developed a pulmonary embolism and has been on Eliquis since that time. She presented to the orthopedic clinic approximately 2 to 3 weeks ago with a thermal burn, which we determined that had been secondary to improper application of the Cryo/Cuff [cooling pad] directly onto the skin, which subsequently developed into an open wound. She was being treated initially at the wound care center; however, the wound care center sent her to the hospital for evaluation after it was determined that the patient's wound was getting worse and an ultrasound revealed her to have a small hematoma associated with the area of dehiscence. She was admitted by my partner on call on the 19th, was evaluated by myself, her surgeon for the total knee replacement and was taken for an irrigation and debridement of her wound. Postoperatively, her wound does look well. She has been on IV antibiotics, which were broad-spectrum in nature, although on postoperative day #3, her cultures have returned having grown Enterobacter cloacae complex and Enterococcus faecium. Sensitivities have be provided. On postoperative day #3, she is eating and excreting well. tolerating oral pain medications and is aware of how to perform dressing changes." Date of discharge 10/21/2016.
Note: This note by the surgeon was signed 01/18/2017, well past the 30 day limits for physicians.

D. Record review of the Hospital's several Quality Council Agenda for a meeting held 04/06/2017 and 05/04/2017 revealed no discussion of the 62 readmissions to the hospital within a day of discharge between September, 2016 and March, 2017.
No analysis was performed on the data and no process improvement project was instituted to address the readmissions within one day after discharge issues.