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Based on interviews, medical record reviews and review of policy and procedure, the hospital failed to ensure:

1. The Emergency Department (ED) Physician correctly read Patient Identifier's (PI ) # 1's x-ray to verify placement of the patient's PEG (Percutaneous Endoscopic Gastrostomy) tube

2. Patient Identifier (PI) # 1's x-ray was read by the radiologist to confirm the correct placement of the PEG tube prior to discharging the patient from the ED

3. The radiologist notified the ED Physician of the critical interpretation of PI # 1's x-ray to confirm feeding tube placement (feeding tube tip does not lie within the lumen of the stomach) prior to discharging the patient from the ED on 2/15/14.

Findings Include:

Refer to A0049 for findings.

Based on interviews, review of medical records, Medical Staff Bylaws and policy and procedure, it was determined:

1. The Emergency Department (ED) Physician failed to identify incorrect placement of the feeding tube by x-ray and ensure Patient Identifier (PI) # 1's x-ray was read by the radiologist to confirm the correct placement of the PEG (Percutaneous Endoscopic Gastrostomy) Tube prior to discharging the patient from the ED on 2/15/14.

2. The radiologist also failed to notify the ED Physician that the patient's feeding tube was not in the stomach.

As a result of these failures, PI # 1 returned to the Emergency Department in a deteriorated, critical clinical condition in slightly over nine hours after discharge with early signs of sepsis (blood infection) to include pain, increased heart rate, increased respirations, fever and bleeding from the site of the feeding tube. PI # 1 required extensive testing and treatment in the ED, was hospitalized and required continued treatment in a long term hospital. This affected one of eight sampled Emergency Department patients and had the potential to affect all patients served.

Findings Include:

Patient Identifier # 1's First ED Visit on 2/15/14 at 11:02:

According to a review of the Nursing Triage notes, PI # 1 arrived in the ED on 2/15/14 at 11:02 with a chief complaint of "From (name of nursing home) after pulling...G (Gastrostomy) tube out." (Gastrostomy is a surgical procedure for inserting a hollow tube through the abdominal wall into the stomach to deliver nutrition).

The patient was assigned an Urgent/Level 4 (based on ESI Emergency Severity Index, a five level triage scale to determine patient acuity in the ED. Level 4: patient can wait several hours to be seen by a provider). The airway is open. Breathing is spontaneous and non-labored. The pulse is regular and strong.

Temperature: 98.5
Pulse: 90
Respirations: 20
Blood Pressure: 148/104

History of Present Illness (documented by the ED Physician # 1) on 2/15/14 at 11:14:

The patient presents with a complaint of PEG (Percutaneous Endoscopic Gastrostomy) tube complication ( A surgical procedure for placing a tube for feeding without having to perform an open operation on the abdomen).
The onset was sudden. The pain severity is mild. The patient was sent here from (name of nursing home) to have...PEG tube reinserted after pulling it out this morning.

Examination by ED Physician:
Constitutional: The patient is alert and in no apparent distress.
Cardiovascular: Regular rate and rhythm.
Respiratory: Breath sounds clear; no distress present.
Gastrointestinal/Abdomen: Soft, non-tender. Normal bowel sounds. PEG tube tract in LUQ (Left Upper Quadrant) with blood in OS (opening).
Integumentary: Warm and dry.


Procedures - Physician
Notes: 20 french PEG tube inserted into existing tract to guard without difficulty and balloon filled with 6 cc's (cubic centimeters) saline. No resistance, Gastrografin infused without difficulty and tube appears to be in the small bowel.


Orders:
X-Ray Abdomen AP view (Anterior/Posterior).
Reason for exam: Feeding tube dislodged.
Special Instructions: Instill gastrografin (into PEG tube) to confirm G tube placement.


Diagnoses: G tube/PEG tube malfunction, Huntington's Chorea


Discharge from ED: The patient is discharged to (name of nursing home)...Condition is satisfactory...


Disposition (Nursing) 2/15/14 at 12:58:

Discharged home. PEG tube problem resolved. The patient is the same as prior to arrival/ Condition is stable.


Single Supine Abdomen/KUB (kidneys, ureter, bladder) X-ray on 2/15/14 at 17:08 (Read by Radiologist after patient's discharge from first ED visit):

Result: "Feeding tube does not lie within the lumen of the stomach. It is difficult to determine it if lies within the mesenteric folds or atypical appearing small bowel lumen. Mild small bowel dilatation is present which could represent ileus, gastroenteritis or mechanical bowel obstruction."
Electronically signed by (name of Radiologist). Date 2/15/14 17:08. (There was no documentation the result of the x-ray was communicated to the ED Physician).


Second ED Visit on 2/15/14 at 20:05:

According to a review of the Nursing Triage notes, PI # 1 arrived in the ED on 2/15/14 at 20:05.

Chief complaint: Bleeding around PEG tube.

Encounter Type: Unscheduled return to ED in less than 12 hours.

Acuity: Level 2 - Critical

History of Present Illness (documented by the Nurse Practitioner, Employee Identifier, EI # 2) on 2/15/14 at 20:12:

This visit is a certified emergency. Vital Signs reviewed. The patient presents with a complaint of g tube problem. The onset was sudden. The symptoms have been constant. Pain severity is moderate. Context: Patient pulled out g tube earlier today and was seen here in the ED where a new tube was placed. Patient was discharged to nursing home.

Modifying factors include: Worse with palpation. Nursing home staff states patient began to bleed from g tube and blood pressure has not been stable. Patient has a history of Huntington's Disease.

Examination:
Examination limited due to altered mental status; patient has baseline AMS (Altered Mental Status).
Constitutional: Patient appears chronically ill. Moaning.
Eyes: Abnormal injected conjuctiva.
Cardiovascular: Tachycardia (resting heart rate over 100 beats per minute).
Respiratory: Tachypneic (rapid breathing). Wheezing, rales and rhonchi bilaterally.
GI/Abdomen: Rigid abdomen. Bloody drainage around g tube site. Bowel sounds absent in all quadrants.
Musculoskeletal/Extremities: Contracted upper extremities.
Integumentary: Hot to touch.

Vital Signs at 20:18:
Temperature: 103.7
Pulse: 148
Respirations: 30
Blood Pressure: 159/99

Pain Scale: 5

Physician Orders:

Saline lock (type of IV)
Acetaminophen 650 milligrams (mg.) rectally at 20:28
Zosyn IVP (Intravenous push) 3.375 grams at 21:33
Flagyl IVPB (intravenous piggy back) at 22:02
Normal Saline bolus x 2
Acetaminophen 650 milligrams (mg.) rectally at 23:32
Cardizem IVP 20 mg. at 23:41 - slow IV push
Cardizem 145 mg. IV drip (maintenance) at 23:47
Ativan 1 mg. IVP at 00:24


Radiology:
"CT (Computed Axial Tomography) Thorax, Abdomen and Pelvis with Contrast. Reason: Shortness of breath / ABD (Abdominal) / Pelvic Pain; Instructions: IV (intravenous) contrast - 2/15/14:

Technique: 5 mm (millimeter) axial images were obtained through the chest, abdomen and pelvis after intravenous contrast. Coronal reformatted images were performed.

Findings:

Chest CT: Mild increased interstitial markings likely represents chronic interstitial lung disease. Mild pulmonary vascular congestion is not excluded. The heart is mildly enlarged. No pneumothorax or pleural effusion is seen. No mediastinal or hilar adenopathy is identified.

Abdominal CT: The PEG (Percutaneous Endoscopic Gastrostomy) tube/enteral feeding tube lies within the left rectus muscle sheath. There is gas and fluid noted within the left rectus sheath which could represent abscess or be related to injection of material through the PEG tube. No free intraperitoneal air or intraperitoneal abscess is seen. The liver, spleen, pancreas, gallbladder, adrenal glands and kidneys are unremarkable. Mild gaseous distention of the small intestine could represent ileus.

Pelvic CT: Appendix is normal...Stranding is seen along the anterior abdominal wall of the pelvis and within the anterior lower mesentery of the pelvis...

Impression:
1. Fluid and gas with the left rectus sheath muscle which could or present abscess. PEG tube lies within the left rectus sheath.
2. Inflammatory stranding of the anterior abdominal wall within the pelvis...
Electronically signed by Name of MD/Radiologist 2/17/14 at 08:26."


Chest X-ray. Reason: Fever. Results: Mild increased interstitial markings are noted; worse on the left...Heart is borderline enlarged. This could represent interstitial pneumonia or asymmetrical pulmonary vascular congestion.
Electronically signed by Name of MD/Radiologist 2/17/14 at 08:26

Treatment:
NPO (nothing by mouth)
Continuous cardiac monitoring
Foley catheter

Respiratory:
- ABG (Arterial Blood Gas)
- BIPAP: (Bi-level positive airway pressure, a type of noninvasive ventilation that helps keep the upper airways of the lungs open by providing a flow of air delivered through a face mask.)

Consultations: Colo-Rectal Surgery and Family Medicine: Stat (Immediate)

Diagnoses:
Sepsis (Blood Infection)
Abdominal Rigidity
G-tube malfunction
Hypoxemia

Disposition by Physician:

The ED Physician spoke with the attending physician. Admit to Progressive Care Unit. Condition is critical. (Name of surgeon) saw patient in the ED.
Critical Care Indication: Patient was critically ill with a high probability of imminent or life threatening deterioration.


Nursing Notes:

2/15/14 20:20: Airway patent. Respirations are grunting, labored, fast and shallow. Breath sounds diminished on the left and clear on the right. Radial pulse is weak. Capillary refill time is sluggish (greater than three seconds). Level of consciousness upon arrival is non-verbal...unable to talk.
Skin is hot/febrile and dry. Pedal pulses are weak bilaterally.

Patient is bleeding from site. Moaning. Family member states she has never heard patient moan like this before. Febrile.

2/15/14 at 20:28 - Urine output: 50 milliliters via foley catheter.

21:50:
Temperature: 103.1
Pulse: 162
Respirations: 130
Blood Pressure: 143/87


Surgical Consultation Report dated 2/16/14; Author: EI # 7 (Surgeon)

Chief Complaint: Abdominal Pain, malpositioned gastrostomy tube.

History of Present Illness: ...The patient presented to the ED earlier today after the G tube was dislodged. By report of the current Emergency Room physician the tube was replaced and confirmed with "Gastrografin" study. The patient returned to the ED this evening with signs of severe illness including a firm tender abdomen and some bleeding around the PEG tube site and significant tachycardia. Because of this a CAT (Computed Axial Tomography) scan was performed which did demonstrate a malposition of the feeding tube and surgical consultation was placed.


Physical Examination:
Vital Signs: Temperature : 103.7; Pulse: 170's; Respiratory Rate: 30's; Blood Pressure: 159/99. The patient is on supplemental oxygen with a nonrebreather mask.
Neurologic: Patient is awake.
Gastrointestinal (GI): Abdomen is somewhat distended, but particularly on the left portion of the abdomen. There was some firmness and the G tube site has some venous appearing type blood coming from the site. This appears to be controlled with direct pressure.
Skin: Warm.
Musculoskeletal: Has upper extremity contractures. (Huntington's).

Laboratory Data: White Blood Cell Count: 22; Hemoglobin: 18.5.

CAT scan of the abdomen and pelvis by virtual radiology shows percutaneous gastrostomy tract present, malpositioning of the gastrostomy tube. The tube does not enter the abdominal cavity, but rather it deviates quarterly with dissection to the left rectus abdominis muscular sheath with the balloon inflated within the rectus sheath itself. There is also possibility of vascular contrast extravasation with possible hematoma. There is fluid and gas collection suspicious for hematoma or abscess.

Impression:
1. Malpositioned gastrostomy tube.
2. Early sepsis.
3. Huntington's chorea.
4. The patient is do not resuscitate.

Plan: I had a very long discussion with the family...family understands the fact that with the patient's current presentation it may be very difficult to correct the current stage without...requiring a trip to the operating room. The patient has elevated temperature and elevated white blood cell count.

The patient is hypoxic, requiring supplemental oxygen and definitely has signs of early sepsis compounded by the fact that he may require general anesthesia....the patient may have a difficult time recovering from surgery even if the patient were to survive the operation...the family has decided not to go through with the operation this evening...


History and Physical written by the Attending Physician; Dictated 2/16/14:

Admission Date: 2/15/14

Reason for coming to the hospital: Abdominal Pain.

History of Present Illness: The patient...pulled out PEG tube....taken to the ER (Emergency Room), PEG was positioned, patient came back to the nursing home, and then returned to the ER. In the ER, found to have a malpositioned PEG tube in rectus sheath related to bleeding...Admitted now for positioning of the PEG tube and TPN (Total Parenteral Nutrition).

Physical Examination:
Skin: Pale...
Abdomen: A pressure dressing on the upper abdomen at the PEG site wound...Some tenderness of the midline abdominal muscles...Patient is conscious but not able to respond to name or give time or date.

Laboratory Data: Dehydration with a creatinine of 1.8; White blood cell count 24.9, showing sepsis. Hematocrit is high at 53.4; Platelets low at 115,000.

Assessment: Malpositioning of the PEG tube with abdominal muscle bleeding...


Discharge Summary dictated 3/10/14 by Attending Physician, EI # 9:

Date of Admission: 2/15/14
Date of Discharge: 2/19/14

Final Diagnoses:
1. Severe Huntington's Chorea...Patient removal of PEG tube in a traumatic way.
2. Malpositioning of the PEG tube with abdominal muscle bleeding due to prior patient-induced trauma...

Disposition: (Name of Long Term Care Hospital).

History of Present Illness:
Abdominal pain after patient traumatically removed PEG tube.
Malpositioning of PEG tube.

Hospital Course: ...Nursing home patient with severe limb chorea who forcefully pulled out PEG tube. We were not able to reposition it, so the patient had to be admitted. The patient had an abdominal wall abscess. The patient was placed on Flagyl, Zosyn and TPN. The long term goal is to reinsert the PEG tube after a month of IV (intravenous) Flagyl and Zosyn...


Interviews:

Interview on 4/22/14 at 16:32 with the ED RN (Registered Nurse), EI # 3:

During the interview, the RN (EI # 3) responsible for triage of the patient during the first ED visit on 2/15/14, said the patient was non-verbal, but could communicate by nodding of the head. The RN (EI # 3) heard the ED Physician (EI # 1) say he thought the patient's feeding tube was in the small bowel after he replaced the feeding tube during the patient's first ED visit.

Prior to the patient's return to the ED on 2/15/14 at 20:05, the RN (EI # 3) stated she received report from EMS (Emergency Medical Services) staff. "I suspected it was the same patient. I told (name of ED Physician/EI # 1). I pulled up the x-ray and showed him the interpretation by the radiologist." According to the report from EMS, the patient sounded, "Pretty critical."

According to EI # 3 she was not assigned to the patient during the second visit, but assisted in caring for the patient. The RN (EI # 3) said, "I tried to paint a picture of the patient. The difference between the patient's first and second visit for staff at shift change."

During the second ED visit the patient was in and out of consciousness and had severe abdominal pain, abdominal distention, tachypneia (rapid breathing), tachycardia (resting pulse > 100) and blood around the PEG tube. The RN did not recall the amount of blood, but said the blood was, "A darker color, not like a hemorrhage." According to the RN, the patient during the second ED visit, was in obvious distress and pain with hard, fast respirations that, "Looked painful." The patient could not lie flat. His abdomen was distended and rigid. The feeding tube was clamped off. The patient had a fever of 103.7 and was hypertensive with an elevated heart rate in the 180's.


Interview with the Nurse Practitioner (NP), EI # 4, on 4/22/14 at 15:45, who was assigned to the patient during the patient's return ED visit at 20:05 on 2/15/14:

According to the NP, the patient had a problem with the feeding tube and was not responding much. The patient was moaning, tachycardic and rales and rhonchi were present in the lungs. The abdomen was rigid with blood draining around the tube site and no bowel sounds were present. When asked if the patient's family was present, the NP said, "A lady showed up...not sure of relationship." The NP said he was aware the patient had a feeding tube placed earlier in the day in the ED.

"(Name of surgeon) saw the patient in the ER, I think." The patient was made a DNR (Do Not Resuscitate). According to the Nurse Practitioner, the tube was in the muscle, not where it should be." The NP said the tube should be in the stomach or bowel depending on the type of feeding tube. "(Name of ED Physician) saw the patient within a few minutes."


Interview with ED Nurse Manager (EI # 5) and Risk Manager (EI # 6) on 4/22/14 at 17:05:

The managers were asked if they were aware of the incident related to PI # 1's PEG tube on 2/15/14 and they both answered, "No." They also said no when asked if an incident /event report had been completed.


Interview on 4/23/14 at 09:30 with PI # 1's Attending Physician, EI # 9:

The patient had constant movement related to Huntington's Disease. The patient pulled the PEG tube out..."ripped it out of his/her stomach" and was sent to the ED. The ED Physician tried to reinsert the tube. The patient was sent back to the nursing home. The PEG (tube) was not in the stomach and the patient had to return to the ED.


Interview on 4/23/14 at 09:50 with the Surgeon, EI # 7, who was consulted by ED staff during the patient's second ED visit:

According to the surgeon PEG tubes are usually placed endoscopically (use of scope to visualize the inside of an organ or passageway). When a tube has been in place for a long time and is dislodged, it should be easy to replace with a catheter to maintain the opening until the tube can be replaced. The surgeon said it would take "force" to dislodge a PEG tube.


Telephone Interview on 4/23/14 at 11:07 with the Radiologist, EI # 8, who read the patient's abdominal x-ray on 2/15/14 to verify placement of the feeding tube during the first ED visit:

The radiologist was asked if he called anyone after reading the patient's abdominal x-ray that indicated the feeding tube was not in the lumen of the patient's stomach. He responded, "I don't know. I can't remember. Usually I do, but I didn't document." The radiologist was asked how abnormal radiological findings are communicated by the Radiology Department to ED Physicians. The Radiologist said, "They can get results. If critical I will call the MD (Medical Doctor)."


Interview with ED Physician, EI # 1, on 4/23/14 at 11:30, who was assigned to the patient during the first ED visit on 2/15/14:

According to EI # 1, the bulb of the feeding tube was in the gastrostomy opening when he evaluated the patient during the first visit to the ED. EI # 1 stated no bleeding was present. The tube was easily inserted. After inserting the PEG tube, the ED Physician ordered an abdominal x-ray with gastrografin to confirm placement. The ED physician stated he read the x-ray and thought the tube was in the patient's small bowel. The physician said Gastrografin, a radiopaque substance, "Goes into whatever cavity the tube is in. It can't be pushed into tissue." The surveyor asked the ED Physician if the radiologist called or notified him about the radiologist's interpretation of the x-ray (feeding tube not in the stomach) and he said, "No." The ED Physician was asked if anyone informed him of the x-ray reading by the radiologist. According to the ED Physician, he said the next day he learned the patient returned to the ED and was septic. The ED Physician was asked if he discussed his interpretation of the patient's x-ray versus the interpretation by the radiologist with staff. He said he discussed it with the ED Medical Director and the ED Physician who was assigned to the patient when the patient returned to the ED on 2/15/14.

The ED Physician / EI # 1 was asked about his medical opinion regarding the dramatic change in the patient's condition by the time the patient returned to the ED on 2/15/14. According to the ED Physician, when he re-inserted the new PEG tube, he hit a walled off pocket in the stomach and "popped" an abscess. When the patient's tube feeding was resumed, the infection was circulated. The ED Physician said he called radiology to get the results and "waited a while." "We (ED) were busy. I thought the tube placement was correct." The patient was sent back to the nursing home. "The only thing I could have done differently: I could have called the radiologist and asked him to read the x-ray or the other option: Admit the patient and have the tube inserted in a procedure area like the GI lab."


Interview with Radiology Director, EI # 10, on 4/23/14 at 15:19:

According to the Director, it is the practice of the radiologist to report critical/urgent results to the ER Physician via telephone. The Director stated there is a policy related to notification of critical results and he will provide a copy to the surveyor.


Interview with ED Medical Director, EI # 11, on 4/24/14 at 11:07:

The Medical Director said he was aware of the misread of the patient's abdominal x-ray in the ED on 2/15/14 and the failure of the radiologist to notify the ED Physician about his interpretation that the feeding tube was not in the patient's stomach. He stated the "overread process is not crisp," and there is a practice improvement project in place unrelated to this event. Regarding the radiologist's reading of PI # 1's x-ray the Medical Director said, "I would have wanted the radiologist to call me." The Medical Director said he spoke with the Chair of Radiology (EI # 12) who was also aware of the incident. Both departments (ED and Radiology) "redoubled" efforts regarding the communication lapse.


Interview with Chair of the Radiology, EI # 12, on 4/24/14 at 13:35:

According to the radiologist, critical radiology results are communicated to the ED physician usually via a telephone call. The surveyor asked the radiologist to interpret the results of abdominal x-ray as documented by the radiologist who read the x-ray on 2/15//14. A copy of the patient's x-ray result was available. The radiologist stated the patient's feeding tube was not in the stomach. The radiologist was asked where the tube should be located and he said, "Should be in the stomach." When asked if the reading radiologist should have called the ED Physician with his interpretation the radiologist said, "I guess." The radiologist was also asked to identify who has the responsibility to read x-rays. He responded, "Radiologist. A lot of times the ED reads initially because the ER moves fast - faster than the radiologist can keep up." The radiologist said he was not sure how he found out about the incident and was not sure if he had a discussion with the ED Medical Director. According to the radiologist the general practice and policy of the Radiology Department is to call the ED Physician if the radiologist determines his reading is significant/critical. The radiologist stated, "Don't know why Dr. (name of radiologist who read x-ray) didn't call. Don't know what was going on at the time of this incident. He (name of radiologist who read x-ray) calls a lot of results. I'm surprised he did not call."


Telephone interview with ED Medical Director, EI # 11, on 4/25/14 at 12:04:

The Medical Director was asked what, if any, immediate action was taken when he became aware of the incident related to the misplacement of the patient's feeding tube and the failure of the radiologist after reading the x-ray to notify the ED Physician that the feeding tube was not in the patient's stomach. The Medical Director replied, "No. We didn't. We already had a process to improve in place."

The Medical Director (EI # 11) said he and EI # 12 (Chair of the Radiology Department) spoke today. Effective immediately all patients with a feeding tube are not to be discharged from the ED until placement of the tube is confirmed by a Radiologist.


Medical Staff Bylaws, Revised July 2013 Review:

Article II Membership

2.5 Basic Responsibilities of Medical Staff Membership

Except for the honorary and retired staff, the ongoing responsibilities of each member of the medical staff shall include:
(a) providing patients with the quality of care that meets the professional standards of the medical staff of this hospital...


Policy and Procedure Review:

Subject: Communicating Critical Tests and Values/Interpretations

Purpose: To describe the process for timely and reliable reporting of critical tests and values or interpretations to health care providers.

Definitions:
Critical Tests and Values/Interpretations are defined as those that indicate the patient may be in danger of death or serious adverse consequences unless treatment is initiated promptly or require immediate reporting so the physician may make a decision regarding the appropriate clinical action for the patient.

The Medical Executive Committee shall develop and regularly update a list of tests, values or interpretations that require immediate notification and are, therefore, deemed to be critical tests, values or interpretations under this policy.

Scope:
This policy applies to critical test, values, or interpretations from Laboratory, Imaging, Obstetric and NC (Neurocardiology) Services reporting to inpatient, outpatient and Emergency Department (ED) areas...

Policy: Procedure for communicating critical tests and values/interpretations

The specified time frame is provided for guidance purposes only...There are certain circumstances that may arise where adherence to the specified time frame is not feasible. When these circumstances arise, notification should be provided pursuant to this policy as soon as possible to a physician who can take action.

1. Time frame for notification critical tests and values/interpretations:

A. When a critical test or value/interpretation is identified and verified, the clinician shall notify the physician. For inpatient areas, if the physician cannot be notified, then the clinician caring for the patient shall be notified.

B. Time frame for notification of a critical value is 60 minutes....

C. Time frame for notification of critical test interpretation is specific to the individual test...

Attachment C: Critical Values - Imaging Services...

2. The notification process for reporting critical tests, values, or interpretations:

A. Under no circumstances should results be left with an answering service, email...
C. To prevent errors when giving verbal results, there must be verification that the accepting professional understood the result correctly. The process to accomplish this is read-back verification...
E. ...The clinician in Imaging Services shall document notification on the dictated radiology reports.

3. The physician who is notified of the critical test or value/interpretation has the responsibility if interpreting the result in the context of each patient and to take appropriate action, if and as needed.

Approved by the Medical Executive Committee April 10, 2007 and the Regional Medical Center Board April 23, 2010
Revised: August 2010

Based on interviews, medical record reviews and review of policy and procedure, the hospital failed to ensure:

1. The Emergency Department (ED) Physician correctly read Patient Identifier's (PI ) # 1's x-ray to verify placement of the patient's PEG (Percutaneous Endoscopic Gastrostomy) tube

2. Patient Identifier (PI) # 1's x-ray was read by the radiologist to confirm the correct placement of the PEG tube prior to discharging the patient from the ED.

Findings include:

Refer to A0347 for findings.

Based on interviews, review of medical records and medical staff bylaws, it was determined the Emergency Department (ED) Physician failed to identify incorrect placement of the feeding tube by x-ray and assure Patient Identifier (PI) # 1's x-ray was read by the radiologist to confirm the correct placement of the PEG (Percutaneous Endoscopic Gastrostomy) Tube prior to discharging the patient from the ED on 2/15/14.


As a result of these failures, PI # 1 returned to the Emergency Department in a deteriorated, critical clinical condition in slightly over nine hours after discharge with early signs of sepsis (blood infection) to include pain, increased heart rate, increased respirations, fever and bleeding from the site of the feeding tube. PI # 1 required extensive testing and treatment in the ED, was hospitalized and required continued treatment in a long term hospital.

This affected one of eight sampled Emergency Department patients and had the potential to affect all patients served.


Findings include:

Patient Identifier # 1's First ED Visit on 2/15/14 at 11:02:

According to a review of the Nursing Triage notes, PI # 1 arrived in the ED on 2/15/14 at 11:02 with a chief complaint of "From (name of nursing home) after pulling...G (Gastrostomy) tube out." (Gastrostomy is a surgical procedure for inserting a hollow tube through the abdominal wall into the stomach to deliver nutrition).

The patient was assigned an Urgent/Level 4 (based on ESI Emergency Severity Index, a five level triage scale to determine patient acuity in the ED. Level 4: patient can wait several hours to be seen by a provider). The airway is open. Breathing is spontaneous and non-labored. The pulse is regular and strong.

Temperature: 98.5
Pulse: 90
Respirations: 20
Blood Pressure: 148/104

History of Present Illness (documented by the ED Physician # 1) on 2/15/14 at 11:14:

The patient presents with a complaint of PEG (Percutaneous Endoscopic Gastrostomy) tube complication ( A surgical procedure for placing a tube for feeding without having to perform an open operation on the abdomen).
The onset was sudden. The pain severity is mild. The patient was sent here from (name of nursing home) to have...PEG tube reinserted after pulling it out this morning.

Examination by ED Physician:
Constitutional: The patient is alert and in no apparent distress.
Cardiovascular: Regular rate and rhythm.
Respiratory: Breath sounds clear; no distress present.
Gastrointestinal/Abdomen: Soft, non-tender. Normal bowel sounds. PEG tube tract in LUQ (Left Upper Quadrant) with blood in OS (opening).
Integumentary: Warm and dry.


Procedures - Physician
Notes: 20 french PEG tube inserted into existing tract to guard without difficulty and balloon filled with 6 cc's (cubic centimeters) saline. No resistance, Gastrografin infused without difficulty and tube appears to be in the small bowel.


Orders:
X-Ray Abdomen AP view (Anterior/Posterior).
Reason for exam: Feeding tube dislodged.
Special Instructions: Instill gastrografin (into PEG tube) to confirm G tube placement.


Diagnoses: G tube/PEG tube malfunction, Huntington's Chorea


Discharge from ED: The patient is discharged to (name of nursing home)...Condition is satisfactory...


Disposition (Nursing) 2/15/14 at 12:58:

Discharged home. PEG tube problem resolved. The patient is the same as prior to arrival/ Condition is stable.


Single Supine Abdomen/KUB (kidneys, ureter, bladder) X-ray on 2/15/14 at 17:08 (Read by Radiologist after patient's discharge from first ED visit):

Result: "Feeding tube does not lie within the lumen of the stomach. It is difficult to determine it if lies within the mesenteric folds or atypical appearing small bowel lumen. Mild small bowel dilatation is present which could represent ileus, gastroenteritis or mechanical bowel obstruction."
Electronically signed by (name of Radiologist). Date 2/15/14 17:08. (There was no documentation the result of the x-ray was communicated to the ED Physician).


Second ED Visit on 2/15/14 at 20:05:

According to a review of the Nursing Triage notes, PI # 1 arrived in the ED on 2/15/14 at 20:05.

Chief complaint: Bleeding around PEG tube.

Encounter Type: Unscheduled return to ED in less than 12 hours.

Acuity: Level 2 - Critical

History of Present Illness (documented by the Nurse Practitioner, Employee Identifier, EI # 2) on 2/15/14 at 20:12:

This visit is a certified emergency. Vital Signs reviewed. The patient presents with a complaint of g tube problem. The onset was sudden. The symptoms have been constant. Pain severity is moderate. Context: Patient pulled out g tube earlier today and was seen here in the ED where a new tube was placed. Patient was discharged to nursing home.

Modifying factors include: Worse with palpation. Nursing home staff states patient began to bleed from g tube and blood pressure has not been stable. Patient has a history of Huntington's Disease.

Examination:
Examination limited due to altered mental status; patient has baseline AMS (Altered Mental Status).
Constitutional: Patient appears chronically ill. Moaning.
Eyes: Abnormal injected conjuctiva.
Cardiovascular: Tachycardia (resting heart rate over 100 beats per minute).
Respiratory: Tachypneic (rapid breathing). Wheezing, rales and rhonchi bilaterally.
GI/Abdomen: Rigid abdomen. Bloody drainage around g tube site. Bowel sounds absent in all quadrants.
Musculoskeletal/Extremities: Contracted upper extremities.
Integumentary: Hot to touch.

Vital Signs at 20:18:
Temperature: 103.7
Pulse: 148
Respirations: 30
Blood Pressure: 159/99

Pain Scale: 5

Physician Orders:

Saline lock (type of IV)
Acetaminophen 650 milligrams (mg.) rectally at 20:28
Zosyn IVP (Intravenous push) 3.375 grams at 21:33
Flagyl IVPB (intravenous piggy back) at 22:02
Normal Saline bolus x 2
Acetaminophen 650 milligrams (mg.) rectally at 23:32
Cardizem IVP 20 mg. at 23:41 - slow IV push
Cardizem 145 mg. IV drip (maintenance) at 23:47
Ativan 1 mg. IVP at 00:24


Radiology:
"CT (Computed Axial Tomography) Thorax, Abdomen and Pelvis with Contrast. Reason: Shortness of breath / ABD (Abdominal) / Pelvic Pain; Instructions: IV (intravenous) contrast - 2/15/14:

Technique: 5 mm (millimeter) axial images were obtained through the chest, abdomen and pelvis after intravenous contrast. Coronal reformatted images were performed.

Findings:

Abdominal CT: The PEG (Percutaneous Endoscopic Gastrostomy) tube/enteral feeding tube lies within the left rectus muscle sheath. There is gas and fluid noted within the left rectus sheath which could represent abscess or be related to injection of material through the PEG tube. No free intraperitoneal air or intraperitoneal abscess is seen. The liver, spleen, pancreas, gallbladder, adrenal glands and kidneys are unremarkable. Mild gaseous distention of the small intestine could represent ileus.


Impression:
1. Fluid and gas with the left rectus sheath muscle which could or present abscess. PEG tube lies within the left rectus sheath.
2. Inflammatory stranding of the anterior abdominal wall within the pelvis...
Electronically signed by Name of MD/Radiologist 2/17/14 at 08:26."

Consultations: Colo-Rectal Surgery and Family Medicine: Stat (Immediate)

Diagnoses:
Sepsis (Blood Infection)
Abdominal Rigidity
G-tube malfunction
Hypoxemia

Disposition by Physician:

The ED Physician spoke with the attending physician. Admit to Progressive Care Unit. Condition is critical. (Name of surgeon) saw patient in the ED.
Critical Care Indication: Patient was critically ill with a high probability of imminent or life threatening deterioration.


Surgical Consultation Report dated 2/16/14; Author: EI # 7 (Surgeon)

Chief Complaint: Abdominal Pain, malpositioned gastrostomy tube.

History of Present Illness: ...The patient presented to the ED earlier today after the G tube was dislodged. By report of the current Emergency Room physician the tube was replaced and confirmed with "Gastrografin" study. The patient returned to the ED this evening with signs of severe illness including a firm tender abdomen and some bleeding around the PEG tube site and significant tachycardia. Because of this a CAT (Computed Axial Tomography) scan was performed which did demonstrate a malposition of the feeding tube and surgical consultation was placed.


Physical Examination:
Vital Signs: Temperature : 103.7; Pulse: 170's; Respiratory Rate: 30's; Blood Pressure: 159/99. The patient is on supplemental oxygen with a nonrebreather mask.
Neurologic: Patient is awake.
Gastrointestinal (GI): Abdomen is somewhat distended, but particularly on the left portion of the abdomen. There was some firmness and the G tube site has some venous appearing type blood coming from the site. This appears to be controlled with direct pressure.
Skin: Warm.
Musculoskeletal: Has upper extremity contractures. (Huntington's).

Laboratory Data: White Blood Cell Count: 22; Hemoglobin: 18.5.

CAT scan of the abdomen and pelvis by virtual radiology shows percutaneous gastrostomy tract present, malpositioning of the gastrostomy tube. The tube does not enter the abdominal cavity, but rather it deviates quarterly with dissection to the left rectus abdominis muscular sheath with the balloon inflated within the rectus sheath itself. There is also possibility of vascular contrast extravasation with possible hematoma. There is fluid and gas collection suspicious for hematoma or abscess.

Impression:
1. Malpositioned gastrostomy tube.
2. Early sepsis.
3. Huntington's chorea.
4. The patient is do not resuscitate.

Plan: I had a very long discussion with the family...family understands the fact that with the patient's current presentation it may be very difficult to correct the current stage without...requiring a trip to the operating room. The patient has elevated temperature and elevated white blood cell count.

The patient is hypoxic, requiring supplemental oxygen and definitely has signs of early sepsis compounded by the fact that he may require general anesthesia....the patient may have a difficult time recovering from surgery even if the patient were to survive the operation...the family has decided not to go through with the operation this evening...


Discharge Summary dictated 3/10/14 by Attending Physician, EI # 9:

Date of Admission: 2/15/14
Date of Discharge: 2/19/14

Final Diagnoses:
1. Severe Huntington's Chorea...Patient removal of PEG tube in a traumatic way.
2. Malpositioning of the PEG tube with abdominal muscle bleeding due to prior patient-induced trauma...

Disposition: (Name of Long Term Care Hospital).

History of Present Illness:
Abdominal pain after patient traumatically removed PEG tube.
Malpositioning of PEG tube.

Hospital Course: ...Nursing home patient with severe limb chorea who forcefully pulled out PEG tube. We were not able to reposition it, so the patient had to be admitted. The patient had an abdominal wall abscess. The patient was placed on Flagyl, Zosyn and TPN. The long term goal is to reinsert the PEG tube after a month of IV (intravenous) Flagyl and Zosyn...


Interviews:

Interview on 4/22/14 at 16:32 with the ED RN (Registered Nurse), EI # 3:

During the interview, the RN (EI # 3) responsible for triage of the patient during the first ED visit on 2/15/14, said the patient was non-verbal, but could communicate by nodding of the head. The RN (EI # 3) heard the ED Physician (EI # 1) say he thought the patient's feeding tube was in the small bowel after he replaced the feeding tube during the patient's first ED visit.

Prior to the patient's return to the ED on 2/15/14 at 20:05, the RN (EI # 3) stated she received report from EMS (Emergency Medical Services) staff. "I suspected it was the same patient. I told (name of ED Physician/EI # 1). I pulled up the x-ray and showed him the interpretation by the radiologist." According to the report from EMS, the patient sounded, "Pretty critical."

According to EI # 3 she was not assigned to the patient during the second visit, but assisted in caring for the patient. The RN (EI # 3) said, "I tried to paint a picture of the patient. The difference between the patient's first and second visit for staff at shift change."

During the second ED visit the patient was in and out of consciousness and had severe abdominal pain, abdominal distention, tachypneia (rapid breathing), tachycardia (resting pulse > 100) and blood around the PEG tube. The RN did not recall the amount of blood, but said the blood was, "A darker color, not like a hemorrhage." According to the RN, the patient during the second ED visit, was in obvious distress and pain with hard, fast respirations that, "Looked painful." The patient could not lie flat. His abdomen was distended and rigid. The feeding tube was clamped off. The patient had a fever of 103.7 and was hypertensive with an elevated heart rate in the 180's.


Interview with the Nurse Practitioner (NP), EI # 4, on 4/22/14 at 15:45, who was assigned to the patient during the patient's return ED visit at 20:05 on 2/15/14:

According to the NP, the patient had a problem with the feeding tube and was not responding much. The patient was moaning, tachycardic and rales and rhonchi were present in the lungs. The abdomen was rigid with blood draining around the tube site and no bowel sounds were present. When asked if the patient's family was present, the NP said, "A lady showed up...not sure of relationship." The NP said he was aware the patient had a feeding tube placed earlier in the day in the ED.

"(Name of surgeon) saw the patient in the ER, I think." The patient was made a DNR (Do Not Resuscitate). According to the Nurse Practitioner, the tube was in the muscle, not where it should be." The NP said the tube should be in the stomach or bowel depending on the type of feeding tube. "(Name of ED Physician) saw the patient within a few minutes."


Interview on 4/23/14 at 09:30 with PI # 1's Attending Physician, EI # 9:

The patient had constant movement related to Huntington's Disease. The patient pulled the PEG tube out..."ripped it out of his/her stomach" and was sent to the ED. The ED Physician tried to reinsert the tube. The patient was sent back to the nursing home. The PEG (tube) was not in the stomach and the patient had to return to the ED.


Interview on 4/23/14 at 09:50 with the Surgeon, EI # 7, who was consulted by ED staff during the patient's second ED visit:

According to the surgeon PEG tubes are usually placed endoscopically (use of scope to visualize the inside of an organ or passageway). When a tube has been in place for a long time and is dislodged, it should be easy to replace with a catheter to maintain the opening until the tube can be replaced. The surgeon said it would take "force" to dislodge a PEG tube.


Telephone Interview on 4/23/14 at 11:07 with the Radiologist, EI # 8, who read the patient's abdominal x-ray on 2/15/14 to verify placement of the feeding tube during the first ED visit:

The radiologist was asked if he called anyone after reading the patient's abdominal x-ray that indicated the feeding tube was not in the lumen of the patient's stomach. He responded, "I don't know. I can't remember. Usually I do, but I didn't document." The radiologist was asked how abnormal radiological findings are communicated by the Radiology Department to ED Physicians. The Radiologist said, "They can get results. If critical I will call the MD (Medical Doctor)."


Interview with ED Physician, EI # 1, on 4/23/14 at 11:30, who was assigned to the patient during the first ED visit on 2/15/14:

According to EI # 1, the bulb of the feeding tube was in the gastrostomy opening when he evaluated the patient during the first visit to the ED. EI # 1 stated no bleeding was present. The tube was easily inserted. After inserting the PEG tube, the ED Physician ordered an abdominal x-ray with gastrografin to confirm placement. The ED physician stated he read the x-ray and thought the tube was in the patient's small bowel. The physician said Gastrografin, a radiopaque substance, "Goes into whatever cavity the tube is in. It can't be pushed into tissue." The surveyor asked the ED Physician if the radiologist called or notified him about the radiologist's interpretation of the x-ray (feeding tube not in the stomach) and he said, "No." The ED Physician was asked if anyone informed him of the x-ray reading by the radiologist. According to the ED Physician, he said the next day he learned the patient returned to the ED and was septic. The ED Physician was asked if he discussed his interpretation of the patient's x-ray versus the interpretation by the radiologist with staff. He said he discussed it with the ED Medical Director and the ED Physician who was assigned to the patient when the patient returned to the ED on 2/15/14.

The ED Physician / EI # 1 was asked about his medical opinion regarding the dramatic change in the patient's condition by the time the patient returned to the ED on 2/15/14. According to the ED Physician, when he re-inserted the new PEG tube, he hit a walled off pocket in the stomach and "popped" an abscess. When the patient's tube feeding was resumed, the infection was circulated. The ED Physician said he called radiology to get the results and "waited a while." "We (ED) were busy. I thought the tube placement was correct." The patient was sent back to the nursing home. "The only thing I could have done differently: I could have called the radiologist and asked him to read the x-ray or the other option: Admit the patient and have the tube inserted in a procedure area like the GI lab."


Interview with Radiology Director, EI # 10, on 4/23/14 at 15:19:

According to the Director, it is the practice of the radiologist to report critical/urgent results to the ER Physician via telephone. The Director stated there is a policy related to notification of critical results and he will provide a copy to the surveyor.


Interview with ED Medical Director, EI # 11, on 4/24/14 at 11:07:

The Medical Director said he was aware of the misread of the patient's abdominal x-ray in the ED on 2/15/14 and the failure of the radiologist to notify the ED Physician about his interpretation that the feeding tube was not in the patient's stomach. He stated the "overread process is not crisp," and there is a practice improvement project in place unrelated to this event. Regarding the radiologist's reading of PI # 1's x-ray the Medical Director said, "I would have wanted the radiologist to call me." The Medical Director said he spoke with the Chair of Radiology (EI # 12) who was also aware of the incident. Both departments (ED and Radiology) "redoubled" efforts regarding the communication lapse.


Interview with Chair of the Radiology, EI # 12, on 4/24/14 at 13:35:

According to the radiologist, critical radiology results are communicated to the ED physician usually via a telephone call. The surveyor asked the radiologist to interpret the results of abdominal x-ray as documented by the radiologist who read the x-ray on 2/15//14. A copy of the patient's x-ray result was available. The radiologist stated the patient's feeding tube was not in the stomach. The radiologist was asked where the tube should be located and he said, "Should be in the stomach." When asked if the reading radiologist should have called the ED Physician with his interpretation the radiologist said, "I guess." The radiologist was also asked to identify who has the responsibility to read x-rays. He responded, "Radiologist. A lot of times the ED reads initially because the ER moves fast - faster than the radiologist can keep up." The radiologist said he was not sure how he found out about the incident and was not sure if he had a discussion with the ED Medical Director. According to the radiologist the general practice and policy of the Radiology Department is to call the ED Physician if the radiologist determines his reading is significant/critical. The radiologist stated, "Don't know why Dr. (name of radiologist who read x-ray) didn't call. Don't know what was going on at the time of this incident. He (name of radiologist who read x-ray) calls a lot of results. I'm surprised he did not call."


Telephone interview with ED Medical Director, EI # 11, on 4/25/14 at 12:04:

The Medical Director was asked what, if any, immediate action was taken when he became aware of the incident related to the misplacement of the patient's feeding tube and the failure of the radiologist after reading the x-ray to notify the ED Physician that the feeding tube was not in the patient's stomach. The Medical Director replied, "No. We didn't. We already had a process to improve in place."

The Medical Director (EI # 11) said he and EI # 12 (Chair of the Radiology Department) spoke today. Effective immediately all patients with a feeding tube are not to be discharged from the ED until placement of the tube is confirmed by a Radiologist.


Medical Staff Bylaws, Revised July 2013 Review:

Article II Membership

2.5 Basic Responsibilities of Medical Staff Membership

Except for the honorary and retired staff, the ongoing responsibilities of each member of the medical staff shall include:
(a) providing patients with the quality of care that meets the professional standards of the medical staff of this hospital...


EI # 1, ED Physician failed to identify the incorrect PEG tube placement during PI # 1's first ED visit.

EI # 8, Radiologist failed to call a critical results to the ED physician.

Based on interviews, medical record reviews and review of policy and procedure, the hospital failed to ensure the radiologist notified the Emergency Department (ED) Physician of the critical interpretation of Patient Identifier (PI) # 1's x-ray to confirm feeding tube placement (feeding tube tip does not lie within the lumen of the stomach) prior to discharging the patient from the ED on 2/15/14.

Findings Include:

Refer to A0546 for findings.

Based on interviews, medical record reviews and review of policy and procedure, it was determined the radiologist failed to notify the Emergency Department (ED) Physician that Patient Identifier (PI) # 1's feeding tube was not in the stomach. As a result of these failures, Patient Identifier (PI) # 1 returned to the Emergency Department in a deteriorated, critical clinical condition in slightly over nine hours after discharge with early signs of sepsis (blood infection) to include pain, increased heart rate, increased respirations, fever and bleeding from the site of the feeding tube. PI # 1 required extensive testing and treatment in the ED, was hospitalized and required continued treatment in a long term hospital. This affected one of eight sampled Emergency Department patients and had the potential to affect all patients served.

Findings Include:

Patient Identifier # 1's first ED Visit on 2/15/14 at 11:02:

According to a review of the Nursing Triage notes, PI # 1 arrived in the ED on 2/15/14 at 11:02 AM with a chief complaint of "From (name of nursing home) after pulling...G (Gastrostomy) tube out." (Gastrostomy is a surgical procedure for inserting a hollow tube through the abdominal wall into the stomach to deliver nutrition).

The patient was assigned an Urgent/Level 4 (based on ESI Emergency Severity Index, a five level triage scale to determine patient acuity in the ED. Level 4: patient can wait several hours to be seen by a provider). The airway is open. Breathing is spontaneous and non-labored. The pulse is regular and strong.

Temperature: 98.5
Pulse: 90
Respirations: 20
Blood Pressure: 148/104

History of Present Illness (documented by the ED Physician # 1) on 2/15/14 at 11:14:

The patient presents with a complaint of PEG (Percutaneous Endoscopic Gastrostomy) tube complication ( A surgical procedure for placing a tube for feeding without having to perform an open operation on the abdomen).
The onset was sudden. The pain severity is mild. The patient was sent here from (name of nursing home) to have...PEG tube reinserted after pulling it out this morning.

Examination by ED Physician:
Constitutional: The patient is alert and in no apparent distress.
Cardiovascular: Regular rate and rhythm.
Respiratory: Breath sounds clear; no distress present.
Gastrointestinal/Abdomen: Soft, non-tender. Normal bowel sounds. PEG tube tract in LUQ (Left Upper Quadrant) with blood in OS (opening).
Integumentary: Warm and dry.


Procedures - Physician
Notes: 20 french PEG tube inserted into existing tract to guard without difficulty and balloon filled with 6 cc's (cubic centimeters) saline. No resistance, Gastrografin infused without difficulty and tube appears to be in the small bowel.


Orders:
X-Ray Abdomen AP view (Anterior/Posterior).
Reason for exam: Feeding tube dislodged.
Special Instructions: Instill gastrografin (into PEG tube) to confirm G tube placement.


Diagnoses: G tube/PEG tube malfunction, Huntington's Chorea


Discharge from ED: The patient is discharged to (name of nursing home)...Condition is satisfactory...


Disposition (Nursing) 2/15/14 at 12:58:

Discharged home. PEG tube problem resolved. The patient is the same as prior to arrival/ Condition is stable.


Single Supine Abdomen/KUB (kidneys, ureter, bladder) X-ray on 2/15/14 at 17:08 (Read by Radiologist after patient's discharge from first ED visit):

Result: "Feeding tube does not lie within the lumen of the stomach. It is difficult to determine it if lies within the mesenteric folds or atypical appearing small bowel lumen. Mild small bowel dilatation is present which could represent ileus, gastroenteritis or mechanical bowel obstruction."
Electronically signed by (name of Radiologist). Date 2/15/14 17:08. (There was no documentation the result of the x-ray was communicated to the ED Physician).


Second ED Visit on 2/15/14 at 20:05:

According to a review of the Nursing Triage notes, PI # 1 arrived in the ED on 2/15/14 at 20:05.

Chief complaint: Bleeding around PEG tube.

Encounter Type: Unscheduled return to ED in less than 12 hours.

Acuity: Level 2 - Critical

History of Present Illness (documented by the Nurse Practitioner, Employee Identifier, EI # 2) on 2/15/14 at 20:12:

This visit is a certified emergency. Vital Signs reviewed. The patient presents with a complaint of g tube problem. The onset was sudden. The symptoms have been constant. Pain severity is moderate. Context: Patient pulled out g tube earlier today and was seen here in the ED where a new tube was placed. Patient was discharged to nursing home.

Modifying factors include: Worse with palpation. Nursing home staff states patient began to bleed from g tube and blood pressure has not been stable. Patient has a history of Huntington's Disease.

Examination:
Examination limited due to altered mental status; patient has baseline AMS (Altered Mental Status).
Constitutional: Patient appears chronically ill. Moaning.
Eyes: Abnormal injected conjuctiva.
Cardiovascular: Tachycardia (resting heart rate over 100 beats per minute).
Respiratory: Tachypneic (rapid breathing). Wheezing, rales and rhonchi bilaterally.
GI/Abdomen: Rigid abdomen. Bloody drainage around g tube site. Bowel sounds absent in all quadrants.
Musculoskeletal/Extremities: Contracted upper extremities.
Integumentary: Hot to touch.

Vital Signs at 20:18:
Temperature: 103.7
Pulse: 148
Respirations: 30
Blood Pressure: 159/99

Pain Scale: 5


Radiology:
"CT (Computed Axial Tomography) Thorax, Abdomen and Pelvis with Contrast. Reason: Shortness of breath / ABD (Abdominal) / Pelvic Pain; Instructions: IV (intravenous) contrast - 2/15/14:

Technique: 5 mm (millimeter) axial images were obtained through the chest, abdomen and pelvis after intravenous contrast. Coronal reformatted images were performed.

Findings:

Abdominal CT: The PEG (Percutaneous Endoscopic Gastrostomy) tube/enteral feeding tube lies within the left rectus muscle sheath. There is gas and fluid noted within the left rectus sheath which could represent abscess or be related to injection of material through the PEG tube. No free intraperitoneal air or intraperitoneal abscess is seen. The liver, spleen, pancreas, gallbladder, adrenal glands and kidneys are unremarkable. Mild gaseous distention of the small intestine could represent ileus.


Impression:
1. Fluid and gas with the left rectus sheath muscle which could or present abscess. PEG tube lies within the left rectus sheath.
2. Inflammatory stranding of the anterior abdominal wall within the pelvis...
Electronically signed by Name of MD/Radiologist 2/17/14 at 08:26."


Consultations: Colo-Rectal Surgery and Family Medicine: Stat (Immediate)

Diagnoses:
Sepsis (Blood Infection)
Abdominal Rigidity
G-tube malfunction
Hypoxemia

Disposition by Physician:

The ED Physician spoke with the attending physician. Admit to Progressive Care Unit. Condition is critical. (Name of surgeon) saw patient in the ED.
Critical Care Indication: Patient was critically ill with a high probability of imminent or life threatening deterioration.


Surgical Consultation Report dated 2/16/14; Author: EI # 7 (Surgeon)

Chief Complaint: Abdominal Pain, malpositioned gastrostomy tube.

History of Present Illness: ...The patient presented to the ED earlier today after the G tube was dislodged. By report of the current Emergency Room physician the tube was replaced and confirmed with "Gastrografin" study. The patient returned to the ED this evening with signs of severe illness including a firm tender abdomen and some bleeding around the PEG tube site and significant tachycardia. Because of this a CAT (Computed Axial Tomography) scan was performed which did demonstrate a malposition of the feeding tube and surgical consultation was placed.


CAT scan of the abdomen and pelvis by virtual radiology shows percutaneous gastrostomy tract present, malpositioning of the gastrostomy tube. The tube does not enter the abdominal cavity, but rather it deviates quarterly with dissection to the left rectus abdominis muscular sheath with the balloon inflated within the rectus sheath itself. There is also possibility of vascular contrast extravasation with possible hematoma. There is fluid and gas collection suspicious for hematoma or abscess.

Impression:
1. Malpositioned gastrostomy tube.
2. Early sepsis.
3. Huntington's chorea.
4. The patient is do not resuscitate.


Interviews:

Interview on 4/22/14 at 16:32 with the ED RN (Registered Nurse), EI # 3:

During the interview, the RN (EI # 3) responsible for triage of the patient during the first ED visit on 2/15/14, said the patient was non-verbal, but could communicate by nodding of the head. The RN (EI # 3) heard the ED Physician (EI # 1) say he thought the patient's feeding tube was in the small bowel after he replaced the feeding tube during the patient's first ED visit.

Prior to the patient's return to the ED on 2/15/14 at 20:05, the RN (EI # 3) stated she received report from EMS (Emergency Medical Services) staff. "I suspected it was the same patient. I told (name of ED Physician/EI # 1). I pulled up the x-ray and showed him the interpretation by the radiologist." According to the report from EMS, the patient sounded, "Pretty critical."


Interview on 4/23/14 at 09:50 AM with the Surgeon, EI # 7, who was consulted by ED staff during the patient's second ED visit:

According to the surgeon PEG tubes are usually placed endoscopically (use of scope to visualize the inside of an organ or passageway). When a tube has been in place for a long time and is dislodged, it should be easy to replace with a catheter to maintain the opening until the tube can be replaced. The surgeon said it would take "force" to dislodge a PEG tube.


Telephone Interview on 4/23/14 at 11:07 with the Radiologist, EI # 8, who read the patient's abdominal x-ray on 2/15/14 to verify placement of the feeding tube during the first ED visit:

The radiologist was asked if he called anyone after reading the patient's abdominal x-ray that indicated the feeding tube was not in the lumen of the patient's stomach. He responded, "I don't know. I can't remember. Usually I do, but I didn't document." The radiologist was asked how abnormal radiological findings are communicated by the Radiology Department to ED Physicians. The Radiologist said, "They can get results. If critical I will call the MD (Medical Doctor)."


Interview with ED Physician, EI # 1, on 4/23/14 at 11:30, who was assigned to the patient during the first ED visit on 2/15/14:

According to EI # 1, the bulb of the feeding tube was in the gastrostomy opening when he evaluated the patient during the first visit to the ED. EI # 1 stated no bleeding was present. The tube was easily inserted. After inserting the PEG tube, the ED Physician ordered an abdominal x-ray with gastrografin to confirm placement. The ED physician stated he read the x-ray and thought the tube was in the patient's small bowel. The physician said Gastrografin, a radiopaque substance, "Goes into whatever cavity the tube is in. It can't be pushed into tissue." The surveyor asked the ED Physician if the radiologist called or notified him about the radiologist's interpretation of the x-ray (feeding tube not in the stomach) and he said, "No." The ED Physician was asked if anyone informed him of the x-ray reading by the radiologist. According to the ED Physician, he said the next day he learned the patient returned to the ED and was septic. The ED Physician was asked if he discussed his interpretation of the patient's x-ray versus the interpretation by the radiologist with staff. He said he discussed it with the ED Medical Director and the ED Physician who was assigned to the patient when the patient returned to the ED on 2/15/14.

The ED Physician said he called radiology to get the results and "waited a while." "We (ED) were busy. I thought the tube placement was correct." The patient was sent back to the nursing home. "The only thing I could have done differently: I could have called the radiologist and asked him to read the x-ray or the other option: Admit the patient and have the tube inserted in a procedure area like the GI lab."


Interview with Radiology Director, EI # 10, on 4/23/14 at 15:19:

According to the Director, it is the practice of the radiologist to report critical/urgent results to the ER Physician via telephone. The Director stated there is a policy related to notification of critical results and he will provide a copy to the surveyor.


Interview with Chair of the Radiology, EI # 12, on 4/24/14 at 13:35:

According to the radiologist, critical radiology results are communicated to the ED physician usually via a telephone call. The surveyor asked the radiologist to interpret the results of abdominal x-ray as documented by the radiologist who read the x-ray on 2/15//14. A copy of the patient's x-ray result was available. The radiologist stated the patient's feeding tube was not in the stomach. The radiologist was asked where the tube should be located and he said, "Should be in the stomach." When asked if the reading radiologist should have called the ED Physician with his interpretation the radiologist said, "I guess." The radiologist was also asked to identify who has the responsibility to read x-rays. He responded, "Radiologist. A lot of times the ED reads initially because the ER moves fast - faster than the radiologist can keep up." The radiologist said he was not sure how he found out about the incident and was not sure if he had a discussion with the ED Medical Director. According to the radiologist the general practice and policy of the Radiology Department is to call the ED Physician if the radiologist determines his reading is significant/critical. The radiologist stated, "Don't know why Dr. (name of radiologist who read x-ray) didn't call. Don't know what was going on at the time of this incident. He (name of radiologist who read x-ray) calls a lot of results. I'm surprised he did not call."


Policy and Procedure Review:

Subject: Communicating Critical Tests and Values/Interpretations

Purpose: To describe the process for timely and reliable reporting of critical tests and values or interpretations to health care providers.

Definitions:
Critical Tests and Values/Interpretations are defined as those that indicate the patient may be in danger of death or serious adverse consequences unless treatment is initiated promptly or require immediate reporting so the physician may make a decision regarding the appropriate clinical action for the patient.

The Medical Executive Committee shall develop and regularly update a list of tests, values or interpretations that require immediate notification and are, therefore, deemed to be critical tests, values or interpretations under this policy.

Scope:
This policy applies to critical test, values, or interpretations from Laboratory, Imaging, Obstetric and NC (Neurocardiology) Services reporting to inpatient, outpatient and Emergency Department (ED) areas...

Policy: Procedure for communicating critical tests and values/interpretations

The specified time frame is provided for guidance purposes only...There are certain circumstances that may arise where adherence to the specified time frame is not feasible. When these circumstances arise, notification should be provided pursuant to this policy as soon as possible to a physician who can take action.

1. Time frame for notification critical tests and values/interpretations:

A. When a critical test or value/interpretation is identified and verified, the clinician shall notify the physician. For inpatient areas, if the physician cannot be notified, then the clinician caring for the patient shall be notified.

B. Time frame for notification of a critical value is 60 minutes....

C. Time frame for notification of critical test interpretation is specific to the individual test...

Attachment C: Critical Values - Imaging Services...

2. The notification process for reporting critical tests, values, or interpretations:

A. Under no circumstances should results be left with an answering service, email...
C. To prevent errors when giving verbal results, there must be verification that the accepting professional understood the result correctly. The process to accomplish this is read-back verification...
E. ...The clinician in Imaging Services shall document notification on the dictated radiology reports.

3. The physician who is notified of the critical test or value/interpretation has the responsibility if interpreting the result in the context of each patient and to take appropriate action, if and as needed.

Approved by the Medical Executive Committee April 10, 2007 and the Regional Medical Center Board April 23, 2010
Revised: August 2010


EI # 8, Radiologist failed to follow the hospital policy and call a critical results to the ED Physician.