HospitalInspections.org

Based on interview and record review, the facility failed to track an adverse patient event for one of ten patients reviewed (Patient #2). This could affect all patients receiving services from the facility. The patient census was 123.

Findings include:

Review of the policy and procedure titled, Premier Incident Reports, effective 02/28/20, revealed the objective is to outline the use of an incident report as a tool to notify Risk Management of any incident that is not consistent with the routine operations or situations that may potentially or actually result in injury, harm or loss to any patient/non-patient. The definition of incident is any happening not consistent with the routine operation of the facility or routine care of a particular patient; an unexpected incident; an occurrence that leaves a patient, visitor or other person feeling either rightly or wrongly that he has been mistreated, neglected or injured in some manner. The following guidelines shall generally be followed in the case of any incident including, it is the responsibility of every employee to report incidents/errors as a means for the hospital to assess and improve processes and systems related to safe patient care and/or operations and to identify potential claims against the hospital. Should an employee have a question as to whether or not to report an incident, report the incident. Events/errors need to be reported as soon as they are recognized. When possible, the report should be filed by the employee who discovered or was involved in the incident. Reportable incidents involving injury or potential injury to patients or visitors included (but are not limited to) the following major categories including equipment/device/product problem and medical treatment problem/complication.

Review of a written complaint to the hospital by Patient #2 dated 06/20/21 revealed the patient's "blood port" was torn out of her back, which caused bleeding that he/she was left to lay in.

Review of the surgical history revealed Patient #2 had a ventral hernia repair on 06/14/21 and a stealth guided posterior lumbar inner body fusion of the lumbar 4-5 and L-5S1 anterior lumbar interbody fusion (ALIF) and L4-S1 posterior lumbar decompression and fusion on 06/15/21. There was a Hemovac drain inserted after Patient #2's surgery on 06/15/21.

The medical record revealed documentation that a full assessment of the drain site was completed every 12 hour shift. The full assessment of the Hemovac drain site was completed by Staff F at 7:34 PM on the 7:00 PM to 7:00 AM shift. The documentation on the drain site appearance was normal, dressing was clean dry and intact and the suction was continuous.

Interview with Staff B of four north medical surgical unit on 08/10/21 at 2:13 PM revealed Staff F, who took care of Patient #2 from 7:00 PM to 7:00 AM on 06/16/21, told him the Hemovac drain was leaking and Patient #2 was very upset. Staff F told Staff B that she had taped the tubing at the Y coupling because there was no suction and the tubing was disconnected from the Hemovac. Staff B then contacted Staff E and they both went into Patient #2's room to look at the Hemovac and noticed the the nurse put tape around the Y port that went to the Hemovac to stop it from leaking. Staff B stated there was about 30 milliliters of dark red drainage on the chux (pad) beneath the patient. Further interview with Staff B revealed he educated Staff F in regard to taping the port and that this could not be done.

Interview on 08/12/21 at 8:53 AM with Staff F, who provided care to Patient #2 on 06/16/21, revealed that she worked from 7:00 PM to 7:00 AM on 06/16/21. Staff F revealed that the connection to the Hemovac became disconnected two times during the night shift. The first time she just reconnected the tubing and that there was already tape in place at the connection site. Approximately 1/4 of the chux was covered with red drainage, but it was not soaked. When the tubing was disconnected at the Y port there was no suction and the blood was draining onto the chux (pad) beneath the patient and not into the Hemovac container (reservoir). Staff F stated she did not notify the surgeon and she should not have taped the Y port. Staff F stated when the Hemovac tubing disconnected it would not compress to suction the blood into the container. Staff F did not recall if she documented about the Hemovac becoming disconnected at the Y port. Staff F revealed she did not complete an incident report. Staff F stated she notified the nurse manager the morning of 06/16/21 when he was making rounds.

Review of the medical record for the date of 06/16/21 from 7:00 PM to 7:00 AM revealed there was no documentation regarding the disconnected tubing or of an incident report.

Interview with Staff A on 08/12/21 following (no time) revealed there was no incident report completed and there should have been one based on their policy.

Based on interview and record review, the facility failed to evaluate the nursing care for one of ten patients reviewed (Patient #2). This could affect all patients receiving services from the facility. The patient census was 123.

Findings include:

Review of information titled, Hemovac Drain (Patient Education and Procedure), last reviewed 06/07/21, revealed a Hemovac drain may be used to help get rid of the extra fluid from around the cut site. A Hemovac drain is made up of two parts. The first part is a thin rubber tube. The other part is a round drain with springs inside and a removable cap. When the round drain is compressed, it creates suction and the container collects fluid from the body. As the drain collects fluid, it becomes less and less compressed and loses suction when it is full. After emptying the drain, it is compressed again to create suction to drain the wound. The patient should contact the doctor when the drain becomes loose, comes apart, won't stay compressed, or falls out.

Review of a written complaint to the hospital by Patient #2 dated 06/20/21 revealed the patient's "blood port" was torn out of her back, which caused bleeding that he/she was left to lay in.

Review of Patient #2's surgical history revealed the patient had a ventral hernia repair on 06/14/21 and a stealth guided posterior lumbar inner body fusion of the lumbar 4-5 and L-5S1 anterior lumbar interbody fusion (ALIF) and L4-S1 posterior lumbar decompression and fusion on 06/15/21. There was a Hemovac drain inserted after Patient #2's surgery on 06/15/21.

The medical record revealed documentation that a full assessment of the drain site was completed every 12 hour shift. The full assessment of the Hemovac drain site was completed by Staff F at 7:34 PM on the 7:00 PM to 7:00 AM shift. The documentation on the drain site appearance revealed it was normal, the dressing was clean dry and intact and the suction was continuous.

Interview with Staff B of four north medical surgical unit on 08/10/21 at 2:13 PM revealed Staff F, who took care of Patient #2 from 7:00 PM to 7:00 AM on 06/16/21, told him the Hemovac drain was leaking and Patient #2 was very upset. Staff F told Staff B that she had taped the tubing at the Y coupling because there was no suction and the tubing was disconnected from the Hemovac. Staff B then contacted Staff E and they both went into Patient #2's room to look at the Hemovac and noticed the the nurse put tape around the Y port that went to the Hemovac to stop it from leaking. Staff B stated there was about 30 milliliters of dark red drainage on the chux (pad) beneath the patient. Further interview with Staff B revealed he educated Staff F in regard to taping the port and that this could not be done.

Interview on 08/12/21 at 8:53 AM with Staff F, who provided care to Patient #2 on 06/16/21, revealed that she worked from 7:00 PM to 7:00 AM on 06/16/21. Staff F revealed that the connection to the Hemovac became disconnected two times during the night shift. The first time she just reconnected the tubing and that there was already tape in place at the connection site. Approximately 1/4 of the chux was covered with red drainage, but it was not soaked. When the tubing was disconnected at the Y port there was no suction and the blood was draining onto the chux (pad) beneath the patient and not into the Hemovac container (reservoir). Staff F stated she did not notify the surgeon and she should not have taped the Y port. Staff F stated when the Hemovac tubing disconnected it would not compress to suction the blood into the container. Staff F did not recall if she documented about the Hemovac becoming disconnected at the Y port. Staff F stated she notified the nurse manager the morning of 06/16/21 when he was making rounds.

Review of the medical record for the date of 06/16/21 from 7:00 PM to 7:00 AM revealed there was no documentation regarding the disconnected tubing or notification to the surgeon for the Hemovac issues according to the Hemovac instructions that were provided.

Interview with Staff G on 08/12/21 at 9:45 AM revealed Staff F taped the tubing at the Y port to the wrong side of the Y port and it was not compressing to suction the blood. Further interview with Staff G revealed the physician should have been notified.

This substantiates Substantial Allegation OH00124007.