HospitalInspections.org

Based on interview and record review, the governing body failed to:

1. Prevent an adverse event with a wrong-site surgical procedure.
2. Prevent a patient in the emergency department (ED) from falling and fracturing his nose

Findings:

1. A review of Patient 30's medical chart included a signed consent for a left thoracentesis (a procedure used to drain excess fluid from the space between the lungs and the chest wall.) with the possible placement of a chest tube dated 4/13/2020. A review of the pre-procedure verification form dated 4/13/20 at 2:54 p.m. indicated the provider performing the procedure marked "thoracentesis." Still, there was no laterality (a term that refers to the preference most people show for one side of their body over the other) documented. On 4/13/20 at 3:26 p.m., a staff member verified the "Time Out" record noted the procedure site and side.

A review of the operative note dated 4/13/20 documented physician (MD) 14 performed a right-sided thoracentesis. After completing the right-sided thoracentesis, MD 14 wrote, "The intended side of the intervention was the left." MD 14 then performed a left-sided thoracentesis.

An interview with the Patient Safety Director (PSD) on 4/7/2020 at 11:35 a.m. indicated to mark the procedure site preoperatively. During Time Out, the provider should read the procedure from the signed consent form.

A review of the facility's policy titled "Patient Identification, procedure and site verification for surgical and invasive procedures" dated 2/18 indicated that the surgeon, physician, or proceduralist shall read the consent aloud procedure title. The circulating nurse shall read the procedure title from the consent aloud as a secondary independent double-check. The entire team the procedure matches the consent and is correct before proceeding. During the final Time Out, the surgeon reads the patient's name, medical record number, and procedure from the whiteboard while the RN compares and confirms by reading the consent.

2. A review of Patient 33's record showed an admission to the Emergency Department (ED) on 4/21/2020 at 6:41 p.m. A review of an ED notes at 6:43 p.m. documented Patient 33, found on the floor by ED staff after being brought in by paramedic. There was blood noted on the floor. The bed was in the highest position, with one side rail down. Blood coming from the patient's nose.

A review of Patient 33's imaging tests after the fall, dated 4/21/2020, documented "Nasal fracture is noted. Additional fracture of the nasal septum is noted".

Review of the facility's documentation titled "Handoff Communication" dated 8/2017 indicated 'Handoff communication is required of all care providers in all care settings" and includes a fall risk assessment.

On 10/6/2020, at 4:15 p.m., an interview with the Regulatory Director indicated all patient safety findings concerns are reported and reviewed by the medical executive committee (MEC). The MEC determines and decides which events to report to the Department.

The Department did not receive a report about Patient 33's fall. The Regulatory Director indicated Patient 33 fracture was not considered reportable.

A review of a facility policy titled "Hospital Quality and Patient Safety Program Description" dated 7/12/2020 indicated, "The MEC has oversight of the quality of care and patient safety provided to the patients."

Based on observation, interview, and record review, the facility failed to evaluate 1 of 32 patients (Patient 12) when a staff member, who monitors the patient's via telemetry (a monitor that tracks the patient's heart status), noted the patient off telemetry. This deficient practice resulted in Patient 12 being found nonresponsive in her room, and eventually dying.


Findings:

1. A review of Patient 12's History and Physical (H&P, report that gathers information about the patient's past and present medical condition) indicated an admission to the Intensive Care Unit (ICU, an area where care requires intensive monitoring and special emergency equipment). The H&P showed that Patient 12 came to the facility with worsening shortness of breath, and abdominal pain associated with nausea and vomiting. The patient history included the use of alcohol and illicit drugs. The H&P assessed Patient 12 with respiratory failure (condition when there is not enough oxygen into the body), right-sided pleural effusion (accumulation of excess fluid in the cavity surrounding the right side of the lungs), alcoholic cirrhosis (the most advanced form of liver disease related to alcohol consumption), and anemia (deficiency of red blood cells which carry oxygen to all parts of the body). The H&P plan to counteract alcoholic cirrhosis included a blood transfusion to keep hemoglobin (a protein that carries oxygen to the body) and start an antibiotic. The patient needed a thoracentesis (draining fluid from the lungs) and monitoring the hemodynamics (monitoring heart function to ensure proper blood flow).

According to Patient 12's Multi-Discipline Progress Note dated 7/16/2020 at 8:45 p.m., RN 17 reported on 7/16/2020 at 9:15 a.m., Patient 12 was lying on the bed, with half of her body and the legs dangling off the side of the bed. The patient was not responsive. The RN called a code blue (an emergency announced in a hospital where specialized personnel and equipment are required to renew a person in cardiopulmonary arrest). At 9:43 a.m., Patient 12 was pronounced dead.

A review of Patient 12's "Death Summary" indicated a need for more oxygen, which complicated patient 12's condition. An imaging study showed COVID 19 (an infectious disease caused by severe acute respiratory syndrome from the coronavirus) pneumonia. The summary stated, at 9 a.m. on 7/16, 2020, the nursing staff called a code blue and performed life-sustaining measures for 24 minutes before Patient 12 expired.

A review of Patient 12's medical record indicated no nursing notation regarding the telemetry monitoring leads (remote cardiac monitoring with electrical leads attached to the patient).

During an interview with Monitor Tech (MT) 1 on 10/2/2020 at 1:30 p.m., MT 1 stated that when a patient is disconnected from telemetry, an alarm is signaled to the monitoring station and the registered nurse about a particular patient. MT 1 added that the nurse's electronic device informs him/her of disconnection. MT 1 stated that he believes the monitoring machine stores data for any individual patient for two days. This information can be retrieved to determine if and how long the monitoring leads became disconnected from the patient.

On 10/7/2020 at 3:05 p.m., an interview with the Patient Safety Director stated the facility uses an 'escalation' process. If the telemetry unit leads disconnect, it notifies a staff member to check the patient. The Patient Safety Director explained the process involves overhead (sound speaker in the ceiling) broadcasting the patient is off the lead if the responsible nurse is not located and notified. The Patient Safety Director stated the hospital's policy is not to allow unassigned personnel into the rooms diagnosed with Covid-19. The Patient Safety Director added the facility's assessment indicated the technician monitoring Patient 12's cardiac status noted the patient off monitoring lead but was stable. The technician saw the patient moving in her room, so he took no further action. The electronic device did not notify the attending nurse that Patient 12 was off the lead. After the change of shift, the device was not given to the oncoming nurse.

Based on observation, interview, and record review, the facility failed to prepare and administer medications according to accepted practices for 2 of 32 sampled patients (Patients 4 and 31).

This practice had the potential to increase medication errors and decrease safety for patients.

Findings:


1. During a medication administration observation on 10/2/2020 at 3:00 p.m., RN 1 administer Patient 4's medication. One of the medicines scheduled to be issued was heparin (a medication used to prevent blood clots) 5000 Units (unit of measure) IM (medication injected into the muscle). RN 1 placed the drug on the bedside computer countertop and used a new needle and syringe to withdraw and inject the IM.

After the observation, RN 1 stated that Patient 4 had an order to inject Heparin IM 5000 units every 12 hours.

According John Hopkins Nursing Research- heparin is given by deep subcutaneous injection in the arm or abdomen with a fine needle (25 to 26 gauge) to minimize tissue trauma. https://magazine.nursing.jhu.edu/2011/07/anticoagulation-drugs-what-nurses-need-to-know/

2. On 10/7/2020, at 3:41 p.m., during a concurrent interview and record review, the Informatics Registered Nurse indicated Patient 31 was admitted to the facility on January 22, 2020, with the diagnosis of atrial flutter (an abnormal heart rhythm that is associated with a fast heart rate that begins suddenly).

Patient 31's Code Record, dated January 24, 2020, indicated a nurse gave Patient 31 Ibutilide (an antiarrhythmic agent to convert the heart's fast rhythm to a normal rhythm) 1 milligram (mg) intravenously (into the vein). Patient 31's medication administration record dated January 24, 2020, indicated a physician's order to hold Ibutilide at the bedside for cardioversion (a medical procedure by which an abnormally fast heart rate is converted to a normal rhythm using electricity or drugs) and do not administer.

A review of Patient 31's physician order, dated January 24, 2020, indicated the following:
1. Ibutilide 1 mg IV - one time
2. Note to the pharmacy - hold at the bedside for cardioversion today
3. Administration Instructions - hold at the bedside for cardioversion. Do not administer.

A review of the facility's job description for Registered Nurse (RN), dated June 6, 2020, indicated the RN demonstrates proficiency in the following skills, competencies, and behaviors, which included:
1. Upholds facility's policies and procedures, principles of responsibilities, and applicable state, federal and local laws
6. Ensures patient safety related to medications and procedures utilizing the five rights