HospitalInspections.org

This condition is not met as evidence by;

Based on surveyor review of patient chart including radiology reports, physician consult notes, nursing documentation, and staff interview, the facility staff failed to provide the patient or patient representative the right to participate in the development and implementation of her plan of care (Refer to A129); the facility failed to allow patient or patient representative to make informed decisions regarding care (Refer to A129); and failed to update patient or patient representative on health status, preventing the patient or patient representative to request or refuse treatment (Refer to A131).

The cumulative effect of the systemic problems resulted in the patient's inability to have timely treatment of their emergency condition, requiring withdrawal of care and placing do not resuscitate orders after patient decompensation.

Based on review of patient's medical record, policy and procedures, official grievance letter, facility's response to grievance, and interviews, the facility failed to allow patient or patient's representative to exercise patient rights to request or refuse treatment.

Findings include:

*The facility lacked documentation that patient #19's condition was discussed with patient # 19 and/or patient representative allowing informed decisions.

-Patient #19 did not have an advance directive or (DNR) do not resuscitate document on admission. Advance Directive information refused in emergency room (ER). Once incapacitated patient #19's representative became medical decision maker.

-Patient #19's representative grievance letter to the hospital stated, "the death certificate says we decided to terminate care. That is not true. We had no choice . . . at this point due to the [requested second surgeons] explanation at the time we received it [8/1/19 1000 am] her intestines, blockage, and sepsis were too far gone. . ."

-The facility's response to grievance on 9/17/20 stated, "the general surgeons . . .elective consult was within our Unified Rules and Regulations. . . (first surgeon) was called at 0830 am and updated upon receipt of the diagnostic test."

-The second diagnostic test (CT scan with angiography) results read at 08/1/19 0245 am with critical findings, "3 cm long segment occlusion of the superior mesenteric artery. Moderate ischemic colitis of the transverse colon. Small pneumoperitoneum. . ."

*Facility failed to follow their "Standard for Radiology Communication of Critical Findings" policy.

-For critical results the policy stated, "the radiologist will communicate directly with the referring physician, other healthcare provider, or an appropriate individual in a manner that insure receipt of the findings. . ." The standard communication details should be "documented in the radiology report. The time of discovery of the critical value, name and title of the person to whom findings were reported, the date and time of interchange, and when appropriate, whether or not a read-back occurred must be indicated on the report."

-Radiologist note time and dated 8/1/19 1033 pm stated, "Addendum #1 Notification confirmed with RN. . . telephonically by CORE RSC at 8/1/19 0305 am." (abbreviations CORE RSC written as per documented on radiology report)

-Radiologist failed to communicate directly with healthcare provider or nurse.

-Radiologist failed to document communication of results per facility's policy.

-RN failed to document receiving critical result, calling physician with results, or attempts at notifying physician of results.

Validated findings with Director of Quality on the afternoon of 5/18/21 at 1400 in hospital conference room. Director of Quality stated, "Yes the nurse should have informed the physician within 45 minutes of receipt of critical results and there is nothing charted stating that it was done."

Based on review of patient's medical record, policy and procedures, grievance letter, grievance letter response, and physician consultation report, the facility failed to provide patient #19 or the patient's representative with timely updates on health condition preventing patient and/or representative the ability to request or refuse treatment.

The facility lacks physician documentation regarding discussion of final CT results or patient #19 health condition with family and/or family representative.


Findings include:

Grievance letter from patient #19's family, dated 7/31/20, stated, "we were never told about an occluded artery. We were only told about ischemic colitis. . . No angioplasty was conducted to remove the occlusion, nor any medications were discussed to dissolve it."

ER provider discussed first CT scan with GI consult per ER provider notes. ER provider stated, GI Consult "will see her [patient #19] in the morning, at time of admission still awaiting CTA to be done."


Facility's response to patient #19 grievance on 9/17/20 stated, Gastrointestinal (GI) consult "was contacted by ER as a routine (elective) consult. . . (GI) doctor was contacted (again) at 0830 am on 8/1/19 and the nurse provided an update on the patient's [#19] status; to include diagnostic results . . ."


On 8/1/19 approximately 1100 am Intensivist documented, "I was never called from the ER. . . the surgical service on-call was contacted from the ER, but no intervention was done. At the time of my evaluation this morning, the family noted to be very upset and they want a second opinion from a surgeon . . . The patient's [#19] overall prognosis unfortunately is very poor given the free intraperitoneal air and diffuse colitis. . . the patient [#19] was diagnosed with diffuse colitis and possible free intraperitoneal air and was admitted to the cardiac floor. I was notified of the patient [#19] decompensating at around 5 this morning. I immediately transferred the patient to the intensive care unit (ICU)."

On 8/1/19 0950 am Cardiologist documented, " At this time it is not advised to take patient [#19] to arteriogram with possible PCI to SMA as it may be little benefit."


PCI- percutaneous intervention
SMA- superior mesenteric artery