HospitalInspections.org

Based on records reviewed and interviews the Hospital failed for one patient (Patient #5) in a sample of ten patients to ensure in its resolution of a grievance, to provide the Complainant with written notice of the Hospital's decision that contained the name of the Hospital contact person, the steps taken on behalf of the Patient #5 to investigate the grievance, the results of the grievance process, and the date of completion.

Findings included:

The policy titled Patient Family Complaint and Grievance Mechanism Policy, dated 6/8/2021, indicated a grievance was a formal or informal ,written or verbal complaint that was made to the Hospital by a patient or patient's representative regarding patient care. The policy indicated each grievance was completed with a written response to the Complainant, the responsibility of Patient Relations and completed within seven days. Grievances requiring extensive investigation and analysis, the patient or patient representative was sent a written interim response stating the Hospital was working on a response that should be expected within thirty days if possible.

During an interview, at 3:00 P.M. on 6/30/2021, the Director of Patient and Guest Relations said the Hospital received a complaint regarding Patient #5's care, investigated the complaint and no letter was provided to the that Complainant.

The Hospital provided no documentation to indicate a written of response to the Complainant in accordance with Hospital policy.

Based on records reviewed and interviews the Hospital's Quality Assessment & Performance Improvement (QAPI) Activities failed for two patients (Patients #6 & #8) in a sample of ten patients to ensure after implementing corrective actions, track performance to ensure improvements were sustained.

Findings included:

1.) The Baystate Medical Center Quality Management and Patient safety Plan, dated 2021, indicated that the effectiveness of actions was evaluated.

The Hospital report, dated 6/9/2021, indicated an Oncology (cancer) patient, (Patient #6) should have received a slow titration of Rituximab (medication used to treat the cancer, Chronic Lymphocytic Leukemia), however, Patient #6 received a rapid infusion of Rituximab, in error, in the Hospital Cancer Center.

The Hematology Oncology Note, dated at 11:58 A.M. on 6/2/2021, indicated Patient #6 experienced a reaction to the first administration of the cancer medication, tolerated the second administration of the cancer medication and experienced dizziness and was unresponsive without a heartbeat; Patient #6 required resuscitation to regain a heartbeat and responsiveness, and was transferred to the Hospital by ambulance.

During an interview, at 1:00 P.M. on 6/29/2021, the Oncology Medical Director and Oncology Regional Nurse Manager said and described the ordering process for cancer medication as follows:

-The Physician entered the first cancer medication to be administered into the computerized physician medication ordering system,

-The Pharmacy reviewed the cancer medication order and

-The Oncology Nursing Staff administered the cancer medication as ordered.

-The Oncology Nursing Staff entered a nursing messaging note, recorded the patient's electronic medical record, regarding patient tolerance to the medication.

-Prior to the next administration of the cancer medication an Oncologist (Cancer Physician) and Pharmacist would review the nursing messaging note regarding patient tolerance to the cancer medication and the Oncologist made appropriate adjustments to the cancer medication,

-The Pharmacist adjusted the cancer medication according to the Oncologist cancer medication order.

The Oncology Medical Director and Oncology Regional Nurse Manager said, regarding the cancer medication error of Patient #6, the Pharmacist did not see the special instructions regarding medication adjustments in the comments section of the cancer medication order and that Patient #6's medical record contained no electronic nursing messaging note regarding Patient #'s adverse reactions to the cancer medication.

The Oncology Medical Director and Oncology Regional Nurse Manager said the Hospital implemented corrective actions to clarify the computerized physician medication ordering system for the cancer medication, educated Physicians ordering cancer medication, and Pharmacists reviewing cancer medication order. The Oncology Medical Director and Oncology Regional Nurse Manager said that the Hospital was not monitoring or auditing that the Physicians ordering cancer medication and Pharmacists reviewing cancer medication orders were compliant with the corrective actions.

The Hospital provided no documentation to indicate after implementing corrective actions, they tracked performance to ensure improvements were sustained, by the time of the Survey. The Hospital provided no documentation to indicate criteria for electronic nursing messaging note communication regarding patient tolerance to the cancer medication, by the time of the Survey. The Hospital provided no documentation to indicate a policy, procedure, guideline, nor algorithm regarding their process (of cancer medication ordering, electronic nursing messaging note communication and Pharmacist review), specifically to clarify the function(s) of the electronic nursing messaging note.

2.) The Hospital Report, dated 1/26/2021, indicated a sterilization machine (used in to sterilize surgical instruments) was set to test mode instead of sterilization mode, in error. The Report indicated the Hospital investigated the event, determined the sterilizer machine defaulted to test mode (per manufacturer design) when paper was changed, and identified corrective actions that included surgical technician staff education, and auditing surgical tech review of instrument sterility indicators by having the Circulator Nurse, (in the Operating Room) verify the instrument sterility indicators.

During an interview at approximately 2:30 P.M. on 6/29/2021, the Nurse Educator and the Regional Director for Surgical Support Services said they did not have documentation that the sterility indicators were checked (verified) with the time-out procedure (safety procedure conducted prior to surgery). The Nurse Educator and the Regional Director for Surgical Support Services said the event occurred on 12/22/2020.

Intraoperative Documentation, dated 6/30/2021 regarding Patient #8, indicated no indication that sterility indicators were verified during the time-out procedure.

The Hospital provided no documentation to indicate after implementing corrective actions to verify sterility indicators, in accordance with their plan of correction, they audited performance to confirm improvements were sustained, by the time of the Survey more than six months after the event.

Based on records reviewed and interviews the Hospital failed for one patient (Patient #10) in a sample of ten patients to ensure a thorough analysis (investigation) regarding a restraint event.

Findings included:

The Hospital Restraint Log, dated 4/29/2021, indicated events regarding patient restraint. The Hospital Restraint Log indicated an on-coming shift nurse (Nurse A) received a verbal report from an off-going shift nurse (Nurse B) that Patient #10 was placed in wrist restraints (two-point wrist restraint). The Hospital Restraint Log indicated upon full inspection of Patient #10, Nurse A found Patient #10 in bilateral wrist restraints, bilateral ankle restraints and a Posey vest (five-point restraint). The Hospital Restraint Log indicated the restraint order was for wrist restraints and Posey vest.

Medical Record review indicated physician orders, at 12:25 A.M. on 4/28/2021, for soft wrists and vest restraint for Patient #10.

During an interview, at 1:50 P.M. on 7/1/2021, the Nursing Professional Practice Chair and Clinical Nurse Leader said that the electronic physician order entry for restraint automatically generated tasks regarding restraints in the electronic nursing documentation system for nursing staff to implement. The Nursing Professional Practice Chair and Clinical Nurse Leader said the electronic nursing documentation system did not generate a location for nursing staff to document what restraint was on the patient.

The Hospital provided no documentation of a thorough analysis of this restraint event, to verify Patient #10's restraints. implement appropriate corrective actions. Medical record review of nursing documentation regarding Patient #1 restraint did not identify if Patient #1 was in three-point (wrists and vest) restraint as the Hospital investigation discovered or five-point (wrists, ankles, and vest) restraint as indicated in the, 4/29/2021, Hospital Restraint Log.