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Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure established policy on documentation of an unusual incident was include in the medical record for one of one medical records where an unusual incident occurred. (MR1)

Findings include:

Review on July 24, 2015 of the facility policy,"Disclosure and Discussion of Serious Adverse Events" dated effective June 6, 2003, and last reviewed May 12, 2015, revealed "Scope: This policy applies to all adverse events or outcomes, and specifically to preventable events. ... Procedure: Initial Phase ... 4. Document in the medical record, by the appropriated care giver, a complete, accurate and factual description of the pertinent clinical information including and avoiding derisive comments about other providers and entries that appear self-serving. a. Date/time/place of the patient's medical condition immediately before the time of the event b. Medical intervention and patient response c. Notification of the physician including specifically what was communicated. d. ongoing treatment plans. ..."

Review on July 23, 2015, of MR1 revealed the patient underwent a surgical bowel obstruction repair on May 22, 2015. The patient was unable to be extubated in the Post Anesthesia Care Unit (PACU). It was decided to keep the patient ventilated and transfer to the Critical Care Unit (CCU). During transport, the patient was ventilated using a bag valve device (AMBU bag). Upon entering the elevator, the patient's condition deteriorated. A cardiac arrest occurred. Resuscitation was started on arrival in the CCU.

Review of facility documents revealed in the CCU, EMP4 discovered the AMBU bag was incorrectly connected, and the patient was not being ventilated. There was no documentation in MR1 regarding the incorrect connection of the AMBU bag. There was no documentation the patient was not ventilated during transport.

Further review of MR1 revealed the patient was transported without cardiac or pulse oximetry monitoring.

Telephone interview with EMP4 on July 23, 2015, confirmed the AMBU bag was incorrectly connected. The patient was connected to a filter which is an exhalation port. EMP4 confirmed completing the facility's incident report. EMP4 did not recall documenting the event in the patient's medical record (MR1).

Interview with EMP1 on July 23, 2015, confirmed there was no documentation in MR1 describing the incident or noting that the AMBU was incorrectly connected. EMP1 confirmed the policy for disclosure and discussion of serious events was not followed with regard to documentation within the medical record.

Interview with EMP2 confirmed the AMBU bag was not correctly connected; the patient was not ventilated during transport; and the patient was transferred without cardiac or pulse oximetry monitoring.