HospitalInspections.org

Based on records reviewed and interviews the Hospital failed for one patient (Patient #1) of ten sampled patients to ensure measurement of compliance that improvement activities were sustained.

Findings included:

The Hospital report, dated 3/11/2021, indicated a Patient (neonate, newborn) developed bradycardia (decreased heart rate) requiring cardio-pulmonary resuscitation (CPR), abdominal compartment syndrome (abnormal increase in abdominal pressure) requiring pressure release via abdominal incision and bilateral pneumothoraces (air trapped in the lungs) requiring bilateral chest tube placement following intubation (placement of a breathing tube) using a video stylet with supplemental oxygen (a device to aid with placement of the breathing tube).

The Quality Assurance and Performance Improvement (QAPI) Plan, dated 2021, indicated the Hospital took actions aimed a performance improvement and after implementing those actions, measured success, and sustainability.

The Hospital Report, (undated), indicated the Hospital's investigation. The report indicated the Anesthesia Department recommended the use of a pressure regulation device with administration of supplemental oxygen for infants in the Operating Room that required laryngoscopy tracheal intubation, as a performance improvement activity. The Hospital Report indicated no documentation for a plan to measured success, and sustainability of the performance improvement activity.

During an interview, on 5/27/2021 at 11:10 A.M., Quality Manager #1 said he/she believed it was [monitored (measured success and sustainability)].

During an interview, on 5/27/2021 at 11:30 A.M., the Chair for Anesthesia said he/she understood the Respiratory Therapy Department audited [monitored (measured success and sustainability)].

The Hospital provided no documentation to indicate measurement of success, and sustainability following implementation of performance the improvement activity to use of a pressure regulation device with administration of supplemental oxygen for infants in the Operating Room that required laryngoscopy tracheal intubation, almost three months following Patient #1's adverse patient event on 3/4/2021.