HospitalInspections.org

Based on medical record (MR) review, document review and interview, it was determined the facility failed to ensure that the medical staff provided quality medical care consistent with prevailing standards of practice.
This was found in one (1) of 10 medical records reviewed. (Patient #2)


Findings include:

Review of medical record for Patient #2 noted the following: Patient #2 was brought to the Emergency Department (ED) by EMS at 11:49 PM on April 14, 2016, with a complaint of progressive shortness of breath, wheezing and productive cough which was getting worse. Review of the Emergency Medical Service report noted the patient's oxygen saturation was in the 70's on oxygen. (The normal range is 96-100% on room air).
The physician's notes documented on April 14, 2016 at 11:50 PM, stated the patient had developed shortness of breath 15 minutes after he awoke that morning and upon arrival in the Emergency Department he was alert but was in moderate respiratory distress with labored breathing and retractions. Previous medical history included Asthma, Cancer of the Tonsil, Hypertension and Kidney failure.


During the patient's stay in the ED, the respiratory rate remained above 30 (normal range
12-20) and the heart rate was above 100 (normal range 60-100), with a high of 132. At 1:57 AM on April 15, 2016, oxygen saturation was 81% on a high concentration of oxygen (BiPAP) and was 82% at 5:28, with the heart rate at 117 and the respiratory rate at 37 breaths per minute. The oxygen saturation decreased to 77% at 6:13 AM.
The patient was intubated at 6:40 AM when the patient's oxygen saturation decreased to 53% ,with the blood pressure at 170/137 (normal adult range 120/80 mmHg). The patient was subsequently diagnosed with acute hypoxic respiratory failure and metabolic and respiratory acidosis. The patient sustained a cardiac arrest at 10:08 AM and despite resuscitative measures remained hypoxic and in asystole. He was pronounced dead at 10:36 AM that morning.


The physician's monitoring of the patient's blood gases and intubation were not performed in a timely manner. This patient presented to the ED with a complaint of progressive shortness of breath; the patient experienced labored breathing and hypoxia (insufficient concentration of oxygen in the blood) for almost twenty-four hours.

The physician's documented reassessment occurred at 5:58 AM on April 15, 2016, more than 6 hours after the patient's arrival to the ED. There was no documented evidence that the physicians monitored the patient's cardiac and respiratory status continuously and modified the plan care in a timely manner.


The findings were shared with the Director, Patient Safety at 3:30 PM on April 29, 2016.

Based on medical record review, document review and interview, it was determined the hospital failed to ensure that the staff in the emergency department (ED) followed its policies for: (a) timely management of patients' acute stroke symptoms, and (b) reassessment of patients' elevated blood pressure. This was found in 2 (two) of 10 medical records reviewed (Patient #1, Patient #3).


Findings include:

Review of the medical record for Patient #1 noted: the patient presented to the ED on January 28, 2016 at 1:49 PM with a complaint of headache since 10:00 AM that morning, left upper extremity tingling, heaviness and facial numbness and left foot numbness. The patient had been sent to the ED by her primary doctor, for a stroke evaluation. The triage was completed at 2:12 PM, twenty-three minutes after arrival and the patient was seen by an ED doctor at 2:25 PM, who noted the patient had blurred vision, "squiggly lines," numbness, tingling and paresthesia (burning or prickling sensation) to the left side of her body. The stroke team was activated at 2:29 PM, forty minutes after the patient's arrival in the ED.

The facility's policy titled "Guidelines for Management of Acute Stroke Patients," last reviewed 10/2014, states, "For acute stroke patients (presenting within 6 hours of onset), activate the Code Stroke system. The stroke team will arrive within 10 minutes of notification for urgent assessment and management." The policy further states urgent assessment and management includes "neurologic screening examination, including an NIHSS." (The National Institutes of Health Stroke Scale).


These policies were not followed as required by its stroke designation status and staff did not activate the Code Stroke system in a timely manner to manage the patient's acute stroke symptoms.
The "NIH Stroke scale" form was signed but an assessment was not documented on the form.

These findings were shared with the Director, Patient Safety on April 29, 2016 at 3:30 PM.


Review of the medical record for Patient #3 noted the following: patient presented to the ED on March 17, 2016 at 1:39 PM with a complaint of "chest, neck and back pain x 1 hour." The patient's pain score was 2 (on a scale of 0 - no pain, to 10 - most severe pain); blood pressure 169/101 (normal adult range 120/80 mmHg). The patient's previous medical history was significant for Hypertension and he had taken Aspirin as an anticoagulant. The patient was sent to the waiting area and documentation at 4:11 PM (approximately 2 hours 30 minutes after arrival in the ED) revealed the patient was "called in the waiting room. No answer."

There was no documentation that the patient's elevated blood pressure was reassessed while the patient was waiting in the ED. This is not in compliance with the facility's policy titled "Vital Signs," last revised 08/15, which states, "vital signs are reassessed on all patients when vital signs are not within normal limits." The policy further states vital signs should be repeated "to determine if any change in patient condition has occurred."

These findings were shared with the Director, Patient Safety on April 26, 2016 at approximately 2:00 PM.