HospitalInspections.org

Based on complaint investigation PR00000543, review of fifty closed and active records reviewed (R.R), policies/procedures review with to the Emergency Room Medical Sub Director on 01/20/16 at 3:15 pm, it was determined that the facility failed to ensure that the physician monitors all conditions that patient shows during the admission and hospitalization process, as observed in 1 out 50 RR (RR # 17).

Findings include:

1.According to record review performed on 01/ 21/16 at 10:00 am, an 81 years old female patient arrived in an ambulance service at the Emergency Room of the receiving hospital on 11/18/15 at 10:29 pm. According to family member, the main complaint was right side lips deviation and disorientation. The triage Acute Stroke Activase Screening sheet allows identifying stroke symptoms on the first 3.5 onset hours.
According to the documentation of this stroke screening performed by the registered nurse on 11/18/15 at 10:35 pm the patient onset symptoms were shown early in the morning, the same day and has 216 mg/dl on glucose levels which means that patient is showing hyperglycemia.
However, no evidence was found of a physician's order for glucose monitoring and the administration of insulin or oral glycemic control medications during patient's stay at the emergency room or during the hospitalization process.

Based on complaint investigation PR00000543, review of fifty closed and active records reviewed (R.R), policies/procedures review and interview performed to the Social Services Director (employee #3) on 01/21/16 at 4:00 pm, it was determined that the facility failed to ensure implementation of the patient's discharge plan and orient patient and family members to prepare them for patient post-hospital care for 1 out of 50 records reviewed (R.R #17).

Findings include:

1. RR#17 performed on 01/ 21/16 at 10:00 am, an 81 years old female patient arrived in an ambulance service at the Emergency Room of the receiving hospital on 11/18/15 at 10:29 pm. According to family member, the main complaint was right side lips deviation and disorientation. The Internal Medicine physician documented on the Medical History and Physical Examination form on 11/19/15 that patient is showing dizziness, extremities weakness (does not mention what body side) and dysarthria.
The Nursing Initial assessment performed on 11/19/15 at 2:00 am by the registered nurse indicates that no discharge planning is needed. The Discharge Planning Initial Assessment performed by the Social Worker on 11/19/15 at 9:00 am indicates that patient and daughter were oriented about discharge planning process, that the patient has family support to attend patient ' s needs and daughter is requesting a glucometer to be used at home.
The Social Worker documented that she will discuss with physician this case but does not specify about her concerns that requires case discussion. On 11/20/15 at 5:15 pm the physician ordered Social Worker for placement and on 11/21/15 at 4:30 pm the physician ordered " discharge home and social worker evaluation" .
The Social Worker performed a summary of discharged planning intervention on 11/21/15 at 4:55 pm where she documented that she discussed this case with the physician and home health services will be provided for physical therapy. She failed to document the home health agency name, only documented " as health insurance indicates " . She added on the flow sheet comments section that " the physical therapy order was sent to the health insurance at the discharge moment" .
a. No evidence was found with whom the health insurance made agreements with a home health agency to provide physical therapy services. The Social Worker failed to add this information as evidence of a continuous care was coordinated and provided to the patient. The Interdisciplinary team failed to identify that patient has showing aphasia and dysarthria as mentioned by the Speech Pathologist on her evaluation performed on 11/19/15 at 3:00 pm. She recommended some interventions which the one that was provided was to offer a mashed and ground diet consistency to the patient which initiated on 11/19/15 after 6:00 pm and as ordered by the physician. The Speech Pathology service was not included for continuity of care through the home health services to be provided at home.
b. The discharged planning process of this case was discussed with the Social Worker Supervisor on 01/21/16 at 4:00 pm, where she stated: "The Physiatrist evaluated the patient at late night. It was 7:45 pm that day (11/19/15). The Social Worker performed her initial evaluation the same day early in the morning at 9:00 am. The physician ' s order from 11/20/15 at 5:15 pm was informed. There was a holyday, the same week that possibly no communication was done between the nurses and the social worker. The physician placed the discharge home order at 4:30 pm (11/21/15) but Social Worker had intervention with the patient because she documented that the order for physical therapy was sent to the health insurance. The health insurance sometimes answers late the decisions that they do related to the services that they approved.

c. The physician failed to specify in the Discharge Summary sheet that patient was going home with home health services. He documented that patient was going home and wrote prescriptions for laboratories (CMP (complete metabolic panel), Hgb A1C (Glycosylated hemoglobin)) for Physical therapy frequency and for medications (Vasotec 10 mg by mouth (PO) daily, ASA 81 mg PO daily and Zocor 40 mg PO daily).
d. According to the policies and procedures (P&P ' s) for discharge planning established by the hospital, which review was performed on 01/21/16 at 4:30 pm accompanied by administrative staff including Social Services Director (employee #3 ), the article IX of the P&P " s, on item B, step1 establishes the following: " The patient ' s discharge planning should begin since patient ' s admission. It should be a continuous process and should include patient and family members. Periodically, during hospitalization process, patient ' s needs must be reevaluated to determine if modifications to the discharge planning process are required. However, the evidence found on the clinical record indicates that the physician and the nursing staff failed to identify the patient ' s need for a discharge planning evaluation since the admission process.
e. According to step 2 of the same P&P's, indicates: " Identify that patient has any medical or nursing problems considering the admitting criteria established by the Discharge Planning protocol. This is going to be performed reviewing the admission's order copy where it is included the diagnostic and procedures that initiate the admission's order. "
According to RR performed on 01/21/16 at 10:00 am, the physician mentioned on the Medical History and Physical Examination and the Speech Pathologist consult evaluation, both performed on 11/19/15, that patient is showing aphasia and dysarthria which suggest that patient is having neurological deficit due to the diagnose of Stroke. Also, the Social Worker documented on the initial assessment performed on 11/19/15 and the discharge planning summary on 11/21/15 that she discussed the case with the physician. However, the interdisciplinary staff, knowing the health condition of the patient, failed to keep in mind the neurological deficit that suggest to activate the Discharge Planning protocol.
f. According to step 6 of the same P&P ' s, indicates: " The physician will document the referrals as needed and authorization procedures will be performed with the different health insurance/ services companies. This will be performed between 24 to 36 hours previously to the discharge process " . Step 11 indicates: " The physician will inform the Social Services with 24-36 hours of anticipation, about the discharge plan of the patient; this could be by verbal or written prescription orders ". The physician is responsible to lead the multidisciplinary team during the discharge planning process.
The evidenced found on the clinical record was that the discharge planning process was performed the same day when the physician placed the order for discharge home on 11/21/15. Nevertheless, the physician placed a first social work services evaluation order on 11/20/15 at 5:15 pm but no evidence was found if nursing staff notified the social services in advance, in a manner that the 24 hours required period is in compliance with the agency's policies and procedures. No follow up documentation performed by the Social Worker after patient has been discharged home, was found on the clinical record", (Cross reference TAG A821).

Based on complaint investigation PR00000543, review of fifty closed and active records reviewed (R.R), policies/procedures review and interview performed to the Social Services Director (employee #3) on 01/21/16 at 4:00 pm, it was determined that the facility failed to reassess the patient's discharge plan to identify and address factors that may affect continuity of care accordingly with patient needs, as observed in 1 out of 50 records review (RR #17).

Findings include:

1. According to record review performed on 01/ 21/16 at 10:00 am, an 81 years old female patient arrived in an ambulance service at the Emergency Room of the receiving hospital on 11/18/15 at 10:29 pm. According to family member, the main complaint was right side lips deviation and disorientation. The physician failed to specify in the Discharge Summary sheet, documented on 11/21/15, that patient was going home with home health services. He documented that patient was going home and wrote prescriptions for laboratories (CMP (complete metabolic panel), Hgb A1C Glycosylated hemoglobin for Physical therapy frequency and for medications (Vasotec 10 mg by mouth (PO) daily, ASA 81 mg PO daily and Zocor 40 mg PO daily), (Cross Refrence TAG A 820).
a. The physician failed to notify in a period of 24-36 hours in advanced that a discharge home order was going to be placed for this patient in a manner that Social Worker could coordinate with the health insurance the services that patient required.
The Social Worker failed to reassess that the disphagia and dysarthria problems require speech pathology evaluation and treatment which was not included in the physician's order to be provided by the home health services.
b. The hospital failed to ensure that the Social Services establish a mechanism to ensure that a reassessment will be performed before patient leaves the facility for continuity of care in a manner that patient could improve her conditions through the intervention of the interdisciplinary team at the home health services.

Based on complaint investigation PR00000543, review of fifty closed and active records reviewed (R.R), policies/procedures manual with the emergency nursing supervisor (employee # 4) and medical director (employee #1) and interviews, it was determined that the facility failed to operationalize accepted procedures to ensure that intravenous medication administration and the use of medical terminology and abbreviations follow standard of practices and accepted guidelines for 5 out of 50 records reviewed ( R.R. #10, # 25,# 26,#32 and # 33 ).

Findings include:
1. A mechanism to ensure that intravenous medication administration procedures follow standard of practices and accepted guidelines was not promoted not followed accordingly with the following findings:
a. Case #33 is a 56 years old male, who visited the Emergency Room on 11/26/15 at 8:00 am. The patient was diagnosed with Stroke and Suspected Encephalitis. The case was classified as and urgent case. Physician evaluates the patient on 11/26/15 at 8:15 am, order Labetalol 40 mgs intravenous the management of this patient follows facility TIA/Stroke protocols and heparin lock was also ordered.
This case was discussed with emergency room nursing supervisor (employee # 4) and medical director (employee # 1) on 1/22/15 at 1:00 pm.
No evidence was found on nursing progress notes related with Labetalol administration as ordered by physician. No evidence was found documented who indicate the method of administration of Labetalol (IV injection, or slow continuous infusion).
Information that indicates if the intravenous Labetalol was administered in a dedicated intravenous line was not found documented.
b. Case #32 is an 86 years old male, who visited the Emergency Room on 11/8/15 at 10:52 am. The patient was diagnosed with Decompensate congestive Heart Failure. The case was classified as an emergent case. Physician evaluates the patient on 11/8/15 at 10:52 am, order Tridil 50/250 to run at 6 milliliters ml/hour for two doses and heparin lock was also ordered. No evidence was found documented that indicate if the Tridil was administered by a secondary intravenous line connected to the heparin lock or in a dedicated line for infusion. This case was discussed with emergency room nursing supervisor (employee # 4) and medical director (employee # 1) on 1/22/15 at 1:20 pm.
2. A mechanism to ensure that the use of medical terminology and abbreviations by healthcare personnel follow standard of practices and accepted guidelines was not promoted not followed accordingly with the following findings:
a. Case #26 is a 60 years old female, who visited the Emergency Room on 7/12/15 at 10:39 am. The patient was diagnosed with Chest Pain. The case was classified at semi-urgent case. Physician evaluate the patient on 7/12/15 at 11:30 am, order blood work up, electrocardiography, chest x-rays and cardiac monitoring. Nursing progress notes documentation of care provided to this patient while receiving treatment at emergency room was review on 1/22/16 at 1:55 pm with emergency room nursing supervisor. On this documentation nursing personnel abbreviate cardiac monitor treatment using m/c abbreviation.
Emergency room department nursing supervisor stated on interview on 1/22/16 at 2:15 pm that sometimes nursing personnel make their own version of abbreviations and that this is not an acceptable way to document treatment of services provided.
b. Case #25 is a 44 years old female, who visited the Emergency Room on 7/1/15 at 12:14 pm. The patient was diagnosed with General Weakness. The case was classified as an emergency case and treatment was offered immediately, the management of this patient follows facility TIA/Stroke. After emergency room stabilized patient condition she was admitted to the hospital to receive further treatment and care. Nursing progress notes documentation of admission process to this patient and internal transfer procedure was review on 1/22/16 at 2:47 pm with emergency room nursing supervisor. On this documentation nursing personnel abbreviate that patient was ordered and receiving medications accordingly with an established schedule using M/H abbreviation.
The emergency room department nursing supervisor stated on interview on 1/22/16 at 3:20 pm that sometimes nursing personnel abbreviate phrases simply because they think those words are too long. Emergency room nursing supervisor stated on interview on 1/22/16 at 3:30 pm that this is not an acceptable way to document hospital admission process details.


20423


3. Case #10 is a 63 years old male, who visited the Emergency Room on 10/8/15 at 5:51 pm. The patient was diagnosed with Headache and the record was reviewed on 1/22/16 at 10:00 am. This case was triaged, evaluated by the physician and received treatment, however the patient refused further treatment and signed an " Against Medical Advice " (AMA) exoneration form and left the facility. However, the nurse did not document the vital sign of patient before he left the facility. The Against Medical Advice was signed by the patient but was not witnessed and the physician did not sign the AMA form.