HospitalInspections.org

Based on records reviewed and interviews the Hospital failed for three patients (Patients #6, #8 & #9) of 10 sampled patients to ensure a thorough investigation and that opportunities for improvement were identified.

Findings included:

The Hospital policy titled Sentinel Events, dated 10/1/19, indicated goals of the Root Cause Analysis Team (Hospital investigation team) were to understand how and why an even occurred to identify processes of system changes, which would improve performance.

Regarding Patient #6:

The Surveyor interviewed the Quality Director at 8:00 A.M. on 9/1/2020. The Quality Director said the Hospital investigation revealed that this was a patient (Patient #6) with an extensive history of chronic back pain with multiple back surgeries that presented with complaints of increased back pain and no reported trauma. Patient #6 was evaluated by the Emergency Department, Infectious Disease, Orthopedic Surgery, and Hospital Medicine. Upon completion of Computerized Tomography (CT scan, computerized rotating x-rays to view more detailed x-rays of bones) imaging studies Patient #6 reported he/she was unable to move his/her legs, and the CT scans confirmed an acute T9 fracture with partial vertebral compression (spinal) fracture that was present on the chest x-ray earlier that day. The Quality Director said that the Hospital investigation revealed that care was appropriate, staff performed according to policy and that no corrective actions were identified.

1.) The CT physician order, dated at 4:08 P.M. on 8/16/2020, indicated that Patient #6 was to be transported from Patient #6's room to Radiology for the CT scan by stretcher.

The Quality Director said that Patient #6 was transported from Patient #6's room to Radiology for the CT scan by wheelchair and that it was unknown how or why Patient #6 was transported using a wheelchair instead of a stretcher as ordered by the Physician.

The Hospital failed to thoroughly investigate, or identify and implement opportunities for improvement or corrective actions regarding tracking patient transport.

2.) The Quality Director said sign and symptoms for spinal precautions include (patient report or examination of) decreased sensation, decreased strength and or bowel or bladder incontinence.

The Surveyor interviewed the Radiology Director at 12:55 P.M. on 9/1/2020. The Radiology Director said that Patient #6 complained to the CT Technologist and the Transporter that he/she could not feel his/her legs (after completion of the CT test). The Radiology Director said that the Radiology CT Technician thought Patient #6's complaint was because of "sleepy" legs. The Radiology Director said that Radiology Technologists were required to call a member of the Patient Care Team for questions or handoff (report). The Radiology Director said that the CT Technologist called Patient #6's Patient Care Unit to provide a handoff report however Patient #6's Care Team Registered Nurse (RN) was not available for the handoff and Patient #6 was then transported back to Patient #6's Patient Care Unit on a stretcher.

The Surveyor interviewed the Quality Director at 2:00 P.M. on 9/1/2020. The Quality Director said that Patient #6's Care Team RN immediately called the Rapid Response Team upon handoff of Patient #6's change in condition, inability to move his/her legs.

Patient #6's Medical Record indicated no documentation of an Event Note regarding Patient #6's "sleepy legs" generated by the CT Technologist.

The Hospital failed to identify and implement opportunities for improvement regarding procedures for Radiology Technician communications regarding Patient complaints while a patient was in the Radiology Department.

The Hospital failed to identify and implement opportunities for improvement regarding Radiology Technician handoff (report) procedures when the Care Team RN was not available for the handoff report.

3.) The Surveyor interviewed the Nuclear Medicine Manager. The Nuclear Medicine Manager said that she managed Service Hub which was the Hospitals computer system for documentation of patient transport reservations according to physician orders. The Nuclear Medicine Manager said that Service Hub maintains the patient transport information for two days.

The Quality Director said that the Hospital investigation did not explore if the Service Hub software could maintain patient transport information longer than two days.

The Hospital failed to identify and implement opportunities for improvement regarding exploring if the Service Hub software could maintain Patient transport information longer than two days in order to track patient transport information of patient events.


Regarding Patient #8:

The Hospital policy titled, Rapid Response Team, dated 10/2/18, indicated expectations of the RN caring for the patient included to document interventions and response in the SBAR (Situation, Background, Assessment, Recommendations) documentation flow sheet, medication administration record if needed and in the patient Electronic Medical Record.

The Hospital Report, dated 7/6/2020, indicated that Patient #8 complained of chest pain while in Radiology for an Magnetic Resonance Imaging (MRI, a medical imaging study used in radiology to take imaging pictures) and Radiology staff called the Rapid Response Team (emergency team).

Patient #8's Medical Record indicated no documentation of an Event Note generated by the MRI Technician or care provided regarding Patient #8's chest pain while in Radiology Department. The Medical Record indicated no documentation from the Rapid Response Team.

The Surveyor interviewed the Intensive Care Unit (ICU) Director at 11:30 A.M. on 9/2/2020. The ICU Director said that she managed the Rapid Response Team and that the Rapid Response Team was responsible for documentation of patient assessment and care provided to the patient where ever the Rapid Response Team was called to in the Hospital, including the Radiology Department, on the Rapid Response Assessment Form.

The Hospital failed to identify and implement opportunities for improvement regarding documentation of Rapid Response Events that occurred in the Radiology Department.

Regarding Patient #9:

The Hospital Report, dated 7/16/2020, indicated that Patient #9 complained of nausea, dizziness and had vomiting after an MRI, and Radiology staff called the Rapid Response Team.

Patient #9's Medical Record indicated no documentation of an Event Note regarding the Patient's nausea, dizziness and vomiting generated by the MRI Technician. The Medical Record indicated no documentation from the Rapid Response Team.

The Hospital failed to identify and implement opportunities for improvement regarding documentation of Patient Events that occurred in the Radiology Department.