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Based on observation, interviews, a review of a self-reported unusual event and interviews with medical and nursing staff, the medical staff failed to be accountable to the governing body for the quality and appropriateness of care provided to two of four sampled patients (Patients A and B). The medical staff failed to ensure timely medical care for Patient B during an emergency in surgery. This resulted in an amputation of a leg and an altered mental state for Patient B. The medical staff failed to ensure timely intervention for Patient A when he refused to eat or drink anything for 16 days. This contributed to Patient A's death.

Findings:

1. According to the medical record and interviews with MD Q conducted on 9/12/11 at 1330 hours, Patient B had sustained a knee injury in 2007. After a surgical repair, the patient had developed a knee joint and surgical infection requiring prolonged post operative treatment, including surgical debridements, a rotational flap and a skin graft. Patient B had undergone a surgical procedure on 9/3/10 to remove surgical hardware. At that time, Patient B was told he might require a total knee replacement because he had significant post traumatic arthritis with severe persistent pain and scarring in the surgical area. Patient B was offered a total knee replacement surgery for which he came to the hospital on 8/5/11.

A review of the anesthesia record and the history and physical examination revealed that the laboratory work and informed consent had been performed on 3/15/11, five months prior to the surgery. When interviewed at 1400 hours on 9/12/11, MD R stated that the general guidelines for lab work for young and healthy patients did not require repeat lab work prior to a surgical procedure. MD R stated that she was unaware the lab work was not recent. MD R stated the lab work should be dated when placed into the preanesthetic assessment.

On 8/5/11 anesthesia was induced for Patient B at 1600 hours. A tourniquet for bloodless surgery was placed at 1650 hours at 300 mmHg (millimeters mercury) pressure.

MD Q stated that the early portion of the surgical procedure was not difficult, however, as the surgery progressed, the previous operations and infections had resulted in considerable distortion of the anatomy. He stated that it took several hours to free up the structures in the knee requiring a long tourniquet time, which by the end of the procedure, reached a total of 326 minutes. He stated that the patient was stable with no blood loss, but noted that during the surgery, the main artery and vein in the knee had been cut when using the saw. (The popliteal artery and vein had been transected during the knee replacement.).

A note placed into the anesthesia record at 1700 hours, by MD S revealed "popliteal artery iatrogenic injury." The operative note placed by MD T "the artery was completely transected in at least two places. Because the tourniquet was inflated, no bleeding was evident." Interviews with MD V revealed that a vascular repair would be required to repair the cut artery and vein in the knee. It was elected to wait until the total knee replacement surgery was completed in order to have a stable surgical field for the vascular repair. At 2200 hours, blood had not yet been received from the blood bank.

At approximately 2230 hours, the tourniquet was released. The anesthesia record revealed 1000 cc (cubic centimeters) of blood loss. On 9/12/11 at approximately 1130 hours, MD T was interviewed. He stated that he was focused on performing the surgical procedure and did not recall being informed by MD S regarding a 1000 cc blood loss. However, RN 1 stated, during an interview on 9/13/11 at 1500 hours, he recalled hearing MD S tell MD T that 1000 cc. of blood had been lost. RN 1 stated that MD S was going to order one unit of blood to be transfused immediately and have a second unit ready. However, RN 1 told MD S that no blood had been requested from the blood bank because the surgery was done under tourniquet, supposedly a bloodless surgery. RN 1 asked MD S to obtain a blood specimen for a type and cross match. RN 1 stated that MD S was having difficulty obtaining blood for the type and cross match and it took "almost an hour" to obtain 1/2 of a laboratory tube of blood to send to the blood bank. The tube of blood was sent to the blood bank at 2300 hours. RN 1 stated that the blood bank offered unmatched blood for Patient B, at approximately 2330 hours; however, MD S did not request the unmatched blood from the blood bank. RN 1 stated that MD S wanted to wait for the type and cross matched unit of blood for Patient B.

At approximately 2230 hours Patient B was turned into the prone position (face down) to repair the vessels in the posterior aspect of the knee. The tourniquet was released and blood loss was noted by MD R "despite control of the proximal artery." Exploration of the vessels revealed that there were more vascular injuries than originally noted. According to the operative note, "it took longer to gain control of the bleeding." MD T noted "considerable oozing from the structures in the knee, including the bony structures. MD T asked MD S regarding the blood loss and was informed that 2500 cc of blood had now been lost, however, no blood had been infused for Patient B. MD T noted that bleeding "stopped abruptly" and MD S reported that Patient A had no blood pressure or pulse. Patient B was rotated back into the supine position (face up) and CPR was initiated at 0030 hours.

Patient B was administered four units of O negative blood, and later, additional blood and blood products. After a total of 14 units of blood and four units of fresh frozen plasma and platelets, Patient B had a "gradually improving blood pressure and near-normalization of the heart rate." Marked abdominal distention was noted by the physicians. The abdomen was opened and an amount of fluid removed. During the ongoing resuscitation of the patient, a "four compartment fasciotomy" was performed (opening the muscles in the right leg to allow the soft tissues to swell). Patient B was then rotated back to the supine position and the vascular surgical procedure was completed.

From 0145 hours until 0200 hours, the anesthesia record revealed an oxygen saturation of 85% (normal is 95-100%). The operative note revealed that Patient A had been placed on a ventilator, obtained from "one of the ICUs." Multiple medications to elevate the blood pressure (vasopressors) were administered. Blood pressure was recorded as 70-80 mmHg. The record revealed that the pulse in the artery to the right leg (femoral artery) was not present by palpation or by Doppler determination. Patient B was then taken to the ICU of the hospital, despite no blood supply to the right lower extremity.

On 8/10/11, a below the knee amputation was performed and irrigation of the abdominal wound performed. On 8/16/11 a tracheostomy (tube through the throat into the trachea to help breathing) was performed and a percutaneous gastrointestinal feeding tube was inserted. At the same time on 8/16/2011 a right above the knee amputation was performed. On 9/10/11 the amputation site was revised surgically. As of 9/13/11 at 1130 hours, Patient B was observed in the Stepdown Unit with an altered mental status. Hi eyes were open but he did not respond to commands. His arms and legs were restlessly moving without purpose.

2. Review of the medical record showed Patient A came to the psychiatry emergency department on 7/9/11 at approximately 1635 hours. Patient A was placed on a 72 hour involuntary hold and was assessed as requiring inpatient hospitalization and treatment as gravely disabled (a condition evidenced by behavior in which a person, as a result of a mental disorder, is likely to come to serious physical harm or serious illness because he/she is unable to provide for his/her basic physical needs), danger to self, and danger to others. While being observed in the Psychiatry Emergency Department, Patient A refused all oral intake and was found to be selectively mute, refused to answer questions, except to say "I will take no medications."

On 7/11/11 at 1635 hours, Patient A was admitted to the Psychiatric Unit of the hospital. The attending physician, MD X, was interviewed on 8/2/11 at 0930 hours. MD X stated Patient A was exhibiting bizarre behavior at home and was a physical danger to an elderly female. He stated Patient A refused all feedings because "he was being held against his will." Patient A was ambulatory but refused all laboratory evaluation and all physical evaluation or vital signs. MD X stated here were no signs of dehydration but admitted the patient could not be assessed for how many days, prior to admission, he had not eaten or consumed fluids. Patient A did not have an assessment by a physician from internal medicine. MD X stated a court order was obtained to administer emergency medications, but he did not obtain a court order for forced feedings or fluids. On 7/18/11, Patient A remained without eating or drinking, refusing all lab work and vital signs and remained selectively mute. MD X ordered Haldol 5 mg. (an anti-psychotic drug), Lorazepam 2 mg. (an anti-anxiety drug), and Benadryl 25 mg. (an antihistamine). Patient A refused these medications by mouth. As a result, these medications were administered intramuscularly. No medical assessment documented dehydration, failure to thrive, or malnutrition.

On 7/19/11 a Nutritional Assessment recommended "enteral feedings." Patient A remained in this state from 7/9/11 until 7/25/11. At 0500 hours on 7/25/11, Patient A was observed by nursing staff to have collapsed and was unresponsive. The rapid response team was summoned. A femoral line (a large bore catheter to deliver fluids and nutrients intravenously) was placed. Patient A was intubated. Medications to raise blood pressure and antibiotics were administered. 50% Dextrose and 1000 cc of Saline were administered.

Attempts for defibrillation for Patient A could not be immediately performed because incompatible pads had been placed on the emergency cart. Once the correct pads were obtained, two defibrillation attempts resulted in a restored cardiac rhythm. MD Y was interviewed on 8/3/11 at 1100 hours. She was the trauma surgeon who had placed the femoral line. The catheter was thought to be in the femoral vein, however, once blood pressure was restored to a higher level, the catheter was found to be in the femoral artery. She stated administration of the medications and fluids being given via an intra-arterial line were perfectly acceptable in an emergency situation.

MD Z was interviewed on 8/3/11 at 1305 hours. She stated that she assessed Patient A during the code. She observed "skin extremely dry, retracted, cool, mucus membranes dry." MD G was interviewed at 1310 hours on 8/3/11. She stated, upon her arrival at the code blue, Patient A was "obtunded and not moving." Patient A was pale, with decreased skin turgor. Vital signs were absent.

Laboratory results revealed that Patient A had a potassium level of 7.7 (normal value was 3.5-5), the BUN (waste products in the blood cleared by the kidney) was greater than 200, (normal value was less than 20), and the sodium level was determined to be 175 (normal value was 125-135). According to interviews with MD U, the critical care physician, the laboratory values were consistent with severe dehydration and volume depletion (not enough fluid in the circulating blood stream). Patient A expired on 7/28/11.

According to interviews with MD X and MD P, no consultation with internal medicine was obtained despite minimal to no witnessed intake of food or water since 7/9/11, a total of 16 days.

Based on observations, interviews and a review of two self reported incidents and policies and procedures, the hospital failed to ensure the medical staff provided quality care to two of four sampled patients (Patients A and B).

Findings:

1. The medical staff failed to ensure appropriate consultation from specialty services to meet the needs of Patient A. Cross reference A 049.

On 9/13/11 at 1600 hours, the Administrator was notified of Immediate Jeopardy (IJ) to the health and safety of patients who refused oral intake, physical assessment and/or vital signs as a result of a mental disorder. Patient A came to the Psychiatry Emergency Department on 7/9/11 at 1635 hours. On 7/18/11, Patient A remained without eating or drinking, refusing all lab work and vital signs, and remained selectively mute. On 7/25/2011 at 0500 hours, Patient A was found by nursing staff to be unresponsive. Cardiopulmonary resuscitation (CPR) ensued. During resuscitation on 7/25/11 at 0505 hours, attempts for defibrillation (induced electrical shock) for Patient A who had no heart beat could not be immediately performed because incompatible pads had been placed on the emergency cart. The defibrillator pad that was available on top of the crash cart was for transport monitoring only and not for delivery of electrical shocks. There was no back-up supply in the unit's central supply. Per the Code Blue record for Patient A, the first defibrillation was recorded at 0550 hours, 45 minutes after the Code Blue was initiated.

Patient A was transferred to ICU but the patient remained comatose and not able to sustain his blood pressure. Patient A subsequently died on 7/28/11. According to interviews with the Critical Care physician (MD U) on 8/2/11 at 1100 hours, the laboratory values for Patient A were consistent with severe dehydration and volume depletion (not enough fluid in the circulating blood stream). Per record review on 8/3/11, there was no medical or nursing assessment documented for dehydration, malnutrition, failure to thrive, and/or suicidal ideation. There was no medical consultation sought to assess for dehydration despite minimal to no witnessed intake of food or water for a total of approximately 16 days.

On 9/14/11, the hospital presented a plan of correction for the IJ. On 9/20/11, the immediate jeopardy was abated with the plan of correction. Cross reference A000.

2. The medical staff failed to ensure timely intervention during a surgical emergency for Patient B. Cross reference A 049.

On 9/13/11 at 1600 hours, the administration was notified of another IJ situation that was identified during the investigation of Patient B's elective right total knee replacement surgery performed on 8/5/11.

A review of the anesthesia record and the history and physical examination for Patient B revealed that the laboratory results and informed consent had been performed on 3/15/11, five months prior to the surgery.

Per interview with the orthopedic surgeon on 9/13/11 and review of Patient B's medical record, the popliteal artery and vein had been cut during the knee replacement surgery. The vascular surgery team was asked to repair the blood vessels. There was no blood loss evident during the orthopedic surgical event because the tourniquet used throughout the total knee replacement remained inflated. There was no type and cross match of the patient's blood performed or equipment set up to harvest and replace the patient's own blood in preparation for removal of the tourniquet.

There was a change of shift for the anesthesiologists at 1900 hours and a new anesthesiologist took over the case. As of 2200 hours no blood had been requested from the blood bank for Patient B.

At approximately 2230 hours, the tourniquet was released from Patient B's leg. After the tourniquet was released, the vascular surgeon had difficulty controlling the bleeding. Patient B had lost an estimated 1000 cc of blood. The anesthesiologist requested blood from the blood bank but there was none typed and cross matched for Patient B. The anesthesiologist had a difficult time obtaining a specimen for the type and cross match for blood and it was not sent to the laboratory until approximately 2300 hours. When the anesthesiologist was asked by the surgeon regarding Patient B's blood loss, 2500 cc of estimated blood loss (EBL) was reported but no blood had been infused for Patient B. The anesthesiologist decided against the unmatched blood offered by the blood bank and decided to wait for the typed and cross matched unit of blood. During exploration of the vessels, the vascular surgeon noted that bleeding stopped abruptly, and Patient B had no blood pressure or pulse. CPR was started after the patient was changed to face up position. Patient B was resuscitated after a total of 14 units of blood and four units of fresh frozen plasma and platelets.

When Patient B had improved blood pressure and near normalization of the heart rate, marked abdominal distention was noted by the physicians. The abdomen was opened and explored. In addition, a four compartment fasciotomy (surgical incision/opening of the muscles to allow soft tissues to swell) was performed to the patient right leg. Blood flow to the right leg could not be restored.

Patient B was then taken to the ICU. On 8/10/11, a right below the knee amputation and irrigation of the abdominal wound was performed. On 8/16/11 an above the knee amputation was performed on Patient B's right leg. On 9/10/11, the right above the knee amputation was revised. As of 9/13/11 at 1130 hours, Patient B was observed in the Stepdown Unit. His eyes were open but he did not respond to commands. His arms and legs were moving but without purpose.

On 9/14/11, the hospital presented a plan of correction for the IJ. On 9/20/11, the immediate jeopardy was abated with the plan of correction. Cross reference A 000.

These deficient practices resulted in the inability of the medical staff to provide quality care in a safe environment.

Based on observation, interviews, record review, and review of a self-reported incident, the medical staff failed to be accountable to the governing body for the quality of care being provided to meet the needs of two of four sampled patients (Patients A and B). No interventions were provided to ensure adequate fluid and food intake for Patient A for a period of 16 days. This contributed to Patient A's death. During an elective surgical procedure for Patient B the arteries and veins in his leg were accidently cut. The medical staff failed to plan for anticipated bleeding when the tourniquet on the leg was released. These medical errors contributed to Patient B's cardiopulmonary arrest while in the operating room, the need for amputation of the leg, and a change in Patient B's neurological status.

Findings:

Review of the medical record showed Patient A came to the Psychiatry Emergency Department on 7/9/11 at approximately 1635 hours. Patient A was placed on a 72 hour involuntary hold and was assessed as requiring inpatient hospitalization and treatment for a condition in which a person, as a result of a mental disorder, is unable to provide for his/her basic physical needs.

On 7/11/11 at 1635 hours, Patient A was admitted to the Psychiatric Unit of the hospital. The patient remained on an involuntary legal hold status throughout his hospital stay. The attending physician, MD X, was interviewed on 8/2/11 at 0930 hours. He stated Patient A refused all feedings because "he was being held against his will." Patient A was ambulatory but refused all laboratory evaluation and all physical evaluation or vital signs. MD X stated there were no signs of dehydration but admitted the patient could not be assessed for how many days, prior to admission, he had not eaten or consumed fluids. Patient A did not have an assessment by a physician from internal medicine. MD X stated a court order was obtained to administer emergency medications, but he did not obtain a court order for forced feedings or fluids.

On 7/19/11 a Nutritional Assessment in the medical record recommended "enteral feedings." There was no documented evidence the medical staff acted on the nutritional assessment recommendations. Documentation showed Patient A continued to refuse fluids and food from 7/9/11 until 7/25/11. At 0500 hours on 7/25/2011, Patient A was observed by nursing staff to have collapsed and was unresponsive. The rapid response team was summoned and a "Code Blue" was initiated. A large bore catheter to deliver fluids and nutrients intravenously was placed. Patient A was intubated and medications to raise blood pressure and antibiotics were administered. 50% Dextrose and 1000 cc of Saline were administered intravenously.

MD Z was interviewed on 8/3/11 at 1305 hours. She stated that she assessed Patient A during the code. She observed "skin extremely dry, retracted, cool, mucus membranes dry." MD G was interviewed at 1310 hours on 8/3/11. She stated, upon her arrival at the code blue, Patient A was "obtunded and not moving." Patient A was pale, with decreased skin turgor. Vital signs were absent. According to interviews with MD U, the critical care physician, the laboratory values for Patient A at the time of the code were consistent with severe dehydration and volume depletion (not enough fluid in the circulating blood stream). Patient A expired on 7/28/11.

According to interviews with MD X and MD P, no consultation with internal medicine was obtained despite minimal to no witnessed intake of food or water since 7/9/11, a total of 16 days. Cross reference A 338.

2. According to the medical record and interviews with MD Q conducted on 9/12/11 at 1330 hours, Patient B was offered a total knee replacement surgery for which he came to the hospital on 8/5/11.

A review of the anesthesia record and the history and physical examination revealed that the laboratory work and informed consent had been performed on 3/15/11, five months prior to the surgery. When interviewed at 1400 hours on 9/12/11, MD R stated that the general guidelines for lab work for young and healthy patients did not require repeat lab work prior to a surgical procedure. MD R stated that she was unaware the lab work was not recent. MD R stated the lab work should be dated when placed into the preanesthetic assessment.

On 8/5/11 anesthesia was induced for Patient B at 1600 hours. A tourniquet for bloodless surgery was used on the right leg.

MD Q stated it took several hours to free up the structures in the knee requiring a long tourniquet time, which by the end of the procedure, reached a total of 326 minutes. He stated that the patient was stable with no blood loss, but noted that during the surgery, the main artery and vein in the knee had been cut when using the saw.

Interviews with MD V revealed that a vascular repair would be required to repair the cut artery and vein in the knee. It was elected to wait until the total knee replacement surgery was completed in order to have a stable surgical field for the vascular repair. At 2200 hours, blood had not yet been received from the blood bank.

At approximately 2230 hours, the tourniquet was released. The anesthesia record of 8/5/11 revealed 1000 cc (cubic centimeters) of blood loss. On 9/12/11 at approximately 1130 hours, MD T was interviewed. RN 1 stated, during an interview on 9/13/11 at 1500 hours, he recalled hearing MD S tell MD T that 1000 cc. of blood had been lost. RN 1 stated that MD S was going to order one unit of blood to be transfused immediately and have a second unit ready. However, RN 1 told MD S that no blood had been requested from the blood bank because the surgery was done under tourniquet, supposedly a bloodless surgery. RN 1 asked MD S to obtain a blood specimen for a type and cross match. RN 1 stated that MD S was having difficulty obtaining blood for the type and cross match and it took "almost an hour" to obtain 1/2 of a laboratory tube of blood to send to the blood bank. The tube of blood was sent to the blood bank at 2300 hours. RN 1 stated that the blood bank offered unmatched blood for Patient B, at approximately 2330 hours; however, MD S did not request the unmatched blood from the blood bank. RN 1 stated that MD S wanted to wait for the type and cross matched unit of blood for Patient B.

According to the operative note, "it took longer to gain control of the bleeding." MD T noted "considerable oozing from the structures in the knee, including the bony structures. MD T asked MD S regarding the blood loss and was informed that 2500 cc of blood had now been lost, however, no blood had been infused for Patient B. MD T noted that bleeding "stopped abruptly" and MD S reported that Patient A had no blood pressure or pulse. Patient B was turned into a face up position and CPR was initiated at 0030 hours on 8/6/11.

After a total of 14 units of blood and four units of fresh frozen plasma and platelets, Patient B had a "gradually improving blood pressure and near-normalization of the heart rate." Marked abdominal distention was noted by the physicians. The abdomen was opened and an amount of fluid removed. During the ongoing resuscitation of the patient, a "four compartment fasciotomy" was performed (opening the muscles in the right leg to allow the soft tissues to swell). Patient B was then rotated back to the face down position and the vascular surgical procedure was completed. Patient B was then taken to the ICU of the hospital, despite no blood supply to the right lower extremity.

On 8/10/11, a below the knee amputation was and irrigation of Patient B's abdominal wound performed. On 8/16/11 a tracheostomy (tube through the throat into the trachea to help breathing) was performed and a percutaneous gastrointestinal feeding tube was inserted. At the same time on 8/16/2011 a right above the knee amputation was performed. On 9/10/11 the amputation site was revised surgically. As of 9/13/11 at 1130 hours, Patient B was observed in the Stepdown Unit. His eyes were open but he did not respond to commands.

Based on interviews, a review of a closed medical record, and a review of documents from the hospital, the medical staff failed to ensure the bylaws included criteria for mandatory consultation as required by State law California Code of Regulations, Title 22, Section 70703(h). This resulted in the failure to obtain a medical consultation for the care of one of four sampled patients (Patient A).

Findings:

Review of the medical record showed Patient A came to the Psychiatry Emergency Department on 7/9/11 at approximately 1635 hours. Patient A was placed on a 72 hour involuntary hold and was assessed as requiring inpatient hospitalization and treatment as gravely disabled (unable to provide for his/her basic physical needs), danger to self, and danger to others. While being observed in the Psychiatry Emergency Department, Patient A refused all oral intake and was found to be selectively mute, refused to answer questions, except to say "I will take no medications."

On 7/11/11 at 1635 hours, Patient A was admitted to the Psychiatric Unit of the hospital. The attending physician, MD X was interviewed on 8/2/11 at 0930 hours. He stated Patient A refused all feedings because "he was being held against his will." MD X stated Patient A was ambulatory but refused all laboratory evaluation and all physical evaluation or vital signs. MD X stated there were no signs of dehydration but admitted the patient could not be assessed for how many days prior to admission he had not eaten or consumed fluids. Patient A did not have an assessment by a physician from internal medicine. MD X stated a court order was obtained to administer emergency medication but he did not obtain a court order for forced feedings or fluids.

On 7/25/11, Patient A remained without eating or drinking, refusing all lab work and vital signs and remained selectively mute. According to interviews with MD X and MD P, no consultation with internal medicine was obtained despite minimal to no witnessed intake of food or water since 7/9/11.

Review of the medical staff bylaws revealed there was no criteria developed for mandatory consultation as required by state law.

Based on observation, staff interview, and record review, the hospital failed to ensure nursing services met the hydration needs for one of four sampled patients (Patient A). This resulted in Patient A becoming dehydrated and not having adequate emergency equipment to resuscitate Patient A.

Findings:

1. The psychiatric nursing service failed to provide hydration assessment of Patient A who had minimal oral intake. The nursing service failed to ensure a physician was notified when Patient A's vital signs were abnormal. Cross reference to A395 #1.

2. The nursing service failed to supervise the presence of accurate emergency supplies, including back up supplies, to prevent delay of patient emergency treatments. Cross reference A395#2.

These deficient practices resulted in the inability of the hospital to provide quality care in a safe environment.

Based on observation, record review and staff interview, the nursing service failed to provide an accurate medical and mental assessment for one of four sampled patients (Patient A). The nursing staff failed to assess Patient A's hydration status and evaluate the patient's care on an ongoing basis. The nursing service failed to ensure physician notification of an elevated heart rate for Patient A. The nursing service failed to supervise emergency care for one of four sampled patients as evidenced by the failure to ensure emergency equipment was readily available for emergency resuscitation (Patient A). This resulted in Patient A becoming dehydrated, a lack of physician knowledge of abnormal vital signs, and a delay in defibrillation of his heart when needed.

Findings:

1. Per record review on 8/3/11, Patient A was admitted to the hospital on 7/9/11. Patient A was placed on a 72 hour involuntary hold and was assessed as a danger to self and others, and unable to provide for his basic physical needs secondary to a mental disorder.

Patient A was documented from the date of admission as selectively mute, refusing to speak to the medical and nursing staff. The patient refused all oral intake including medications, any physical examination, and vital signs. Review of nursing notes from 7/9/11 to 7/19/11 showed Patient A did not consume his meals. The nursing notes on 7/20/11 at 1400 hours stated 2 cups of water (480 cc) were left at the bedside and were empty at the end of the shift. There was no documentation; however, Patient A was seen actually drinking the water. Patient A was assessed with good skin turgor and appeared adequately hydrated but with no documented evidence of measurable fluid or food intake since admission. From 7/21/11 to 7/22/11, Patient A was "noted going to bathroom x 2;" however, it was not noted whether Patient A urinated or had a bowel movement. On 7/23/11 at 0900 hours Patient A "had a bowel movement x 1." Patient A was observed drinking tap water from the sink faucet three times from 7/23/11 to 7/24/11 at 1630 hours; however, there was no approximate amount of fluid documented.

On 7/18/11, MD X ordered Haldol 5 mg. (an anti-psychotic drug), Lorazepam 2 mg. (an anti-anxiety drug), and Benadryl 25 mg. (an antihistamine). Patient A refused these medications by mouth. As a result, these medications were administered intramuscularly. All medications could affect Patient A's vital signs, however, the vital signs were taken on a rare occasion.

On 8/3/11, review of the vital signs log sheets filled in by the nursing assistants, from 7/13/11 to 7/24/11, Patient A refused to have his vital signs taken. Per review of the vital signs documented in the computer from 7/15/11-7/24/11, Patient A had only one full set of vital signs recorded. On 7/15/11 at 1700 hours, Patient A had a heart rate of 98, respiratory rate of 20 and a blood pressure of 124/84. There was no temperature recorded because of patient refusal. On 7/24/11, Patient A had a temperature of 97.5 degrees Fahrenheit, a heart rate of 137, respiratory rate of 22 and a blood pressure of 127/57. There was no documentation if the high heart rate (normal rate 60-100) was reported to the physician. There was no documented reassessment of Patient A's vital signs or assessment of the reason for the patient's high heart rate.

On 7/25/11 at 0500 hours, Patient A was found unresponsive on his bed. A "Code Blue" was called. Patient A was resuscitated and was transferred to Intensive Care Unit in critical condition. Patient A expired on 7/28/11.

MD X was interviewed on 8/2/11 at 0930 hours. MD X stated that Patient A was exhibiting bizarre behavior at home and was a physical danger to an elderly female. He stated Patient A refused all feedings because "he was being held against his will." MD X stated Patient A was ambulatory but refused all laboratory evaluation and all physical evaluation or vital signs. MD X stated there were no signs of dehydration but the patient could not be assessed for how many days he had not eaten or consumed fluids prior to his admission.

MD Z was interviewed on 8/3/11 at 1305 hours. She responded to the Code Blue and assessed Patient A as "skin extremely dry, retracted, cool, mucus membranes dry." She added that "the patient was extremely dry" and help was sought from the Emergency Room and Critical Care nurses to insert a peripheral intravenous site to infuse fluids. MD G also responded to the Code Blue and was interviewed on 8/3/11 at 1310 hours. She stated upon her arrival at the Code Blue, Patient A was "obtunded and not moving, pale, with decreased skin turgor and with vital signs absent."

In an interview with RN B and the Psychiatric Unit Manager on 8/3/11 at 1445 hours, they described Patient A as physically able and that he had no signs and symptoms of dehydration. There was no recorded "solid food intake but (the patient) was observed drinking from the sink's faucet." RN B declared the unit was not a medical-surgical unit where vital signs and intake and output were routinely taken. Despite the fact Patient A had not eaten, with minimal fluid intake since admission, the nursing staff had not recorded his intake and output. The Unit Manager agreed however that vital signs were required to monitor side effects of psychotropic medications (drugs altering effect on perception, emotion and behavior) and other medical conditions made worse by mental disorders.

2. Per record review on 8/3/11, Patient A had an unwitnessed cardiopulmonary arrest when he was found unresponsive on 7/25/11. A "Code Blue" was called at 0505 hours. During resuscitation, attempts for defibrillation (induced electrical shock) for Patient A, who had no heart beat, could not be immediately performed because incompatible defibrillator pads had been placed on the emergency cart. Per the Cardiopulmonary Resuscitation Record for Patient A, the first defibrillation was recorded at 0550 hours, 45 minutes after the Code Blue started.

On 8/3/11 at 1100 hours, in an interview with the Risk Manager and the Assistant Director of Nursing, the hospital used one brand of defibrillator pads, but of two types. One for monitoring during transport of patients and one for defibrillation and as external pacer electrodes. The transport pads had a yellow stripe and the defibrillator/pacer pads had an orange stripe. The transport pads were the ones that were wrongly stocked on top of the emergency cart used for Patient A. Review of the the emergency cart's checklist showed the cart had been checked on a daily basis by nursing staff.

In an interview with MD Z who responded to Patient A's Code Blue on 8/3/11 at 1310 hours, the defibrillator pads were unwrapped but were unable to be connected to the defibrillator equipment secondary to incompatibility. MD Z was unable to confirm the exact delay time while waiting for another emergency crash cart to be able to deliver the therapeutic electrical energy to revive the patient.

On 8/3/11 at 1330 hours, the Psychiatric Unit's supply room was inspected with the Unit Manager. When asked if there was any back up supplies for defibrillator pads, she stated the supply bin for the appropriate defibrillator pads was found empty at the time of Patient A's Code Blue. She added that there was lack of monitoring whether Central Supply Technicians were appropriately stocking their supplies.

On 5/14/10, the hospital was also investigated for a similar safety issue of a defibrillator that occurred on 4/19/10. The investigation showed that during a resuscitation event in the CAT Scan (computerized imaging method) Department, defibrillation was not immediately performed on a patient who arrested while being transported. The nursing staff did not know how to work an older model of a defibrillator and so the Emergency Department was called to bring another defibrillator which the nurses knew how to operate. Part of the hospital's plan of correction for this event was hospital wide training.

Based on observation, record review and staff interview, the hospital failed to ensure cardiac defibrillator supplies were stocked to ensure timely emergency resuscitation of patients on one psychiatric unit. This resulted in a delay of defibrillation for Patient A during an emergency on 7/25/11.

Findings:

Per record review on 8/3/11, Patient A had an unwitnessed cardiopulmonary arrest when he was found unresponsive on 7/25/11. A "Code Blue" was called at 0505 hours. During resuscitation, attempts for defibrillation (induced electrical shock) for Patient A, who had no heart beat, could not be immediately performed because incompatible defibrillator pads had been placed on the emergency cart. Per the Cardiopulmonary Resuscitation Record for Patient A, the first defibrillation was recorded at 0550 hours, 45 minutes after the Code Blue started.

On 8/3/11 at 1100 hours, the Risk Manager and the Assistant Director of Nursing, stated transport pads were stocked on top of the emergency cart instead of defibrillator pads.

On 8/3/11 at 1330 hours, the Psychiatric Unit's supply room was inspected with the Unit Manager. When asked if there was any back up supplies for defibrillator pads, she stated the supply bin for the appropriate defibrillator pads was found empty at the time of Patient A's Code Blue. She added that there was lack of monitoring whether Central Supply Technicians were appropriately stocking their supplies.

Based on interviews, and record review the hospital failed to ensure the provision of anesthesia services in a safe, manner to meet the needs of one of rour sampled patients (patient B).

Findings:

The hospital failed to ensure anesthesia services were provided to ensure blood was readily available to meet the emergency needs for one of four sampled patients (Patient B).

This deficient practice led to the inability of the anesthesia department to provide anesthesia services in a safe environment.

Based on a review of a self-reported unusual event and interviews with medical and nursing staff, two anesthesiologists failed to ensure the availability of blood to meet the emergency needs of one of four sampled patients (Patient B). This resulted in a cardiac arrest for Patient B.

Findings:

The Practice Guidelines for Perioperative Blood Transfusion and Adjuvant Therapies by the American Society of Anesthesiologists (ASA) Task Force published in Anesthesiology, V 105, No. 1, July 2006, stated the practice guidelines were intended to improve the perioperative management of blood transfusion and to reduce the risks that cause morbidity and mortality associated with blood transfusions, bleeding and anemia.

The guidelines were focused on perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss occurred or was expected. It included patients undergoing urgent and emergent procedures.

Guideline III for Intraoperative and Postoperative Management of Blood Loss and Transfusions stated that a periodic visual assessment of the surgical field and communication with the surgical team should be done to assess the presence of excessive bleeding. Among the recommendations made were to monitor for inadequate perfusion and oxygenation of vital organs, and to monitor for transfusion indications. Hemoglobin and hematocrit (basic laboratory test for red blood cells) levels should be measured during substantial blood loss and intraoperative blood recovery can be appropriate to decrease the patient's blood loss. Adequate quantities of red blood cells should be transfused to maintain organ perfusion (to supply organs with nutrients and oxygen).

On 9/12/11 at 1330 hours, Patient B's medical record was reviewed. Patient B came to the hospital on 8/5 11 for an elective total knee replacement on the right side.

A review of the anesthesia record and the history and physical examination revealed that the laboratory work and informed consent had been performed on 3/15/11, five months prior to the surgery. The informed consent identified there would be no need for blood replacement during the surgery.

On 8/5/11 anesthesia was induced for Patient B at 1600 hours. A tourniquet for bloodless surgery was placed at 1650 hours.

At 1330 hours on 9/12/11, MD Q stated that the early portion of the surgical procedure was not difficult; however, as the surgery progressed, distortion of the patient's anatomy was identified. He stated that it took several hours to free up the structures in the knee. He stated that the patient was stable with no blood loss, but noted that during the surgery, the main artery and vein in the knee had been cut when using the saw. (The popliteal artery and vein had been transected during the knee replacement.).

A note placed into the anesthesia record at 1700 hours, revealed "popliteal artery iatrogenic injury." There was no documented evidence the anesthesiologist prepared blood for the patient in anticipation of any blood loss when the tourniquet was removed from the patient's leg. No blood specimen was obtained to determine if blood would be needed. There was no documented evidence the anesthesiologist directed the nursing staff to prepare equipment to collect any blood lost by the patient after the tourniquet was released for re-infusion to the patient.

At 1900 hours another anesthesiologist, MD s, took over the care of Patient B. At 2200 hours, blood had not been received from the blood bank. There was no evidence the anesthesiologist directed nursing staff to set up equipment to collect any blood lost by the patient so it could be returned to the patient intravenously.

At approximately 2230 hours, the tourniquet was released. The operative report revealed exploration of the vessels revealed there were more vascular injuries than originally noted. MD T noted "considerable oozing from the structures in the knee, including the bony structures." The anesthesia record revealed 1000 cc (cubic centimeters) of blood loss.

RN 1 stated, during an interview on 9/13/11 at 1500 hours, he recalled hearing MD S tell MD T that 1000 cc. of blood had been lost. RN 1 stated that MD S was going to order one unit of blood to be transfused immediately and have a second unit ready. However, RN 1 told MD S that no preparation of blood for Patient B had been requested from the blood bank because the surgery was done under tourniquet. RN 1 asked MD S to obtain a blood specimen for a type and cross match. RN 1 stated that MD S was having difficulty obtaining blood for the type and cross match and it took "almost an hour" to obtain 1/2 of a laboratory tube of blood to send to the blood bank. The tube of blood was sent to the blood bank at 2300 hours. RN 1 stated that at approximately 2330 hours the blood bank offered unmatched blood for Patient B. MD S did not request the unmatched blood from the blood bank. RN 1 stated that MD S wanted to wait for the typed and cross matched unit of blood for Patient B.

MD T asked MD S regarding the blood loss and was informed that 2500 cc of blood had now been lost; however, no blood had been infused for Patient B. MD T noted that bleeding "stopped abruptly" and MD S reported that Patient A had no blood pressure or pulse. Patient B was rotated back into the supine position (face up) and CPR was initiated at 0030 hours.

Patient B was administered four units of O negative blood, and later, additional blood and blood products. After a total of 14 units of blood and four units of fresh frozen plasma and platelets, Patient B had a "gradually improving blood pressure and near-normalization of the heart rate." The patient was observed on 9/13/11 with an altered level of neurological function.