HospitalInspections.org

The facility failed to meet the regulatory requirements for the Condition of Participation: §CFR 482.23 Nursing Services as evidenced by the following:

Based on interview and record review the hospital failed to ensure nursing staff followed its Policies and Procedures (P&P) titled "Emergency Standardized Procedures [legal mechanism for registered nurses [RN] to perform functions which would otherwise be considered the practice of medicine]" and "Informed Consent [process in which a medical doctor (MD) educates a patient about the risks, benefits and alternatives to a procedure]" for two of four sampled patients (Patient 1 and Patient 24) when:

1. Based on interview and record review the hospital failed to ensure eight of 12 sampled Emergency Department (ED) registered nurses (RN) (RN 1, RN 3, RN 4, RN 5, RN 6, RN 7, RN 8, and RN 9) completed Critical Test Results (CTR - abnormal laboratory [lab] values that are outside the normal range to a degree that may constitute an immediate health risk to the individual or require immediate action on the part of the ordering physician) education. (Refer to A 397)

2. Follow its "Emergency Standardized Procedures [legal mechanism for RN to perform functions which would otherwise be considered the practice of medicine]" and "Informed Consent" policy and procedure (P&P) when:

a. RN 12 had conflicting triage assessment documentation for Patient 1.

b. Physician 4 documented Patient 1 had oral (PO) intake and adequate output but there was no order for PO intake and no documentation of Patient 1 having intake or output.

c. RN 13 gave Tylenol but did not obtain a physician's signature for the order.

d. The risks, benefits, and alternatives (RBAs) to a procedure were not documented by a physician for one of one sampled patient (Patient 24) prior to Patient 24 undergoing an invasive procedure. (Refer to A 398).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure nursing services were provided in a safe manner, patient care needs were being met, and contributed to Patient 2's diagnosis of bacterial meningitis with a poor prognosis for meaningful recovery and discharged to hospice (specialized care for people near the end of life) care.

Based on interview and record review the hospital failed to ensure eight of 12 sampled Emergency Department (ED) registered nurses (RN) (RN 1, RN 3, RN 4, RN 5, RN 6, RN 7, RN 8, and RN 9) completed Critical Test Results (CTR - abnormal laboratory [lab] values that are outside the normal range to a degree that may constitute an immediate health risk to the individual or require immediate action on the part of the ordering physician) education. This failure resulted in CTR not being communicated to a physician and for Patient 2's positive blood culture (test that looks for germs in the blood) for Escherichia coli (E. coli- bacteria typically found in the intestines) progressing from bacteria in the blood to meningitis (infection and swelling of the fluid and membranes surrounding the brain and spinal cord), which required transfer to a children's hospital in another county for a higher level of care, with a poor prognosis for recovery and discharged under hospice (specialized care for people near the end of life) care and had the potential for CTRs to not be communicated timely to a physician.

Findings:

During an interview on with Clinical Lab Scientist (CLS, performs scientific testing on samples and reports results to physicians) 1 on 3/5/24 at 11:37 a.m. CLS 1 stated she confirmed prior interview and record review findings on 1/22/24 at 10:31 a.m. when she stated the lab's blood culture "machine" alarmed on 12/19/24 and indicated Patient 2's blood culture had abnormal bacterial growth. CLS 1 stated when she printed Patient 2's information from the machine, the printout indicated Patient 2 had been in the hospital's ED but was no longer there. CLS 1 stated the hospital's process when a patient had already been discharged home from the ED, the ED charge nurse was given the CTR. During a review of Patient 2's "Microbiology Result Details [MRD]" dated 12/19/23 at 11:47 a.m. the MRD indicated, "Gram Negative Rods [type of bacteria] . . . Phoned to [RN 1].

During an interview on 3/4/24 at 11:39 a.m. with RN 1, RN 1 stated she received the CTR for Patient 2 on 12/19/23. RN 1 stated for blood culture CTRs she typically waits until around "5 p.m." to make calls to physicians to report findings, unless she had time earlier. RN 1 stated she realized Patient 2 had not been in the ED and she called the lab back to let them know. RN 1 stated when she called the lab, she was told the staff who reported the CTR to her earlier in the day was already gone and to call back the next day. RN 1 stated she did not document the conversation. RN 1 stated she did work the next day but never called the lab back. RN 1 stated blood culture CTR should be communicated to a physician within "one to two hours" like all other CTRs. RN 1 stated she never reported the CTR to a physician.

During a concurrent interview and record review on 3/4/24 at 12:14 p.m. with Quality Manager (QM), Patient 2's medical record was reviewed. QM stated there was no documentation of RN 1 notifying a physician of Patient 2's CTR.

During an interview on 3/5/24 at 9:38 a.m. with Quality Director (QD), QD stated no Critical Test Results education was found for RN 1 or RN 3.

During an interview on 3/5/24 at 10:51 a.m. with Emergency Department Director of Nursing (EDDN), EDDN stated CTR education was done upon hire.

During a concurrent interview and record review on 3/7/24 at 12:55 p.m. with Director of Education (DE), DE reviewed education records for ED RNs. DE stated many ED RNs whose date of hire was prior to 2016 had no recorded CTR education.

During an interview on 3/7/24 at 1:38 p.m. with DE, DE stated RN 4, RN 5, RN 6, RN 7, RN 8, and RN 9 had no recorded CTR education.

During a review of the hospital's P&P titled, "Critical Test Results and Test Result Reporting" dated 10/25/23. The P&P indicated, "Purpose: It is the policy of the laboratory, nursing, cardiovascular services, and imaging departments to report results of critical tests and critical test results to patient caregivers accurately and timely. This policy outlines the conditions under which critical test results are communicated. Guidelines/Policy Statement: Staff will receive orientation to this process and are responsible for following [the P&P]."

Based on interview and record review the hospital failed to ensure nursing staff followed its Policies and Procedures (P&P) titled "Emergency Standardized Procedures [legal mechanism for registered nurses [RN] to perform functions which would otherwise be considered the practice of medicine]" and "Informed Consent [process in which a medical doctor (MD) educates a patient about the risks, benefits and alternatives to a procedure]" for two of four sampled patients (Patient 1 and Patient 24) when:

1. RN 12 documented conflicting triage assessment for Patient 1. This failure resulted in an inaccurate medical (triage) record.

2. Physician 4 documented Patient 1 had oral (PO) intake and adequate output but there was no order for PO intake and no documentation of Patient 1 having intake or output. These failures had the potential to negatively impact patients' care and outcome.

3. RN 13 gave Patient 1 Tylenol but did not obtain a physician's signature for the order. This failure resulted in an inaccurate medical record.

4. Physician failed to document the risks, benefits and alternatives (RBAs) prior to one of one sampled patient (Patient 24) undergoing an invasive procedure. This failure resulted in Patient 24 and Family Member being unaware of risks, benefits and alternatives to the procedure and unable to make a fully informed consent.

Findings:

1. During an interview on 1/22/24 at 8:46 a.m. with Family Member (FM) 1, FM 1 stated she went to Hospital 1 by ambulance with Patient 1 (10-month-old female) because Patient 1 had fever, "rash over her entire body", and was not feeding well. FM 1 stated she felt not much was done by the ED staff. FM 1 stated Physician 4 talked to her [FM 1] "like I was stupid." FM 1 stated Physician 4 told her, "It's a virus. I see it all the time. Let her sleep it off." FM 1 stated after several hours in Hospital 1's ED, Patient 1 was discharged home. FM 1 stated she felt something was wrong with Patient 1 so she and her husband drove Patient 1 straight from Hospital 1 to Hospital 2's ED.

During a review of Patient 1's Hospital 1 "ED [Emergency Department] Triage" (EDT), dated 12/29/23 at 9:13 a.m. the EDT indicated RN 12 documented, "Chief Complaint ED: Rash, fever. . . Vomiting X 1 [one time]. . . Arrives with generalized red rash. . . Rash of unknown origin: NO." The EDT indicated on 12/29/23 at 9:19 a.m. RN 13 documented, "Diagnoses (Active). . . Rash. . . Skin Assessment Skin Integrity Intact (ED): Rash, Other generalized rash." The "ED Physician Notes" (EDPN), dated 12/29/24 indicated, "[Patient 1 ] has a rash on torso [trunk of body] and face."

During a concurrent interview and record review on 3/4/24 at 9:14 a.m. with Physician 4, Patient 1's ED Physician Notes (EDPN), dated 12/29/24 indicated, "[Patient 1 ] has a rash on torso [trunk of body] and face." Physician 4 stated he did not remember Patient 1 and could not comment on the conflicting documentation."

2. During an interview on 3/6/24 at 6:59 a.m. with RN 12, RN 12 stated patients in the emergency department are typically not fed. RN 12 stated if a "PO trial [feeding a patient to determine if the feeding does not cause diarrhea or vomiting]" would require a "verbal order [VO- an order stated to a nurse by a physician]." RN 12 stated "I don't know" if a VO is placed in the computer by the nurse or ordering physician. RN 12 stated she would only document input and output (I&O - method of documenting what a patient consumes by mouth, feeding tube, or intravenously and what is eliminated through urination, bowel movement, or vomiting) if it was "pertinent" to why the patient was in the ED. RN 12 did not respond when asked if fever and vomiting were pertinent to documenting I&O. RN 12 stated, "We do not document every wet and poopy diaper."

During an interview on 3/6/24 at 9:27 a.m. with Quality Manager (QM), QM stated there was no documented I&O for Patient 1.

During an interview on 3/6/24 at 10 a.m. with QM and Director of Nursing Med/Surg Tele (DNMT), QM and DNMT both stated a physician's order would be required for a "PO trial." QM and DNMT stated there was no order for a PO trial for Patient 1.

During an interview on 3/6/24 at 10:45 a.m. with RN 13, RN 13 stated a PO trial would require a physician to place an order or give a verbal order. RN 13 stated the order would indicate what type of food or liquid and how much to give. RN 13 stated once she got a PO trial order, she would document what time the PO trial started, what and how much was given, how the patient tolerated the feeding, and report the intake to the physician. RN 13 stated she would also document the output. RN 13 stated PO trials are usually liquids, graham crackers, or applesauce."

During an interview on 3/6/24 at 11:03 a.m. with Emergency Department Director of Nursing (EDDN) and Nurse Manager Emergency Department (NMED), NMED stated intake and output documentation should be done in the ED. EDDN stated at the very least an event note should be entered to document what and how much was given to the patient and how it was tolerated. EDDN stated a physician order is needed for PO trial.

During a review of Patient 1's "Emergency Documentation - MD" (EDMD), dated 12/29/23 at 2:32 p.m. the EDMD indicated, "Upon recheck, the patient was able to eat and drink. She is making normal amounts of wet diapers so unlikely to be dehydration."

3. During a concurrent interview and record review on 3/7/24 at 9:08 a.m. with DNMT, Patient 1's medical record was reviewed. The "Order Information" (OI) dated 12/29/23 at 2:56 p.m. indicated Patient 1 was given Tylenol 145.95 milligrams (mg) by mouth by RN 13. The OI indicated RN 13 entered the order electronically with an order entry of "No co-signature required." DNMT stated the order was not signed by a physician.

During a review of the hospital's policy and procedure (P&P) titled, "Emergency Standardized Procedures" dated 4/11/23, the P&P indicated, "This policy provides guidance, in alignment with the guideline set by the Board of Registered Nursing article 7; by which a Registered Nurse (RN) can implement laboratory and/or radiological studies as well as provide the patient with pain and/or fever alleviating medication. . . 2. Scope and Setting of Practice a. Competent emergency department triage RNs may perform the following functions within their training specialty area and consistent with their experience and credentialing: triage assessment, assessment of acute illness and acute on[set] chronic illness (including but not limited to ordering laboratory procedures, x-rays, and medications when indicated). . . Procedure: The utilization of Emergency Standardized Procedures is a five-step process as follows. . . 4. The order will be placed in the EHR [medical record] as "co-signature required" with the signature being required by the MD on duty."

During a review of the hospital's P&P titled, "Documentation by Nursing Personnel," dated 12/1/17, the P&P indicated, "6. Nursing Progress Notes/Event Notes a. Entries will accurately reflect an issue or incident with the patient or patient's care. B. Pertinent and concise entries that reflect the problem statement, the patient's needs, problems, capabilities, and limitations, as well as the patient's response to nursing interventions, will be recorded."

4. During a concurrent interview and record review on 3/7/24 with Director of Nursing Med/Surg Tele (DNMT), Patient 24's "Progress Note" (PN), dated 1/3/24 at 7:28 p.m. the PN indicated a lumbar puncture (LP- also known as a spinal tap, a medical procedure where a needle is inserted into the spinal canal, most commonly to collect cerebrospinal fluid [CSF - protective fluid for brain and spinal cord] for diagnostic testing). DNMT stated the was no documented "risks versus benefits language" for the LP in Patient 24's medial record.

During a review of the hospital's policy and procedure (P&P) titled, "Informed Consent" dated 4/4/22, the P&P indicated, "a. Process by Which the Physician Informs the Patient. . . it is the expectation that the physician shall give a personal explanation of the nature of the operation of procedure, the expected benefits or effects of the operation or procedure, a description of any attendant discomfort, complications, or risks to the patient that may occur, a description of any alternative methods of treatment, including the nature of such treatments, their expected benefits or effects, and their possible risks and complications, the likelihood of achieving care, treatment, and service goals with procedure verse [sic] alternative."

During a review of the American Medical Association (AMA) Code of Medical Ethics, The Code of Ethics indicated 1.1.3 Patient Rights ...Physicians can best contribute to a mutually respectful alliance with patients by serving as their patients' advocates and by respecting patients' rights These include the right: ...(b) To receive information from their physicians and to have the opportunity to discuss the benefits, risks and cost of appropriate treatment alternatives, including the risks, benefits and costs of foregoing treatment. ...(c) To ask questions about their health status or recommended treatment when they do not fully understand what has been described and to have their questions answered (d) to make decisions about the care the physician recommends ...(g) To obtain a second opinion ...AMA Principles of Medical Ethics: I, IV, V, VIII, IX)

During a review of the hospital's P&P titled, "Universal Protocol Procedure," dated 1/26/22, the P&P indicated, "5. Pre-operative Unit - Procedure Verification. . . c. Documentation will be compared to confirm patient identified procedure and site matches. . . iii. LIP [Licensed Independent Practitioner - medical provider] documentation of informed consent (Risks, Benefits, and Alternatives."

Based on interview and record review, the facility failed to develop and fund a plan to ensure the transfer and storage of all units of blood and blood component records (over the past 10 years) in the event of facility ceases to operate. This failure had the potential for newly identified infectious blood or blood component information to not be provided to blood recipients thereby putting the all patients who received blood or blood components at risk for possible transmissible blood borne illness, disease, or death.

Findings:

During a concurrent interview and record review on 3/7/24 at 2:20 p.m. with Director of Quality (DOQ), The facility's "Business Continuity Plan, Continuity of Operations Plan," dated 1/2/24 and "Affiliation Agreement [AA]," dated 12/1/1995 were reviewed. DOQ stated she would not provide the surveyor a copy of the facility's "AA." DOQ was unable to provide documentation of a fully funded plan for storage of all the facility's blood and blood component records (over the past 10 years) in the event of facility ceases to operate for any reason.

The facility failed to meet the regulatory requirements for the Condition of Participation: §CFR 482.55 Emergency Services as evidenced by the following:

Based on interview and record review, the hospital failed to ensure the safety of patients in accordance with the policy and procedures and with the regulations as evidenced by:

1. Critical Test Results (CTR- abnormal laboratory [lab] values that may cause an immediate health risk to the patient or require immediate action by a physician) for Patient 2 (7-week old male infant) were not reported to a physician within one hour. (Refer to A 1112)

2. Patient 2's CTR was never reported to the ordering physician (Physician 1) by the hospital. (A 1112)

3. Emergency Department (ED) Registered Nurses (RN) did not document receiving CTRs from lab staff for six of ten sampled patients (Patient 2, Patient 24, Patient 25, Patient 26, Patient 27, and Patient 20). (Refer to A 1112)

These failures resulted in Patient 2's positive blood culture (test that looks for germs in the blood) for Escherichia coli (E. coli- bacteria typically found in the intestines) progressing from bacteria in the blood to meningitis (infection and swelling of the fluid and membranes surrounding the brain and spinal cord) requiring transfer to a children's hospital in another county for a higher level of care with a poor prognosis (likely outcome or course of a disease; the chance of recovery or recurrence) for recovery and discharge under hospice (specialized care for people near the end of life) care, for CTRs to not be reported timely to a physician, and incomplete medical records for Patient 2, Patient 24, Patient 25, Patient 26, Patient 27, and Patient 20.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure emergency services were provided in a safe manner, patient care need were being met, and for Patient 2's discharge from a higher level of care hospital under hospice care.

Based on interview and record the Hospital failed to follow its policy and procedure titled, "Critical Test Results and Test Result Reporting" when:

1. Critical Test Results (CTR - abnormal laboratory [lab] values that are outside the normal range to a degree that may signify an immediate health risk to the individual or require immediate action on the part of the ordering physician) for one of 16 sampled patients (Patient 2- a 7-week-old male infant) were not reported to a physician within one hour.

2. The hospital never reported Patient 2's CTR to the ordering physician (Physician 1).

These failures resulted in Patient 2's positive blood culture (test that looks for germs in the blood) for Escherichia coli (E. coli- bacteria typically found in the intestines) progressing from bacteria in the blood to meningitis (infection and swelling of the fluid and membranes surrounding the brain and spinal cord) requiring transfer to a children's hospital (Hospital 4) in another county for a higher level of care, with a poor prognosis for recovery and discharged under hospice (specialized care for people near the end of life) care.

3. Emergency Department (ED) Registered Nurses (RN) did not document receiving CTRs from lab staff for six of ten sampled patients (Patient 2, Patient 24, Patient 25, Patient 26, Patient 27, and Patient 20).

This failure had the potential for a delay in reporting CTR and timely follow up care and resulted in an incomplete medical record.

Findings:

1. During an interview on 3/4/24 at 2:51 p.m. with Registrar 1, Registrar 1 stated she confirmed prior interview findings on 1/22/24 at 11:40 a.m. when she stated she registered Patient 2 to have outpatient blood work done in the hospital's lab on 12/18/23 at 6:15 p.m. Registrar 1 stated Patient 2 was brought to the hospital's main admitting area by his mother. Registrar 1 stated when she registered Patient 2 for lab work, she "inadvertently" registered Patient 2's location as "OB [obstetrics- area of hospital where women give birth] instead of "lab."

During an interview on 3/5/24 at 9:25 a.m. with RN 2, RN 2 stated she was working in the hospital's OB triage on 12/18/23. RN 2 stated Patient 2's name showed up on the OB tracking board (electronic system which shows patients registered to be seen and their status). RN 2 stated when she looked up Patient 2's information, she saw that Patient 2 was a seven-week-old baby. RN 2 stated she could move patients on the tracking board to other areas of the hospital. RN 2 stated she "assumed" Patient 2 was being seen in the ED and electronically transferred him to the ED. RN 2 stated she did not confirm with the registration department or call the ED when she changed Patient 2's electronic location. RN 2 stated her reason for electronically transferring Patient 2 to the ED was "probably just a guess."

During a concurrent interview and record review on 3/5/24 at 11:37 a.m. with Clinical Lab Scientist (CLS) 1, CLS 1 stated she confirmed prior interview and record review findings on 1/22/24 at 10:31 a.m. when she stated the lab's blood culture "machine" alarmed on 12/19/24 and indicated Patient 2's blood culture had abnormal bacterial growth. CLS 1 stated when she printed Patient 2's information from the machine, the printout indicated Patient 2 had been in the hospital's ED but was no longer there. CLS 1 stated the hospital's process when a patient has already been discharged home from the ED, the ED charge nurse is given the CTR. During a review of Patient 2's "Microbiology Result Details [MRD]" dated 12/19/23 at 11:47 a.m. the MRD indicated, "Gram Negative Rods [type of bacteria] . . . Phoned to [RN 1].

During an interview on 3/4/24 at 11:39 a.m. with RN 1, RN 1 stated she received CTR for Patient 2 on 12/19/23. RN 1 stated for blood culture CTRs she typically waits until around "5 p.m." to make calls to physicians to report findings unless she has time earlier. RN 1 stated she realized Patient 2 had not been in the ED and she called the lab back to let them know. RN 1 stated when she called the lab, she was told the staff who reported the CTR to her earlier in the day was already gone and to call back the next day. RN 1 stated she did not document the conversation. RN 1 stated she did work the next day but never called the lab back. RN 1 stated blood culture CTR should be communicated to a physician within "one to two hours" like and other CTR. RN 1 stated she never reported Patient 2's CTR to a physician.

During a review of Patient 2's medical record, the "ED Physician Notes [EDPN]" dated 12/23/23 at 12:21 a.m. indicated Patient 2 was brought to the hospital's ED on 12/22/23 and admitted to the hospital's Pediatric Intensive Care Unit (PICU- hospital unit that provides sick children with the highest level of medical care) in Condition Critical [unstable state, resulting from severe illness or injury, vital signs and other symptoms indicate a significant risk of death]. The "Discharge Summary" dated 12/23/23 at 10:36 p.m. indicated Patient 2's "Reason for Admission" was "E. coli with meningitis." The "Admission, Transfer, Discharge Orders" indicated Patient 2 was admitted to the hospital's PICU on 12/23/23 at 1:14 a.m. and was transferred to Hospital 4 on 12/23/23 at 8:20 p.m. The "Emergency Documentation - MD" dated 12/23/23 at 12:26 a.m. indicated, "The medical records from patient's admission at birth were reviewed by me [Physician 2]. While reviewing these records, I [Physician 2] noticed that patient had some laboratory results posted on 12/18. . . Blood culture with gram negative rods identified on the morning of 12/19/23 with final identification of pansensitive [bacteria is sensitive to all the antibiotics usually tested for potential treatment] E. coli. Upon further questioning, parents report that patient was sent for outpatient laboratory studies on 12/18. Parents report that they were not notified of any abnormal laboratory results and were unaware that patient had a positive blood culture when they decided to bring him to the ED tonight."

During an interview with Chief Nursing Office (CNO) on 3/4/24 at 3:16 p.m. CNO stated her expectation was for nursing staff to follow CTR policy and document who the nurse spoke with, which results were reported on, and any orders received."

During an interview on 3/4/24 at 4:57 p.m. with Physician 3, Physician 3 stated if he was told of an CTR for a patient who was not in hospital, he would "one hundred thousand percent" ask for the patient to be brought back to the hospital.

2. During an interview on 3/4/24 at 2:41 p.m. with Physician 1, Physician 1 stated he sent Patient 2 to the hospital for outpatient lab work to be done. Physician 1 stated was "never" notified of Patient 2's CTR from the hospital. Physician 1 stated he found out about Patient 2's abnormal lab results on 12/26/23 when a doctor from the Hospital 4 called him and informed him of Patient 2's critical condition.

During a concurrent interview and record review on 3/7/24 at 9:15 a.m. with Director of Nursing for Med/Surg Tele (DNMT), Patient 2's medical record was reviewed. DNMT stated she was unable to find documentation of RN 1 notifying a physician of Patient 2's CTR dated 12/19/23.

During a review of Patient 2's "Discharge Summary" dated 2/15/23 at 11:42 a.m. from Hospital 4, the Discharge Summary indicated, "Hospital Course: History of Present Illness: [Patient 2] is an ex-term [born at full term pregnancy] male, now 3 months of age, who presented at 8 weeks of age on 12/24/2023 as transfer from [Hospital 1] with Ecoli [sic] meningitis. Per outside hospital records, he presented to his PCP [primary doctor] on 12/18 with 5 days of fever, was diagnosed with flu and sent home after labs (including a blood culture [Bcx]). On 12/19, he re-presented to the PCP office with increased fussiness, but was sent home again. On 12/22, he was taken to [Hospital 1] ED where he was noted to have a positive Bcx from 12/18 growing gram-negative rods. An [sic] LP [lumbar puncture- also known as a spinal tap, a medical procedure where a needle is inserted into the spinal canal, most commonly to collect cerebrospinal fluid [CSF] for diagnostic testing] was performed with retrieval of cloudy/pustular [pus filled] appearing CSF fluid [sic]. . . After admission to [Hospital 4] PICU, he was noted to have tonic neck [normal reflex would be an infant's arm and leg opposite of the side the infant was turned to flex toward the head] deviation [abnormal response] with sudden tachycardia [heart rate increased out of normal range] and conjugate gaze [both eyes move in the same direction] suggestive of a seizure [sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain]. . . a repeat head CT [imaging test to help detect injury and disease] was obtained and discussed at length with radiology [physicians who interpret imaging tests] and neurosurgery [physicians who diagnose and treat nervous system disorders]. He [Patient 2] has extensive, devastating findings and further evolution [development] of parenchymal [functional tissue of the brain] loss with little functional brain apart from brainstem [part of brain responsible for vital life functions such as breathing, consciousness, blood pressure, heart rate, and sleep]. . . [Patient 2] was accepted as concurrent care patient with [local] Hospice [specialized care for people near the end of life]."

3a. During a concurrent interview and record review on 3/7/24 at 9:15 a.m. with (DNMT), Patient 2's medical record was reviewed. DNMT stated she was unable to find nursing documentation of RN 1 receiving CTR, dated 12/19/23 from CLS 1.

b. During a concurrent interview and record review on 3/7/23 at 12:33 p.m. with Quality Manager (QM), Patient 24's medical record was reviewed. The "Results Detail" dated 1/6/24 at 11:36 a.m. indicated Clinical Lab Scientist (CLS, performs scientific testing on samples and reports results to physicians) 2 notified RN 14 of Patient 24's CTR for an elevated blood potassium. QM stated there was no documentation by RN 14 of receiving the CTR, dated 1/6/24 from CLS 2.

c. During a concurrent interview and record review on 3/7/23 at 12:39 p.m. with QM, Patient 25's medical record was reviewed. The "Blood Culture" dated 2/19/24 at 1:02 p.m. indicated CLS 3 notified RN 1 of Patient 25's CTR for positive blood culture. QM stated there was no documentation by RN 1 of receiving the CTR, dated 2/19/24 from CLS 3.

d. During a concurrent interview and record review on 3/7/23 at 12:44 p.m. with QM, Patient 26's medical record was reviewed. The "Blood Culture" dated 2/12/24 at 8:06 p.m. indicated CLS 4 notified RN 15 of Patient 26's CTR for positive blood culture. QM stated there was no documentation by RN 15 of receiving the CTR, dated 2/12/24 from CLS 4.

e. During a concurrent interview and record review on 3/7/23 at 12:57 p.m. with QM, Patient 27's medical record was reviewed. The "Results Detail" dated 2/5/24 at 8:20 a.m. indicated CLS 5 notified RN 16 of Patient 27's CTR for positive blood culture. QM stated there was no documentation by RN 16 of receiving the CTR, dated 2/5/24 from CLS 5.


39650

f. During a review of Patient 20's "OUTPATIENT FACESHEET [OPFC]," dated 2/4/24, the "OPFC" indicated Patient 20 was admitted to the ED on 2/4/24 at 7:55 p.m.

During a review of Patient 20's "ED Physician Notes [EDPN]," dated 2/4/24, the "EDPN" indicated, "Encounter information: 2/4/24-2/4/24. History of Present Illness Patient 20 went to [facility name]'s urgent care was told to come to ER due to elevated heart rate, increased temperature and for 2 plus SIRS criteria [Systemic Inflammatory Response Syndrome - severe inflammation throughout body that can lead to organ failure and death. To be diagnosed with SIRS criteria: two or more of the following: Body temperature over 100.4 degrees Fahrenheit (F) or under 96.8 degrees, heart rate greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute or partial pressure of CO2 [carbon dioxide-waste product of breathing] less than 32 mmHg (millimeters of mercury-a unit of pressure equal to the pressure exerted) or white blood cell count greater than 12,000) per urgent care doctor's note. Patient 20's first vital signs included: Heart Rate 106 (beats per minute) Temperature PO [by mouth] 39.5 [Celsius-a unit to measure temperature - 103.4 Fahrenheit]".

During a concurrent interview and record review on 3/7/24 at 10:55 a.m. with Quality Safety Program Manager (QSPM) 1 Patient 20's "Blood Culture (Bcx)," dated 2/5/24 at 11:46 a.m. was reviewed. Patient 20's "Bcx" indicated, gram negative rods (antibiotic resistant bacteria in blood stream which can include E. coli, which can result in an inflammatory response that can lead to sepsis-a life threatening emergency) in Patient 20's blood. The results were phoned by the lab to Emergency Department (ED) Registered Nurse (RN) 16." Patient 20's electronic medical record (EMR) was reviewed. QSPM 1 was unable to provide documentation by RN 16 of the date and time of she received Patient 20's "BC" laboratory (lab) test results dated 3/5/24 or who provided the results from the lab. QSPM 1 stated RN 16 should have documented date and time of when she received Patient 20's "BC" laboratory (lab) test results and who provided the results from the lab in the EMR.

During an interview on 3/7/24 at 11:05 a.m. with Director Emergency Services (DES), DES stated the expectation was for the RN to contact the provider in the Emergency Department (ED) within 60 minutes of receipt of a critical value from the lab and the patient should be notified by the ED department as soon as provider reviewed the lab results.

During a concurrent interview and record review on 3/7/24 at 11:08 a.m. with DES and QPSPM 1, Patient 20's "Blood Culture," dated 2/5/24 at 11:46 a.m. was reviewed. Patient 20's "Bcx" indicated, gram negative rods in Patient 20's blood. The results were "phoned to. . . Registered Nurse (RN) 10 at 11:46 a.m. Patient 20's electronic medical record (EMR) was reviewed. DES stated if Patient 20 was notified of the positive lab results, Patient 20's notification should have been documented in EMR by the staff member or provider who provided the notification. Patient 20's "ED Follow Up-Text [EDFU]" dated 2/5/24 at 1:11 p.m. and EMR were reviewed. Patient 20's "EDFU" indicated, "Follow up action: Blood Culture Follow-up Comments: Pt [patient] results given to Physician Assistant - Certified [PAC] 1. PAC 1 to review chart and make contact w/[with] pt. RN 1-2/5/25 at 1:11 p.m." DES did not provide documentation PA-C 1 contacted Patient 20 with Bcx results. DES stated PA-C 1 should have contacted Patient 20 and documented the contact in the EMR right after receipt of the critical results or as soon as possible on 2/5/24. Patient 20's "ED Results Callback [EDRC]," dated 2/10/24 at 7:54 a.m. was reviewed. The "EDRC" indicated on 2/7/24, at 11:12 a.m., RN 11 "Spoke with provider in ED. Looked at blood culture result. Positive for E-coli pt on susceptible antibiotics, return if worse. . .message left. . .no f/u [follow up] needed."

During a review of the hospital's P&P titled, "Critical Test Results and Test Result Reporting" dated 10/25/23. The P&P indicated, "Purpose: It is the policy of the laboratory, nursing, cardiovascular services, and imaging departments to report results of critical tests and critical test results to patient caregivers accurately and timely. This policy outlines the conditions under which critical test results are communicated. . . Procedure: 1. Staff in the Laboratory, Imaging, and Cardiovascular Services departments will call critical test results to the licensed personnel and/or physician caring for the patient. For laboratory critical values, if an unconfirmed test result is a new critical level, the licensed staff member will be informed that a critical test value has been obtained and will be re-run for confirmation. 2. The licensed staff member will receive a call from the Laboratory, Imaging, or Cardiovascular Services departments within 15 minutes of the time the results are available. Staff calling the result will document date, time, first initial and last name of the person receiving the results in the medical record. Staff receiving the critical result will document date, time, first initial and last name of the person reporting and signature. This will be documented on the Critical Diagnostic Results Read-Back Documentation form or elsewhere in the patient's medical record. The responsible physician must be notified regarding a critical test result within 60 minutes of the time received by the licensed staff member (total lapse time 1 hour and 15 minutes). The exception to this requirement is the newborn bilirubin assessment. See policy "Newborn Hyperbilirubinemia, Screening and Management" for the process. 3. If a call is placed to report a critical test value and the nurse or physician cannot be contacted, the staff member will initiate the chain of command (see also policy "Chain of Command/Escalating Patient Care Concerns"). a. Nursing Non-Response 1) Initiate a second call within 5 minutes. 2) If no response, call charge RN in the department. 3) If no response, call the Nurse Manager or Director of the Department (House Supervisor during nights and weekends). b. Physician Non-Response 4. After two (2) phone calls within 15 minutes and no response or inappropriate response, the licensed personnel or designee will immediately activate the chain of command: a. The proper documentation of all efforts to obtain medical care for patients in emergency situations is essential. Documentation must include times, dates, names of physician and administrative notification as well as actions taken. 5. The receiving licensed person or physician will be asked to read back the test result that was given to them by the Imaging, EEG Tech, Laboratory and Cardiovascular Services personnel. 6. In the case of outpatients or discharged patients, the department reporting results will phone the ordering physician, the physician on call of physician's licensed office staff immediately. Document the first and last name of the physician or person receiving the results and date and time received on the Critical Diagnostic Result Readback Documentation Form or elsewhere in the patient's medical record."