HospitalInspections.org

A. Based on review of documents and interviews, it was determined that in 1 of 10 (Pt. #1) clinical records reviewed, the Hospital failed to ensure supervision of the Surgical Resident, as required.

Findings include:

1. The Hospital's "Bylaws/Rules and Regulations for the Professional Staff of Northshore University Health System," dated 11/8/12, "...16. Supervision of the Medical Housestaff 16.2 Responsibilities of Member of Participating Departments- A member of the department shall supervise each participant in a professional graduate medical education program in the performance of all...therapeutic and surgical procedures..."

2. The clinical record of Pt. #1 was reviewed on 1/24/13. Pt # 1 was a 95 year old male admitted on 10/8/12 with admitting diagnoses of Chest Pain, Parkinson's and Atrial Fibrillation. Pt. #1's clinical record included nursing documentation dated and timed 11/19/12 at 5:36 PM, "On arrival from floor Pt had clotted J tube. Flushed with warm water and found to have a split in the tubing above the skin right below the y-connector." Pt. #1's Nursing documentation dated 11/19/12 at 7:30 PM indicated, "Attempted to flush J tube upon arrival to ICU; appears to be clogged. Other port (gastric) used for med administration is patent ..."
On 11/19/12 at 11:41 PM, the nursing staff notified that Physician Assistant, E #6 regarding J-tube. The J-tube was flushed with warm water but was found to have a split in the tubing above the skin right below the y- connector. E #6 updated the resident who requested tubing to be taped for now.
At 6:33 PM on 11/20/12 nursing documentation indicated, "J- tube unusable due to leak. Two (2) unsuccessful attempts made to repair tube with epoxy glue ...it continues to leak at split below y-connector."
3. Pt. #1's clinical record lacks documentation of who applied the adhesive or glue to the J-tube. The clinical record lacked documentation that Pt #1's J tube was used from time of insertion on 11/17/12 until the identification of cracked J-tube on 11/19/12.
4. The Surgeon (E #1)caring for Pt #1, was interviewed on 1/25/13 at approximately 10:30 AM. E#1 stated, "I do not remember who used derma bond on the j tube ". E #1 does not know specifically who he instructed to apply the adhesive to the J-tube. E #1 stated that he worked with 5 residents, 3 Physician Assistants but E #1 did give the instruction use adhesive since the tape that he initially applied did not work.
5. The Surgical Resident (E #9), responsible for attempting to repair Pt #1's J Tube was interviewed on 1/29/13 at approximately 12:00 PM. E #9 stated that he was the one who attempted to fix Pt #1's J tube leak by applying Octyseal, as instructed by E #1. However I failed to write a procedure note documenting the attempt.

B. Based on review of documents and interviews, it was determined that in 1 of 10 (Pt. #1)clinical records reviewed, the Hospital failed to ensure patient care orders were written by the responsible practitioner.

Findings include:

1. The Hospital's "Bylaws/Rules and Regulations for the Professional Staff of Northshore University Health System," dated 11/8/12, "...4. Patient Orders - All orders shall be written or otherwise entered by the responsible practitioners, their designees or participants in Professional Graduate Education programs under the responsible practitioner's supervision."

2. The clinical record of Pt. #1 was reviewed on 1/24/13. Pt # 1 was a 95 year old male admitted on 10/8/12 with admitting diagnoses of Chest Pain, Parkinson's and Atrial Fibrillation. Pt. #1's clinical record included documentation dated and timed 11/19/12 at 5:36 PM, "On arrival from floor pt had clotted J tube. Flushed with warm water and found to have a split in the tubing above the skin right below the y-connector."
At 6:33 PM on 11/20/12 nursing documentation indicated, "J- tube unusable due to leak. Two (2) unsuccessful attempts made to repair tube with epoxy glue ...it continues to leak at split below y-connector." Pt. #1's clinical record lacks documentation of physician order to repair J- tube.
3. The Surgeon, E #1 was interviewed on 1/25/13 at approximately 10:30 AM. E #1 stated, "I do not remember who used derma bond on the J tube".
4. The Surgical Resident (E #9), responsible for attempting to repair Pt #1's J Tube was interviewed on 1/29/13 at approximately 12:00 PM. E #9 stated that there was not a written order to repair Pt #1's J tube.