HospitalInspections.org

Based on interview and record review, it was determined Jordan Valley Medical Center failed to promote and protect each patients' rights.

Findings include:

1. The hospital failed to obtain an informed consent to treat for patients who were unable to sign for themselves. (Refer to tag A-117)

2. The hospital failed to ensure that each patient or the patient's representative was given information on the patient's health status, diagnosis, and prognosis. (Refer to tag A-131)

Based on interview and record review, it was determined that the hospital did not obtain an informed consent to treat for 1 of 13 sampled patients who had a medical review completed by the survey team. Specifically, the hospital did not obtain written or verbal consent to treat for patients who were incapacitated or otherwise unable to consent to treatment upon admission.
(Patient identifier: 3)

Findings include:

Patient 3 was admitted to the hospital on 11/18/2021, with diagnoses of acute hypoxemic respiratory failure due to COVID, liver disease, congestive heart failure, and diabetes. Patient 3 passed away on 11/23/2021.

On 1/4/2022, patient 3's medical record was reviewed.

A review of the informed consent forms revealed the forms had not been signed by the patient or the patient's representative. The documentation on the consent forms indicated the patient did not sign due to, "conditions and patient in isolation."

On 1/11/2022 at 10:29 AM, an interview was conducted with the admitting director (AD). The AD stated if a patient was unable to sign consent forms due to their condition or isolation, the admitting person was to contact the patient's representative either in person or over the phone. The AD stated if the patient was alert and oriented and in isolation, the admitting person would call the patient on the telephone and get verbal consent. The AD stated the admitting person would complete an audit of the prior day's admissions to ensure all consent forms had been signed. If they had not been signed, the admitting person would call the patient/family representative to obtain a verbal consent. The AD stated she was not sure if the admitting person had followed up with patient 3 or his family representative. She confirmed there was no documented evidence of follow-up.

Based on interview and record review, it was determined the hospital did not ensure that each patient or the patient's representative was given information on the patient's health status, diagnosis, and prognosis for 1 of 13 sampled patients who had a full medical review completed by the survey team. (Patient identifier: 3)

Findings include:

Patient 3 was admitted to the hospital on 11/18/2021, with diagnoses of acute hypoxemic respiratory failure due to COVID, liver disease, congestive heart failure, and diabetes. Patient 3 passed away on 11/23/2021.

A review of patient 3's medcial record revealed that the hospital was instructed to always call either the daughter or wife with any updates or changes due to his intermittent confusion and the seriousness of COVID. The hospital was given both names and numbers. Evidence revealed that the hospital did not call them when patient 3's mental status started declining on the night of 11/22/2021.

An interview was conducted with the daughter of patient 3 on 1/6/2022 at 1:30 PM. The daughter stated the hospital had not called them with any updates or concerns with her father. She stated she requested her father's medical record after his death and in reviewing the record she stated she found the results of a chest CT (computed tomography) scan that had been completed. She stated the results indicated her father had an aortic aneurysm and the hospital never told her or her mother about it.

From 1/4/2022 through 1/11/2022, patient 3's medical record was reviewed.

A review of the nursing documentation revealed a nursing entry dated 11/19/2021 at 8:53 PM, that noted the contact information for both the wife and the daughter. No further documentation was found to indicate that the wife or daughter had been contacted concerning the condition and decline of patient 3.

A review of the medical record revealed a chest CT scan was competed on patient 3 on 11/19/2021. The results indicated the patient had a "fusiform (spindle shaped) aneurysmal dilation of the ascending thoracic aorta".

Further review of the medical record revealed patient 3 had a decline in mental status starting on 11/23/2021 at approximately 7:30 AM.

A review of the general medicine progress note dated 11/23/2021 at 10:00 AM, indicated "the patient has been encephalopathic (altered mental status) today per nursing report. Patient had been placed on BIPAP (ventilator) last night? Because ?he (sic) became encephalopathic, No indication that there was a call to the doctor overnight or early this morning ...".

Further documentation revealed patient 3's daughter came in around 11:30 AM on 11/23/2021 and stated that her father was very far from his normal mental and physical baseline. Patient 3's eyes had been wandering and he was not verbal or following commands. No documentation was provided to indicate the patient's wife or daughter had been contacted regarding his aortic aneurysm or change in condition.

On 1/6/2022 at 11:30 AM, an interview was conducted with the physician who provided care to patient 3. The physician stated she had not been made aware of the change in patient 3's condition until after the morning meeting on 11/23/2021. She stated no one notified her or the physician covering the night shift from 11/22/2021 to 11/23/2021. She was unaware that patient 3 was placed on BIPAP on 11/22/2021 at 4:59 PM. She further stated she did not know who ordered the ABG that was done at 3:47 PM on 11/22/2021, as the order was placed under the attending physician who had not worked since patient 3 had been admitted. She further stated nobody notified her of the abnormal ABG results from the 3:47 PM test completed on 11/22/2021. The physician stated if she had been notified she would have implemented interventions sooner. Note: The patient had abnormal labs for approximately 16 hours and intermittent BIPAP use without the physician being notified.

Based on interview and record review, it was determined Jordan Valley Medical Center failed to provide nursing services in an organized and safe manner. Specifically, for 6 of 20 sampled patients, delays in patient care and a lack of coordination of care was identified. Additionally, physician orders were not implemented. (Patient identifiers: 3, 5, 7, 9, 15, and 19.)

Findings include:

1. Patient 3 was admitted to the hospital on 11/18/2021, with diagnoses of acute hypoxemic respiratory failure due to COVID, liver disease, congestive heart failure, and diabetes.

On 1/4/2022 through 1/11/2022, patient 3's medical record was reviewed.

a. On 11/22/2021 it was documented arterial blood gases (ABG) (test to measure oxygen and carbon dioxide levels in the blood or how well lungs are working) were drawn at 3:47 PM, and patient 3 was subsequently placed on BIPAP (ventilator) at 4:59 PM on 11/22/2021. No documentation was provided to indicate that a physician had been notified of either the need for BIPAP or ABG.

On 11/23/2021 it was documented that patient 3 had a decline in his condition and was placed on BIPAP at 12:42 AM, and an ABG was drawn at 3:00 AM. No documentation was provided to indicate that a physician had been notified of either the need for BIPAP or ABG.

A review of the general medicine physician progress notes revealed the following entry dated 11/23/2021:

"Patient has been encephalopathic (altered mental status) today per nursing report after morning meeting. He was put on BiPAP last night because...?he (sic) became encephalopathic, No indication that there was a call to the doctor overnight or early this morning. An ABG was done that showed a pH of 7.5, CO2 of 28.3, O2 of 78.5. (abnormal results) Today daughter says that he is very far from baseline ..."

On 1/6/2022 at 11:30 AM, an interview was conducted with the physician who provided care to patient 3. The physician stated she had not been made aware of the change in patient 3's condition until after the morning meeting on 11/23/2021. She stated no one notified her or the physician covering the night shift from 11/22/2021 to 11/23/2021. She was unaware that patient 3 was placed on BIPAP on 11/22/2021 at 4:59 PM. She further stated she did not know who ordered the ABG that was done at 3:47 PM on 11/22/2021, as the order was placed under the attending physician who had not worked since patient 3 had been admitted. She further stated nobody notified her of the abnormal ABG results from the 3:47 PM test completed on 11/22/2021. The physician stated if she had been notified she would have implemented interventions sooner. Note: The patient had abnormal labs for approximately 16 hours and intermittent BIPAP use without the physician being notified.

b. A review of the physician orders revealed a STAT order for a head CT w/o (without) contrast to rule out stroke dated 11/23/2021 at 10:07 AM. The order was completed at 1:07 PM. The CT was not completed for approximately 3 hours after the STAT order was placed.

An interview was conducted with the physician, the quality director and the senior quality director on 1/6/2022 at 11:30 AM. The quality director stated the ICU (intensive care unit) did not have transport technicians, the nurses were the ones that had to transport the patient and that might have caused the delay. She also stated there was documentation that patient 3 was agitated in imaging which could also have contributed to the delay. The physician then stated she was notified that patient 3 was agitated prior to him going to have the CT done and was given Ativan prior to the procedure to help calm him for transfer. The physician stated that because patient 3 was COVID positive the CT area had to be cleared of other patients, which could again lead to a delay. Note: There was no documented evidence in patient 3's medical record that indicated the exact reason for the delay in the completion of the STAT CT.

c. Further review of the physician orders revealed a STAT order for an Ammonia level dated 11/23/21 at 10:09 AM. The lab was not completed until 10:55 AM. The sample was not collected for approximately 45 minutes after the STAT order was placed.


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2. Patient 9 was admitted to the hospital on 12/24/2021 with an admitting diagnosis of cardiac arrest.

A review of patient 9's medical record was completed on 1/11/2021.

a. At 9:50 AM on 12/27/2021 a physician documented that patient 9 was assessed, and the patient continued to experience acute renal failure but with "Improving urine output" as of 12/27/2021.

Patient 9's urine output for 12/27/2021 and 12/28/2021 was documented as follows:

12/27/2021 at 1:00 AM, 20 milliliters (mL).
12/27/2021 at 2:00 AM, 20 mL.
12/27/2021 at 4:00 AM, 250 mL.
12/27/2021 at 5:13 AM, 50 mL.
12/27/2021 at 8:00 AM, 60 mL.
12/27/2021 at 11:00 AM, 75 mL.
12/27/2021 at 12:00 PM, 40 mL.
12/27/2021 at 2:00 PM, 20 mL.
12/27/2021 at 5:00 PM, 6 mL.
12/27/2021 at 5:54 PM, 12 mL.
12/27/2021 at 7:00 PM, 3 mL.
12/27/2021 at 8:56 PM, 3 mL.
12/28/2021 at 12:00 AM, 8 mL.
12/28/2021 at 2:00 AM, 4 mL.
12/28/2021 at 5:00 AM, 3 mL.
12/28/2021 at 7:00 AM, 15 mL.
12/28/2021 at 8:00 AM, 1,000 mL.
12/28/2021 at 9:00 AM, 300 mL.
12/28/2021 at 10:00 AM, 100 mL.
12/28/2021 at 11:00 AM, 100 mL.

Note: Patient 9 had only 21 mL of urine output from 7:00 PM on 12/27/2021 to 5:00 AM on 12/28/2021, a 10 hour period. No documented evidence could be found in patient 9's medical record to indicate the physician was notified of patient 9's decreasing urine output.

Patient 9's potassium levels for 12/27/2021 and 12/28/2021 were documented as follows:

12/27/20201 at 5:00 AM, 5.8 Note: The normal reference range according to hospital laboratory forms was 3.5 to 5.0.
12/27/20201 at 4:30 PM, 5.8
12/28/2021 at 3:50 AM, 7.1
12/28/2021 at 6:30 AM, 6.8
12/28/2021 at 11:20 AM, 6.4

On 12/28/2021 at 4:55 AM, a physician ordered a STAT renal ultrasound.

On 12/28/2021 at 7:00 AM, patient 9 was taken to the imaging department for the ordered renal ultrasound. This was approximately two hours after the physician ordered the STAT ultrasound.

On 12/28/2021, the results of the renal ultrasound were dictated and the following was documented, " ...Foley catheter is seen within the bladder, bladder is mildly distended. Questions (sic) Foley clamped ..."

At 11:07 AM on 12/28/2021 a physician assessed patient 9, and documented, " ...Acute renal failure with critical hyperkalemia (high potassium)- after foley flushed 1.5 L (liters) urine out, bladder large on US (ultrasound), thus I would expect his potassium to improve ..."

In an email dated 1/11/2022 at 12:07 PM, the hospital's quality director stated no evidence could be found in patient 9's medical record that the physician was notified of his low urine output from 7:00 PM on 12/27/2021 through 4:54 AM on 12/28/2021. The quality director stated at 4:54 AM on 12/28/2021 the physician ordered a renal ultrasound, intravenous fluids, and a diuretic. The quality director further stated an ultrasound technician was not onsite at the hospital when the physician ordered the STAT renal ultrasound on 12/28/2021 at 4:54 AM. He stated there was a technician on call, but they were not called. The imaging department rescheduled the ultrasound for 7:00 AM on 12/28/2021 when the regularly scheduled technician would be available. The quality director stated, "We found no documentation that the physician was consulted regarding this change."

A policy titled, "Emergency and Prioritization of Exams/Procedures," was reviewed. The policy indicated a STAT procedure must be started within 15 minutes unless the order was placed after hours and staff needed to be called in. In this case, the procedure should begin within 15 minutes of staff arrival.

b. A STAT respiratory culture and gram stain was ordered by a physician on 12/24/2021 at 3:22 PM for patient 9. The following was documented in the electronic order sheet printed for the survey team on 1/3/2022 in the section containing the STAT respiratory culture, "Nurse/Care Provider to collect," as well as, "Uncollected."

No documented evidence could be found in patient 9's medical record to indicate the respiratory culture had been completed.

Order reviews were documented as completed by a nurse twice daily from 12/26/2021 to 1/7/2021.

In an email on 1/11/2022 at 1:39 PM, the senior director of quality stated the respiratory culture ordered for patient 9 on 12/24/2021 was canceled on 1/7/2022 after a verbal order from the physician. Note: This order was placed after the survey team had identified concerns with laboratory tests not being completed or not completed timely.



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3. Patient 7 was admitted on 12/21/2021 with a diagnosis of pneumonia.

Patient 7's medical record review was completed on 1/6/2022 and revealed the following:

In a physician order dated 12/31/2021 and timed 1:15 PM, it was documented that the physician ordered a urinalysis "STAT". It was documented that the sample was not collected until 7:57 PM on 12/31/2021. The sample was not collected for approximately 6 hours and 45 minutes after the STAT order was placed.

4. Patient 15 was admitted on 1/4/2022 with a diagnosis of dyspnea.

A focused medical record review for patient 15 was completed on 1/6/2022 and revealed the following:

In a physician order dated 1/4/2022 and timed 4:20 PM, it was documented the physician ordered a respiratory culture and gram stain "STAT". As of 1/5/2022 at 1:00 PM, the respiratory culture and gram stain order status was still uncollected. This sample had still not been collected approximately 22 hours after the STAT order was placed.

5. Patient 19 was admitted on 12/12/2021 with a diagnosis of confusion and weakness.

A focused medical record review for patient 19 was completed on 1/6/2022 and revealed the following:

In a physician order dated 1/5/2022 and timed 3:33 PM, it was documented the physician ordered a Prothrombin Time INR (international normalized ratio) "STAT". It was documented that the sample was not collected until 5:56 PM. The sample was not collected for approximately 2 hours and 30 minutes after the STAT order was placed.

6. Patient 5 was admitted on 12/19/2021 with a diagnosis of Covid 19 with hypoxia.

Patient 5's medical record review was completed on 1/6/2022 and revealed the following:

In a general medicine progress note dated 12/31/2021, it was documented that patient 5's white blood cell count had increased from 19 to 31 (potentially indicating severe infection). It was further documented to "Repeat cultures and start broad-spectrum abx (antibiotic) therapy with Zosyn + vanco."

In a physician order dated 12/31/2021 and timed 4:46 PM, it was documented the physician ordered the following lab tests:

Blood culture "STAT"
Urinalysis with culture "STAT"
MRSA (methicillin-resistant Staphylococcus aureus) screen "routine"
Sputum culture "routine"

The laboratory results section of patient 5's medical record indicated the following:

The blood culture was not collected until 1/1/2022 at 8:00 AM. The sample was not collected for approximately 15 hours after the STAT order was placed.

The urinalysis was not collected until 1/1/2022 at 7:19 AM. The sample was not collected for approximately 14 hours and 30 minutes after the STAT order was placed.

The MRSA screen was not collected until 1/1/2022 at 7:15 AM. The sample was not collected for approximately 14 hours and 30 minutes after the routine order was placed.

As of 1/5/2022 at 1:00 PM the sputum culture status was still uncollected. This sample had still not been collected approximately 5 days after the routine order was placed.

7. A hospital policy titled "Testing Priorities and In-House Test List" was reviewed. The policy indicated that "STAT" lab orders were to be collected within 10 minutes of the order and "routine" lab orders were to be collected within two hours of the order.

8. In an interview on 1/5/2022 at 2:10 PM, with the quality director and senior director of quality, they stated the orders were being input as "nurse to collect" therefore the lab was not getting the orders. They stated that possibly some physicians did not know how their electronic order system worked and were inputting orders incorrectly. They further stated that registered nurses were to review the lab "pending log" for each patient on each shift to verify no orders had been missed.

The quality director and senior director of quality verified that the lab "pending log" for patient 5 had been documented as completed each shift from 12/31/2021 through 1/4/2022.