HospitalInspections.org

Based on record review and staff interview, it was determined the facility failed to ensure the family for one (#8) of 10 sampled patients was notified of a significant change in the patient's condition.

Findings included:

The Nursing Assessment dated 1/8/18 at 17:55 p.m. indicated Patient #8 arrived on the nursing unit following surgery and anesthesia recovery from a lumbar spine surgical procedure. The patient's vital signs were stable compared to earlier post-operative vital signs, documented in the 120's/60's.

The Nursing Assessment and Vital Signs documented at 2:00 a.m. on 1/9/18 reported the patient's blood pressure at 98/50. At 6:00 a.m. on 1/9/18 the patient's blood pressure was 85/40. The Nursing Assessment indicated Patient #8 was transferred to Intensive Care on 1/9/18 at 9:59 a.m.

The detailed review of the medical record failed to reveal any evidence the family of Patient #8 was notified of the significant change in the patient's condition.

The Director of Quality and Risk Management confirmed the finding in an interview conducted on 3/27/18 at 2:30 p.m.

Based on record review and staff interview the facility failed to ensure: 1) the treating physician personally assessed one (#9) of 10 sampled patients on a daily basis in compliance with the medical staff Rules and Regulations, and 2) members of the medical staff coordinated the medical care and services to meet the needs for one (#8) of 10 sampled patients.

Findings included:

1. The Medical Staff Rules and Regulations, page 29 paragraph 3, indicated the treating physician is required to personally assess and record a progress note at least every day for a patient in the acute care setting.

Patient #9 was admitted to the outpatient surgery department of the facility by the treating surgeon on 3/15/18 at 7:59 a.m. The operative report dated 3/15/18 indicated Patient #9 underwent a planned surgical procedure. Post-operative orders dated 3/15/18 and signed by the surgeon included an order to admit the patient overnight.

The Physician Orders dated 3/16/18 at 3:19 p.m. included a telephone order from the treating surgeon to discharge Patient #9 to home independently. The order was entered and electronically signed by the Registered Nurse.

The detailed review of the medical record failed to reveal any evidence the treating surgeon personally assessed Patient #9 on 3/16/18. The record did not contain a progress note documented by the treating surgeon on 3/16/18.

The Director of Quality and Risk Management confirmed the finding in an interview conducted on 3/27/18 at 2:30 p.m.

2. The Operative Report dated January 8, 2018 at 14:09 and signed by the admitting surgeon, indicated the surgeon was unsuccessful in his initial lateral approach to the lumbar spine through an incision in the right abdomen and flank to perform lumbar spine surgery on Patient #8. The operative report described a technically challenging operative procedure in which extensive retraction of multiple layers of muscle tissue were required to visualize the operative area. For complex anatomical reasons, the surgeon was unable to successfully accomplish the desired procedure during this initial approach. This procedure was terminated and the patient was repositioned to allow for a posterior approach. A second incision was made over the patient's spine and extended to the L5 vertebrae. The surgeon described the use of a drill to enlarge the nerve openings in the spine, thinning the bone of the spine, removing portions of bone and grafting bone. The surgeon described Patient #8 as having a scoliosis deformity (curvature) of the spine which presented additional anatomic challenges to the performance of the surgery.

The nursing documentation dated 1/8/18 indicated Patient #8 was transferred from PACU (post anesthesia care unit) to the Ortho/Spine nursing unit at 5:55 p.m. The patient's blood pressure had been stable post-operatively in the 120's/60's. Patient #8's blood pressure was documented as 98/54 at 2:00 a.m. on 1/9/18. It was rechecked again at 6:00 a.m. and measured 85/40. The physician orders dated 1/9/18 at 6:33 a.m. included a telephone order from the consulting medical physician to administer normal saline intravenous fluid at 75 cc (cubic centimeters) per hour. The blood pressure at 7:40 a.m. on 1/9/18 was 70/40. The consulting medical physician provided additional telephone orders for blood tests. Patient #8 was transferred to intensive care on 1/9/18 at 9:59 a.m.

The review of the medical record failed to reveal any evidence the consulting medical physician made any attempt to notify the treating surgeon of the significant change in Patient #8's condition. The treating surgeon was notified when the medical care of Patient #8 was transferred to the daytime hospitalist, who advised the treating surgeon his patient had undergone a CT scan of the abdomen and had been transferred to intensive care.

The treating surgeon was notified the CT scan of the abdomen revealed Patient #8 had a perforated colon on 1/9/18 at 10:56 a.m. and ordered Patient #8 to be prepped for surgery. The surgical log revealed the general surgeon notified the OR (operating room) on 1/9/18 at 11:30 a.m. he would be bringing Patient #8 to surgery for an exploratory laparotomy. The Intraoperative Nursing Record documented the emergency laparotomy surgery did not start until 2:39 p.m., a period of 3 hours from the time the general surgeon notified the OR.

An interview was conducted with the Director of Surgical Services on 3/27/18 at 3:15 p.m. The Director indicated a perforated colon is a medical emergency that takes priority over all other scheduled surgeries except those being performed for immediate life-threatening conditions such as severe head trauma or hemorrhage. The Director stated she had an operating room and surgical staff available to perform the emergency surgery on 1/9/18 at 12:15 p.m. The Director was unable to explain the cause of the surgery being delayed for an additional two hours and fifteen minutes.

The Discharge Summary dated 2/8/18 and signed by the treating surgeon indicated Patient #8 expired on 1/10/18.