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Based on interview and record review, the facility failed to ensure the provision of patient rights when:

1. A second "An Important Message from Medicare about Your Rights [IM - Patient's right to appeal discharge]" notice was not provided for two of two sampled patients (Patient 6 and Patient 7). This failure had the potential for Patient 6 and Patient 7 to not be informed of their right to appeal their discharge from the hospital.

2. A representative of one of one sampled patient (Patient 2) was not informed of changes in Patient 2's plan of care. This failure had the potential for Patient 2 to receive unwanted treatments.

Findings:

1. During a review of Patient 6's Facesheet (FS), undated, the FS indicated Patient 6 was admitted on 8/26/24 and discharged from the hospital on 9/4/24.

During a review of Patient 6's medical record (MR), an IM signed and dated on 8/26/24, was reviewed. No other IM was found in Patient 6's MR.

During a review of Patient 7's FS, undated, the FS indicated Patient 7 was admitted on 8/27/24 and discharged from the hospital on 9/4/24.

During a review of Patient 7's MR, an IM signed and dated on 8/28/24, was reviewed. No other IM was found in Patient 7's MR.

During an interview on 10/1/24 at 4:15 p.m. with Manager of Cardiology Program (MCP), MCP stated there was no record of a second IM notice given to Patient 6 or Patient 7.

During a review of "Fast appeals" (FA - law regarding a Medicare patients' right to appeal their hospital discharges), the FA indicated, "In a hospital: Within 2 days of your admission and prior to your discharge, you should get a notice called 'An Important Message from Medicare about Your Rights.' This notice is sometimes called the Important Message from Medicare or the IM. . . If the hospital gives you the IM more than 2 days before your discharge day, it must give you a copy of your original, signed IM or provide you with a new one (that you must sign) before you're discharged."

2. During a review of Patient 2's "XR Swallow Function Video or Cine [SF - special real-time form of x-ray that tests ability to swallow liquids and foods]" order, dated 9/29/24 at 8:14 a.m. The SF indicated the test was ordered as routine (not urgent or emergent) and the reason for test was "dysphagia" (difficulty swallowing).

During a review of Patient 2's "Level 4 Pureed Dysphagia Diet (DD - a diet of smooth, moist foods that are easy to swallow and don't require chewing)" dated 9/30/24 at 10:19 a.m. was ordered.

During a review of Patient 2's SF, the SF indicated the swallow function test was performed on 9/30/24 at 9:30 a.m.

During a review of Patient 2's "Advance Health Care Directive Form (AHCD-gives instructions about patient's health care choices and/or name someone to make health decisions for that patient)," dated 4/25/23, the AHCD indicated "DESIGNATION OF AGENT: I [Patient 2] designate the following as my agent to make health care decisions for me [Patient 2]": Family Member (FM) 1, and FM 2 as Patient 2's first alternative agent "If I [Patient 2] revoke my agent's authority or if my agent is not willing, able, or reasonably available to make a health care decision for me.

During an interview on 10/1/24 at 9:08 a.m. with FM 1, FM 1 stated she was not aware Patient 2 received a SF test. FM 1 stated she makes medical decisions for Patient 2. FM 1 stated she did not know how the SF worked, and she would have like to have known of any risks or the benefits of the test. FM 1 stated she did not know the result of the SF test and did not know that there was a recent change in Patient 2's diet order. FM 1 stated she would like for Patient 2 to be comfortable and did not want any unnecessary tests, procedures, and medications for Patient 2.

During an interview and record review on 10/1/24 at 1:29 p.m. with Manager of Cardiology Program (MCP) Patient 2's medical record was reviewed. MCP stated there was no documentation in Patient 2's medical record that his representatives (FM 1 and/or FM 2) were informed of the SF test or changes to his diet.

During a review of the hospital's policy and procedure (P&P) titled, "Advance Health Care Directives" dated 7/28/21, the P&P indicated, "While the focus of advance health care planning often addresses whether to withhold or withdraw life-sustaining treatment, it also can serve as an important resource for other type of health care decisions. Advance health care planning facilities the patient's and family's understanding of illness and prognosis, addresses the goals of care, patients' treatment preferences and decisions, options for pain and symptoms management, preferences regarding organ and tissue donation and provision for psychological, social and spiritual needs."

Based on interview and record review, the Hospital failed to ensure its procedure titled, "Electrosurgery [use of high-frequency electrical current to cut and stop tissue from bleeding] Safety" (ES) was followed for one of 10 sampled patients (Patient 22) when a "Rocker Switch Pencil [Bovie pencil - electrode tip - surgical device used to cut or destroy tissue, and/or control bleeding]" was placed on Patient 22's surgical bed instead of being placed in the holster (sterile nonconductive holder for Bovie pencil) when not in use. This failure resulted in Patient 22 sustaining a second degree burn (burn that affects both the outer and underlying layers of skin) to left inner thigh.

Findings:

During a review of Patient 22's "History and Physical" (H&P) dated 9/27/24 at 3:35 p.m. the H&P indicated, "[Patient 22] is a 32yo [year old] male without any PMHx [past medical history] who was BIBA [brought in by ambulance] this afternoon after sustaining burns while working when the semi-truck he was driving caught fire."

During a review of Patient 22's "Perioperative Record" (PR) dated 9/3/24 at 9:51 a.m. the PR indicated, "There was a bovie malfunction with spark of the bovie that caused a partial thickness burn to inner left thigh which was 4x2cm [centimeter - unit of measure]. This was excised [cut out surgically] and autograft [use of a person's own tissue to repair another area of skin on their body] was placed and secured with dermabond [topical skin adhesive]."

During a review of Patient 22's "Physician Note" (PN) dated 9/3/24 at 12 p.m. the PN indicated, "post op [after surgery] discussed with patient the the [sic] electocaughtery [sic] incident that occurred intraoperatively [during surgery]. Described that the electrocaughtery [sic] malfunctioned, created sparks and it caused a small 2x2 deep 2nd degree burn to left inner thigh near his previous burned injury. discussed [sic] that the area was then excised and autografted, along with the rest of his previous right lower extremity injury. And that it should not cause any lasting medical problems. Patient understood what happened and was thankful everything was grafted."

During an interview on 9/30/24 at 2:20 p.m. with Surgical Tech (ST), ST stated midway thru the case with the patient (Patient 22), the bovie pencil was "acting up" and becoming sparkly. ST stated Surgeon 1 picked up the Bovie pencil which had been placed between the patients legs and the Bovie pencil continued to spark. ST stated the Bovie pencil should not have been laying next to patients legs.

During an interview on 9/30/24 at 3:15 p.m. with Physician Assistant (PA), PA stated in the middle of the case, "I smelled something" and we saw smoke between Patient 22's legs. PA stated Surgeon 1 picked up the Bovie pencil under Patient 22's legs and the Bovie pencil was sparking and smoking without being activated. PA stated the Bovie pencil had not been placed in the holster and whoever last used the Bovie pencil should have put it back in the holster.

During an interview on 10/1/24 at 9:27 a.m. with Surgeon 1, Surgeon 1 stated Patient 22 had multiple burn sites being treated and sustained a small burn to left thigh. Surgeon 1 stated the Bovie pencil malfunctioned and was sparking. Surgeon 1 stated the Bovie pencil was on the surgical bed and laying next to the Patient 22's legs. Surgeon 1 stated Bovie pencil should not be on the surgical bed and should be holstered. Surgeon 1 stated, "I assume the tech (Surgical Tech) is responsible (for holstering the Bovie pencil)."

During an interview on 10/1/24 at 9:33 a.m. with Operating Room Registered Nurse (ORRN), ORRN stated during the case we all smelled something burning. ORRN stated Surgeon 1 picked up the Bovie pencil that was on the surgical bed and the Bovie pencil was sparking without being activated. ORRN stated the Bovie pencil should not be lying on the surgical bed.

During a review of the hospital's Procedure titled, "Electrosurgery Safety" dated 10/25/23, the procedure indicated, "Electrosurgery Unit [ESU] (Perioperative - [around the time of surgery]). . .10. Follow the manufacturer's instructions for use (IFU) for safe operation of the ESU generator and use accessories that are compatible with the specific ESU generator per the manufacturer's IFU. . .32. The scrub person returns the active electrode [Bovie pencil] to the provided nonconductive holster when not in use."

During a review of the Manufacture's IFU's for "Rocker Switch Pencil", the IFU indicated, "When not in use, place active accessories in a holster or in a clean, dry, nonconductive, and highly visible area not in contact with the patient. Inadvertent contact with the patient may result in burns."

Based on observation, interview, and record review, the hospital failed to:

1. Follow their policy and procedure (P&P) titled, "Peripheral Intravenous Catheter (PIVC): Insertion, Maintenance, Removal (Adult)" for one of two sampled patient's (Patient 3) when Patient 3's intravenous (IV - into a vein) medications and tubing were not labeled. This failure had the potential to cause infection and to receive the wrong medication.

2. Follow their P&P titled, "Gastrointestinal (GI - passageway of the digestive system that leads from the mouth to the anus) Tubes, Gastric Lavage (medical procedure that involves cleaning out the contents of the stomach using a tube), and Enteral Feeding (process of the delivery of nutritional needs directly to the stomach or upper intestines) for Adult Patients," for one of one sampled patient (Patient 2) when Patient 2's formula was not labeled. This failure had the potential for Patient 2 developing GI complications.

Findings:

1. During a concurrent observation and interview on 9/30/24 at 10:07 a.m. with Medical Surgical Nurse Manager (MSNM) in Patient 3's room, Patient 3 had two IV medications being administered without any labels indicating time, date or clinical staff's initials. MSNM stated the IV medication and tubing should had been labeled when administered or when tubing was changed.

During a review of the facility's P&P titled, "Peripheral Intravenous Catheter (PIVC): Insertion, Maintenance, Removal (Adult)," dated 3/7/23, the P&P indicated, "administration sets will be labeled with time, date and clinical staff's initials. The date and time used may be the date of set change or the date that the tubing should be changed next, depending on facility policy. The label should clearly indicate which date/time reference is used (e.g. Tubing changed on xx versus Tubing to be changed on xx)."

2. During a concurrent observation and interview on 9/30/24 at 9:33 a.m. in Patient 2's room, Patient 2's enteral feeding formula and associated tubing was not labeled with date, time, or clinical staff's initials. The Registered Nurse (RN) 1 stated she did not notice that the formula bottle was not labeled. RN 1 stated she did not know how long the formula had been hanging open. RN 1 stated nurses have to make sure that the formula bottle has the patient's name, date formula was open and time of expiration.

During an interview on 9/30/24 at 9:50 a.m. with MSNM, MSNM stated the expectation is the nurse will label the formula with the patient's name, date, and time. MSNM stated it is important to label the formula to make sure you do not give "spoiled" formula to the patient. MSNM stated if it is not labeled then the formula should be thrown away and replaced.

During a review of the facility's P&P titled, "Gastrointestinal (GI) Tubes, Gastric Lavage, and Enteral Feeding for Adult Patients," dated 9/26/24, the P&P indicated, "POLICY: 5. b. Follow the guidance in Elsevier Skills [Evidence-based skills and procedures]. . .Procedure: Refer to the following Elsevier Clinical Skills: Feeding Tube: Enteral Nutrition via Nasoenteric Tube. . .3. Flushing, feeding, and set-up: a. Enteral feeding bags, tubing, and syringes are changed every 24 hours. b. The formula in a closed enteral feeding system is changed every 24 hours or any time the tubing is changed."

During a review of Elsevier Clinical Skills: Feeding Tube: Enteral Nutrition via Nasoenteric Tube, the clinical skill indicated, "h. Label the bag with patient information; enteral access type; and the tube feeding formula type, strength, and amount. Include the date and time and initial it."