HospitalInspections.org

Based on findings from document review, interview and medical record (MR) review, in 4 of 4 MRs, Emergency Department (ED) nursing staff did not follow the hospital's Sepsis Protocol. Additionally, all staff required to complete a sepsis educational activity did not. These lapses could place patients at risk for delayed sepsis recognition.

Findings include:

-- Review of hospital policy and procedure (P&P) titled "Sepsis Protocol," (not dated) indicated the following: "Early identification: Patients who present with symptoms or signs of actual or suspected infection in association with certain manifestations of the systemic inflammatory response syndrome (SIRS) will be evaluated for progression along the continuum of sepsis, severe sepsis, and septic shock so that they can receive appropriate and timely treatment. Screening for sepsis, severe sepsis and septic shock are addressed at the time of initial hospital presentation and at least twice daily on all patients in the ED ... "

-- Per review of hospital training document titled "Sepsis Screening and Severe Sepsis Protocol," not dated, it indicates when a patient meets criteria for SIRS a Sepsis screening should be completed. If the sepsis screening identifies that the patient has a suspected new infection, the Sepsis Protocol is initiated. The document describes to nursing staff that when there is a possible sepsis risk an automatic Best Practice Advisory (BPA) pops up on the computer screen alerting the nurse to sepsis possibility. The nurse has two choices in addressing the BPA, a) complete the Sepsis Screening from within the BPA or b) acknowledge the BPA, but it will continue to pop up until the nurse addresses the questions related to potential for sepsis.

-- Per interview of Staff A, (Assistant Director of Quality Resources) on 2/10/17 at 10:30 am, he/she reported that the BPA identifies that the patient has met 2 indicators for SIRS (Systemic Inflammatory Response Syndrome) criteria (i.e., tachycardia, tachypnea, fever). Nursing staff should then either acknowledge the BPA, which will then cause the BPA to continue to pop up to alert the nurse to address Sepsis Protocol, or go right into the Sepsis Screening box from within the BPA.

-- Review of Patient #1's (MB-index case) MR identified the following information: On 8/4/16 at 2:11 pm Patient #1 presented to the ED with chief complaint of post-operative pain (9/10) (scale of 1-10, with 10 being worst pain) following a surgical procedure on her left axilla the previous day. At 2:29 pm she was triaged as a level 4 on the Emergency Severity Index (ESI) scale (scale of 1-5, 1 being the most severe and 5 being the least.) Vital signs were as follows: Temperature = 97.7 Fahrenheit (F), heart rate (HR) = 122, respiratory rate (RR) = 28, blood pressure (BP) = 108/72. At 2:32 pm and 3:50 pm the Sepsis BPA (best practice alert) screen popped up in the nursing assessment. Nursing documentation lacked evidence that the sepsis screen was completed even though Patient #1 met criteria.

-- Review of Patient #2's (MD) MR revealed that after the BPA alerted nursing staff to complete the Sepsis Screening form. However, staff answered "no" on the Sepsis Screening form to the question "Suspected new infection?" even though Patient #2 met two criteria ( HR=111, temp=101.3 F) to qualify for initiation of the sepsis protocol.

The same lack of documentation regarding sepsis screening was found in Patient #3 and #4's MR.

-- During interview with Staff A on 2/10/17 at 10:30 am, he/she acknowledged these findings.

-- Per interview of Staff B (ED Nurse Manager) on 2/13/17 at 11:10 am, Sepsis BPA training for ED RNs was held in September 2016 and staff attendance was mandatory. However, per review of Educational Activity Attendance Roster titled "September 2016 Staff Meeting" dated 9/28/16, 9/29/16 and 9/30/2016, not all ED RNs attended this mandatory training. Staff B acknowledged that not all ED RNs had received this training.

Based on findings from document review and interview, the Quality Assurance (QA) department did not perform a complete investigation of a complaint. This could hinder the ability to improve care and processes at the hospital.

Findings include (1) :

-- Per review of the hospital's complaint investigation, on 12/16/16 a complaint was received by Staff A ( Assistant Director of Quality Resources) via telephone outlining several issues regarding the medical care and treatment of Patient #1 received on 8/4/15. Staff A completed the Patient Complaint Form and forwarded it to response coordinators i.e., Staff B (ED Nurse manager), Staff C (ED Medical Director), Staff D (Chief Nursing Officer), Staff E (Vice President Quality Resources.) and Staff F (Chief Executive Officer). On 12/19/16 a letter was sent to the complainant informing her that her concerns had been forwarded to the appropriate clinical directors for a thorough review and follow-up. Upon completion of the review, findings would be shared with her.

-- Per review of the facility policy and procedure (P&P) titled "Patient Complaints and Grievances" last revised 9/2015, "The VP of Quality Resources logs the complaint and forwards the complaint information to the appropriate Department Director/Nurse Manager/ Medical Director for investigation. The investigator then develops a follow up report to include: conclusions, actions taken, recommendations and resolution. The process will be completed as quickly as possible, and within seven days after receipt of the complaint when possible. Once the investigation is completed, and a plan of action developed, the VP of Quality Resources, in consultation with the Department Director/Nurse Manager, Administrator, or Medical Director shall determine how to respond to the patient."

-- However, during interview with Staff E on 2/10/17 at 11:50 am, he/she indicated the usual complaint procedure was not followed in this case. Staff E indicated the hospital had not responded to the complainant.