HospitalInspections.org

The hospital reported a census of 264 patients Based on observation, staff interview, and document review the hospital failed to meet the emergency medical needs for one of seven patients (Patient #1) that presented to the hospital for emergency medical treatment.

Findings include:

- Document titled "Performance Improvement Plan, 2015" reviewed on 12/14/15 directed " ...The Medical Staff is responsible to the Board of Trustees for effectively and efficiently delivering patient care according to established and accepted standards of care ..."

- Patient #1's medical record reviewed on 12/1/2015 revealed the patient arrived to the hospitals ED (Emergency Department) on 2/25/15 at 11:59am after complications occurred during a scheduled eye surgery. Patient #1 arrived via ambulance after being extubated (removal of a breathing tube) at the surgical center. The medical record indicated the patient's intial vital signs were Heart rate (HR) 89, Respiratory rate (RR) 34, Oxygen saturation (O2) 90% with non-invasive ventilations (bag valve mask device used to force oxygen into the lungs), and Blood pressure (BP) 132/76. The Arterial Blood Gas (ABG) lab that was performed at the hospital, provided to the surgical center prior to transfer, and available to the ED physician revealed a PH of 7.14, CO2 70, BE -5, PO2 65 (drawn at surgery center at 11:02am) on 100% FIO2. The patient was placed on 15liters/per minute (lpm) of oxygen using a facemask and ABG labs were redrawn and resulted at 12:27pm and recorded as follows; a PH of 7.28, CO2 50, BE -3, PO2 57. Staff C, the ED physician, consulted Staff E at 12:41pm. Patient #1 was reportedly more awake and had complaints of dyspnea (short of air) at 2:01pm. Patient #1's ABG's were again obtained, PH of 7.314, CO2 47, BE -2, PO2 91 on 21% FI02, and resulted at 2:16pm. At 4:25pm the patient had a sudden decompensation in respiratory status, tachypnea and hypoxic, patient feeling like he is unable to breath, respirations were in the 40's with O2 sat 90% on 15 liters using a non-rebreather mask. The medical record revealed RT Staff E was called at 4:25pm and he placed the order for intubation. At 4:28pm Staff C performed endotracheal intubation to patient. The patient was transported at 6:00 pm by cart to the ICU with wife by his side. The medical record revealed the patient was intubated (a tube placed into the airway to assist breathing) ABG's resulting at 4:44pm revealed a PH of 7.16, CO2 60.1, BE -7, PO2 61 on 100% FI02 using an adult vent. The medical revealed at 11:43pm the patient went into cardio-respiratory arrest, a code blue was called, and CPR (cardiopulmonary resuscitation) started. Code efforts terminated after 26 mins of CPR. Time of death was reported as 12:06am on 2/26/15.

- The complainant, interviewed on 12/01/15 at 1:20pm via phone call indicated when her husband, Patient #1, was transferred to the hospital's ED on 2/25/15. The complainant revealed they tried several times to alert the ED staff of their concerns regarding patient #1's vital signs and trouble breathing but felt ignored. The complainant indicated alarms in the room had sounded several times and the ED ignored them. The complainant reported that their sister in-law is a nurse anesthetist and was shocked that patient #1was extubated prior to transfer. The complainant stated patient #1sat up and said, "I can't breathe". The complainant went out of room and spoke with the ED physician stating patient #1was not doing well. The complaintant indicated that shortly after a call to the Pulmonologist the patient was intubated. The complainant reported her husband needed more critical care than the ER gave.

- Physician Staff D, interviewed on 12/02/15 at 3:10pm indicated they remembered patient #1, that a dog bit them in the eye, requiring eye surgery. Staff D admitted patient #1 to the ICU from the ED after being intubated and placed on the Ventilator. Staff D stated they organize where patients are placed, no contact with this patient during their stay.

- Physician Staff C interviewed on 12/02/15 at 11:00am indicated patient #1 had come from a surgery center awake and talking, was intubated for the surgical procedure and extubated prior to arriving to ED. Staff C revealed that patient #1's GCS score was 10 and they usually do not intubate until score is eight or below. Staff C indicated that patient #1 was on a non-breather upon arrival to ED and clinically improved until 2:41pm when the patient became more dyspneic and ABG's were ordered. Staff C reported at 4:35pm that patient #1 required intubation due to their clinical presentation and labs. Staff C indicated they consulted a pulmonologist throughout the patient's stay in ED. Staff C indicated they do not extubate patients unless a patient was a DNR and was not informed until family arrives giving the details of the patient wishes then he would extubate.

- Registered Nurse Staff G, interviewed on 12/02/15 at 11:05am by phone indicated they remember patient #1 very well. Staff G stated RT Staff O, a Pulmonologist, helped us all evening with patient's condition by phone and Staff O came into the hospital in the evening to speak with family.

- RT Staff E, Pulmonologist, interviewed on 12/02/15 at 10:25am indicated patient had come to the ED in critical condition with critical ABG's that were drawn at a surgery center prior to arrival. Patient #1 came to us on a non-breather and progressively worsened. Staff E stated the patient was in acute distress with low oxygen saturations and possible air embolism. Staff E indicated tests were done, the CTA revealed no large defects, air embolism. Staff E indicated patient #1 became more hypoxic and was intubated around 4:45pm and placed on ventilator on high peep settings. Staff E acknowledged that intubating a patient depends on the patient's clinical presentations and lab results combined. During the interview Staff E was shown the critical ABG's that were drawn from the transferring facility at 11:02am on 2/25/15. Staff E stated that with those ABG results they would not have extubated the patient. Staff E acknowledged they would definitely wait for the ordered ABG's results prior to making a decision to extubate.

- Registered Nurse Staff F interviewed on 12/02/15 at 12:40pm indicated patient #1 was very anxious when they arrived to the ED. Staff F indicated the physicians were debating due to patient's air hunger to intubate or not, discussing the best medical decision for the patient.