HospitalInspections.org

A review of the personnel file of the Vice President of Medical Affairs (VPMA) revealed that the hospital had failed to abide by facility policy to ensure that an applicant for employment was eligible for the position and had met State and local laws.


The VPMA was hired and began working on 8/10/15. At the time of employment the VPMA was licensed to practice medicine in the State of Virginia. During an interview conducted on 10/20/15 the VPMA stated that she was in the process of applying for a Maryland license and was currently not performing clinical services. Per the position's job description the VPMA for the hospital must have the ability to demonstrate ethical behavior that supports the hospital's mission, values and commitment to compliance with all Federal, State and regulatory laws. The position requirements under certification and license include possession of a license to practice medicine in the State of the hospital location, which in this case is Maryland. The hospital had failed to meet the regulatory requirement when it failed to ensure that the VPMA was licensed in the State of Maryland.

Based on observation, review of patient medical records, and an interview of the staff, it was determined that not all patient medical records contained accurate information important in the planning of patient care. This was evident for 2 of 16 patient medical records.


The findings were:

1) Patient #2 was a 75 years old female with a history of dementia. She was homebound and had a feeding tube. She presented to the Emergency Department (ED) via 911 on 10/19/15 with complaints of vomiting and diarrhea during the previous 2 - 3 days. The patient was admitted with a Stage II-III sacral pressure ulcer (3 cm x 5 cm) and with two smaller Stage II pressure ulcers. A review of her medical record and an interview of the ED staff revealed that the patient had been admitted from her daughter's home. A review of the patient's ED Chart revealed that the Physician's Assistant (PA) had documented at 5:27 AM on 10/19/15 that the patient was admitted from a Nursing Home. At 6:15 AM the ED physician noted that he had interviewed and examined the patient and agreed with the PA's plan of care. Accurate patient history information is important in the development of a treatment plan and a discharge plan.



2) Patient #10 was admitted 09/18/15 for all over body pain and end stage renal disease. Patient #10 was on dialysis and received this treatment 3 times a week. Assessment by nurses for patient #10 on 10/17/15-10/19/15 revealed that the patient was alert and oriented times 4. Contrary to this assessment the patient's dialysis physician documented that the patient was not oriented and possibly needed certification for lacking capacity. The nurse for Patient #10 was interviewed on 10/19/15. She stated that the patient's mental status fluctuated from times 4 to times 0. This was inconsistent to the documentation that was found in Patient #10's medical record.

Based on observations of staff on 2 East, review of a patient's medical record, review of policies and procedures and interviews of staff, it was determined that the medical staff failed to complete a Suicide Risk Assessment (SAT) for patient #13 and the nursing staff failed to complete the assessment documentation when a 1:1 sitter was initiated and maintained for safety precautions.

Patient #13 was admitted on 10/17/15 for complications with his dialysis catheter (patient pulled the catheter out of his chest after dialysis the day prior to admission) and for a bleeding wound on his left foot. On admission to 2 East the patient reported to nursing staff that he wanted to kill himself and wanted to hurt others. The nurse reported this finding to the physician and then obtained an order for a 1:1 sitter. The sitter was initiated on 10/18/15 at 3:15 AM. Information about the patient's behaviors was limited in the documentation. The next nursing documentation occurred on 10/18/15 at 8:53 PM, again with limited information about the patient's behavior.

During an interview on 10/19/15 the Assistant Director of nursing confirmed that the every 15 minute documentation required of the 1:1 sitter was missing from Patient #13's medical record and that the unit "had identified this lack of documentation as an issue."

According to a hospital policy entitled "Suicide/Homicide Screen: Precautions and Observation Level" effective 12/1983 and last revised 10/2012 staff performing 1:1 observation must remain in arm's length of the patient at all times and must document patient observations every 15 minutes on an observational sheet. Additionally, the physician must evaluate the patient within 2 hours after initiation of the 1:1 observation. The physician must also document the suicidal assessment daily and include the patient's verbalization of continued suicidal/homicidal thoughts.

Failure of staff to document a patient's behavior that resulted in the use of a sitter did not reflect the status of the patient's behavior with regard to determining if the interventions were successful or if additional interventions would be required.

Based on review of 16 medical records, review of policies and procedures and interviews of staff, it was determined that staff failed to obtain and document a dietary/nutritional consultation to assure that the dietary requirements were being met for 1 of 16 patients (patient #14) after being ordered "nothing by mouth (NPO)" for 5 days.

Patient #14 was admitted on 10/14/15 and was diagnosed with an acute stroke. The patient failed a swallow evaluation, making her a risk for aspiration if allowed to eat and drink. On 10/14/15 the patient was ordered nothing by mouth (NPO). A review of the patient's chart on 10/19/15 revealed that the patient had been ordered NPO for 5 days and no dietary consultation had been ordered or documented.

According to a hospital policy entitled "NPO/Clear Liquids" effective June 1984 and revised April 2011, each morning the Registered Dietician is to review records of patients who have been ordered NPO and then to complete a nutritional assessment on patients remaining NPO for greater than 3 days. If the patient is not receiving a nutritional source, such as peripheral parenteral nutrition (PPN) or tube feedings, the Dietician is to document appropriate recommendations to the patient's physician. An interview on 10/19/15 with the unit director and assistant director revealed that no dietary consultation had been ordered or documented for Patient #14.

Based on observation and review of the Emergency Department (ED) services and an interview of the staff on 10/19/15, it was determined that the emergency crash carts and respiratory boxes (adult & pediatric) were not consistently monitored and were noted as checked every 24 hours.

The findings were:
1) Adult Emergency Crash Carts in 1A and 1B were not checked on 10/18/15 (Sunday).
2) Airway Boxes #3190569 and #3187036 were not checked on 10/18/15 (Sunday).
3) Adult Emergency Crash Cart 12A was not checked on 10/18/15(Sunday).
4) Pediatric Emergency Cart 12A was not checked on 10/18/15(Sunday).

An interview of the ED Staff on 10/19/15 revealed that the staff was not aware of the location of the 3-ring binder (that contains signage sheet) for the 1A Adult Emergency Crash Cart. Staff explained that they had not been able to locate the notebook as over the week-end there was a code in Room #5 which was the last time it was seen. Staff eventually were able to locate the notebook and as noted in #1 above the cart was not checked for on 10/18/15 and had not been checked in the morning of 10/19/15.

Failure by the ED Staff to consistently check emergency crash carts and airway boxes potentially places a patient at risk for incurring a delay in treatment in the event of a respiratory failure or cardiac arrest. In addition, the inconsistent checks are reflective of the hospital's fragmented maintenance of an acceptable level of safety.