HospitalInspections.org

Based on review of documentation and interviews with facility staff, the facility failed to ensure Patient # 1 and his primary care provider, after discharge, was notified of positive lab result for I streptococci\js group b.

Findings were:

A review of the document titled "Source: BLOOD-2ND DRAW" revealed the following:
Blood culture final result was dated 02/24/2024. The culture was a second work up due to inclusive results on 02/22/2024. The final result was positive for STREPTOCOCC\JS GROUP B . Isolated in 2 of 2 sets.
02/23/24: Critical Results called to Staff # 11, at 1227 by Lab Staff
(Note: Read back confirmation is documented on documentation tool on chart.)

Interviews:

An interview with staff # 1, MD-Medical Director/Hospitalist-Med Surg on 04/09 2024 at approximately 1:20 PM revealed the following:
Surveyor: Can you tell me about your treatment or Patient # 1?
Staff # 1: Patient was clinically stable on admission. I talked with him and his wife and told the patient not to use his insulin pump. We would be taking care of his medical needs while in the hospital. Overnight the patient was non-compliant with his medication, he was using his insulin and pain medication pump. Patient was also verbally abusive to staff and me. Patient refused physical Therapy and testing blood sugars. The patient said we were not managing his pain. Patient said he wanted to go home, to be discharged "now" and, "our hands were tied."
Surveyor: Did Patient # 1 have any infections?
Staff # 1: "Not to my knowledge." When a patient arrives with respiratory and or pain with an increased heart rate, we order antibiotics as a safety measure. After his discharge his blood cultures results came back positive for strep and staff.
Surveyor: Did you notify the patient?
Staff # 1: No, I was not on duty when the results came in.
Surveyor: Should the patient be notified of the results of the blood culture?
Staff # 1: Yes, he should be contacted.

An interview with Staff # 7, MD-ED on 04/09/2024 at approximately 4:15 PM revealed the following:
Surveyor: Do you remember receiving lab results from Staff # 6 for Patient # 1? The patient was discharged one day prior to the lab results being sent.
Staff # 7: No, I do not. If I receive lab results for a patient and the ED doctor is not in, I will call the patient, make a note in the patient's chart and leave word for the ED treating doctor.
Surveyor: Would staff strep B cause a perforated ulcer?
Staff # 7: "Ideally not", most often you might see septicemia, bacteremia and infections to the skin.

An interview with Staff # 6, RN-House Supervisor on 04/09/2024 at approximately 4:20 PM revealed the following:
Surveyor: Do you remember receiving lab results for Patient # 1?
Staff # 6: I remember receiving lab results about twice while I've worked here. The last time it happened I took the results to the doctor working at the time.
Surveyor: Do you recall seeing the patient's name on the lab report?
Staff# 6: No, I'm not sure I did.

An interview with Staff # 8, Vice President of Quality, Infection Prevention. Patient Safety & Risk Management on 04/09/2024 at approximately 4:30 PM revealed the following:
Surveyor: Was Patient # 1 notified of the infection from the lab results?
Staff # 8: No, the patient was not notified.
Surveyor: Who is supposed to notify the patient?
Staff # 8: A physician. The lab did notify the charge nurse

A review of the policy titled "PC 3.070, Critical Values and Critical Tests Reporting" revealed the following: page 2, II Policy
"It is the responsibility of the nurse or licensed professional receiving a
critical result to contact the provider caring for the patient, to convey
critical values and receive orders within 30 minutes of receipt of critical
value results, unless certain exceptions, apply." ...