HospitalInspections.org

Based on record review and staff interviews, it has been determined that the hospital failed to meet the Condition of Participation of Patient's Rights relative to care in a safe setting for 3 sampled patients.

Findings are as follows:

1. The hospital failed to ensure that an Angiography machine necessary for care was in working order for Patient ID #5.

2. The facility failed to ensure that the policy for Universal Protocol for Correct Patient, Procedure, Site Side Surgery and Invasive Procedures was followed for Patient ID #1.

3. The facility failed to ensure that the policy for Patient Identification was followed for Patient ID#2.



(refer to A 144)


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Based on record review and staff interviews, it has been determined that the hospital failed to ensure care in a safe setting for 3 sampled residents. The hospital failed to ensure that necessary angiograph services were available for Patient ID #5. The hospital failed to ensure that the policy for Universal Protocol for Correct Patient, Procedure, Site Side Surgery and Invasive Procedures was followed for Patient ID #1 and the policy for Patient Identification was followed for Patient ID #2.

Findings are as follows:

1. Review of Patient ID #5's clinical record revealed the patient presented to the Emergency Department (ED) on 11/16/2018 at 2:38 PM after a motor vehicle accident which crushed the patient's right knee. The patient complained of right knee and lower leg pain, weakness and numbness with loss of feeling and cool sensation to the right lower leg below the knee. During transport, rescue personal noted that the patient had no pulse in the right foot.

The record further revealed the patient was examined in the ED and found with no pulse at the top of the right foot and behind the medial right ankle bone by palpation and Doppler (test that uses high-frequency sound waves to measure the amount of blood flow through arteries and veins). The patient was also found with loss of sensation below the right knee, laxity (loss of power) of the knee joint, and high riding patella (kneecap) with surrounding effusion (abnormal accumulation of fluid/swelling).

Review of the ED Documentation revealed that in addition to fractured bones, the patient had an injury of the left popliteal artery (blood vessel in the knee and the back of the leg).

Review of a vascular surgeon Consultation Note dated 11/16/2018 revealed that the right leg was dys-vascular (defective blood supply).

An Orthopedic Consultation Note, "Assessment/Plan," dated 11/16/2018, indicates the Orthopedist discussed the case with the vascular surgeon who was prepared, after orthopedic surgical interventions, "to angio the right lower extremity and restore flow as needed ..."

The record further indicates the patient was brought into the operative room for the orthopedic surgery at approximately 4:40 PM on 11/16/2018, with the vascular surgeons waiting for the procedure to be completed to see if pulses were returned to the lower extremity or if the Angiograph would be needed.

Surgical Documentation dated 11/16/2018 at 7:00 PM states in part, "The pin sites were cleaned and dried and a Xeroform sterile dressing was applied. At this point... could not palpate pulses. Furthermore, all of us used the Doppler and could not find a doppler-able pulse ..."

An interview with the vascular surgeon on 8/16/2019 at approximately 2:00 PM revealed that while waiting, she called to have the "angiograph machine" (image intensifier) brought to the operating room. She stated that when the staff went to get the angiograph machine in preparation for the surgery it was found to be out of service.

"At this point in time, I was informed that the angiograph machine that was required in order to successfully evaluate the patient and potentially revascularize was not working." She stated that she placed a call to another hospital and arranged to transfer the patient so that vascular surgery could be performed.

During an interview on 8/22/2019 at approximately 11:50 AM, the Director of Clinical Engineering stated that there had been multiple issues with the machine. She further revealed that she participates in a daily management meeting with all department directors during which she reports on equipment issues. She stated she had reported on the angiograph machine each day that it was out of service.

During an interview with the Chief of Surgery on 8/20/2019 at approximately 3:00 PM, he revealed that on 11/16/2018, he was not aware that the angiograph machine was out of service. He further revealed that if he had been aware, he would not have planned to do the procedure but would have sent the patient to another hospital.

During an interview the Risk Manager on 8/20/2019 at approximately 3:30 PM she was unable to provide evidence that the vascular surgeons were made aware that the angiograph machine was out of order on 11/16/2018.

2. The hospital's policy titled, "Universal Protocol for Correct Patient, Procedure, Site Side Surgery and Invasive Procedures," dated August 17, 2018 states in part;

" ...The purpose of this Universal Protocol for Correct Patient, Procedure, Site Side Surgery and Invasive Procedures Policy is to define patient safety requirements to assure the correct site, procedure and patient when undergoing any operative or invasive procedure ...Universal Protocol applies to all operative and invasive procedures performed...Invasive procedures includes ...Local and regional nerve blocks...

SITE MARKING:
1. Site marking is required for all procedures involving laterality (right or left) ...
3. The procedure site is marked with the practitioner's initials, with approved indelible marker, at or near the procedure site and sufficiently permanent to be visible after the skin preparation and draping...

TIME OUT
The purpose of Time Out is to conduct a final verification of the correct patient, procedure (s), site(s)/side(s).... The Time Out must be conducted by the practitioner performing the procedure, immediately prior to incision/puncture and with all members of the procedure team participating in the procedure..."


Review of Patient ID #1's clinical record, revealed the patient presented to the Ambulatory Surgery Center (ASC) on 7/24/2019 for an open reduction internal fixation (ORIF, surgical procedure to fix broken bones) of the left wrist. The record indicates the patient signed anesthesia consent which stated left supraclavicular nerve block (analgesia of the left shoulder, arm and hand).

Review of the Anesthesiology Documentation dated 7/24/2019 revealed the right supraclavicular nerve was blocked in error.

During an interview on 8/19/2019 at 10:50 AM, Anesthesiologist (Staff A) stated the injection site of the nerve block should have been on the left side of the patient's neck (just above the collarbone), however, he placed the marking on the patient's inner left arm at the elbow region. He then left the room to get the ultrasound (US) monitor. Staff A revealed his normal practice is to have the US monitor on the opposite side of the procedure site for visualization of the nerve. Staff A further revealed upon returning, he inadvertently placed the US monitor on the patient's left side, instead of the right side and then incorrectly prepped the right side of the patient's neck to perform the nerve block. He revealed that he placed the needle on the right side of the patient's neck, and the patient was injected with anesthetic agent by a Certified Registered Nurse Anesthetist (CRNA). He also revealed that he did not look for the site marking prior to inserting the needle for the nerve block. When the nerve block was completed, and the drape was removed, he immediately recognized that the wrong side had been blocked.

During an interview on 8/19/2019 at 1:30 PM, the CRNA (Staff B) stated the patient was assigned to him however he was not in the room during the time out process. He revealed he had two cases and they "moved very quickly so we tried to expedite to move the case." Staff B revealed when he stepped into the room, the Anesthesiologist (Staff A) was "already prepped and ready to block." He asked Staff A if he need any assistance and Staff A asked him to "push the medication". Staff B revealed he did not see the marking and did not verify the procedure site with Staff A.

During an interview with the Clinical Effectiveness Manager of Risk Management on 8/19/2019 at 2:00 PM, she confirmed that Patient ID #1 had the incorrect arm blocked.

3. The hospital's policy titled "Patient Identification Policy," dated September 29, 2017 states in part, " ...This policy applies to ALL hospital employees ...It is the policy of Kent Hospital that two (2) patient identifiers are used prior to ANY care, treatment or services being provided. The caregiver/staff will identify and verify with the patient, the patient's name and date of birth, confirming that to the patient's identification band. At any point in time a third (3rd) patient identifier is required; the Medical Record number will be used...

3 step process to identify & verify patient identification...
1. Ask the patient to tell you their name and date of birth i.e.: Please tell me your name and date of birth...
2. Verifying what the patient is telling you (name and date of birth) to the patient's identification band.
3. Prior to any test, treatment, procedure or ...., the staff is to verify the name and date of birth to any corresponding requisitions....orders, consent, etc, and confirm all the document match the patient identification band."

Review of Patient ID #2's clinical record revealed the patient presented in the Emergency Department (ED) on 5/31/2019 with abdominal pain. Further review revealed an order dated 5/31/2019 for abdominal ultrasound.

Record review revealed that on 5/31/2019 at approximately 4:00 AM, Patient ID #2 was brought to the Diagnostic Imaging (DI) Department and received a lower leg ultrasound, ordered for a different patient, in error. Shortly after, the ED physician noted the wrong patient had the lower leg ultrasound. The ED physician notified the DI technician (Staff C) and informed her of the error.

During an interview with the DI technician (Staff C) on 8/16/2019 at 1:30 PM, she revealed she did not verify Patient ID# 2's name and date of birth, per policy, prior to performing the ultrasound.

During an interview with the Transporter (Staff D) on 8/16/2019 at 2:45 PM, he revealed he did not verify Patient ID #2's name and date of birth, per policy, before transporting the patient to the DI department.







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