HospitalInspections.org

Based on record review and interview the facility failed to provide knowledge to the patient and family regarding care decisions that impacted the patient after discharge, in one of one patients. Pt #3 had a below the knee amputation within 2 days of discharge from the hospital.


This deficient practice had the likelihood to effect all patients in the hospital.


Findings included.

On 9/6/2019 a review of Patient (pt) #3's medical record )MR) was reviewed. Findings are below.

On 4/4/2019 pt #3 was brought to the Emergency Department via ambulance.

On 4/5/2019 Pt #3 underwent a surgical procedure to remove her Rt. great toe because it was mummified upon arrival. During this procedure the operative report indicated tissue damage traveled from the joint of the great toe through planter foot to the heel. Surgery was limited to the removal of the great toe secondary to the vast tissue damage found in the foot. The consultation report diagnosis was gangrenous necrosis, right great toe with some heel involvement. recommendation was for flow studies prior to considering level of amputation.

On 4/15/2019 a cardiac catheterization confirmed blockage of the anterior tibial artery and the tibioperoneal trunk and another occlusion at the posterior tibial artery. The cardiac catheterization report indicated sever below the knee artery disease that will require intervention in a few weeks.

This report failed to indicate the pt/family was given this information of sever below the knee artery disease that would require surgical intervention within a few weeks.

Through out the MR reports indicate conversation between medical disciplines. There was no evidence the physician's communicated with the patient or mother of the patient who was her emergency contact. The only report of discussion with family indicates"Family made aware". There was no clarification of what the family was made aware of.

Pt #3 was discharge on 4/17/2019. The Discharge Summary, found under Hospital Course, indicated pt #3 was stable with severe occlusive disease involving the tibia vessels. She was discharge on ciprofloxin 500 milligrams Twice a day and follow up with podiatry and cardiology after discharge. Discharge home with home health. This report was entered into the MR in accurate, with erroneous information.

The discharging physician failed to document this information was presented to and explained to the family or patient. The discharging physician also failed to understand the daughter, who was not pt #3's emergency contact, refused home health services at discharge.

The patient was taken to another hospital two days after discharge and underwent a below the knee amputation of her Right lower leg. The family stated, "They didn't understand why her leg was cut off".

Based on interview and record review the facility failed to insure the patient's representative signed consent for treatments and services in the absence of the patient's ability to sign for her self in one of one patients identified, (patient #3).

This deficient practice had the likelihood to effect all patients of the hospital.

Findings included.

On 9/6/2019 a review of the medical record (MR) for Patinet (Pt) #3 was conducted in the conference room.

Pt #3's MR indicated on the admission face page that her, "In case of emergency" contact, was her mother.

Review of the admission consent indicated the patient may have signed by initial only but used a "G" rather than a "J" to initial her name.

Admission information indicated the patient's last name began with a "J". However the patient name was signed with a "G". This is the only time the full name of the patient is found signed in the MR.

Pt #3 underwent a cardiac catheterization and a surgery. Both of these consents were initialed by her daughter. Identified as "MR" on the signature line.

Interview with staff #87 confirmed the facility did not have a Power of Attorney in the MR.

Documentation identified in the discharge planning of pt #3 indicated her mother was fearful to challenge the daughter. Also discharge planning notes indicated "Red flags observed by the nursing staff indicated Adult Protective Services (APS) might need to be contacted related to adult neglect situation".

Confirmed with discharge planning staff, APS was not contacted on behalf of pt #3.

Daughter refused home health, skilled nursing care and insisted pt #3 be discharge home with provider care only.

Based on review of documents and interview, the facility failed to:

A. ensure all staff had effective training on abuse and neglect to prevent staff abuse and neglect and allowed all hospital staff to identify allegations of abuse and neglect of patients by hospital staff to include the Risk Manager and Patient Advocate in 5 (Patients #85, # 95, #97, #98, and #99) out of 7 patients.

B. develop policies and procedures that clearly define abuse and neglect of a patient by hospital staff or to follow the steps for conducting an abuse and neglect investigation as outlined in the current policy for in 7 (Patients #2, #4, #85, # 95, #97, #98, and #99) out of 7 patients.

C. develop processes to ensure that vulnerable patients to include children who were known victims of abuse were not discharged until it was determined through investigation and contact with appropriate agencies that the patient was being discharge into a safe environment and not discharged to the perpetrator of the abuse in 1 (Patient # 100 )out of 1 case of known sexual assault reviewed.

Findings included:

Review of the requirements for this regulation show that the definition of neglect was, "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness"

On 9-4-2019 a review was made of a document titled, "Event Log for Regulators" that listed the complaints and grievances that had been filed. A sample of complaints and grievances investigations for the month of March were requested and reviewed. Investigations were documented on a form titled, "Event Reports".

The documents titled, Event Reports, had a column titled "Investigation Findings". Upon reviewing the investigations, it was noted that only 2 out of the 5 complaints and grievances reviewed that contained potential allegations of patient abuse and neglect by hospital staff had been processed appropriately as grievances. Five (5) of them (Patients # 85, #95, #97, #98, and #99) had been processed as complaints.

Patient #85

The Patient Advocate had met with Patient #85 and treated the patient's allegations as a complaint. The "Description of Event" was as follows:

"PtAdv received called from charge nurse ______ (staff name) asking her to visit with patient. PtAdv went to patient's bedside. Patient stated that because she had soiled herself and had to clean herself up due to no one coming to help her. She stated each time she calls for a nurse, it is an extremely long time before they come. Patient states that all her nurses have terrible attitudes. She states that she does not want Charge nurse ________ (staff name) to come into her room anymore. Patient was unable to tell me specifics as to why she doesn't want to see her anymore-just that she had a really bad attitude. PtAdv told patient the ______ (staff name) would not be back until Monday, but that she would let her know the patient does not want to see her. Patient states her bedside toilet was full and "stinking" and no emptied it until she asked them to. She also says she asked for 24 hours for a cup of ice before it was finally brought to her.

PtAdv did talk to Charge Nurse _____ (staff name) about the patient's complaints and will notify Director of Medical, as well. PtAdv will speak to RN _______ (staff name) on Monday and if patient is still here will instruct ______ (staff name) not to see her. Patient was satisfied when PtAdv left and stated she would call back if things got worse."

Per the allegations, staff neglected the patient's toileting needs forcing the patient to clean herself up, were not emptying her bedside commode causing the patient to have sit in a room that was "stinking" until she had to ask staff to perform their duties, was not given a cup of ice for until 24 hours after the original request, and endured staff with bad attitudes.

All allegations of abuse and neglect require the facility to initiate an investigation. By definition, since an investigation should have occurred, this complaint should have been treated as a grievance and not a complaint.

The investigation portion of the Event Report did not contain any information on an investigation. On 9-9-2019, an interview was conducted with the Risk Manager. The Risk Manager stated the Patient Advocate worked under the Risk Manager, and at times, the Risk Manager also performed Patient Advocate duties. The Risk Manager stated that she reviewed all complaints and grievances that are logged. When asked why this had not been investigated as grievance as abuse and neglect, the Risk Manager stated the she and the Patient Advocate had failed to identify the allegations as neglect.

The Policy Title: Risk Management Abuse, Neglect, and Exploitation Policy was reviewed. The policy reference cited was "Medicare Condition for Coverage: (3/15/2013) 42 CFR: 416.50(d)(1)(2)(3) Standard: Submission and Investigation of Grievances." This reference cited was found to requirements for Medicare participation for Ambulatory Surgery Centers and the required Conditions of Participation for an Acute Care Hospital.

The policy on page 3 of 8 stated the following:
"The following criteria may be used to assist in the identification of abuse:
...
Neglect - The failure to provide for one's self the goods or services necessary to avoid physical harm, mental anguish or mental illness or the failure of a caretaker to provide such goods or services, for example:
Malnourishment, dehydration
Over/under medication
Lack of heat and/or running water
Lack of medical care
Lack of personal hygiene and/or appropriate clothing"

The policy did not specify that this pertained to the patient's care outside of the facility, as well as the care inside the hospital provided by staff employed by the hospital. When asked about the vagueness of the definition along with other language in the policy that inferred the definitions given pertained to care provided outside of the facility, the Risk Manager stated, "This policy is geared more towards the screening of the patient for abuse and neglect outside of the hospital."

A section titled "Management of Suspected Abuse/Neglect was found on Page 5 of 8; and a section titled "Grievance Allegations Related to Verbal, Mental, Sexual, or Physical Abuse" were noted. These sections did not clearly differentiate between the actions taken to protect the patient and report/investigate incidences of abuse and neglect of a patient that occurred outside of the facility versus allegations of abuse and neglect that occurred inside of the facility and involved hospital staff.

Because the policy did not include the definitions from the appropriate reference source and did not clearly define the process for identifying, documenting, investigating and protecting the patient when allegations of abuse and neglect were made in different settings, (out of the facility by others versus in the facility by hospital staff), the potential for confusion among staff and missed investigations placed patients at risk of continued harm in both settings.

Other incidents of patient allegations either not being identified as potential neglect, adequately investigated as abuse/neglect, and/or adequate steps taken to protect the patient from being discharged back into an unsafe setting where known abuse and neglect had occurred included:

Patient #2:

A patient satisfaction survey had been sent to Patient #2 after services. The patient's spouse had returned a written complaint attached to the survey. The complaint was stamped as received on May 10, 2019, a response letter was typed up and sent out the same day. The letter included in part, "Thank you very much for taking the time to express your concerns and detail the interactions you had with the individual staff member on the 1st of May here in the facility. We will use this information to improve our processes, provide continuing education to our staff, and enhance the experience that patients have when they use Longview Regional for medical care.

The process includes an internal investigation, which is now concluded. Your concerns were reviewed with the Chief Nursing Officer, the Pharmacy Director, the Director of the Surgical Unit, the Chief Executive Officer, and the Chief Quality Officer. They will address with their teams and the hospital leadership, and implement corrective actions as appropriate."

Review of the Event Report did not include notes of the investigation of neglect allegations. The Risk Manager was asked if there was any evidence that the staff listed in the response letter had been involved. An email from the Risk Manager to the staff listed above was presented as evidence that the complaint was forwarded to the above mentioned staff and that an investigation was done. The e-mail read, "This letter was received in Admin today. I've drafted a response letter, but please review and make corrective actions as appropriate. _______ (Pharmacy Director name), is there any truth to the statement that we have "limited" IV Tylenol: or that it was withheld for any other reason?"

The letter that was drafted and sent to the complainant the same day, falsely claiming that the investigation was completed, everyone had reviewed the allegations and were taking action. This, in fact, had never been done. The grievance was marked that the parties involved were satisfied, all without evidence that the Risk Manager had spoken to the parties involved and without an investigation into the allegations of neglect being completed.

The facility failed to investigate allegations of neglect that included:
The patient was moved from the Post Anesthesia Care Unit after neck surgery to her room at 12:10 PM. Her family arrived to her room at 1:10 PM to find her lying flat on her back and too weak to get up and help herself. The patient had not been checked on by nursing staff she arrived in her room and had not been given a call button. For an hour she had been hitting the button to raise and lower the bed in an attempt to find the call button. The nurse assigned to her told the patient that didn't have time to find the equipment needed for patient care. The nurse assigned failed to administer the ordered medications needed to control pain after surgery until another nurse intervened and went to pharmacy to pick the medication up herself.

The Assistant Chief Nursing Officer (ACNO) was interviewed on 9-9-2019 regarding her role in the investigation of these allegations of neglect. The ACNO stated she did not have any documentation of an investigation. The ACNO stated that the assigned nurse mentioned in the complaint had been let go at the end of May for similar allegations by other patients. An email was provided that was dated 5-30-2019 that confirmed this.

Patient #4:

Allegations of possible neglect that were not identified and investigated as neglect included:

Procedure delayed due to no one contacting the physician and the physician was unaware of blood pressure and other information.

The complainant had taken pictures of the condition of the patient's room and tried to have a conversation with staff. When the situation escalated, she tried to record the conversation. Security was called and she was escorted off of the property. She alleged that this was in retaliation to previously filing a complaint.
Staff members were rude, didn't change his sheets and left him with bowel movement and urine on the bed.

The patient's arms and hands were swollen because the bandages were placed too tight and the site where intravenous medications were given was bad.

The patient suffered an unwitnessed fall and no precautions had been put in place despite patient having suffered several strokes.

The patient care technician (PCT) had asked the patient to say, "Yes ma'am" when he addressed her.

The complainant expressed fear that staff were mistreating the patient when the family was not around.

The complete investigation documentation on the Event Report was as follows:
"The RM answered _______ (complainant's name) questions and concerns throughout their conversations from the 14th through the 18. The RM made sure to let _______ (complainant's name) know that the events that took place involving security were not in any way a form of retaliation. The RM has provided __________ (complainant's name) with her contact information if any further issues should arise throughout the remainder of the pt's stay. It is likely that the pt will be continuing to HH (home health) or SNF (skilled nursing facility)".

No evidence was provided that the allegations above were thoroughly investigated. While it was noted in the descriptions of the event that the complainant did not have medical power of attorney and that the patient was his own decision maker, the events as described showed that the complainant was acting as the patient representative. The facility failed to confirm this and provide her with the information she requested as his representative. She had asked for policy that limited her right to record conversations that was not addressed and was not provided a written response to the allegations she made on behalf of her family member.

The patient records show that he was discharged to a SNF in Longview, TX. The written response to the grievance was sent to an address in Hallsville, TX that neither the complainant or the patient resided at. No effort had been made to verify that the address listed on the chart was still going to be the correct mailing address at time of discharge. The Risk Manager stated that the hospital does not do that. They send their letters to the address listed in the patient record. The Risk Manager did not provide evidence of the letter being sent or delivered, such as postal tracking with confirmation of delivery.

A telephone interview was conducted with the complainant at the onset of the survey. The complainant provided pictures of the patient and the patient's room that supported the allegations that the patient's sheets and gown were not changed, as well as his hands being swollen and bandages that appeared to be tight around his hand. The complainant stated that neither the patient or she, acting as the patient's representative, received a written response to her allegations of neglect.

Patient #95

Allegations of neglect were not investigated. These allegations were classified as a complaint that was resolved at that time. Allegations included:

Family alleged that the patient "was a victim of neglect due to him to being fed for 3 days, and they state he has become weaker and weaker with every day."

No evidence was alleged or provided of an investigation of the events that led up to the delay in the patient having a feeding tube placed or what action would be taken to improve the process so that other patients would not be negatively affected through repeated occurrences.

Patient #97

Allegations of neglect were not investigated. These allegations were classified as a complaint that was resolved at the time. Allegations included:

The wound care nurse found the patient in with his gown and bedding soaked in urine. A blue bed pad had been stuffed into the front of the patient's diaper to catch urine. However, blue pads were not absorbent and intended for that purpose. Instead, it held urine against the patient's skin, increasing his risk for skin breakdown. The patient's spouse told the wound care nurse that the patient urinates a lot and suspected the PCT of placing it there for that reason.

This was never investigated to find out why someone would neglect to change the patient's appropriate briefs when wet and stuff it with an inappropriate pad.

Patient #98

Allegations of neglect were not investigated. These allegations were classified as a complaint that was resolved at the time. Allegations included:

The patient's family member stated he had asked for the nurse to give the patient something for her headache and something for the anxiety she was experiencing due to breathing difficulties and having to be on a machine to assist with her breathing. The family member (who was a nurse) stated that the patient's assigned nurse had not completed an assessment of the patient yet and stated "it could be 24 hours before the doc/Hospitalist come to see her"

No investigation was conducted to determine if there were significant delays in care due to the physicians or hospitalists not seeing patients in a timely manner.

An interview was conducted with Staff #69, a nurse, who confirmed that patients arrive from the emergency department to the inpatient floors without any orders. Staff #69 stated that the Emergency Room physicians won't write orders to hold the patient over until the primary physician can see them. Staff #69 stated it has taken up to 12 hours at times to get orders for patients.

Patient #99

Allegations of neglect were not investigated. These allegations were classified as a complaint that was resolved at the time. Allegations included:

The wound care nurse reported that during the initial wound care visit on 3-30-2019 at 3:00 pm, the patient was found lying flat on his back and buttocks where he had a pressure ulcer. The patient had left the ER to go to the room at 11:13 am. The wound care nurse found that the patient had not been oriented to the call light/TV remote because he didn't have one. Staff had not placed his slip resistant socks on him because they were still in a bucket at the bedside. The patient had no water, skin protection (waffle mattress) and "no identifier of being a veteran. "

No investigation was conducted regarding the staff neglecting to provide initial care of the patient for almost 4 hours or why a patient with skin breakdown was left in that position for that length of time.

During interview with the Risk Manager and the ACNO, they were asked if the hospital had adequate staffing to take care of patients' needs. Both agreed that adequate staffing was an issue that was being addressed by trying to recruit more nursing staff. One problem identified was the lower pay offered to PCT than what they could get at Long Term Care facilities (nursing homes). No plan to increase pay in order to be competitive was presented.

On the morning of 9-3-2019, an interview was conducted with Staff #107 on the Progressive Care Unit (PCU). The patients on PCU did not require as much care as patients in the Intensive Care Unit (ICU), but were not stable enough to go to a regular medical or surgical care unit. Staff #107 explained that they were allowed to have 1 nurse assigned to 4 patients during the day. At night, the patient load increased to 1 nurse assigned to 5 patients. This was a 50 bed unit and was currently with 31 patients. Staff #107 stated that the unit was only allowed to have 1 Patient Care Technician (PCT) assigned to the floor. PCTs provided care that was not required to be provided by licensed nursing staff. This included assisting with bathing and toileting needs, feeding needs, linen changes, checking vital signs, providing supplies like water, and other tasks that would free up licensed staff to provide necessary patient care. On the day of interview, 1 PCT was responsible for providing all of those services for 31 patients (and potentially, up to 50 patients)

During interview with the Risk Manager and ACNO on 9-9-2019, they were asked about the staffing. They both agreed that it could be "challenging" at times and that nursing staff were expected to perform those duties a PCT could perform, potentially taking them away from other duties that must be performed by a licensed nurse. Neither could provide documented investigations of alleged neglect due to inadequate staffing even though the Complaint and Grievance log for Regulators listed 17 complaints/grievances between 5-24-2019 and 8-9-2019 that were listed as Event Type Sub-category of "Staff response to call light or request for assistance".

Patient # (ADD Shanda's Patient Number)

Patient # was a minor seen in the emergency department with evidence that she had been sexually assaulted at some time prior to her arrival.

Review of Policy Title: Risk Management Abuse, Neglect, and Exploitation Policy, Page 6 of 8 was as follows:

"To protect the patient from a real or suspected mental, physical, sexual and verbal abuse, neglect and/or exploitation, staff will safeguard the patient from the offending individual(s). This "safeguarding" may be overt or covert, dependent upon the patient's mental and physical sense of wellbeing. If any type of abuse or exploitation is proven legitimate (witnessed and obvious), the offending individual will be restricted from access to the patient. If the abuse is suspected, however unproven, staff shall be present at all times when the patient receives visitors, staff may contact the House Supervisor for additional support if support is not immediately available, the House Supervisor or Security will stay with the patient until additional support arrives."

The policy did not address the need to ensure that a minor who had been abused would not be discharged until all reasonable efforts were made through investigation by the hospital and/or responsible authorities to ensure that the minor would be discharged to a safe environment rather than discharged to an environment with the potential perpetrator of the physical or sexual abuse.




32143

ED Findings:

Review of Patient #100's Emergency Department (ED) chart revealed she was a 10-year-old girl brought in for a sore throat and dysuria on 2/17/19 at 11:13AM.

Review of the nurse's notes dated 2/17/19 at 11:34 AM revealed the patient was accompanied by her mother, father and a sibling. "Parent/ caregiver report the patient having burning upon urination."

Review of the physician notes dated 2/17/19 at 13:36(1:36 PM) revealed Patient #100 had "pustules noted to the post pharyngeal area." The patient was swabbed for the flu, strep, and a urinalysis was done. The patient was treated with antibiotics, Tylenol and Motrin. The patient was discharged to home at 13:29 (1:39 PM).

Review of Patient #100's chart revealed she was brought back into the ED on 2/18/19 at 10:58 AM. Review of the nurse's notes dated 2/18/19 at 10:57 AM revealed, "Father states: seen here yesterday treated for UTI, has taken 2 doses of antibiotics. Motrin given at 6am, dad brought patient back because she has been crying and also he was told that we were going to check her "private parts" but never did yesterday. 11:11 AM Complains of pain in pelvis appears uncomfortable."

Review of Patient #100's nurses note on 2/18/19 revealed the following:
12:19 PM-Pt visited by father.
13:06 Assist provider with pelvic exam: Pelvic tray set up. patient moved temporarily to room 25 for pelvic exam.
13:20 Assist provider with pelvic exam: Assisted ____ (Staff #134 NP) with assessing patient's vagina. Several ulcerations inside both labia's. Green discharge noted. Patient denies anyone touching her inappropriately but seems very scared and is crying. Police notified and Child Protective Services (CPS) notified.
13:40 Assist provider with pelvic exam: Specimens sent to lab. Performed by ____ (Staff #134) patient was assessed on the labia - visible blister and lesion, round and open, green discharge present.
13:42 Herpes Simplex HSV 1/2 DNA PCR Sent.
14:11 Patient Rounding: patient was in distress, did not want to say what has happened. Dr. ____ (Staff #133), MD, talked to the mother and step-dad that someone touched their daughter inappropriately. I gave her a piece of paper to write down the name who did that to her. She wrote down the name "____ (name of male cousin)." Her mother is talking to her, calmly. Will give them a moment.
14:16 Patient Rounding: ____, step-cousin, abused sexually the patient. it happened in Mexico, last year August 2018, patient's mother took her family to Mexico to visit them. They stayed for one month and returned to the States right before school started. Mother stated they don't come to the States. (There was documented evidence that the child had been interviewed by a trained investigator for a potential crime.)
17:10 Patient Rounding: called ____, RN, at Trinity Mother Frances ER in Tyler, Texas, to give report on the patient at 1709.
18:46 Patient is resting quietly. Pt visited by mother, father."

Review of the Case Management notes dated 2/18/19 at 14:26 stated, "Case Management:
02/18 14:26 Case Management Note: Contacted CPS at request of ____ (Staff #133). Initiated CPS report with _____ (CPS Worker) (ID #5049). Reference #71968911. Case was triaged as a Priority 1 per ____ (CPS Worker). Provided CM and ED phone numbers for call back.

02/18 16:57 Case Management Note: Discussed case with ER MD, NP, LPD, Charge RN, Primary Nurse and CPS. Per MD and LPD, pt will be transferred via Camp County EMS, under Institutional Authorization to Christus Mother Francis ER for SANE exam. Post exam, pt will be transferred via EMS back to LR ER for admission. CM contacted Christus Mother Francis ER and s/w ____ (RN) who, was agreeable to above plan. Report will be called to ___ (RN) @ 903-531-4262. Information provided to Primary RN, _____ (Staff 130)."

There was no found documentation in Patient #100's chart that revealed when the CPS worker arrived at the facility. Who the worker was and what the plan was with CPS.

Review of the nurse's notes revealed Patient #100 revealed the patient was discharged from the ED on 2/18/19 at 19:54. Patient #100 was transferred to CTMF ER by EMS for a SANE exam.
Review of Patient #100's chart revealed she was brought back to the ED by ambulance from Sane Exam on 2/19/19 at 2:18 AM. Patient #100 had been discharged but was readmitted to the ED with a new chart.
Review of the physician notes dated 2/19/19 at 2:46 AM stated, "Pt was here earlier and was determined to have been sexually assaulted by step dad's brother's son who lives in Mexico- Pt has written his name down and given it to her mother. Parents report they were in Mexico visiting family approx. 1 year ago.
2:43 AM- ED course: Pt just returned from Tyler where she had a SANE exam. Pt was brought back with the assumption she would be admitted for further IV Valtrex or transferred to Dallas CMC. Family did not want to go to Dallas. They would prefer to go home. D/W Dr. ____ (on call Pediatrician) on call for ____ (Patient 100's Pediatrician). _____ (on call Pediatrician) agrees with DC home as long as is safe to go home. Family indicates the person who assaulted the pt. is not in the area and pt. will be safe at home. Will DC home with Valtrex and is to FU with ____ (Pediatrician) later this week."

Patient #100 was ordered and administered IV Valtrex on 2/19/19 at 2:29AM for the diagnosis of Genital Herpes. Patient left the ED with her mother and step father on 2/19/19 at 3:46 AM. The ED Physician failed to verify a safety plan was in place before discharging the patient to home.

There was no police report, notes from CPS, or SANE report in the child's chart to determine if the child was properly interviewed away from her parents. There was no found documentation if the parents were allowed in the exam or had time to coach the child. There was no documentation that CPS or law enforcement was notified before the patient left the safety of the ED.

Review of Patient #100's chart for the 2/18/19 visit to the ED revealed a Nurses Note Addendum dated 2/19/19 at 10:40 AM. The note stated, "Spoke with Dr.____ (Patient 100's pediatrician) nurse regarding follow- up appointment. Mom had not made the appointment. Appointment is scheduled for Thursday at 9:20. I called mom to inform of the appointment no answer did leave message. 11:15 spoke with mom and informed about the appointment. Mom stated she would make sure the patient was there and the child was doing ok and resting at this time. I expressed to mom that if she or the patient needed anything don't hesitate to call us. 16:24 Positive IHS 1 DNA report received. Per ____ (Lab personnel) in the lab results were faxed to Dr.____ (patient 100's pediatrician) office, but report given to ____ (Staff #134) for follow up."

Review of the ERS (event reporting system) form dated 2/19/19 revealed nursing Staff #68 made a report concerning Patient #100. The report reflected the nurses concern for an improper discharge. Patient #100 was to stay at the hospital for IV antibiotics. The nurse stated on the report, "I'm not sure if I'm doing this right."

An interview was conducted with Staff #70 on 9/5/19 at 1:28 PM. Staff #70 was asked who reviews the ERS and how was this one processed? Staff #70 stated that she and Staff #115 would review the ERS. Staff #70 stated that she had reviewed Patient #100's chart and felt all the issues had been resolved. Staff #70 stated, "I talked to both Staff #68 and 69 they never said she was unsafe to go home. It seemed to me they were upset over the doctor not following the plan for the patient to stay overnight for antibiotics." Staff #70 reported that the plan was changed by the oncoming ED doctor and she was sent home. Staff #70 reported that Staff # 68 had called the patients mother and checked on them. "I felt it had been resolved." Staff #70 was asked if there were any further information documented on another system concerning CPS and the police involvement? Was there another system for Case management to document? Staff #70 stated, "No." Everything would be in the chart. Staff #70 was asked why CPS information was not in the chart and how where they sure the patient was sent home to a safe environment if there were notes from CPS? Staff #70 stated, "I spoke with Staff #68 and 69. They didn't seem upset about the child going home in danger. They just seemed upset that the doctor did not follow the plan to admit the patient." Staff #70 stated that she was not a clinician and referred the complaint to Staff #1."

An interview was conducted with Staff #1 on 9/5/19 at 1:40 PM with Staff #70. Staff #1 confirmed he was aware of the ERS for Patient #100 and had spoken with Staff #70. Staff #1 reported that he remembers discussing the SANE exam and his concern that the patient had to go to Tyler to receive the exam. Staff #1 reported that he had not reviewed the chart. Staff #1 and #70 failed to properly investigate the incident and protect the patient from potential harm.

An interview was conducted with Staff #69 on 9/6/19 and Staff #72 at 9:30 AM. Staff #69 confirmed she was the case manager for patient #1 on 2/18/19. Staff #69 reported that she had contacted CPS on 2/18/19 at 14:26 (2:26 PM). Staff #69 reported that CPS arrived along with the police department. CPS was told by the nurse that she had the patient to write down the name of her assailant. Staff #69 stated that a plan was made with CPS and ER physician Staff #133 would admit the patient for IV Acyclovir after Patient #100 returned from her SANE exam. CPS to follow up with the patient the next day and decide placement. Staff #69 stated that CPS had left, and the physician and charge nurse was aware and in agreement. Staff #69 stated that the ER physician was concerned because there was a story of a cousin molesting Patient #100 a year ago and then it turned into 6 months ago. Staff #69 stated Staff #133 had reservations about the story. The step-father stated that Patient #100's biological father had a step son living in his house and patient #100 goes to his house to visit. Step father insinuated that maybe it was that boy that molested the patient. Staff #69 stated that raised the awareness of the physician and staff and was worried about the child's safety at home. Staff #69 stated that she went home before Patient #100 went for her SANE exam and did not know the outcome till the next day. Staff #69 stated that she came in the next morning and realized the patient had discharged that night with the parents. Staff #69 stated that she spoke with the charge nurse (Staff #68) in the ED on the following morning. Staff #68 charted in the patient's chart and Staff #69 charted in her Case Management program "Morrisey." Staff #69 stated that her and Staff #68 spoke to Staff #70 concerning Patient #100. Staff #69 stated that she and Staff #68 was visibly upset and made concerns that due to the changing shift, the plan to admit the patient for safety, and IV acyclovir was not followed by the incoming ER physician. Staff #69 confirmed that she shared her concerns of the child's safety at home and potential for further abuse. Staff #69 stated that she called the CPS worker the next morning and reported that the child was d

Based on interview and record review, the facility failed to ensure medications were reconciled appropriately, accurate orders were obtained, and administered safely in 1 of 6 patients reviewed for medication reconciliation(Patient #1).

Patient #1 received an overdose of medications because they were reconciled on presentation into the Emergency department (ED). The facility implemented medication reconciliation training for all staff, but failed to ensure the staff who initially put the medications in incorrectly was trained as of 09/06/2019.


This deficient practice had the likelihood to cause harm to all patients.



Findings include:



Review of the Emergency department (ED) record on Patient #1 revealed he was a 76- year- old male who presented on 08/08/2019 at 11:12 a.m., with complaints of chest pain. Patient #1 had diagnoses which included atrial fibrillation, coronary heart disease, congestive heart failure, chronic kidney disease, depression, diabetes, hypertension and chronic obstructive pulmonary disease.

The following home medications were listed on the ED assessment:

1. Glucovance (diabetic agent)
2. Levothyroxine (thyroid agent)
3. Mirapex (agent used for Parkinson/restless legs)
4. Toprol XL 100 milligrams (blood pressure agent)
5. Lipitor 40 milligrams one tablet daily (cholesterol agent)
6. Cymbalta (anti- depression agent)
7. Gabapentin (anti-convulsant/nerve pain agent)
8. Vaseretic (blood pressure agent)
9. Insulin aspart subcutaneous (diabetic agent)
10. Tresiba FlexTouch (diabetic agent)
11. Eliquis (anti-coagulant agent)
12. Pantoprazole (anti- acid agent)
13. Potassium chloride (potassium supplement)
14. Torsemide 100 milligrams 0.5 tablet twice a day (diuretic agent)
15. Torsemide 50 milligrams one tab daily(diuretic agent)
16. Toprol Xl 50 milligrams one daily(blood pressure agent)
17. Aspirin (anti-coagulant /anti-inflammatory agent)
18. Advair Diskus (bronchodilator agent)
19. Ipratropium-albuterol (bronchodilator agent)
20. Trazadone (anti-depressant agent)
21. Sertraline(anti-depressant agent)
22. Lipitor 80 mg one tablet at bedtime(cholesterol agent)

There was documentation on the assessment that all meds were verified by patient's bottles.

Review of an emergency medical technician's (EMT) trip report dated 08/08/2019 revealed "MED LIST LEFT WITH ER STAFF."

This was a discrepancy and some of the medications on the list had duplicate actions.



According to a physician's order dated 08/08/2019 at 1:57 p.m., revealed Patient #1 was being admitted for observation.

Two days later on 08/10/2019 at 2:30 p.m., a physician's order was received to discharge Patient #1 to home.

According to the discharge instructions Patient #1 was to take continue taking the same list of home medication:


The same medications that was listed on the ED assessment dated 08/08/2019 were listed on the discharge assessment dated 08/10/2019.



Review of ED notes dated 08/10/2019 at 8:52 p.m., revealed that Patient #1 returned to the hospital. The following was documented:

"..Having problems with shaking, can't walk. turns out his med list was his caretakers that the home health nurse had sent with him so he wasn't being given the correct medications. Is wanting to talk to house supervisor immediately."


The following medication list was provided by the family as the ones Patient #1 was supposed to be taking:


Eliquis
Klor Con
Pantaprazole
Torsemide 100 milligrams 0..5 tablet daily
Tamsulosin
Trazedone
Metoprolol
Sertraline
Lipitor 80 milligrams at bedtime
Aspirin
Titropium bromide inhalation
ProAir HFA
Advair Diskus
Iron
Multiple vitamins


According to the physician's documentation dated 08/10/2019, Patient #1 presented to the ED with complaints of shaking and confusion. .."Daughter checked patient's medications and found that he was receiving the wrong meds during his inpatient treatment including Gabapentin, Tresiba, Mirapex, and Cymbalta among other medications. The physician wrote orders to admit Patient #1 for observation.

After a changed in condition, a physician's order dated 08/11/2019 was written for Patient #1 was admitted to intensive care unit.

According to a Nurse practitioner note dated 08/12/2019 revealed the following :

"Toxic encephala secondary to accidental drug overdose-patient is improved as medications are metabolize out of his system. Will continue observing."

During an interview on 09/06/2019 after 2:30 p.m., Staff #70 said she had investigated the complaint about the medications and found that the nurse in the ED had called the family on 08/08/19, but had done a thorough check on the medication list she had received from the EMT's. Staff #70 said she found out from the family that the EMT's were given the wrong list of medications on 08/08/2019. The wrong list of medications was what was left with the ED nurses. When the family called the EMT to pick up Patient #1 the next visit to the ED on 08/10/2019 they noted on the discharge papers dated 08/08/2019 that Patient #1 had been given the wrong medications. The family member recognized that the medications listed belonged to her. Staff #70 said the ED nurse called her the family on 08/08/2019 and had the family read off Patient #1's medication bottles to her, but failed to share the list of medications she already had. When both list of medications were placed in the computer system they all merged. Staff #70 said Patient #1 got wrong does of medications on the 9th and 10th. Patient #1 got doses of his medications and the ones belonging to family members.


Staff #70 said as a result of the medication errors they implemented a training for the nurses and pharmacy staff on medication reconciliation. The nurse had been counseled and the case was sent to peer. As of today (09/06/2019) 54 percent of the staff had done the new education. The nurse who put the medications in the system incorrectly had not been trained yet and she had worked two times since the incident occurred that she knew of.

Based on record review and interview the facility failed to administered blood products in accordance with written policy and established form for blood transfusions. in *** of *** patients. (Pt #3, #19, #20)

This deficient practice had the likelihood to effect all patients of the facility.

Findings included.

Pt #3
On 9/6/2019 in the Physician's dictation room the Medical Record (MR) for pt #3 was reviewed and revealed a blood transfusion was conducted on 4/8/2019. The transfusion began at 0100. Vital signs were recorded at 15 minutes after start of infusion, 1 hour, 2 hours and 3 hours after start of infusion. The vital signs for 1 hour post transfusion were not recorded.

Pt #19
Review of pt #19's MR a blood transfusion was initiated on 8/15/2019. Documentation for, vitals signs, is identified below.

Unit #1
Pre-transmission vitals signs were recorded at 2110
Start time of time of transfusion 2125
15 minutes after start 2140
1 hour after start 2225
2 hours after start no vitals signs documented
3 hours after start no vitals signs documented
one hour post transfusion documented a 2244

This unit ran in in 1 hour and 14 minutes.

Unit #2 was initiated 8/22/2019
Pre-transfusion vital signs were recorded at 2200
Start time for transfusion 2209
15 minute after start 2225
1 hour after start 2310 10 minute late
2 hours after start 0010
1 hour post completion 0200 50 minutes late

Unit #3 was initiated 8/22/2019. Only one nurse verified the correct unit of blood.
The pre-transfusion time had been marked through and was not legible
Start time for transfusion 1130
15 minute after start 1145
1 hours after start 1230
2 hours after start 1330
3 hours after start 1430
1 hour after completion 1530
Transfusion completed 1255 (sic)

The above documentation indicated the blood transfusion started at 1130 and was completed at 1255, 1.25 minutes.

Pt #20
On 9/7/2019 in the Physician's dictation room the MR for pt #20 was reviewed. Pt #20 came to the facility in sickle cell crisis and received 2 units of blood. The first unit was issued at 0140 on 8/30/2019. Documentation indicated the unit began on 8/30/2019 at 0215 and was documented as complete at 0420. Please review the following vitals signs documentation.
Unit #1
Pre-transfusion vitals signs 0130
start time of transfusion 0215
15 minutes after start original time 0300 rewritten time 0215
One hour after start original time 0330 rewritten time 0245
Two hours after start original time 0430 rewritten time 0300
Three hours after start original time 0530 rewritten time 0345
Post transfusion 1 hour original time 0615 rewritten time 0420

Transfusion completed at 0420

Unit #2
Issued on 8/30/2019 at 0430
Pre-transfusion vitals signs 0420
start time 0440
15 minute after start
One hour after start
Two hours after start
Three hours after start
one hour post transfusion
Completed 8/30/2019 at 0620. Vitals signs were recorded but no time was entered.

The above findings were confirmed by staff #22.