HospitalInspections.org

Based on facility policy, medical record review, and interviews, the governing body (after receiving a complaint) failed to inform the Interventional Radiology physician (who performed an invasive procedure involving Patient Identifier (PI) #1 on 5/25/2012), the Medical Hospitalist (who provided inpatient care to PI #1 post radiology procedure), and the surgeon (consulted at request of family and who did not see PI #1 after consult requested) about the complaint, or the hospital's investigation of the allegations.
As a result, the doctors involved in PI #1's care were not aware of the complaint allegations, had no opportunity to implement or recommend changes to current departmental or hospital procedures; And were not aware of the pending medical staff committee's review of the complaint allegations at the time of this survey.
This deficient practice affected 1 of 10 sampled patients (PI #1), and has the potential to affect other patients undergoing Interventional Radiology procedures at this hospital.

Finding Include:

Hospital Policy
The policy entitled "Dressings / Change of / Sterile & Aseptic / Surgical Wounds / Drain Wounds / Pouching a Wound" has a revised date of 7/11 and includes:
"Purpose
To remove soiled dressings and apply sterile ones. The patient's wound will dictate whether sterile technique or aseptic technique must be used ...
General Information ...
6. Many physicians prefer to change the first postoperative dressing to check the incision. Do not change the first dressing unless you have specific instructions to do so.
7. If you have no order to change a dressing and drainage comes through the dressing, reinforce the dressing with fresh sterile gauze. Monitor drainage, if reinforcement is saturated, notify physician. Request an order to change the dressing, or ask the physician to change it as soon as possible...
Document
1. Appearance of wound, amounts of drainage (if any), and condition of surrounding tissue...
3. Presence and location of drains...
7. Record the color and amount of drainage..."

The policy entitled "Jackson-Pratt / J-Vac Drains / Hemovac Drains / irrigation of / Removal of" has a review date of 6/11 and includes:
"Whom May Remove
1. A qualified Registered Nurse or Licensed Practical Nurse may (upon a physician's order) my remove a Jackson-Pratt / J-Vac / Hemovac drain.
2. Only a Qualified RN may irrigate a surgical wound drain...
Procedure
1. Check physician's orders carefully ..."

These policy/procedures do not provide directions for monitoring, emptying, reactivating, or recording output from drains, such as the Jackson Pratt (JP) drain.

Medical Record Review:
PI #1 presented to the hospital's emergency department on 4/24/2012, complaining of abdominal pain. Emergency staff documented PI #1's reported history of a liver cyst, previously aspirated at this hospital (approximately month before the 4/24/12 ED visit). Following emergency assessment and treatment PI #1 was admitted to the hospital.

PI # 1's "AUTHORIZATION FOR PERFORMANCE OF OPERATIVE INVASIVE AND OTHER PROCEDURES"(signed and dated 4/25/12 at 1305 p.m.) includes:
"I hereby authorized Dr...[name of Interventional Radiologist / EI #3] and whomsoever he/she may designate as his/her assistants(s), to perform upon...[PI #1's name] the following operative, invasive and / or procedures...CT [Computerized Tomography] guided drainage of hepatic abscess with intravenous conscious sedation..."

The 4/25/2012 "RADIOLOGY PROCEDURE FLOWSHEET" includes:
"Type of Procedure: CT guided drainage of liver abscess...
Time of Procedure: Begin 1332 p.m...
Chief complaint Liver Cyst ...Inpatient ...
Physician Initial Assessment
1. Planned Procedure CT guided drainage of liver abscess.
2. Planned procedure, risks, benefits, and alternatives to treatment explained to Patient...
I have reviewed pertinent patient history and Home Medication Record; Physical Assessment...TIME OUT [time 1330]...checked prior to the start of the procedure...
6. Relevant Images & results properly labeled & displayed as appropriate...
7. Need for...or irrigation fluids
8. Safety precautions (implants, equipment)

PI #1 is documented as having received intravenous sedation during the procedure at 1336 p.m., 1346 p.m., and 1352 p.m.
At 1405 p.m. the procedure is complete.
At 1420 p.m., the nurse documented:
"Back to room...via stretcher ...dressing @ drainage Jackson Pratt site clean, dry & intake. No bleeding or hematoma noted @ insertion site. SR [arrow up indicating side rails up] X 4...report given to..."

The PHYSICIAN'S PROCEDURE NOTES include:
"CT guided liver cyst drainage completed. Thin brown fluid removed. Sample sent for culture ...pigtail catheter left in with vacuum bulb drainage.
Complications during procedure? No ... [signed by Interventional Radiologist / Employee Identifier #3]..."
The Post Procedure Visit and Discharge Order section on this form are blank.

The 4/25/2012 AT 2:05 p.m. "POST-PERCUTANEOUS DRAINAGE ORDERS include:
1. VS...Notify radiologist if...BP [blood pressure]...pulse rate greater than...
2. Bed rest for 2 hours after the procedure [hand written not beside typed orders "in communication order up @ 1615 prn..." [as needed]
3. Assess patient's accessed site for bleeding. Palpate for tenderness and pain.
4. Resume patient's normal diet as ordered...Resume previous orders...
6. Notify the radiologist of any signs or symptoms of patient instability, including changes in respiratory status or sudden increase in pain."
Order 7, the final order, has a line drawn through the middle of words: "7. Call radiologist to check patient before discharge (2 hours observation)."

There are no orders from Interventional Radiology relative to the care, monitoring, and or removal of the JP drain inserted during PI # 1's procedure.

The General Surgeon / EI #4 [consulted after admission] documented the following note on 4/25/2012 at 8:15 a.m.:
"Progress Record...Pt ref [patient referred] for perc [percutaneous] drainage of large hepatic cyst c [with] possible sclerosing to prevent re-accumulation. If this does not work will need to be referred to liver specialist-perhaps at [name of another hospital]-as this is out of the scope of my practice. Discussed in detail c [with] family who understands. Will sign off..."

The Medical Hospitalist / EI #6 (on 4/25/2012 at 1:00 p.m.) documented"
A "Progress Note / Report" that includes:
"Studies: CT Scan ...re-accumulation of fluid in large hepatic cyst...
Interval History: c/w [consult with] her c/o [complaining] of pain...
Abd: [abdomen] RUQ [right upper quadrant] pigtail catheter in place / drain...Plan ...Liver Cyst ...drainage today...Abdominal pain...
HTN [hypertension]...continue home meds..."

The 4/26/2012 Physician's Orders (at 11:53 a.m.) written by the Medical Hospitalist / EI #6 include:
"Consult Dr...[Interventional Radiologist / EI #3 who inserted the JP drain] regarding instruction & follow-up on the drain..."
At 1157 a.m., EI #6 documented a "Progress Note / Report" that includes: "...JP drainage (+) 250 cc tolerated...pain control...+ BS [bowel sounds]...(R) side JP drain...Assessment /Plan: Liver cyst...drained &...French pigtail left in place. C/W c [consult with] Dr...[surgeon] said interventional radiology...follow up on the drain...call Dr...[Interventional Radiologist who put indrain] left msg [message] & will eventually need to go to liver specialist..."
At 1:00 p.m., EI #6 / Medical Hospitalist ordered: "Schedule appt c Dr ... [appointment with doctor at another hospital] week (or at earliest appt available) for recurrent symptomatic hepatic cyst..."
At 2:08 p.m., EI #6 documented "...called Dr...[the Interventional Radiologist who put in the JP drain] asked ...for consultation & f/u [follow-up] on catheter. Also Dr...[surgeon requested by the family]...said [PI #1] needs f/u c [follow-up with] liver specialist called...[another hospital]...set up appt [appointment]...GI surgery & discussed [PI #1] care c [with] Dr...[GI surgeon on call] ...recommended [PI #1] follow up c [with] Dr ... (transplant surgeon) ...schedule appt @ [at] the earliest available day. [PI # 1] will f/u c IR [follow up with Interventional Radiology] on 4/30/2012 for repeat CT scan & possible removal of drain..."

Interviews:
During an interview (on 6/11/2012 at 11:45 a.m.) EI #6 / Medical Hospitalist recalled PI #1 and talking with the patient's family who were concerned about not getting to talk with the Interventional Radiology Doctor / EI #3 who performed PI #1's procedure. In response to the PI #1's family members concerns, the Medical Hospitalist / EI #6 contacted the Interventional Radiologist / EI #3 to come and explain the procedure to the PI #1, and requesting instructions regarding follow-up care relative to the JP drain. The Interventional Radiologist /EI #3 sent orders to the floor but did not return to see PI #1, or talk with the family.
The Medical Hospitalist / EI #6 stated she contacted the Surgeon / EI #4 who did not visit PI #1, but recommend the patient be referred to a liver specialist (at another hospital) for follow-up surgical evaluation.
EI #6 / Medical Hospitalist stated he/she arranged follow-up appointments for the CT and the surgical referral before PI #1's discharge from this hospital on 4/27/2012.
EI #6 / Medical Hospitalist denied knowledge of the complaint received and investigated by hospital staff after PI #1's discharge or of medical staff committees' pending review.

On 4/26/2012 at 1330 p.m., the Interventional Radiologist / Employee Identifier #3 ordered:
1) "CT abdomen on 4/30/12...Follow up liver cyst drainage
2) Consult interventional radiology regarding removal of drain catheter..."
During an interview (on 6/11/12 at 8:25 a.m.) EI #3 stated that he/she did not specifically recall PI #1, but had reviewed the imaging studies prior to this interview. When asked, "When you put a drain in a patient, who writes the orders for follow-up care of those drains? EI #3 / the Internal Radiologist responded, typically it is the doctor who requested the procedure initially. When asked specifically who would be responsible for the care and removal of the Jackson Pratt (JP) drain in PI #1's liver, EI # 3 / Internal Radiologist said it would be the Medical Hospitalist / EI #6.
EI #3 denied knowing about family member concerns relative to PI #1's care, prior to this interview.

This citation is written as a result of the investigation of complaint AL00026693.

Surveyor
Barbara Little, RN