HospitalInspections.org

The facility's governing Body failed to meet the Conditions of Participation when,

- It failed to ensure the Medical Staff was accountable for providing quality care; the facility's Medical staff was making decisions concerning the medical treatment and care of a pediatric patient without critical information and did not intercede in the care of Patient #3. (A0049)

- A critically ill, 13-month-old-infant (Patient #3) was not being monitored and did not receive emergency treatments as ordered. (A0386)

- The facility failed to complete its investigation into Patient #3's death within 30 days, as the Medical Staff Bylaws required. (A0049)


These failures place patients presenting to the ED at risk for delayed care, worsening conditions, and possible death.

Based on interview and record review, the Governing Body failed to ensure the Medical Staff bylaws, rules, and regulations were implemented and enforced; the Medical Staff failed to be accountable for the quality of care when the facility's Medical staff was making decisions concerning the medical treatment and care of a pediatric patient without critical information, and did not intercede in the care, placing patients at risk for worsening symptoms and death.

a.) Patient #3, a critically ill infant, was being cared for by Staff #4, DO and Staff #18, Medical Resident. The laboratory and medication orders were not completed; neither of the physicians made inquiries into the delay. The patient needed an IO [Intraosseous catheter, access that allows short-term delivery of fluids], the physicians did not insert one until the patient coded.

b.) The Staff #18, Medical Resident ordered Ativan be given without requesting a blood pressure be taken. Patient #3 was at risk for decompensated hypotension as evidenced by the elevated heart rate and respirations. Ativan can decrease respirations and heart rate placing the patient at risk for cardiac arrest and death.

c.) The facility failed to complete its investigation into Patient #3's death within 30 days, as the Medical Staff Bylaws required, delaying process improvements to prevent repeat occupancies.


Findings include:

Review of Patient #3's medical records reflected Staff #18, was in the Emergency Medicine Residency program at a level of PGY-3.

Review of the facility provided Residency Job Description (dated 11/2020) reflected, "PGY 3 residents are expected 'to run the room' and act as junior attendings. They should know all the patients in the ED, facilitate their management and disposition, and supervise and teach junior residents, medical students, and all other healthcare providers. They will also be responsible for administrative ED tasks while on duty. All residents are required to present their patients to faculty. Faculty must be present for procedures, resuscitations and management of critically ill patient or potentially unstable patients. Faculty must have been involved in the decision for consultation prior to the consultation taking place ...
F. ORDERS
Orders are written with faculty physical presence in the ED and under the faculty members' authority ..."

Review of Patient #3's ED provider notes dated 11/29/21 at 10:07 pm, by Staff #18, Medical Resident and 12/5/21 at 1:37 pm, by Staff #4, DO reflected, "13 mo (month) neurologically devastated male with complex PMH (previous medical history) reviewed in chart, who is presenting in severe respiratory distress after multiple episodes of coffee ground emesis. RT (Respiratory therapist) and Radiology tech immediately called to bedside. labs, imaging, VBG (blood gas), and NS (normal saline) bolus ordered. High concern on DDX (diagnostic diagnosis) for aspiration PNA, viral syndrome, sepsis, bacteremia, esophageal tear, electrolyte derangement and trauma. pending lab results ..."

Review of Patient #3's laboratory orders dated 11/29/21 at 9:42 pm, reflected no blood had been sent to the laboratory. The physicians did not question the pending labs.

During an interview, on the morning of 2/14/21, in the administrative office, Staff #3, Quality Director stated, "They made eight attempts to place an IV; it should be 2 sticks and place an IO. The nurses are taught how to place the IOs in PALS (Pediatric Advanced Life Support), but this is a teaching hospital, so the Physician or the Resident will insert the IO."

Review of Patient #3's medical records dated 11/30/21 reflected, at 12:37 am, Staff #4, DO documented awareness that Patient #3 did not have IV access; the physician would have been aware the patient had not been given the ordered IV fluids and IV antibiotic. The physician did not question the two-hour delay in treatment and did not insert an IO to facilitate the treatments.

Review of Patient #3's Staff DO #4's addendum note dated 12/5/21 at 1:37 pm reflected, "Patient assigned a room at 2356 ...I was called to his bedside at approximately 0037, ...Provided RN with verbal order for Ativan. informed by nursing Patient #3 did not have lV access. Ativan order modified ...unaware that the patient remained in the ED, called by staff to room at approximately 0240 ...Code initiated."


c.) Review of the facility provided, current, Medical Staff By laws, reflected, "6.1.5.9 The investigation shall be concluded within thirty (30) days unless there are extenuating circumstances, which are documented in writing."

Review of the facility provided FINAL REVIEW OF (Patient #3's) CASE BY ED Medical Director (dated 1/19/22) reflected, "The care provided by the attending physician in this case did not deviate from the standard of care."

During an interview, on the afternoon of 2/15/22, in the administrative conference room, when asked why the Physicians did not question the care that was being delivered, Staff #2, VP Quality stated, "The Medical Review Committee is making recommendations for the first review; they will make the determine for an outside review ...All the mortalities are reviewed, any standard of care is reviewed." Staff #2, VP Quality confirmed the facility had not completed the investigation.

The facility was unable to provide documented extenuating circumstances.

The facility's Nursing Services failed to meet the Conditions of Participation when

- A critically ill, 13-month-old-infant (Patient #3) was not being monitored and did not receive emergency treatments as ordered. (A0386)

These failures place patients presenting to the ED at risk for delayed care, worsening condition, and possible death.

Based on record review and interview, the facility failed to provide an organized nursing services and ensure standards of care were delivered when the ED staff failed to do the following for Patient #3:

a.) secure an emergency IV (intravenous) access,
b.) dispense the physician ordered medications,
c.) obtain a blood pressure during the stay, and monitor the patient's vital signs following treatments to determine treatment effectiveness,
d.) initiate the Septic Shock Triage Trigger Tool,
e.) expedite Patient #3's transfer to a higher level of care,
f.) prevent the interference of family during the treatment of the patient #3.

These failures in treatment, possibly contributed to the death of a 13-month-old infant and places all patients presenting to the ED at risk for delayed care, worsening condition, and possible death.

Findings include:

Review of Staff #5's Job Description, Patient #3's RN, (dated and signed on 10/14/20) reflected, "Responsible for the delivery of patient care through the nursing process of assessment, diagnosing, planning, implementation, and evaluation. Responsible for directing and coordinating all nursing care for patients based on established clinical nursing practice standards. Collaborates with other professional disciplines to ensure effective and efficient patient care delivery and the achievement of desired patient outcomes. Supports the organization's vision and
mission. Utilizes knowledge of patient's age and cultural diversity in the provision of patient care. Contributes to the provision of quality nursing care through performance improvement techniques that demonstrate positive outcomes in patient care."

a.) Review of the facility provided Lippincott Procedures - Intraosseous catheter insertion, pediatric (Revised: August 20, 2021) reflected, "When achieving rapid venous access is difficult or impossible, intraosseous (IO) access allows short-term delivery of fluids, medications, or blood into the central circulation. (See Understanding intraosseous infusion.) IO access may be appropriate in emergencies or urgent situations in which reliable venous access can't be achieved quickly (such as in children with shock, sepsis, severe dehydration, life-threatening or status epilepticus, extensive burns, major traumatic injuries, or cardiopulmonary arrest or when care would be compromised by a delay in vascular access) or in children for whom venous access is medically necessary and can't be achieved by other means despite multiple attempts."

Review of the facility provided case review reflected, " ...x 2 PIV (two peripheral intravenous) attempts - unsuccessful
Transport RN contacted - additional x6 attempts for PIV - unsuccessful."

On the morning of 2/14/21, in the administrative office, Staff #3, Quality Director stated, "They made eight attempts to place an IV; it should be 2 sticks and place an IO. The nurses are taught how to place the IOs in PALS (Pediatric Advanced Life Support), but this is a teaching hospital, so the Physician or the Residents will insert the IO."


b.) Review of Patient #3's physician orders dated 11/29/21 reflected,
"10:49 pm, Cipro (Antibiotic) 250 mg (milligrams) IVP (Intravenous piggyback infusion) q (every)12 hours.
11:04 pm, Sodium Chloride 0.9% NS (normal saline) 319 mL (milliliters) IVPB NOW."
The medication and fluids were not administered.

On 11/29/21 at 10:35 pm, Patient #3 was administered Tylenol 208mg elixir, there was no recorded response to the medication's effectiveness.
On 11/30/21 at 12:30 am, Patient #3 was administered Ibuprofen 150mg suspension, there was no recorded response to the medication's effectiveness.
On 11/30/21 at 1:00 am, Lorazepam (Ativan, side effects include slowed or trouble breathing and death) 1 mg IM (intramuscular) was injected, there was no recorded response to the medication.
The last recorded vital sign was at 1:30 am., the Peripheral pulse rate was H 160. No temperature or blood pressure was recorded. There were no recorded vital signs from 1:31 am to 2:40 am., when Patient #3 required cardiac resuscitation.


c.) Review of the PALS (Pediatric Advanced Life Support) Guidelines (dated 2021) reflected for a 6-12-month-old infant's normal vital signs were:
Heart Rate, 90-160 bpm [beats per minute]
Blood pressure: SBP 80-100/ DBP: 55-65 [systolice blood pressure/diastolic blood pressure]
Respirations: 22-38 breaths per minute
Normal Pediatric temperature taken by tympanic thermometer is 35.8°C [degrees Celsius] to 38°C (96.4°F [degrees Fahrenheit] to 100.4°F).

Review of Patient #3's medical records reflected the following:
On 11/29/21 at 9:40 pm, Tympanic temperature of 105.6°F, Peripheral pulse rate of H 235, respiration rate H 38. No blood pressure was recorded.

On 11/29/21 at 9:42 pm the Respiratory assessment reflected, HR= 223 beats Per minute, RR = 75 breaths Per minute.

On 11/30/21 at 12:15 am, Tympanic temperature of 104.4°F, Peripheral pulse rate H 190, respiration rate not documented. No blood pressure was recorded.

On 11/30/21 at 1:30 am, the Peripheral pulse rate was H 160. No temperature or blood pressure was recorded. There were no recorded vital signs from 1:31 am to 2:40 am.

During an interview on 2/14/21 at 2:00 pm, in the facility's emergency room, when asked when a patient with a temperature of 105°F should have been checked, Staff # 7, ER Clinical Coordinator stated, "every 15-30 minutes, it should be a full set of vital signs."

During an interview on 2/15/22 at 1:00 pm, in the conference room, Staff #3, Quality Director stated, "I interviewed Staff #5, I asked him if he had taken a blood pressure, Staff #5 said, 'I tried on all four limbs', I asked Staff #5 if he took it manually and he said 'No' ..." Staff #3 confirmed the blood pressure monitor not registering a blood pressure, could indicate the blood pressure is very low and would have required the blood pressure be taken manually and stated, "We had a direct communication with Staff #5, he acknowledged he didn't do what he needed to do to manage his patient. He was taking care of patients in Fast Track. He thought he was helping."

During an interview on 2/16/22 at 11:00 am, in the conference room, Staff #17, ER Director stated, "The temperature should have been taken rectally; it should be a core temperature. The tympanic temperature can be lower than the actual temperature."

Review of Patient #3's medical records (dated 11/29/21) reflected the level of care needed on admission was an ESI level 2 (Emergency Severity Index, a tool to triage emergency patients; level 2 patients are considered an emergency and potentially life-threatening).

Review of the facility provided policy EMERGENCY DEPARTMENT ASSESSMENT RECORD (dated 5/2020) reflected, " ... D. Vital signs will be documented based on the ESI Level and as needed in the emergency medical record (EMR).
1. Level 1- Vital signs will be obtained and documented every 5-15 minutes
until stable. Continuous cardiopulmonary monitoring will be utilized on the
patient.
2. ESI Level 2- Once the patient has been placed in a treatment area vital sign will
be taken and documented every 15-30 minutes times four and every hour thereafter to include oxygen saturation as needed ...
5. Temperatures will be taken and documented in the EMR every hour if febrile
Then every 4 hours if non-febrile, and at discharge if warranted ...
8. All abnormal findings will be reported to the physician ..."

d.) Review of Patient #3's ED provider notes dated 11/29/21 at 10:07 pm, by Staff #18, Medical Resident and on 12/5/21at 1:37 pm , by Staff #4, DO reflected, " ...High concern on DDX (diagnostic diagnosis) for aspiration PNA, viral syndrome, sepsis, bacteremia, esophageal tear, electrolyte derangement and trauma ..."

Review of the facility provided, Pediatric Septic Shock Triage Trigger Tool (undated) reflected, "Findings compatible with septic shock for a 1- to 2-year-old infant included: "temperature <36 or> 38.5 degrees Celsius [< 96.8°F or > 101.3°F], heart rate >190, respirations >40 obtain a full set of vital signs a brief history and physical exam. Is the patient Hypotensive?"

On 2/15/22, in the administrative conference room, when asked if the Pediatric Sepsis Shock Triage trigger tool is being utilized and monitored for completeness Staff #13, Infection Control Nurse, stated, "That is the form used in the ER. I haven't gotten any. I don't review Sepsis in the ER." When asked if the blood pressure was needed to determine if a patient was possibly septic, Staff #13 stated, "Sepsis should have a complete set of vitals, including the blood pressure."

e.) During an interview, on the morning of 2/15/21, in the administrative conference room, Staff #3, Quality Director stated, "Patient #5, was assigned a PICU (pediatric intensive care unit) bed at 12:11 am ...The PICU Charge nurse wanted the CT be completed before transferring to PICU; a staff nurse would have had to go to the CT with the patient."

Review of Patient #3's ER Medical Director review (dated 1/19/22) reflected,
At 22:31 hrs> A.O D. (administrator on duty) contacted for bed request
At 23:50 hrs> Official bed assigned to the PICU
At 02:40 hrs> The physician was called to the room due to the patient in severe respiratory distress and actively having seizures progressing to apnea, bradycardia and pulseless arrest CPR initiated but unsuccessful return of spontaneous circulation was achieved.

During an interview on 2/16/22 at 11:00 am, in the conference room, Staff #17, ER Director stated, "The sickest kids need to go up to the PICU. We use it as a guideline, there isn't anything set in place."

During an interview on 2/16/22 at 11:00 am, in the conference room, Staff #15, PICU Director stated, "The PICU staff are unaware of things going on in the ER, we started floating nurses to the ER to understand. The charge nurse should not have the sickest patient."

f.) Review of Patient #3's Physician's note dated 12/5/21 at 1:37 pm, reflected, "I was called to his bedside at approximately 0037, as guardian requesting to speak with me. When arrived at room noted that patient's oxygen mask had been removed. Guardian stated he removed it on his own initiative as the patient was 'too hot.' He was asked to not interfere with care/interventions and if had concerns to contact the staff."

Review of Patient #3's ED Medical Director review dated 1/19/22 reflected, "We as physicians, nurses and any other medical personnel represent the best interests of the patient. Anyone interfering in the medical care of a child, especially a critically-ill patient, should be removed from the area to protect the patient and provide the appropriate medical care to the best of our abilities."

The nursing notes did not reflect interventions to prevent the family from removing needed treatments or that the nurse had made attempts to ensure Patient #3 remained on the ordered oxygen.