HospitalInspections.org

Based on a review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that one (P#2) out of five sampled patients received safe care by ensuring a laboratory order/blood draw was stopped after several normal values as per the facility's policy.

Findings:

A review of Patient (P) #2 medical record revealed that P#2 was admitted to the facility on 11/5/23 at 1:22 p.m. via the Emergency Department (ED) with the diagnosis of Sepsis (a life-threatening complication of an infection).

A review of the order comments under the Activities and Interventions documentation recorded on 11/5/23 at 1:06 p.m. revealed documentation of: Sepsis ED (emergency department); Bedside POC (Plan of care); Lactate; Repeat POC lactate in two hours or before patient leaves the ED. Up to two times (no more than two repeats).

A review of the History and Physical (H&P) notes by MD HH on 11/5/23 at 2:05 p.m. revealed that P#2 had an elevated lactic acid (a chemical the body produces when the body cells break down carbohydrates for energy) level on admission with a value of 3.8. Normal lactic range as per documentation was 0.50 - 2.20.

A review of the medical record revealed that P#2's Assessment/Plan included:
- Repeat lactic every four hours (q4) until cleared? difficult to clear in setting of chronic kidney disease.
Documentation failed to reveal a stop order for the repeat lactic acid q4.

A review of MD FF's progress notes on 11/6/23 at 9:27 a.m. revealed documentation that P#2's lactic acid was initially elevated, but subsequently normal. Laboratory values on 11/6/23 at 6:06 a.m. was 1.07. Documentation failed to reveal a discontinuation of the lactic acid checks/blood draws.

An electronic review of P#2's medical record was done at the facility on 1/2/24 at 3:00 p.m., which revealed the following times at which the lactic acid check was done with the values documented:
On 11/5/23, at 3:01 p.m., the lactic acid level was 1.97. The normal range indicated on the laboratory test values was (0.50 - 2.20).
On 11/5/23 at 5:59 p.m., the level was 2.08.
On 11/5/23 at 10:31 p.m., the level was 1.78.
On 11/6/23, at 2:13 a.m., the level was 1.60.
On 11/6/23, at 6:06 a.m., the level was 1.07.
On 11/6/23, at 9:59 a.m., the level was 1.82.
On 11/6/23, at 2:06 p.m., the level was 1.89.
On 11/6/23, at 6:13 p.m., the level was 1.26.
On 11/6/23, at 11:57 p.m., the level was 1.66.
On 11/7/23, at 2:17 a.m., the level was 1.41.
On 11/7/23, at 4:46 a.m., the level was 1.67.
The order was discontinued on 11/7/23 at 12:15 p.m.

P#2 was discharged home on 11/8/23 at 12:47 p.m. with a discharge diagnosis of Sepsis, Pre-Syncope (feeling that you are about to faint), Hypertension, Type 2 Diabetes Mellitus, Paroxysmal Atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), and Acute Kidney Injury on Chronic Kidney Disease (slow deterioration of kidney function or persistent kidney dysfunction). P#2 was documented to be discharged in a stable condition with home health.

A review of the "Lactic Acid - Architect" policy, no policy number, effective 12/11/16, last revised 9/14/23, revealed the principle and purpose was that the lactic acid assay was used for the quantitation of lactic acid in human plasma. Quality Control, a minimum of two levels of controls (normal and abnormal) were to be run every 24 hours or reagent use, with each new reagent pack and after calibration.

A review of the "Patient Rights and Responsibilities" policy, no policy number, no effective date last revised 5/2/23 revealed: A. Patients' Basic Rights: All patients at a hospital owned and/or operated by Northside shall receive information on patient rights, responsibilities, and ethics. All patients at a Hospital shall have the following responsibilities: Personal Safety. Patients are responsible for reporting perceived risks in their care and unexpected changes in their condition. Patients are responsible for asking questions when they do not understand what they have been told about their care or what they are expected to do.

A review of the "Plan for Providing Patient Care" policy, policy number 10087, effective date 9/9/2020, last reviewed 9/20/22 revealed Planning for Patient Care Services. The Board of Trustees retains the overall responsibility for the safety and quality of care, treatment and services provided at Northside.

A review of the "Sample Collect by Venipuncture" policy, Policy #24668, effective 9/4/09, last reviewed 9/26/23 revealed the purpose was to establish guidelines for the collection of blood samples by venipuncture and to minimize or eliminate the following causes of unsatisfactory blood specimens or sample collection: unacceptable amount of hemolysis, collection of specimens without adequate preparation of the patient. Policy. To perform a venipuncture with proper patient identification and in a timely manner, with minimal discomfort to the patient and with the minimal amount of blood withdrawn to satisfactorily perform testing requested.

A review of the "Sample Collection by Skin Puncture" policy, Policy #15041, effective 9/13/23, last reviewed 6/1/10 revealed standard procedures and protocols for proper specimen collection are established to prevent pre-analytical errors and protect against complications and patient mismanagement that can otherwise arise when specimens are improperly collected.

A telephone interview took place in the board room on 1/3/24 at 9:35 a.m. with Registered Nurse (RN) AA who stated that she usually followed the doctor's orders on laboratory tests/values. RN AA stated that she has never reported a normal lactic acid value to a doctor. RN AA stated that if the patient requested that the tests be stopped, then she would reach out and ask the doctor. RN AA further stated that the laboratory technicians usually took the blood samples, except it was a central line, then the Registered Nurse would take the sample.

A telephone interview took place in the board room on 1/3/24 at 9:45 a.m. with Registered Nurse (RN) BB who stated that if a patient came in with a high lactic acid value, she would inform the doctor who will put in orders that the nurses would follow through. RN BB stated that if a patient continuously had a normal lactic acid value, she would call the doctor and ask if they (the doctors) wanted to continue with the order. RN BB also stated that she had never reported a normal lactic acid value, that it was the doctor that would decide if they wanted to continue with the order or not.

An interview took place in the board room on 1/3/24 at 10:10 a.m. with Laboratory Technician (LT) CC who stated that she always followed the doctors' orders on blood draws/samples, and she would check the orders before going to see a patient. LT CC stated that she did not look at previous results/values of a patient's laboratory results because she believed if the doctor did not want the orders to continue, they would put a stop to it. LT CC stated that she called the attention of the nurse to P#2 if the lactic acid check was still needed to be done when she noticed she (LT CC) just saw him (P#2) about an hour and half ago, and also took a sample. LT CC stated that the nurse spoke to the doctor, and the doctor cancelled the order.

A telephone interview took place in the board room on 1/3/24 at 10:20 a.m. with Registered Nurse (RN) DD who stated that Lactic acid checks/blood samples were based on the doctor's orders. RN DD stated that if the Lactic acid values were normal on two or three tests, then she would personally inform the doctor if the orders were to be continued. RN DD further stated that she was not 100% sure what the hospital policy stated about Lactic acid checks/blood draws.

An interview took place in the board room on 1/3/24 at 10:35 a.m. with Medical Doctor (MD) EE who stated that he saw P#2 on day two following his (P#2) admission, and he (MD EE) discontinued the lactic acid check/blood draws because the values had been normal. MD EE stated that discontinuing the lactic acid checks/blood draws was based on the severity of the condition of the patient. MD EE also stated that because sepsis was suspected in P#2, the criteria was to monitor the serial lactate.

A telephone interview took place in the board room on 1/3/24 at 10:45 a.m. with Medical Doctor (MD) FF who stated that he saw P#2 just for one day. MD FF stated that the initial concern for P#2 was sepsis and because the lactic acid was initially high. MD FF stated that they (the doctors) accidentally left the lactic acid blood draws to continue, which was why the samples were continually checked despite the levels were within normal range. MD FF further stated that the order should have been stopped if the levels were within normal range on two or three occasions.

An interview took place in the board room on 1/3/24 at 11:00 a.m. with Registered Nurse (RN) GG who stated that she could not recall P#2. RN GG stated that if a patient's lactic acid laboratory values were within normal range and the order was still ongoing, she would notify the doctor and also confirm with the charge nurse if another laboratory test was required.

An interview took place in the board room on 1/3/24 at 11:35 a.m. with Medical Doctor (MD) HH who stated that she initially admitted P#2 in the Emergency Room (E.R.) MD HH stated that P#2 came in with concerns of lactic acid as the lactic acid was very high. MD HH stated that the check box to stop the lactic acid was not checked, which was why the order continued. MD HH stated that this was an oversight.

A telephone interview took place in the board room on 1/3/24 at 12:30 p.m. with Registered Nurse (RN) JJ who stated that P#2's family had complained about the frequent blood draws/samples, and she (RN JJ) went to look at the doctor's orders. RN JJ stated that the doctor had put in the blood draws/checks every four hours, and she (RN JJ) was only following the doctor's orders. RN JJ further stated that when P#2's family complained, she (RN JJ) informed the doctor, and the doctor cancelled the order.