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 2 of 6 sampled patients, Patients ID #'s 1 and 4.

Findings are as follows:
1. The hospital failed to ensure that the policy for "ISBAR [is one of several frameworks for communication between healthcare personnel in relation to patient situations] Ticket-To-Ride" was followed for Patient ID #'s 1 and #4.
2. The hospital failed to ensure that the policy for "Patient Identification" was followed for Patient ID #1.
3. The hospital failed to ensure that the policy for "Informed Consent" was followed for Patient ID #1.
4. The hospital failed to ensure that the policy for "Universal Protocol for Invasive Procedures Performed Outside of the Operating Room, Verification of the Patient's Identity, Procedure, and Site/Side" was followed for Patient ID #1.

(refer to A-144)


32374

Based on record review and staff interviews, it has been determined that the hospital failed to ensure care in a safe setting, based on failure to follow hospital policies related to "ISBAR Ticket-To-Ride (ISBAR- is one of several frameworks for communication between healthcare personnel in relation to patient situations), Patient Identification, Informed Consent, and Universal Protocol for Invasive Procedures.." for 2 of 6 sample patient's, ID #s 1 and 4.

Findings are as follows:

1. The hospital's policy for "ISBAR Ticket-To-Ride" effective date February 4, 2019 states in part,
"I. Purpose: The purpose of this policy is to ensure safe standardized handoff communication with any transition of care. This is for all interdepartmental patient transfers through the facility including all tests, treatments, and procedures...
II. Scope: This policy applies to all Inpatient Nursing Units, Interventional Radiology [IR] and...
III. Policy: It is the policy of the Kent Hospital that any patient traveling for a test, treatment and or procedure must be accompanied by a completed ticket to ride....
V. Procedure: Once the patient has an order for a test, treatment and or procedure, the ticket to ride process will begin....
A, Sending Department: RN [registered Nurse] to complete Sections I-A... The RN will confirm correct patient and correct procedure in the while filling out the ticket to ride....

B. Receiving Department: Complete Section R....
The tech/RN accepting the patient will confirm and verify patient identification (name, DOB, per Patient Identification Policy,...The ticket to ride will be reviewed by the receiving clinician (Tech/RN) to determine the patients transfer abilities,... and additional pertinent clinical information to keep the patient safe..."

2. The hospital's policy for "Patient Identification" effective date October 31, 2019 states in part...
...V. Procedure: ...
III. Compare the name and date of birth against any .... orders, prior to any test, treatment, procedure..."

3. The hospital's policy for "Informed Consent" effective date August 15, 2019 states in part,
"...The process of informed consent is the physician's responsibility... It is the physician's responsibility to fill out and execute properly the consent form and ...

RESPONSIBILITY
A. Physician...
2. The physician is responsible for completely filling out the appropriate consent form (s)...
B. NURSING...
1). Staff Nurse are responsible for checking consent form completeness...
2. The procedure nurse is responsible for conducting a final check of consent forms prior to..."

4. The hospital's policy for "Universal Protocol for Invasive Procedures Performed Outside of the Operating Room: Verification of the Patient's Identity, Procedure, and Site/Side" effective date October 1, 2019 states in part,

...V. PROCEDURE: ...
STEP 1: VERIFICATION
(1) The Proceduralist [A physician, usually a specialist or subspecialist who performs diagnostic or therapeutic procedures] must participate with the Verifier along with the patient or patient representative..., to confirm the patient's identity..., intended procedure...
(2). Primary source documentation is based on the procedure and specialty area and include a signed informed consent and: History and Physical examination or...
that includes the diagnosis and indication for the purpose, and/or
-booking form, requisition, order for other procedure or...

STEP 3: TIME OUT...
The Proceduralist states the patient name, intended procedure, and the Verifier authenticates the information against the source documentation..."

1. Review of Patient ID #1's clinical record revealed the patient presented to the hospital in April of 2021 with altered mental status and a fever of unknown origin.

The "History and Physical" final report dated 4/28/2021 indicates "Due to mentation and fever LP [lumbar puncture] was attempted multiple times without success."

Further record review revealed a physician's order dated 4/29/2021 for an "ISBAR [is one of several frameworks for communication between healthcare personnel in relation to patient situations] Fluora Needle Placement [IR Lumbar Puncture]".

Record review revealed Patient ID #1 was brought to the IR Department on 4/29/2021 at 9:11 AM and received a Peripherally Inserted Central Catheter (PICC line) in his/her left arm, instead of the intended order for a Lumbar Puncture.

Record review revealed the hospital failed to ensure that their policies were followed as evidenced by:

The "Ticket to Ride" sheet dated 4/29/2021 at 9:03 AM was incomplete. The sheet indicates under Procedure: "Specials", instead of the specific procedure (Lumbar puncture) that is be performed on the patient.

During the interview with the IR nurse (Staff B) on 5/12/2021 at 3:05 PM, he revealed that although the "ticket to ride" was incomplete regarding the actual procedure to be performed, he did not verify the order in the electronic medical record system.

During a phone interview, in the presence of the Director of Risk Management, on 5/13/2021 at 12:30 PM, Staff E, the unit nurse who sent the patient to the IR department, revealed she had spoken to the IR receiving nurse on the phone regarding the transfer. The IR nurse asked the transferring nurse if the patient was ready to be sent for the "PICC line" and the transferring nurse, aware the patient was being sent for a lumbar puncture, failed to correct the IR nurse regarding the correct procedure.

Once the patient arrived in the IR department, the accepting nurse failed to verify the physicians order for the treatment procedure, per the ID and Universal Protocol Policies.

After the patient was accepted to the procedure holding area, the Proceduralist failed to complete the consent form per the hospital informed consent policy.

During an interview on 5/12/2021 at 3:05 PM the IR nurse, staff B stated he did not verify the patient ID with the physician's order per the hospital policy. Additionally, he stated he completed the consent form and had the physician sign the form.

2. Record review for Patient #4 revealed a physician's order dated 5/3/2021 at 12:15 PM for "IR [Interventional Radiation] US Guidance for Vascular Access". The record also indicates Patient ID #4 has a physician's order dated 5/3/2021 at 12:53 PM for a Peripherally Inserted Central Catheter "PICC..."

The hospital's "Ticket to Ride" sheet dated 5/3/2021 indicates under Procedure: "Specials", not indicating the exact procedure to be completed.

During an interview on 5/13/2021 at approximately 1:00 PM the Clinical Effectiveness Manager, she stated the exact procedures to be performed should be written on the ticket to ride form.

During an interview on 5/13/2021 with the Director of Risk Management at approximately 2:20 PM, she acknowledged the hospital employees failed to follow the above hospital policies.





32374

Based on record review, staff interview and review of the Bylaws of the Medical Staff, Rules and Regulations of the Medical Staff (last approved by Credentials Committee on December, 2020), it has been determined that the hospital's medical staff failed to enforce the rules pertaining to the Bylaws for 1 of 6 sample patients in the Interventional Radiology (IR) Department, Patient ID #1.

Findings are as follows:

A. The Medical Staff Rules and Regulations, ARTICLE IV, MEDIAL ORDERS
(1) Whenever possible, orders will be entered directly into the EMR [electronic medical record] by the ordering practitioner ....
(3) Orders for test and therapies will be accepted only from:
(a) members of the medical staff; and
(b) advanced practice clinicians who are granted clinical privileges by the Hospital, to the extent permitted by their licenses and clinical privileges...
(6) No order will be discontinued without the knowledge of the attending physician, unless the circumstances casing the discontinuation constitute an emergency...."

Review of Patient ID #1's clinical record revealed the patient presented to the hospital in April of 2021 with altered mental status and a fever unknown origin.

The "History and Physical" final report dated 4/28/2021 indicates "Due to mentation and fever, an LP [lumbar puncture] was attempted multiple times without success."

Record review revealed a physician's order dated 4/29/2021 for a "IR Fluora Needle Placement (IR Lumbar Puncture)".

Further record review revealed Patient ID #1 was brought to the IR Department on 4/29/2021 at 9:11 AM for the above order to be completed. The patient received a Peripherally Inserted Central Catheter (PICC line) in his/her left arm, instead of the intended order for a Lumbar Puncture.

Further review of the "Cerner Imaging: Order Viewer" (electronic medical record) revealed a physician's order for "IR Fluora Needle Placement" dated 4/29/2021 at 9:23 AM which was noted as "canceled". At 9:53 AM, a new order was placed for "IR... PICC".

During surveyor interview with the Director of Radiology Department on 5/12/2021 at 11:30 AM, she revealed the technician changed the "charge" (billing code), which unknowingly changed the physicians order in the computer system.

During surveyor interview in presence of the Clinical Effectiveness Manager on 5/12/2021 at 3:05 PM, an IR nurse (Staff B) stated he thought Patient ID #1 had an order for a PICC line placement; therefore, he told the IR technician (Staff C) to change the "charge" (billing code) to identify the PICC procedure, unaware that would change the physicians order.

During an interview, in the presence of the Director of Risk Management, on 5/13/2021 at 10:40 AM, Staff C stated she was told by the IR nurse (Staff B) to replace the charge to reflect the procedure as a PICC line. Additionally, Staff C further stated that this was the departmental practice in the IR department which has since been stopped following the identification of this incident.

During a surveyor interview, in the presence of the Director of Risk Management, on 5/13/2021 at 1:10 PM, the provider, staff I, stated she and the patient's attending physician did not order the PICC Line. She further stated they did not discontinue the Lumbar Puncture order.





32374

Based on record review and staff interview, it has been determined that the hospital failed to supervise and evaluate the nursing care for each patient ensuring that nursing care was provided in accordance with the hospital's policies and procedures related to patient identification, and inaccurate documentation on the ticket to ride for 1 of 6 patients (Patient ID #1).

Findings are as follows:

1. The hospital's policy for "ISBAR [is one of several frameworks for communication between healthcare personnel in relation to patient situations] Ticket-To-Ride" effective date February 4, 2019 states in part,
"I. Purpose: The purpose of this policy is to ensure safe standardized handoff communication with any transition of care. This is for all interdepartmental patient transfers through the facility including all tests, treatments, and procedures...
II. Scope: This policy applies to all Inpatient Nursing Units, Interventional Radiology [IR] and...
III. Policy: It is the policy of the Kent Hospital that any patient traveling for a test, treatment and or procedure must be accompanied by a completed ticket to ride....
V. Procedure: Once the patient has an order for a test, treatment and or procedure, the ticket to ride process will begin....
A, Sending Department: RN [registered Nurse] to complete Sections I-A... The RN will confirm correct patient and correct, procedure in the while filling out the ticket to ride....
B. Receiving Department: Complete Section R....
The tech/RN accepting the patient will confirm and verify patient identification (name, DOB, per Patient Identification Policy,...The ticket to ride will be reviewed by the receiving clinician (Tech/RN) to determine the patients transfer abilities,... and additional pertinent clinical information to keep the patient safe..."

2. The hospital's policy for "Patient Identification" effective date October 31, 2019 states in part...
...V. Procedure: ...
III. Compare the name and date of birth against any .... orders, prior to any test, treatment, procedure..."

RESPONSIBILITY
B. NURSING...
1). Staff Nurse's are responsible for checking consent form completeness...
2. The procedure nurse is responsible for conducting a final check of consent forms prior to..."

1. Review of Patient ID #1's clinical record revealed the patient presented to the hospital in April of 2021 with altered mental status and fever unknown origin.

Record review revealed a physician's order dated 4/29/2021 for an "IR [Interventional radiology] Fluora Needle Placement (IR Lumbar Puncture)". Patient ID #1 was brought to the IR Department on 4/29/2021 at 9:11 AM and received a Peripherally Inserted Central Catheter (PICC line) in his/her left arm, instead of the intended order for a Lumbar Puncture.

The hospital failed to ensure that their policies were followed as evidenced by:

The "Ticket to Ride" sheet dated 4/29/2021 at 9:03 AM was incomplete. The sheet indicates under Procedure: "Specials", instead of the specific procedure (Lumbar puncture) that is be performed on the patient.

During the interview with the IR nurse (Staff B) on 5/12/2021 at 3:05 PM, he revealed that although the "ticket to ride" is incomplete regarding the actual procedure to be performed, he did not verify the order in the electronic medical record system, per hospital policy.

During a phone interview, in the presence of the Director of Risk Management, on 5/13/2021, at 12:30 PM, staff E, the unit nurse who sent the patient to the IR department revealed she had spoken to the IR receiving nurse on the phone regarding the transfer. The IR nurse asked the transferring nurse if the patient was ready to be sent for the "PICC line" and the transferring nurse, aware the patient was being sent for a lumbar puncture, failed to correct the IR nurse regarding the correct procedure.

Once the patient arrived in the IR department, the accepting nurse failed to verify the physicians order for the treatment procedure, per the ID and Universal Protocol Policies.

During an interview on 5/12/2021 at 3:05 PM with the IR nurse, staff B, he stated he did not verify the patient ID with the physician's order per the hospital policy. Additionally, he stated he completed the consent form, not the proceduralist, and had the physician sign the form, which is not following the hospital's informed consent policy.

During an interview with the Director of Risk Management on 5/12/2021 at spproximately 2:20 PM, she acknowledged the hospital nurse's failed to follow the above hospital policies.

Based on record review and staff interview the hospital failed to properly execute the informed consent form, for 1 of 2 patients reviewed, Patient ID# 1.

Findings are as follows:

The hospital's policy for "Informed Consent" effective date August 15, 2019 states in part,
"...The process of informed consent is the physician's responsibility... It is the physician's responsibility to fill out and execute properly the consent form and ...

RESPONSIBILITY
A. Physician...
2. The physician is responsible for completely filling out the appropriate consent form (s)...
B. NURSING...
1). Staff Nurse are responsible for checking consent form completeness...
2. The procedure nurse is responsible for conducting a final check of consent forms..."

Review of Patient ID #1's clinical record revealed the patient presented to the hospital in April of 2021 with altered mental status and a fever of unknown origin.

Further record review revealed a physician's order dated 4/29/2021 for an "IR [Interventional radiology] Fluora Needle Placement [IR Lumbar Puncture]".

Patient ID# 1 was transferred to the procedure holding area where nurse B completed the consent form.

During an interview on 5/12/2021 at 3:05 PM, the IR nurse, staff B, stated he completed the consent form, and had the physician sign the form.

During an interview with the Director of Risk Management on 5/12/2021 at approximately 2:20 PM, she acknowledged that the hospital policy for informed consent was not followed.