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Based on interview, record review and review of the facility outpatient examples of quality measures and process improvement data, the hospital failed to ensure that the Quality Assessment and Performance Improvement program (QA/PI) provided oversight of the pediatric outpatient endoscopy surgical department, specifically concerning a failed process to document return patient visits and invasive line/tubes/device removals by nursing staff.

Findings:

Cross Reference A1081. The hospital failed to have a process to provide documentation in the clinical record of a nurse who performed a procedure on a patient which consisted of a removal of an invasive probe/apparatus, and failed to document the condition of the patient after the removal, which was not in accordance with acceptable standards of practice.

Review of the hospital pediatric endoscopy outpatient service QA/PI, posted in the unit, reflected two current measures of collection, evaluation, and analysis to (1) improve quality of bowel preps prior to surgical procedure and (2) to decrease the number of canceled surgical cases.

In an interview with the Nursing Operations Manager of the Endoscopies Surgical Outpatient Center, and the Risk Manager on 3/20/18 at 11:40 AM, they related they meet monthly and as needed to discuss any incident tracking and trending, and there are not many incident reports generated from the unit. They related there were no current QA/PI projects that audited clinical record content specifically to document patient return visits for removal/discontinuation of outpatient surgical lines/probes/devices, by nursing staff.

In an interview with the Director of Risk Management on 3/20/19 at 4:20 PM, she confirmed there was no QAPI project to monitor documentation of line/device removal on patient return visits by the Outpatient Department, as it had just been discovered that it was not previously documented by nursing staff. She related it is an expectation of the hospital to document any performed patient procedure or service as is done on the inpatient side.

Based on interview and record review, the facility failed to have a process for documentation in a clinical Outpatient record regarding a return visit of a pediatric outpatient for a 24 hour visit and removal of an invasive pH electrode for 1 of 3 sampled patients (#1).

Findings:

Cross Refer A1081. Record review revealed patient #1, a 9 year old underwent an outpatient procedure at the hospital for an Upper Gastrointestinal Endoscopy Impedance pH monitoring study under general anesthesia. Documentation revealed the patient underwent the procedure on 1/30/18 under general anesthesia. The patient's surgical report under "Recommendation" read, "Discharge patient to home (with parent). Await pathology results. pH Impedance monitoring for 24 hours - return pH machine to 8th floor Endoscopy suite after 24 hours...."

Patient #1's record did not contain any documentation that the patient returned to the outpatient department as instructed to have the pH impedance electrode catheter returned and/or removed. A copy of patient #1's "Ambulatory pH Impedance Study, dated 1/30/19, revealed a handwritten note that read, "Probe Removed on 1/31/18. Procedure finished 13:30 [1:30 PM] D/C'd [discharged] 14:30 [2:30 PM]." There was no nurse's signature, identification, and no documentation regarding the condition of the patient upon discharge.

The hospital failed to have a process for the Outpatient Department to provide documentation in the clinical record of a nurse who performed a procedure on a patient which consisted of the removal of an invasive probe and apparatus, and failed to document the condition of the patient after the removal of the equipment. This was not in accordance with acceptable standards of practice.

Basesd on interview and record review, the facility failed to document in the clinical record a return visit of a pediatric outpatient for a 24 hour check and removal of an invasive pH electrode for 2 of 3 sampled patients (#1 & 2).

Findings:

1. In an interview with the Director of the Risk Management department at 1:45 PM on 3/18/19, she revealed all procedures whether performed inpatient or outpatient are to be documented the same way, because outpatient services is a department of the hospital. She related the documentation must reflect what is done. She related the billing and registration is the only difference, and surgical schedules documents whether it is an inpatient or an outpatient surgical case.

Patient #1 was a 9 year old referred to the Outpatient Department for an Upper Gastrointestinal Endoscopy Impedance pH monitoring study. The patient underwent the procedure on 1/30/18 under general anesthesia. The procedure findings read, "Upon completion of the endoscopy, an MMS (Medical Measurement System) impedance catheter was placed via the nares with the pH electrode positioned 5 centimeters above the GE (Gastroespohageal) Junction, and taped in place." The Impression read, "Normal esophagus, Biopsied, Normal examined duodenum, Biopsied. Gastritis, Biopsied. Old GT (gastrostomy tube) replaced with new - MIC KEY 14 french 2.3 centimeters, Fundoplication 180 degree wrap noted." The Recommendation read, "Discharge patient to home (with parent). Await pathology results. - pH Impedance monitoring for 24 hours - return pH machine to 8th floor Endoscopy suite after 24 hours. Return to GI clinic in 2 weeks."

Patient #1's record did not contain any documentation that the patient returned to the Outpatient Department as instructed on 1/31/19 to have the pH impedance electrode catheter removed. There was no documentation identified that the patient had returned or had the catheter or equipment removed or returned on 1/31/19.

2. Patient #2's record revealed a 3 year old who underwent an upper Gastrointestinal Endoscopy under general anesthesia, and esophageal pH and impedance monitoring probe catheter palcement at 20 centimeters from the left naris on 1/29/18. The patient was admitted for observation. An electronic entry entitled "Discontinue Note-Lines/Drains/Tubes/Devices", dated 1/30/18 at 12:43 PM, read, "Line/Drain/Tube Discontinuation: Device 1; 01/29/2018; 18:17 ; Left; Nare; pH probe. Discontinue Date/Time: 30-Jan-2018 12:43. Removed by: Endo, RN. The electronic signature of the nurse was recognized (signed 30-Jan-2018 12:43).

In an interview with the Risk Manager and Director of Risk Management on 3/20/19 at 1:35 PM, they said documentation could not be found if patient #2 returned for the removal of the catheter and/or returned of the equipment on 1/30/19.

On 3/20/18 at 4:25 PM, the Director of Risk Management stated she had found, after investigating the issue and looking for the note, that the Outpatient Department had not previously documented removal of devices or tubes, etc. when the nurse removed them as an outpatient. She related there has been no process that the nurse documented tube/catheter/device removal, when a patient returns to the Outpatient Endoscopy Department. She related there was no documentation that patient #1 returned to the unit on 1/30/19, and had the device removed. She confirmed that there was no RN assessment documented in the clinical record after the tube was removed. She related the hospital had no clinical record on patient #2 after the discharge of 1/30/18. She provided a copy of patient #1's "Ambulatory pH Impedance Study", dated 1/30/19. The report showed a handwritten note that read, "Probe Removed on 1/31/18. Procedure finished 13:30 (1:30 PM) D/C'd- 14:30 [2:30 PM]." There was no nurse signature, identification, or initials, and no documentation regarding the condition of the patient.

The hospital failed to have a process to provide documentation in the clinical record of a nurse who performed a procedure on a patient which consisted of a removal of an invasive probe/apparatus, and failed to document the condition of the patient after the removal of the equipment. This was not in accordance with acceptable standards of practice.