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Based on review of Hospital policy, clinical records, and family and staff interviews, it was determined, that for 1 of 10 clinical records reviewed (Pt. #1), the Hospital failed to ensure Pt. #1 and family were informed of Pt. #1's cardiac condition, in a timely manner.

Findings include:

1. Hospital policy #NMH PC 05.0001, titled, Patient Rights and Responsibilities, effective 3/2/11, required, "Appendix A... You can expect your healthcare team to explain your diagnoses, treatment and prognoses in terms you can understand..."

2. On 6/6/12 between 10:00 AM and 2:30 PM, the clinical record of Pt #1 was reviewed. Pt. #1 was a 93 year old female, admitted on 5/31/12, with a diagnosis of Displaced Fracture of Left Proximal Femur and Hip. Pt. #1 underwent surgery on 6/1/12 from 12:50 PM to 3:15 PM and was in recovery until 8:25 PM, when she was transported to Medical Intensive Care. An EKG dated 6/1/12 at 10:46 PM, included, " Possibly inferior infarct ... when compared with EKG on 5/31/12 9:25 PM... "

Cardiology consultation notes dated 6/3/12 at 11:59 PM included " ...She underwent surgical nailing on 6/1/12, and was recovering well in the SICU until she reported to the daughter that she felt some chest discomfort ... Trops [Troponin] rising on 6/2/12... EKGs with nonspecific ST/T changes and ++e/o inferior infarct ... Impression - 1. NSTEMI [Non-ST Segment Elevation Myocardial Infarction]..." The Cardiology notes dated 6/3/12, did not indicate that Pt. 1 or Pt. #1's family was informed of the Myocardial Infarction (MI).

A Palliative Care Consult note dated 6/4/12 at 7:16 PM, included, "Family expressed their understanding that patient would not want to be sustained if quality of life were to be profoundly limited..." The note included a stroke Pt. #1 sustained on 6/3/12, but did not include the MI.

3. An interview was conducted with Pt. #1 and Pt. #1's daughters (3) on 6/6/12 between 11:10 AM and 11:40 AM. Pt. #1 was sitting up in bed and spoke with slurred but understandable speech. Pt. #1 fell asleep as the Surveyor spoke with the the daughters. Pt. #1's daughters stated that E #6 (Palliative Care Staff) told them on 6/4/12, that Pt. #1 had suffered a heart attack on the OR table (6/1/12), but they had not been informed before. Pt. #1's daughters stated that later a Cardiologist also told them that Pt. #1 had a heart attack (MI), but the surgical doctors in the room at the time, explained the MI as an episode of low blood pressure.

4. On 6/7/12 at 10:50 PM, a telephone interview was conducted with Pt. #1 ' s Orthopedic Surgeon (E #4). E #4 stated that he did not know if Pt. #1 had a heart attack in the OR, Recovery, or ICU. E #4 was focused on the hip fracture "on the other side of the sheet". An Ortho Resident told E #4 that Pt. #1 had a heart attack, but E #4 stated that it was Cardiology's responsibility to inform the Family.

Based on review of Hospital policy, observational tour, family interview, review of clinical records, and staff interview, it was determined that for 1 of 10 clinical records reviewed (Pt. #1), the Hospital failed to ensure missed IV attempts were documented in the clinical record.

Findings include:

1. Hospital policy #NMH PC 05.0021, titled, Medical Records, was reviewed and required, "II. Policy: A. The purposes of medical record are... 2. To furnish documentary evidence of the patient's medical evaluation and treatment..."

2. On 6/6/12 at 11:10 AM, an observation tour of the 14 East Medical Unit was conducted. Pt. #1 was in room 1425. Pt. #1's left arm was swollen, bruised around the (Peripherally Inserted Cutaneous Catheter (PICC) line site, and dried blood was on the IV site. Both PICC line and IV sites were on the left arm.

3. An interview was conducted with Pt. #1 and Pt. #1's daughters (3) on 6/6/12 between 11:10 AM and 11:40 AM. Pt. #1 was sitting up in bed, spoke with slurred but understandable speech. Pt. #1 fell asleep as the Surveyor spoke with the the daughters. Pt. #1's daughters stated that numerous needle sticks were sustained in IV attempts on the 6/2/12 night shift. Two "people" and a resident were "unable to find vein". Pt. #1's daughters stated that Pt. #1 was bruised from the attempts and staff gave up trying to start the IV.

4. On 6/6/12 between 10:00 AM and 2:30 PM, the clinical record of Pt #1 was reviewed. Pt. #1 was a 93 year old female, admitted on 5/31/12, with a diagnosis of Displaced Fracture of Left Proximal Femur and Hip. Pt. #1's IV Line Insertion and Care sheet dated 6/6/12 at 8:58 PM, included an IV was started on 6/3/12, in the left antecubital and "Peripheral IV attempts (# of times): 1." The note was written by Pt. #1's Registered Nurse (E #2), but did not indicate who started the IV, the time the IV was started, or if anyone had made previous attempts.

5. On 6/7/12 at 11:45 AM, an interview was conducted with the MICU Registered Nurse (E #3) who started Pt. #1 ' s IV on 6/3/12. E #3 stated that she was asked by Pt. #1 ' s Nurse (E #2) to start an IV for Pt. #1. E #3 started the IV on 1 attempt. E #3 did not recall seeing bruising or if other staff had tried to start the IV before her.

6. An interview was conducted with the Education Coordinator for Medical Intensive Care on 6/7/12 at 10:15 AM. The Coordinator stated that failed IV attempts by other staff are not recorded in the clinical record, because the software program does not have a field for failed IV attempts by a previous staff. Only the person who successfully starts the IV can document the IV information, including the number of their own attempts to start the IV.

7. On 6/7/12 at 10:20 AM, the Director of Quality Strategies agreed that missed IV attempts should be recorded in the clinical record.

Based on review of Hospital policy, clinical records, and staff interview, it was determined that in 1 of 6 (Pt #1) clinical records of patients that underwent a surgical procedure, the Hospital failed to ensure the intraoperative report was accurate.

Findings include:

1. Hospital policy entitled, "Medical Records," (effective date 5/17/07) required, "..V Content and Composition of Patient Records:..l. Treatment and Therapy Reports:..3. A post procedure note should be recorded upon completion of the procedure and before the patient moves to the next level of care . The note should contain...procedures performed...and a post operative diagnosis."

2. On 6/6/12 at approximately 2:30 PM the clinical record of Pt # 1 was reviewed. Pt #1 was a 93 year old female admitted on 5/31/12 with a diagnosis of Displaced Fracture of Left Proximal Femur and Hip. The clinical record contained a surgical consent dated 5/31/12 and signed by Pt #1, for "Left Femur Cephalomedullary Nailing, Possible Open Reduction, Possible Internal Fixation." Documentation included that Pt #'1's left hip surgical procedure was performed on 6/1/12 between 1:10 PM and 4:48 PM.

The clinical record contained an Intraoperative Report dated 6/1/12 at 2:48 PM that included "Preop Diagnosis - Right Hip Fracture; Postop Diagnosis - Right Hip Fracture."

3. The Manager of Feinberg Surgery stated during an interview on 6/7/12 at approximately 11:45 AM that the Intraoperative Report Pre and Postop Diagnoses for Pt #1 were incorrect.