HospitalInspections.org

Based on interviews and records reviewed, the Hospital failed to re-evaluate and re-assess Patient #1's condition and change the discharge plan based on findings of such a re-evaluation. Patient #1 complained of a sore throat, dizziness, a stomach ache and had experienced hypertension prior to discharge, with no intervention or documentation by the Physician's Assistant or another medical provider who was responsible for Patient #1's care.

See A-0802

Based on record review and interviews, the Hospital failed to clinically re-evaluate 1 of 10 patient records reviewed (Patient #1) condition to determine if the discharge plan in place required modification, resulting in a readmission within 12 hours of the original discharge.

Patient #1 was admitted to the Hospital for surgery on 10/15/21. Patient #1 was transferred from the operating room to the Intensive Care Unit (ICU) post-operatively. Patient was discharged home from the ICU on 10/16/21 and readmitted 10/17/21 for treatment of pneumonia.

Record review revealed that, on 10/16/21, post-operatively, Patient #1 had been experiencing hypotension (low blood pressure) with his/her systolic blood pressure being in the 80's-90's and it was determined that the intra-venous anti-hypertensive should be stopped and the patient's home hypertensives to resume.

Review of the Critical Care Flow Sheet indicated that on 10/16/21 at 7:18 A.M., Patient #1 had complaints of nausea, abdominal discomfort and pain. The "team" was aware.

Review of the Medical Critical Care Consult dated 10/16/21 at 9:10 A.M. indicated that when Patient #1's blood pressure is stable, he/she may move to the surgical ward.

Review of the Critical Care Flow Sheet, written by Nurse #1, dated 10/16/21 at 10:38 A.M. indicated that there was a possibility that Patient #1 would go home 10/16/21 and the nursing staff was monitoring blood pressure and they would continue ICU level of care at this time.

Review of the Order History indicated that the discharge order was placed by Physician's Assistant #1 at 11:52 A.M.
Review of the Critical Care Flow Sheet, written by Nurse #1, indicated that on 10/16/21 at 12:36 P.M. Patient #1 had complaints of nausea and felt sick. Patient #1 had yellowish emesis one time. Patient told Nurse #1 that "I don't feel good." Surgical ICU providers notified of the Patient's complaints.

Review of the medical record indicated that an abdominal X-Ray (KUB) was ordered. There was no evidence of bowel obstruction. The results indicated that Patient #1's heart was mildly enlarged and there was possible atelectatic changes in the left lung base compared to a chest x-ray from 8/2021. There is no documentation that Physician's Assistant #1 or another provider addressed the results of the KUB showing the mildly enlarged heart and possible atelectatic changes in the left lung base.

Review of the Discharge Planning Report dated 10/16/21 at 12:49 P.M., indicated that Patient #1 endorsed dizziness and did not feel well.

Review of the Critical Care Flow Sheet, written by Nurse #1, indicated 10/16/21 at 1:30 P.M. that Physician's Assistant #1 assessed Patient #1 at the bedside. Nurse #1 documented that Physician's Assistant #1 said that the KUB was within normal limits. Patient #1 continued to remain nauseated, despite Zofran, (anti-nausea medication) Systolic Blood Pressure was up to 160's. Patient up to bed side commode, passing gas only. Physician's Assistant #1 wanted Patient #1 to ambulate, however, Patient #1 continued to complain of nausea and "not feeling well". Assisted back to bed. Will monitor.

Review of the Discharge Instructions indicated that instructions were written and signed by Physician's Assistant #1 at 3:18 P.M. The discharge instructions do not identify the Patient's ongoing complaints of a sore throat, nausea or the findings of the KUB. There is no further documentation in the Patient #1's medical record from Physician's Assistant #1 after the discharge instructions were written.

Review of the Critical Care Flow Sheet indicated that Patient #1's blood pressure began to rise after the hypertensive IV was stopped. At 10:18 A.M. the blood pressure reading was 173/63, at 1:44 P.M., it was 170/62 and the last time a blood pressure was taken and documented for Patient #1 was at 5:10 P.M. Patient #1's Systolic blood pressure was recorded at 181 which is clinically hypertensive. There is no evidence that Physician's Assistant #1 addressed the hypertension prior to Patient #1 being discharged.

Review of the Critical Care Flow Sheet written by Nurse #1, indicated that on 10/16/21 at 6:45 P.M. Patient #1 and his/her grandson voiced concerns that Patient #1 sates he/she doesn't feel well, complained of dry mouth and throat, and abdominal pain. Nurse #1 wrote that the KUB within normal limits. Patient States the dry mouth is affecting his/her breathing, vitals stable, oxygen saturation is 96%. Nurse #1 wrote that Physician Assistant #1 was in to see patient and discussed that Patient #1 is stable to be discharged. (There is not any indication in the Critical Care Flow sheet to identify that futher assessments were performed by the Physician's Assistant.) All discharge instructions reviewed, and forms and prescriptions given to grandson. The grandson continued to voice more concerns about taking patient home. Nurse #1 updated the Charge Registered Nurse. Patient #1 was discharged via wheelchair by Charge Registered Nurse.

Review of the Discharge Summary, with a service date of 10/16/21 (untimed), signed and dated by Physician Assistant #1 on 10/20/21 at 1:57 P.M. indicated that the patient would be discharged home, 10/16/21 in the afternoon. There is no documentation in the discharge summary to address Patient #1's concerns of sore throat, the KUB results indicating mildly enlarged heart and possible atelectatic changes in the left lung base or complaints of dizziness by Physician's Assistant #1 or by another medical provider. Further, there is no documentation to identify evaluation of increased systolic blood pressure as it continued to rise throughout the afternoon.

On 10/17/21, at around 5:00 A.M., Patient #1 returned to the Hospital via ambulance with complaints of shortness of breath.
Review of the Initial Consult Note dated 10/17/21 at 10:29 A.M indicated that Patient #1 had increased white blood count of 20.0 and required 5 liters of oxygen to maintain an oxygen saturation level of 97%, with breath sounds clear but diminished at bases. Chest X-Ray revealed that there was 1. An interval appearance of focal opacity seen in the right base extending from the right hilar region concerning for airspace discase; 2. Reticulonodular opacites within bilateral lungs concerning for infectious/inflammatory process; 3. Mildly prominent vascular markings along with interval appearance of small left pleural effusion concerning for congestion. It was determined that Patient #1 presented to the Emergency Department with symptoms, signs and imaging suggestive of pneumonia and was admitted for work-up and further treatment of upper respiratory infection.

During an interview on 11/10/21 at 11:50 A.M., Physician Assistant #1 said that around 3:00 P.M., the patient's family was visiting and wouldn't take Patient #1 home. Physician Assistant #1 said that the patient has bad baseline blood pressure and the increased systolic blood pressure of 181 at 5:10 could have been because Patient #1 was upset. She said that the family was upset, indicating that Patient #1 was being discharged because the Hospital needed a bed. Physician Assistant #1 said that if they had something to keep her for, they would have.

During an interview on 11/10/21 at 1:15 P.M., the ICU Director said that the increased blood pressure was attributed to Patient #1 being anxious. The ICU director said that the family was not on board with taking the patient home. The ICU Director said that the Patient had been discharged earlier in the afternoon, so vitals aren't necessarily taken again if they were earlier in the shift.

There was no documentation in the record to indicate that the KUB findings showing the mildly enlarged heart and possible atelectatic changes in the left lung base were addressed by the Physician Assistant of other provider prior to discharge, that the patient's complaints of dizziness and difficulty breathing due to sore throat were re-evaluated for a change in the discharge plan or for continued admission by the Physician Assistant or other medical provider prior to discharge. The Patient returned to the Hospital within 12 hours and was found to have pneumonia, was admitted to the hospital for multiple medical concerns and passed away 10/27/21, 10 days after re-admission.