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Based on record review and interview the hospital grievance committee failed to effectively investigate a grievance for one patient (P)2 after concerns were reported by P2's family member. After P2 had a respiratory arrest while inside the Magnetic resonance imaging (MRI) tube, the incident was not thoroughly investigated and/or reported. Documentation of critical information was noted on the intensive care unit (ICU) physicians admission assessment. There was no incident report or unusual event report completed and the problem was not identified nor was a referral made to Quality Committee for investigation. The incident was reviewed only to a peer review physician. The grievance process did not identify important quality concerns related to the health and safety of the patient, which has the potential to place other patients at an increased risk for harm.

Findings include:

On June 24, 2021, Surveyor reviewed Case report details for P2 dated 02/01/2020. Letter was received from P2's daughter on 12/09/19. Stated in her complaint that her father had an MRI on October 22, 2019 and went into respiratory arrest during the procedure. Daughter also stated concern because he has a history of Parkinson disease, has obstructive sleep apnea requiring a continuous positive air pressure (CPAP), a device that provides continuous air through a mask and is worn to prevent airway obstruction. P2 was also given two different pain killers and was placed flat on his back in the MRI. The complaint was forwarded to the Facility's Grievance Senior consultant and coded issue category detail: Quality of care/ treatment quality. On January 7, 2020 a letter was sent to the daughter that the case will be completed no later than 30 calendar days of receipt. You will receive a call or letter informing you of the outcome of your grievance.

On 06/24/21 at 11:00 AM surveyor reviewed the facility Grievance and appeals Policy Number: HI.MR.006. Page 17 6.4.3 Potential Quality of Care Issues: 6.4.3.1 says, "This oversight process assures that there are effective quality assurance systems in place for the potential quality of care referral activities."

Surveyor team interviewed the Grievance department on 06/24/21 at 12:02 PM via conference call. Surveyor asked to explain the process when a member reports a concern.
The National Regulatory Operations Senior consultant, (NRO) stated that all complaints fall under the definition of a grievance. Our policy states that when we receive a grievance request on intake, we can provide a response in five days. We will investigate and provide a response to the member.

The investigation process begins with an "FYI" that is sent via email to the representative department at the facility. There is an investigative review form which is sent to a designated reviewer. It is an electronic form called a METRS. After they receive the FYI, for an investigative review (IR), it is assigned to that department's manager and they will document their findings on the METRS. Once we receive the METRS back from the department manager, we PDF it and put it in the case file manually.

Surveyor asked if the grievance is from a family member, how they follow up. The NRO stated that we have to make sure there is a designated power of attorney (DPOA) on file, to ensure the advocate is able to speak on the member's behalf. Surveyor asked if the letter includes if the complaint is substantiated or not and who sends out the resolution letter. NRO stated, the grievance department sends out the letter. The NRO said there should be a resolution letter for each sample that was requested.

The NRO went on to say the peer review analyst (PR) reviews all of the grievances and decides if it needs to be sent to peer review. If it is not a medical issue for peer review, or has other potential quality issues, it's referred to the hospital quality committee to be investigated.

On 06/24/21 at 12:30 PM, Surveyor reviewed the progress notes by intensive care unit (ICU) physician dated 10/23/19 at 8:59 PM. The notes included; "Respiratory Arrest...: Patient is a 69 year old male history of (H/O) Obstructive sleep apnea (OSA), Parkinson's, recent admit right hand laceration...sent to MRI. Noted to be responsive, but having obstructive pattern breathing en route to MR. Sleepy but responsive in MR suite, but became unresponsive in MR scanner. Code Blue called... Transferred to the critical care unit (CCU)." Parkinson's disease and Obstructive sleep apnea were included in multi problem list.

On 06/25/21 at 01:30 PM, Surveyor interviewed the Director of Quality Risk management and patient safety (QRS) with the Manager accreditation Regulatory licensing (MARL) regarding the peer review conducted by the hospitalist for the grievance. Surveyor questioned if the METRS was completed by the department manager's listed in the case report who reviewed the complaint. The QRS responded that we don't know what to do with the form (the METRS) when we get it so we usually just respond by email a summary of the investigation. Once the response is completed it goes to PR who looks at it, forms questions for the reviewer to answer, and sends it to a physician for peer review or to the risk/quality committee for final evaluation and recommendations. In this situation we did not receive a METRS from the department managers. The PR sent the complaint with questions to the hospitalist for peer review. The Hospitalist reviewed the complaint and Scored it a P-0 ("Standard of care met"). Surveyors reviewed the Physician peer review report that was shared during the interview. The recommendations stated that medications, obstructed sleep apnea and sepsis may have all played a role in the respiratory arrest. It also stated in the report a pulse oximeter may have helped to monitor the patient's respiratory status while he was in the MRI.

Surveyor stated that it was documented in the ICU physician's assessment that the patient was having obstructive patterns of breathing en route to the MRI. Surveyor asked the QRS about this potential quality of care issue since the patient was placed into the MRI in spite of the difficulty breathing that was documented. QRS replied the note about the breathing problem was documented after the patient was taken to the ICU. Surveyor stated to the QRS that someone knew about the obstructed pattern of breathing as it was documented in ICU Physician admission assessment. If P2 had respiratory issues as documented by the physician, he should not have gone into the MRI.

Surveyor questioned the QRS if there was an Incident Report (IR) written to document the incident. The QRS stated we don't complete an unusual occurrence report (UR) for every code. The QRS said there was not an incident report, and they are completed only for certain types of incidents that are unusual. Surveyor asked if this wasn't a serious unusual event that would warrant an incident report. The QRS stated that the code blue team may have done a debrief, or critique after the code. She felt someone may have told the ICU physician that P2 had problems breathing on the way to the procedure. The MRI was documented to be done from "1856 - 2051". The Code blue was called at 2015 and patient went to the CCU at 2039.

On 06/25/21 at 02:40 PM Surveyor interviewed the ICU manager (IM) who was listed in the case report details as a department manager who reviewed the case. Surveyor asked the IM if she was aware of the incident in question. IM replied no, not familiar with the case. Surveyor shared the case report details with her and that she was listed as a contact. Surveyor asked IM if there is a debrief or critique afterward code blues and she said their initial task is to stabilize the patient, take them to ICU, provide a quick synopsis about what brought the patient to the ICU and current status, but we don't have a formal debrief.

Surveyor asked the IM to review the statement on the physicians admission report dated 10/23/21 that noted "to be responsive, but having obstructive pattern breathing en route to MR. Sleepy but responsive in MR suite, but became unresponsive in MR scanner. Code Blue called..." IM stated she doesn't know why the physician wrote that statement. The IM was on the code team that day but didn't recall the details of the event. The Physician who was on the code team and conducted the admission assessment was not available for interview.

On 06/25/21 at 03:00 PM Surveyor reviewed the Hawaii Region Clinical Risk Department Unusual Occurrence Reporting policy last review date 06/29/18. The purpose read "...to establish a system to collect, investigate, aggregate and analyze unusual occurrence data, identify and report patterns and trends, and recommend improvement in processes and systems to reduce risks and prevent recurrences. Definitions. Close Call: is a patient safety event that did not cause harm, but has the potential to do so. Policy. 4.3 "a report shall be generated for the following types of events:...A close call. 4.4 The unusual occurrence reporting system shall be managed by Clinical Risk Management. 4.5. The Clinical Risk Department shall aggregate data, identify patterns and trends and report to the Quality Risk Safety and Service Committee ("QRSS"). 4.6 The QRSS shall analyze UOR reports ... and/or make recommendations for improvement to appropriate quality and/ or leadership groups."

The facility did not identify there were potential quality issues. They did not acknowledge the ICU physicians note of potential breathing issues prior to the MRI, did not interview the MRI technician or the transporter. These quality issues were not identified because the complaint was triaged only for peer review.

Surveyor reviewed a final determination letter dated February 12, 2020 sent to P2 family member from an external quality improvement organization that conducts quality of care reviews of services provided on request of beneficiaries. Summary of Review: Confirmed and/ or Identified Concerns re: P2. Analysis and Decision: The peer reviewer determined that the documentation did not support that P2's severe obstructive sleep apnea was appropriately taken into consideration prior to the MRI examination or that he was appropriately monitored during the MRI examination. In the professional opinion of our peer reviewer, the services that were the subject of this concern did not meet all applicable professionally recognized standards of health care.

Based on record review and interviews, the hospital failed to ensure a patient who they said was not incapacitated, participate in the development and implementation of his/her discharge plan. This was evidenced by lack of documentation in the medical record that patient (P)1 participated in discharge planning and made the decision to be discharged to an inpatient hospice facility rather than discharged home with hospice care.

Findings Include:

Patient (P) 1 was admitted to the hospital's Intensive Care Unit (ICU) on 01/15/20 for sepsis and acute respiratory failure and was transferred to a telemetry unit on 01/20/20. P1 was then discharged on 01/22/20 to a hospice facility.

On 06/23/21, reviewed P1's "Discharge Planning/Admission Assessment Form" dated 01/16/20. Prior to admission to the hospital, P1 was living at home with family as his/her support system. P1's spouse was the only individual documented in P1's discharge planning and expressed " ...concern about being able to provide all care needs for patient [P1] at this time." It was documented that P1's spouse further inquired about hospice services and does not want to place P1 in a facility but would prefer home hospice. The Discharge Planning/Admission Assessment Form had an anticipated discharge plan of home.

Review of P1's "General Plan of Care" dated on 01/16/20, noted "Coordinate discharge to home ..." which was reviewed with P1's spouse.

Review of P1's care coordination notes regarding discharge planning dated 01/20/20, stated "Met with patient in room ...Patient not responding to questions appropriately." The care coordination notes further stated a follow up call was done with P1's spouse and expressed wanting to take P1 home with hospice services, P1's spouse inquired about equipment and was encouraged by care coordinator to ask hospice agencies what is covered. P1's spouse wanted to " ...discuss with son and make house ready."

Interview with Registered Nurse (RN) 1 on 06/25/21 at 09:32 AM, recalled P1's spouse very involved and primarily spoke to the spouse about P1's care. P1 was sometimes confused " ...but would snap out of it." RN1 described P1 as expressive about what she wants and does not want. Concurrent review of RN1's progress note dated on 01/21/20 stated "Plan for hospice ..." Inquired if P1 and P1's spouse mentioned to RN1 if P1 would be discharged to hospice at home or at a facility. RN1 recalled, P1 " ...was supposed to go on Home Hospice ..." and P1's spouse wanted P1 " ...to be on home hospice."

Review of P1's "Durable Power of Attorney for Health Care Decisions" dated on 01/12/99, P1's spouse is listed at the authority of an agent. Review of the hospital's policy and procedure "Advance Health Care Directives" with the effective date of 12/12/19, "Unless otherwise specified in the power of attorney for health care, the authority of an agent becomes effective only upon a determination that the principal lacks capacity and ceases to be effective upon a determination that the principal has recovered."

During an interview with Director of Hospital Quality Risk Management and Patient Safety (QRM) on 06/24/21 at 01:38 PM, inquired about an internal email dated 03/19/20 stating P1 had the mental capacity (able to make decisions for self), DRM stated there is no document stating otherwise and a physician determines capacity.

Interview with Patient Care Coordinator (PCC) 1 on 06/24/21 at 10:56 AM, also stated physicians determine capacity and if there were any concerns, such as the patient being confused, and it is not improving or is a problem, the physician would refer the patient to a cognitive team for further assessment. Inquired if P1 was making the decisions about her discharge plan, PCC1 recalled P1's spouse making the decision. Concurrent review of PCC1's care coordination notes regarding discharge planning, dated on 01/21/20, stated PCC1 telephoned P1's spouse and P1's spouse signed P1 on with hospice " ...to take patient home." It further states P1 son's concern that care may be too much to provide in the home. Inquired if PCC1 had a conversation directly with P1's son about the concern and PCC1 stated she did not and only spoke with P1's spouse. PCC1 further notes contacting the hospice agency regarding next steps and PCC1 was told by the hospice agency " ...to send out to ... for inpatient." During a documented meeting with P1's spouse and the hospice agency in the care coordination note, P1's spouse was informed of an inpatient bed available, " ...however ...is having a hard making a decision for the bed versus taking patient home and providing the care himself." A decision and P1's involvement was not documented in the note. Inquired if a family meeting was held, PCC1 reviewed the medical chart and stated, "I don't know if there was one...a meeting would have been perfect."

Review of the hospital's policy and procedure, "Interdisciplinary Care, Assessments, and Discharge" received by Manager of Accreditation, Regulatory, and Licensing (MAL) on 06/23/21 at 10:28 AM, states "Planning for discharge or transfer involved the patient, license independent practitioners, staff, family members, significant others, and appropriate agencies/caregivers to be involved in the patient's care, treatment, services, after discharge. At the time of discharge, if the family has unresolved concerns or issues, staff shall contact the Patient Care Coordinator for guidance." The policy also said; "Patient/Family conference may benefit patients with certain conditions, including but not limited to: ...an uncertain discharge plan ...lack of caregiver or caregiver issues ..."

A review of the physician's progress note dated 01/21/20, revealed the physician documented a discussion of hospice with P1 and affirmed P1 wanted to go forward with hospice care. The physician did not document if the discussion and decision was for inpatient hospice or home hospice.

On 01/22/20, the physician's order under "Discharge Information" revealed the provider documented the disposition "Home with Hospice" in the drop down menu.

During an interview on 06/25/21 at 03:16 PM with the MAL and Manager of Infection Protection (MIP), inquired what the drop down choices for discharge dispositions were for the physician order. They explained the choices and confirmed "Discharged/Transferred to Hospice- Home" means the patients home, and "Discharged/Transferred to Hospice -Medical Facility (Respite, GIP)", means an inpatient, such as a Long Term Care Facility or a hospice facility.

Reviewed nursing progress note dated 01/22/20 which stated patient is to be discharged to hospice when bed is available and P1's spouse prefers P1 to be closer to home.

The care coordination note regarding discharge planning dated 01/22/20 revealed P1's spouse informed the care coordinator; "still feels ...capable of caring for patient at home." The disposition and placement noted, inpatient hospice unit (IPU). P1's spouse informs the care coordinator of visiting P1 at noon. Between the last care coordination note dated on 01/21/20 leading up to discharge on 01/22/20, there were no further notes documenting P1's decision for inpatient hospice or home hospice.

During an interview with the Manager, Utilization Management (UM) and Assistant Administrator Continuum of Care (AACC) 06/24/21 at 02:28 PM, the UM said the documentation of the discharge plan was not clear. AACC agreed and said, "Not so much documentation of the patient mostly the family," AACC confirmed it was not clear who was leading or making the decisions regarding the patient's discharge plan.

Based on record review (RR) and interview, the facility failed to ensure one registered nurse (RN)5 followed the hospital policy and procedures for medication administration when administering a narcotic medication. The patient (P2) was given a one time dose of Fentanyl 50 mcg via intravenous push (IVP) then sent to the magnetic resonance imaging (MRI) by transporter. RN5 did not assess P2's vital signs after giving the dose of Fentanyl 50 mcg IVP. P2 received a dose of Fentanyl 50 mcg IVP two hours prior to receiving the one time second dose. RN5 also failed to assess the patient for effectiveness of the pain medication prior to going to the MRI. RR revealed P2 had patterns of obstructive breathing enroute to the MRI. This deficient practice potentially placed the patient at an increased risk for harm.

Findings include:

On 06/24/21 at 12:30 PM, Surveyor reviewed the electronic medical record (EMR).
Progress notes by intensive care unit (ICU) physician dated 10/23/19 at 8:59 PM which included:
"Respiratory Arrest...HPI: Patient is a 69 year old male history of (H/O) Obstructive sleep apnea (OSA), Parkinson's, recent admit Right hand laceration...sent to MRI. Noted to be responsive, but having obstructive pattern breathing en route to MR. Sleepy but responsive in MR suite, but became unresponsive in MR scanner. Code Blue called... Transferred to CCU." Parkinson's disease and Obstructive sleep apnea were included in multi problem list.

On 06/25/21 at 11:33 AM Surveyor interviewed the Unit Manager (UM) for Ewa 5. Surveyor asked the UM if she was familiar with the incident that occurred on 10/23/19 when P2 had a respiratory arrest while in MRI. The UM replied she didn't recall the incident. Surveyor asked the UM to describe the process when nursing staff give narcotics. The UM stated if a patient is on the med/surge (medical/surgical) floor, there is no cardiac monitoring. When the nurses give narcotics, the nurses will make an assessment and check their vital signs, focusing on respirations and blood pressure. Then they go back and reassess the patient to see how they are responding to the medications. Surveyor asked UM if there was a nursing assessment done on P2 after RN5 gave the Fentanyl 50 mcg IVP prior to going MRI. The UM reviewed the EMR and stated RN who gave the Fentanyl documented a progress note but didn't include a pain medication assessment with vital signs and respiratory monitoring.

On 06/25/21 at 12:00 PM, surveyor reviewed the EMR for P2.
RN4 progress note dated 10/23/19 at 03:59 PM. Per patient pain to right arm radiating from elbow to hand only. Pt medicated with norco with intermittent relief and pain subsided with Fentanyl. Awaiting MRI today. Pt and daughter stating that patient feels weak and only can walk less than 50 feet with own walker and little shuffling due to Parkinson.

RN5's progress note dated 10/23/19 at 07:45 PM. Addendum: prior to MRI patient complained of 9/10 pain to right hand. MD notified. One time order for Fentanyl 50 mcg IV given with relief. Transport picked up pt from room 565. Patient was alert and oriented prior to transport at 1906 for MRI. Code blue in MRI paged overhead. MRI staff informed I the primary RN of the incident.

Medication administration records reviewed. P2 given NORCO 5-325 mg 2 tablet on 10/23/19 at 0243 AM, 0932 AM and 1514 PM.
Fentanyl 50 mcg given Intravenous on 10/23/19 at 12:40 PM; 1642 and 1847. P2 transported to MRI at 1909 PM. Surveyor noted initial dose of Fentanyl 50 mcg was given at 1642 and a second dose was given two hours later at 1847 for a total of 100 mcg. No documentation was found that vital signs were monitored after giving the second dose of Fentanyl 50 mcg IVP at 1847 prior to P2 being transported to the MRI. Documentation noted P2 had obstructive patterns of breathing enroute to the MRI.

Surveyor interviewed RN5 via phone call on 06/25/21 at 12:29 PM. RN5 stated that he works eve shift on the unit. Surveyor asked if he remembered P2 and could share any details about his care on 10/23/19 when P2 went to the MRI procedure, then had a code blue. RN5 stated that he didn't really exactly remember. Surveyor asked what is involved in the assessment of a patient who receives a narcotic IVP. RN5 replied that usually it requires monitoring of the pain, respirations, and vital signs. I don't really recall any thing about the incident. Surveyor asked RN5 if he recalled the daughter being there? RN5 responded I think they came back to the room, I told them something happened in the MRI, they came to the room and he wasn't there. Surveyor asked if anyone talked to him about the incident afterward and he answered no.

Surveyor reviewed the Hawaii Region Pharmacy Department Medication Administration Exhibit 3: Guidelines for the Administration of Complex IV Medications Policy number 65-61-4 Revision Date 10/24/2017, which included:
Fentanyl: IVP (RN only) Minimum vital signs monitoring on drug initiation-RN to assess/practitioner order supercedes vital sign guidelines. "Every 5 minutes X 2 on initial dose and with any increase in dosing.

On 06/25/21 at 03:20 PM, surveyor reviewed the the Pain Management policy number 6603-00D date 11/27/18 which included: 5.5.3.3. The pain score and acceptable pain level should be assessed prior to and after administration of any pain relief intervention. Reassessment should be done within 59 minutes.
5.5.3.5 Pain score, acceptable pain level and sedation should be assessed, reassessed, and documented whenever opioids are administered...
5.5.3.6 In addition, when appropriate, respiratory status and oxygen saturation should be monitored.
5.5.3.6.1 Respiratory status: assess respiratory rate, quality and adequacy of respiration.
5.5.3.6.2 Oxygenation saturation: Pulse oximeter can be used.