HospitalInspections.org

Based on review of facility documents, clinical record review and interview, the facility failed to ensure 1 of 2 patients (Patient #1) had the right to participate in the development and implementation of his or her plan of care.

Findings included:

Facility document titled, "Patient Rights," dated 01/2024, stated in part, "The right to participate actively in the development and periodic review of an individualized treatment plan (extending to a parent or conservator of a minor, and the legal guardian of the person, when applicable) ... Staff must document in the medical record that the parent, guardian, conservator, or other person was notified of the date, time, and location of each meeting so that he or she could participate ..."

Review of patient #1's clinical record revealed:
- Laboratory report for a blood specimen collected 12/17/24, documented in part, " ... Current Result and Flag: Potassium 8.0 mEq/L [milliequivalents per Liter, a normal potassium 3.5-5.2 mEq/L], Critical ... Reference Interval (3.5 - 5.2) ..."
-"Physician's Order," dated 12/18/24, documented in part, " ... Request Type: NOW, Comments: STAT (immediate) EKG (electrocardiogram - a test that measures the heart's electrical activity), Indication: hyperkalemia (a high level of the electrolyte potassium in the blood) ..."
- "Nursing Note," dated 12/19/24, documented in part, (an undated and untimed) "Addendum: Patient refused EKG x 2 (twice). Vital signs WNL (within normal limits). Medical provider notified will continue to monitor."
- "Interdisciplinary Treatment Plan Master Sheets," dated 12/15/24, documented in part, " ... (undated) Problem: Impaired metabolism related to hyperkalemia as evidenced by medical history of K+ (potassium) 8.8 ... Patient Assets (Strengths) included:, "patient #1 [a minor] reports [parent] is supportive ..."

Review of patient #1's clinical record revealed no documentation of parent's participation in the development and implementation of patient #1's plan of care (including notification of parent regarding laboratory results and patient refusal of EKG test), until 12/20/24, when patient #1 was discharged.

In interview on the morning of 2/18/25, in a facility conference room, (Staff #1), Nurse Manager stated, "Labs 12/17/24 - potassium 8.0, labs 12/18/24 - potassium 8.8. 12/20/24 - [Patient #1's parent] on the way to pick up [patient #1] for discharge, notified [patient #1] needed to go to hospital per physician's order for critical lab value."

In interview on the afternoon of 2/18/25, in a facility conference room, (Staff #10), Chief Nursing Officer (CNO) stated, "In discharge care plan, brought up to [patient #1's parent] about patient refusing EKG twice ..."

Based on review of clinical record, review of facility documents, staff interview, and review of accepted standards of practice, the facility's Nursing Services failed to provide care in an organized manner when, Patient #1's nursing progress notes did not indicate when labs were drawn, when STAT labs were ready to be picked up by the lab, and STAT EKG was refused by Patient #1, a minor without notification to their parent. Facility policy and procedures for documentation were not implemented. The current nursing practices placed patients at risk of critical laboratory findings not being communicated or addressed and delay in the diagnosis and treatment of medical conditions before symptoms develop or worsen.

Findings included:

Patient #1's clinical record revealed:
-an order for a routine blood draw, Comprehensive Metabolic Panel (CMP- provides information about metabolism and certain chemicals in your body) on 12/16/24 at 7:00 am, per lab documentation, this sample was collected on 12/17/24 at 6:23 am. CMP was viewed by the provider on 12/18/24 at 4:23 pm with a critically high potassium value of 8.0 mEq/L [milliequivalents per Liter, a normal potassium 3.5-5.2 mEq/L]. According to the lab documentation, this critical lab resulted at multiple dates and times, as early as 12/18/24 at 6:35 am and as late as 12/19/24 at 6:35 pm. There was no nursing progress note on when the lab was drawn and no critical lab result notification documented by the nursing staff.

-on 12/18/24 at 4:26 pm, the provider ordered a STAT BMP7 (Basic Metabolic Panel - provides information about fluid balance, metabolism, and how well your kidneys are working). The lab report revealed the sample was collected on 12/18/24 at 5:29 pm but did not result until 12/20/24 at 9:35 am (about 44 hours later). BMP7 was viewed by the provider on 12/20/24 at 10:06 am with a critically high potassium value of 8.8 mEq/L. There was no nursing progress note when the lab was drawn nor that the lab was notified there was a stat lab ready to be picked up.

-on 12/18/24 at 4:30 pm, a STAT EKG was ordered with an indication of hyperkalemia; however, this EKG was not completed. Nursing note by Staff #5, RN, dated 12/19/24, stated in part, "Addendum (undated and untimed): Patient refused EKG x2. Vital signs WNL. Medical provider notified will continue to monitor." There was no documentation Patient #1's parent or guardian, was notified of the provider's ordered EKG.

In an interview on the afternoon of 2/18/25, Staff #5, RN, stated, the "MD and parent" should be notified if a minor refused an EKG. Staff #5 reported they completed the addendum later on the afternoon of 12/19/24 and verified there was no date and time when the addendum was completed.

In an interview on the afternoon of 2/18/25, Staff #10, Chief Nursing Officer, stated, "On 12/19/24, (Patient #1) refused EKG twice ... In discharge care plan, brought up to mother about patient refusing EKG twice" and verified the parent was not notified when Patient #1 refused EKG.

Review of the facility provided policy, "Compliance with Accurate and Timely Documentation Policy," (undated) documented in part, " ... Policy Statement: It is the policy of the hospital that all documentation must be accurate, complete, and finalized before the end of the assigned shift. This ensures continuity of care, compliance with regulatory standards, and maintenance of high-quality patient care... Timely Completion: Late entries must be clearly marked as such and include the date and time of entry..."

Review of (undated) facility-provided procedures included:
-Document titled "Lab Process Updates" stated in part, "#1 Nightshift will collect and prepare green bag with all labs.
#2 A Progress Note Must Be Completed For All Lab Draws ... Document: # (number) of attempts, site, patient tolerance and/or if patient refused.
#3 For Critical Labs, be sure to notify the physician but also complete the Critical Lab Note in [the electronic medical record] and complete the Critical Lab Log"

- Document titled "Nursing Communication!!" stated in part, "2. Labs a. There is currently a request for a template to be made by [the electronic medical record software] so that lab draws can be documented.
b. Until then, create a progress note ... below is an example: Location of draw (site): (Right arm, left arm ...); number of attempts: (1, 2, 3+); type of draw: (Venipuncture, Finger Stick, Other:___); gauze and bandage applied - yes or no; patient tolerance (good, fair, or poor); complications noted (none, bruising, hematoma, or other); interventions taken (if complications occurred: ____)
...Miscellaneous items: ...Critical Lab Books: a. ...Please make sure you are documenting critical labs.
b. It is also good practice to make a note: CRITICAL LAB RESULT NOTIFICATION ..."

According to NIH (National Institute of Health) National Library of Medicine, National Center for Biotechnology Information, "STATPEARLS, Hyperkalemia," article found at ncbi.nlm.nih.gov, stated in part, " ... Hyperkalemia defined as a serum or plasma potassium level above the upper limits of normal, usually greater than 5.0 mEq/L to 5.5 mEq/L. While mild hyperkalemia is usually asymptomatic, high potassium levels may cause life threatening cardiac arrhythmias, muscle weakness, or paralysis ... The first test that should be ordered in a patient with suspected hyperkalemia is an ECG (electrocardiogram) since the most lethal complication of hyperkalemia is cardiac condition abnormalities which can lead to dysrhythmias and death ... Patients with hyperkalemia need cardiac monitoring, and nurses should be familiar with ECG features of hyperkalemia, which are often the first to appear..."

Based on review of accepted standards of practice, clinical records, review of facility documents, and staff interview, the facility failed to ensure laboratory services were available 24 hours a day, for 1 of 1 patient (patient #1), when:

A. A mechanism for reporting critical lab value results was not established and Patient #1 did not receive results of critical lab values timely.

B. STAT labs were ordered and drawn on 12/18/24 but did not result until 12/20/24. The facility did not have a procedure for timelines for processing and reporting STAT labs. The facility's failure to specify and operationalize timelines for reporting critical results place patients at risk of delayed medical diagnosis and intervention.

Findings include:

A. Review of patient #1's clinical record revealed:
-An order for a routine blood draw, Comprehensive Metabolic Panel on 12/16/24 at 7:00 am, was collected on 12/17/24 6:24 am. CMP was viewed by the provider on 12/18/24 at 4:23 pm with a critically high potassium value of 8.0 mEq/L.

There were multiple dates and times that critical labs were resulted for this lab, as early 12/18/24 at 6:35 am and as late as 12/19/24 at 6:35 pm.

At an unknown date and time, the lab report documented, "Called/faxed to Staff #11, RN on 12/19/24 at 3:54 pm for test Potassium."

Interview with Staff #1, Nurse Manager, on 2/19/25 revealed Staff #11 is an LVN and was not working on 12/19/24. Staff #1 was unable to determine when or whom the lab reported the critical result.

The provider saw the critical lab value but there was no documentation this critical result was reported to patient care staff.

-At 12/18/24 at 4:26 pm, the provider ordered a STAT BMP7 which was collected on 12/18/24 at 5:29 pm but did not result until 12/20/24 at 9:35 am. BMP7 was viewed by the provider on 12/20/24 at 10:06 am with a critically high potassium value of 8.8 mEq/L. The provider saw the critical lab value but there was no documentation this critical result was reported to patient care staff.

During an interview on the morning of 2/18/25, Staff #1, Nurse Manager, reported since Patient #1, the lab notifies her of any critical lab values and faxes reports to a central location, staffed by nurses 24 hours a day, 7 days a week.

Policies or procedures related to timeframes for reporting critical lab values were requested and were not provided.

B. Review of facility-maintained documents for the provision of laboratory testing services revealed a laboratory quick reference with contact information. There were no resources, processes, or policies, regarding the collection, courier pick-up, delivery, and timeframes for STAT specimens.

Review of patient #1's clinical record documented at 12/18/24 at 4:26 pm, the provider ordered a STAT BMP7. The lab report revealed the sample was collected on 12/18/24 at 5:29 pm but did not result until 12/20/24 at 9:35 am (about 44 hours later). BMP7 was viewed by the provider on 12/20/24 at 10:06 am with a critically high potassium value of 8.8 mEq/L.

In interview on the morning of 2/18/25, in a facility conference room, Staff #1, Nurse Manager, reported procedures for specimen collection, handling and preparation for courier pickup was in place for STAT laboratory testing. Specimens for STAT testing are picked up by courier and delivered to a laboratory provider at another location; however, the facility did not provide information to indicate what time the courier picked up Patient #1's sample nor when it was delivered to the processing lab.

In an interview conducted the morning of 2/19/25, in a facility conference room, Staff #8, facility Medical Director, stated, "Prefer to receive STAT lab results within a few hours."

There were no policies or procedures related to timeframes for any specific tests, including the collection, courier pick-up, and delivery for STAT specimens.