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Based on interviews and record reviews, the hospital failed to provide necessary physician to physician communication and/or consultation services to obtain inpatient orders for surgical wound dressing and staple removal care as recommended by a Cardiac Electrophysiologist Surgeon for a patient who had pacemaker surgery and whose hospital stay was unexpectedly prolonged due to his family's delayed decision as to a discharge location for 1 of 5 sampled patients (#1).

Findings:

A review of patient #1's medical record was performed. He was transported to the Emergency Department on 2/10/22 at 4:15 PM for symptoms that included dizziness and syncope. Later that day, he was admitted to the hospital's medical Progressive Care Unit (PCU) for cardiac monitoring and observation. Patient #1's Information Sheet indicated that he was a Humana Health Maintenance Organization (HMO) Medicare recipient. He lived locally with a family member who was designated as his legally authorized person (LAP).

A review of the history and physical (H&P) report dated 2/10/22 at 9:17 PM for patient #1 read, "... past medical history of hypertension, hyperlipdiemia, chronic kidney disease, Saint Jude pacemaker implanted in 2005 .... recurrence of syncopal episode who presented to the hospital due to generalized weakness, lightheadedness, passing out .... Patient stated that today he experienced lightheadedness,then fell and passed out on the floor for a few seconds. Per [family member] patient has been passing out for the past 4-5 years although he has a pacemaker...." The plan included to admit the patient to the medical PCU and refer the patient to the cardiologist for consultation.

A review of the Cardiologist's consultation note dated 2/11/22 at 10:51 AM for patient #1 included, "... pleasant, hx [history] of pacemaker... At home yesterday, when taking with his HH [Home Health] nurse he stood up to get some food and got dizzy fell to floor and nurse helped him back up to the chair. His present EKG [electrocardiogram] showed AV [aventricular sequential] paced rhythm .... No light headedness or syncope. On telemetry unit. No acute distress. Alert and oriented cooperative appropriate mood and affect .... Pulmonary profusion scan 2/10/21 was negative for pulmonary embolism .... Assessment - Seems orthostatic in nature will r/o [rule out] arrhythmogenic etiology. Head CT [computerized tomagraphy] unremarkable. St Jude PPM [pacemaker] implanted 9/23/11 .... Hx [history] of CVA [cerebral vascular accident, CKD [chronic kidney disease] and advanced age .... Plan: Symptoms consistent with orthostasis. Updated ECHO [echocardiogram] to be obtained. Will interrogate pacemaker to assess for any correlating arrhythmias. Assessed longevity ... 8 months when [last] interrogated 4/2020. Per pt. [patient] has not had generator exchange and advised to change position slowly.

On 2/12/22, patient #1 was transported to the Adventhealth Orlando campus for a pacemaker exchange surgical procedure at their Electrophysiology lab. A review of the Electrophysiology Cardiologist Operative Report dated 2/12/22 at 12:20 PM included the following: ".... The procedure entailed: Dual-chamber pacemaker generator change, Atrial and ventricular lead testing, and Capsulectomy/pocket relocation ....
Indications: Complete AV [atrioventricular] block, pacemaker generator at EOL [end of life]. Encapsulectomy/pocket relocation. Procedure went well .... Recommendations: He can be discharged home later today if stable. Keep dressing on (Aquacell). He can move the left arm gently. No immobilizer needed. He can take showers as far as the Aquacell dressing is fully attached to the skin, this Dressing can be removed in 5 days [2/17/2022]. Regular showers with water and soap are allowed after the dressing is removed, but his wound should always be kept clean and dry. Staples should be removed in 8 to 10 days [2/20/22-2/22/22] .... "

On the same day as his pacemaker surgical procedure on 2/12/22, patient #1 was transferred back to Adventhealth Apopka campus and returned to the medical PCU [Progressive Care Unit] on which he had originally been admitted for observation, telemetry and care.

A review of Hospitalist A's progress note dated 2/16/22 at 2:53 PM for patient #1 included daily subjective findings and as follows: "2/15/22 ... son on the phone patient with dementia and working on trying to get patient placed at facility close to Miami where more family available, patient doing ok w/o [without] complaints .... 2/16/22 feels well and wants to go home. Plan: dressing (generator change per cardiology, may remove dressing in 5 days 2/17/22, f/u in 10 days for staple removal .... d/w [discharged with] cardiology, .... PT [physical therapy] no skilled needs .... Disposition: medically cleared for discharge, d/w [discharge with] son and daughter who would like the patient to go to an ALF [Assisted Living Facility] but having trouble [with discharge] patient/father would like to discharge home [with son], will consult psych [psychiatry] to assess decision making capacity, they would like patient to go to ALF closer to Miami where there is more family support, CM [Case Management] for discharge planning, patient with dementia w/o [without] 24 hr. supervision at home, son is a truck driver who is gone for days/weeks at a time.

On 3/8/22 at 11:33 AM, a review of the daily nursing skin and wound assessment documentation for patient #1 was conducted with his Nurse Manager (NM). Documentation of the those entries were reviewed from the date of his surgical procedure 2/12/22 through the day of his discharge 3/1/22. The Electrophysiology Cardiologist 2/12/22 surgical dressing and staple removal recommendations were reviewed. She acknowledged that there was not any documented evidence to show that the dressing had been removed per Cardiologist recommendations on day 5 post surgical procedure [2/17/22] and/or that the staples were removed 8-10 days [2/20/22-2/22/22] post surgical procedure. At this same time, a continued review of patient #1's medical record with the NM revealed no documented evidence that physician orders had been obtained to clarify the recommendations and obtain in-patient wound care orders.

On 3/8/22 12 PM, a review of patient #1's timed event nursing notes and physician notes was reviewed with RM D. She acknowledged there was no documented evidence to support that the dressing and staples were removed and/or that orders were obtained to remove them as recommended.

On 3/9/22 at 10:04 AM, two of patient #1's floor nurses were interviewed, RN B and RN C. Both worked on the medical PCU. RN B worked the 7 AM-7 PM shift and RN C worked the 7 PM -7 AM shift. Both stated that they recalled the dressing was from a surgical pacemaker procedure. They stated the dressing was to be assessed daily to determine if it was clean, dry, and intact. Neither RN recalled changing the dressing and/or removing the staples. Neither recalled if there was a date on the dressing. Both indicated that they had not clarified or obtained verbal orders to the Cardiologist recommendations. RN C stated that nurses usually get a notification from the doctor when the physician inputs an order. Typically the Cardiologist would put those orders into the electronic medical record and order system. On 3/9/22 at 4:32 PM, interview with RN C, stated she discharged patient #1 on 3/1/22. She recalled that his left upper surgical dressing was still intact when he was readied for transport and discharged from the hospital. RN C's documentation on 3/1/22 at 5 AM read: "dressing present no redness swelling or draining."

On 3/9/22 12 PM, interview Interview with Hospitalist F stated that she had said recalled talking with RN A about the delay in his discharge and about dressing change and staple removal recommendations. Hospitalist F indicated that she thought RN A had put out a call out to the Orlando Electrophysiology Cardiologist to clarify and obtain verbal orders. She recalled the conversation because the RN told her it was too soon to remove the dressing yet, that it was not due until the following day per the recommendations. Hospitalist F said that she could not write a pacemaker surgical wound care order that it would need to be the Cardiologist who had wrote the order. She acknowledged that she did not reach out to the Cardiologist for orders. At 2:02 PM, interview with RN A said that orders are typically already in place for us to follow. If they were not, she would reach out the the Attending Physician and the doctor would say if we need to get a verbal order for a patient. RN A recalled the conversation between she and Hospitalist F about patient #1, but did not recall Hospitalist F asking her to call for a verbal order. RN A said she thought Hospitalist F was to reach out to the Cardiologist.

On 3/9/21 12:42 PM, interview with the Chief Nursing Officer, CNO, acknowledged that from her review of patient #1's medical record, the dressing and staples had not been removed. She stated that while a nurse can clarity and obtain verbal orders. She stated that the expectation for patients is that the care would be provided. She verbalized that in this case, it needed to have been a physician to physician communication or handoff. The CNO indicated that this was an unusual case for the patient to not be discharged as the doctor had anticipated in which he expected his recommendations to be followed after discharge with no issues.

On 3/9/22 1:33 PM phone interview with a family member for patient #1 stated that when the hospital discharged him to his Independent Living Group Home, they did not remove his surgical dressing and that it was still him. She said it looked rather old with no date on it, but was intact. The family stated she removed the dressing and there were 9 staples that remained in the surgery incision site. The family member described the surgical incision area as clean with no redness, no fresh bleeding, no drainage, no odor, and no pain. The family member indicated that he had gone to an the Independent Living Home at the family's request which was about three hours away from the hospital from where he came. The family member said s/he would either call the hospital and/or seek medical attention right away.

3/9/21 2:46, interview with the Chief Medical Officer (CMO) for the Apopka campus verbalized what had occurred with patient #1 was not a typical hospitalization flow for a patient. She stated that she had seen staples in for a long time with little risk of infection when properly maintained. She said the dressings for the procedures like with patient #1 have an antimicrobial component to reduce the risk of infection. She said staples left in longer than recommended is usually more a cosmetic issue than an infection issue. The CMO said that physicians do communicate and consult with each other. She said that the expectation and answer to any question regarding a patient will always be what is in the best interest of that patient.

A review of the hospital's Medical Staff Bylaws, Rules & Regulations, and Policies approved May 5, 2021 revealed a section entitled "Rules and Regulations". In this section under Article 4.1 Attending Physician, it included the following: "Each patient admitted to the Hospital must have an Attending Physician. The Attending Physician is responsible for the admission and overall care and management of the patient in the Hospital. The attending Physician, or his or her covering physician .... round on the patient every day while the patient is admitted to the Hospital and places an entry in the medical record every day regarding the ongoing evaluation and treatment of the patient .... after completing an assessment of the patient, orders and manages appropriate consultations and ensures that all necessary consultations are performed. The requirement that the Attending Physician assess the patient prior to requesting a consultation may be waived when the Attending Physician feels that a stat consultation is indicated and has communicated directly with the requested consultant."