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Based on the Medical Staff Bylaws, Medical Staff Rules and Regulations, policy and procedures, medical record, and interview, it was determined the hospital failed to require the surgeon updated the History and Physical (H&P) to include the abnormal EKG, and abnormal stress test before the start of surgery on Patient #1.

Findings include:

The Medical Staff Bylaws requires: "...Responsibilities:...To develop and maintain Bylaws and policies consistent with sound professional practices, and to enforce compliance with them...."

The policy "Pre-operative Patient Care" requires: "...Scan tests results and paperwork brought in by patient...Place all the following on the chart prior to surgery...Results of all diagnostic studies, i.e., EKG, Lab, Radiology, etc...."

The Medical Staff Rules Regulations requires: "...All History and Physical reports...must be updated...prior to surgery...shall include...patient's current medical status that may hove changed since the prior H&P or to address any areas where more current data is needed...."

Patient #1 presented to the Pre-Operative (pre-op) area on 05/19/10, at 0515, for a planned laparoscopic sigmoid resection, with a possible ostomy, due to having diverticulosis.

The Surgeon's pre-operative order's written on 04/29/10, (prior to surgery) included, "...EKG (electrocardiogram)...."

The EKG report from 02/08/10, was in the medical record, and indicated the EKG test was abnormal.

The H&P (surgeon's office notes) dated 04/27/10, revealed: "...(patient) with follow up consultation regarding diverticulosis...asked to followup for elective colon resection...presents today to discuss elective colon resection for diverticulosis having completed preoperative colonoscopy...denies any symptoms...wants to proceed with surgery. Review of systems otherwise negative."

The surgeon updated the H&P with "No changes" on 5/19/10.

The surgeon did not include the abnormal EKG results in updating H&P.

The surgeon's operative report on 05/19/10, revealed: "... Per patient report, he also was seen by cardiology and had a recent normal stress test that we found out about only after asking him about his abnormal ekg (electrocardiogram). We were able to compare it to his previous ekg from a few months ago and it was stable. We reviewed the cardiology note from the previous visit and they indicated no further inpatient workup given the lack of symptoms. Furthermore, he stated
that he ran about 2 miles daily without symptoms. We expressed the importance of the normal stress test and he again confirmed it. Anesthesia agreed with proceeding with surgery as planned but I had the preop RN obtain the report for our records and asked them to bring it to us in the OR (operating room)...

Intraoperatively we were given a report of the patient's stress test that was actually abnormal. The patient had stated that he had followed up and was told that he had a normal stress test. With these findings, we immediately called his wife and the cardiologist. His wife again stated on speaker phone and able to be heard by the entire operating room that she was told that he had a normal stress test by her husband but she did not actually go to the appointment with him...

We spoke with the patient's cardiologist who said that he failed to follow up. They checked the records and again confirmed the abnormal stress test results and stated that he would need further workup before being cleared for surgery and therefore we decided to abort the procedure...given the abnormal stress test, we had the patient be seen by cardiology post-operatively and they cleared him for discharge home with close follow-up. "

The surgeon did not ensure a copy of the abnormal stress test was in medical record.

The surgeon did not ensure the updated H&P included the abnormal stress test.

On 04/20/11, the Director of Quality Assurance confirmed the surgeon did not update the History and Physical to included the abnormal EKG results and the abnormal Stress test results.

Based on the review of the Registered Nurse's (RN) job description, medical record, and interview, it was determined the Hospital failed to require the nursing staff:

1) follow physician's order to apply a cardiac monitor on Patient #2;

2) documented the removal of Patient #1's intravenous (IV) at the time of discharge;

3) provided and documented daily hygiene to Patient #3;

4) provided and documented peri care after Patient #3 had a bowel movement; and

5) provided and documented oral care to Patient #3.

Findings include:


Findings include:

1)The RN's job description included, "...Provides care based on the physician orders...."

Patient #2 presented to the emergency department (ED) on 06/28/10, at 1437, from the patient's primary care physician (PCP) office, with complaints of abnormal electrocardiogram (EKG), dizziness, and lightheadedness.

On 06/28/10, at 1627, the ED physician's order included, "...monitor...."

On 04/20/11, the Director of Quality Assurance confirmed the RNs are to follow physician's orders.

On 03/14/11, the Quality Clinical Specialist (QCS) reviewed Patient #2's medical record, and confirmed the RN did not document placing Patient #2 on a cardiac monitor.

2) The policy "Patient Care Practice Guideline Intravenous Therapy: Peripheral IV Therapy Practice Guideline for Nursing and Allied Health" requires: "...Removal...observations and actions are documented in the medical record...discontinuation...site appearance...patient response...date and time...."

Patient #1 presented to the Pre-Operative (pre-op) area on 05/19/10, at 0515, for a planned laparoscopic sigmoid resection, with a possible ostomy, due to having diverticulosis.

The Surgeon's pre-operative orders for 05/19/10, included: "...IV (intravenous) Fluids: Lactated Ringers at 50 cubic centimeters / hour...."

On 05/19/10, at 0656, an IV was inserted into left hand, with 18 gauge needle, with the nurse documenting, "no redness, edema, leakage, or pain."

Patient #1 was discharge from the facility on 05/19/10, at 1125.

On 03/03/11, the QCS confirmed the nursing staff did not document the removal of the IV from the left hand.

3) The policy titled "Adult Patient Standards of Care" requires: "...General Nursing Care...All patients will be provided an opportunity for personal hygiene at least daily and as condition warrants and includes but not limited to:...Shampoo and shaving will be offered as patient condition allows...."

Patient #3 presented to the emergency department (ED), on 07/23/10, at 1915, via ambulance with persistent fever, weakness, and confusion.

On 03/08/11, the Nurse Manager of Telemetry (NM) stated the "Activities of Daily Living (ADLs)" include bathing, oral and pericare, which can be documented by either the registered nurse (RN), licensed practical nurse (LPN) or certified nursing assistant (CNA), but usually the CNAs.

The CNAs hired to work the Telemetry Unit are given the "Telemetry CNA Daily Activities" and the "Telemetry CNA Charting Review" to help guide them in ADL completion and documentation.

Patient #3's ADLs in the electronic medical record were as follows:

On 07/23/10: No documented ADLs.

On 07/24/10: 1000 - Lotion by RN at 1500 - Oral care, Skin care, Lotion applied all with "maximum assist." At 2145 - Peri care, Skin care with "maximum assist" and partial linen change. At 2345 - Partial linen change.

On 07/25/10: No ADLs documented.

On 07/26/10: At 1415 - Shower, peri care, and Urinary catheter care with "moderate assist" Oral care "independent:" Skin care with "stand-by assist;" and a complete linen change.

On 07/27/10: No ADLs documented.

On 03/08/11, a QCS confirmed the nursing staff did not provide personal hygiene, such as bathing or showering, at least daily to Patient #3.

4) The policy titled "Adult Patient Standards of Care" requires: "...General Nursing Care...Pericare will be done...with each bowel movement...."

Patient #3's had stools on:

7/24/10 at 2000; 7/25/10 at 0000; and 7/25/10 at 1100

Peri care was documented on 07/24/10, at 1945, and 07/26/10, at 1415.

On 03/08/11, the QCS confirmed the nursing staff did not document performing peri- care 7/24/10 at 2000; 7/25/10 at 0000; 7/25/10 at 1100, after Patient #3 had a stool.

5) The policy titled "Adult Patient Standards of Care" requires: "...General Nursing Care... Oral hygiene will be offered and provided at least 2 times daily...."

Patient #3's medical record had documentation of oral care being completed:

On 07/24/10, at 1500, with moderate assistance; 07/26/10 at 1415, with no assistance, done independently.

On 03/08/11, the QCS confirmed the nursing staff did not offer oral care to Patient #3, at least 2 times a day.

Based on the Medical Staff Rules and Regulations, policy and procedures, medical record, and interview, it was determined the Hospital failed to require the anesthesiologist had included the abnormal EKG, and abnormal stress test, in the pre-anesthesia evaluation before the start of surgery on Patient #1.

Findings include:

The Medical Rules and Regulations require: "...A pre-anesthesia...evaluation must be conducted and documented by an individual qualified to administer anesthesia...within 48 hours prior to the procedure. A pre-anesthesia evaluation of the patient must include pertinent information relative to the choice of anesthesia and the procedure anticipated, pertinent previous drug history, other pertinent anesthetic experience, and potential anesthetic problems, American Society of Anesthesiologists (ASA) patient status classification, and orders for pre-op medication...."

The Anesthesiologist's pre-anesthetic review on 05/19/11, and signed at 0800 included history of cardiovascular system "hypertension, and coronary artery disease." The history under general was obesity comments section: "Patient reports normal stress test done 2 months ago and is currently running 2 miles a day...Gave the patient an ASA score of 3, and will use General anesthesia."

The anesthesiologist did not acknowledge the abnormal EKG, when completing the pre-anesthesia evaluation.

The anesthesiologist's progress notes on 05/19/10, at 1003, revealed: "...(the cardiologist's office) fax arrived after 0830 with surgery underway, and indicated stress test was abnormal...Cardiologist's office informed us that patient had failed to show up for follow up studies...Surgery was aborted...."

The anesthesiologist did not confirm if a stress test had been completed, was normal, and a copy placed in the medical record, when completing the pre-anesthesia evaluation.

On 04/20/11, the Director of Quality Assurance confirmed the anesthesiologist did not include the abnormal EKG, and abnormal stress test when completing the pre-anesthesia evaluation.