HospitalInspections.org

Based on interviews, record reviews, and review of facility policies it was determined the facility failed to have an integrated outpatient services department that met the needs of one (1) of ten (10) sampled patients (Patient #2).

The findings include:

Review of the facility policy titled, "Scope of Care-Patient Care Services," effective January 2013 and last revised December 2018, revealed the Outpatient Services Clinic provides for Short Stay Therapies. The various therapies include, but are not limited to: hydration, blood transfusions, intravenous and intra-muscular medications, adjuvant therapy, long-term indwelling catheter maintenance, lab draws from indwelling catheter, PICC line insertions, allergy injections, and diagnostic procedures, e.g., bone biopsy. Services are provided to pediatrics, adolescents, adults, and geriatrics. Continued review revealed the Post Anesthesia Care Unit (PACU) area was designed to provide nursing care during the acute recovery period for surgical patients. Care was provided by Registered Nurses who treat adult and pediatric patients dependent on type of surgery and medical history. The primary goal of care was the safe and timely recovery and discharge of the surgical patient respectful of Patient Rights. Quality Improvement efforts are patient focused and multidisciplinary. Further review revealed Outpatient Surgery coordinates pre-operative at the point of entry for both in-patient and out-patient surgical cases; assists in the recovery function post-anesthesia; and monitors patients' post-anesthesia care until stable for discharge. Services are provided for pediatric, adolescent, adult, and geriatric patients.

Review of the "Post-Recovery Outpatient Care and Discharge Planning," effective January 2004 and last revised August 2019, revealed discharge was based on assessment process and discharge criteria, and required the responsible physician's order. Continued review revealed the following guidelines would be met before discharge: alert and oriented or pre-anesthesia mental status; vital signs within normal limits; activity consistent with preoperative status or can function with restrictions caused by the procedure; minimal nausea, vomiting, or dizziness, swallow, cough, and gag reflexes present; minimal or not acute bleeding; voiding when appropriate; acute pain controlled; a responsible driver; and a support system in place for patient at home.

Review of the medical record for Patient #2 revealed the facility admitted the patient on 04/18/19 with an admission diagnosis of Gastroesophageal Reflux Disease (GERD) and colonoscopy screening.

Review of the "Pre-Anesthesia evaluation/Nursing History," dated 04/18/19 at 6:35 AM, revealed Patient #2's vital signs were: Blood pressure - 108/65, Heart rate - 91, Respiratory rate - 16, Temperature - 97.8, and oxygen (O2) saturation - 98% (normal level 95 to 100%) on room air.

Review of the "Anesthesia Record" for Procedure, "EDG/Colonoscopy" (diagnostic endoscopic procedures of the upper and lower digestive system), dated 04/18/19, revealed Patient #2's anesthesia was started at 7:23 AM with vital signs documented as: Blood pressure - 100/60, heart rate - 65, and O2 saturation was documented as 99% on 4 liters of oxygen. Continued review of the record revealed anesthesia was stopped at 8:06 AM with documented vital signs of 100/60, 90, 26, and O2 saturation of 97% on a mask.

Review of the "Recovery Record" dated 04/18/19 for Patient #2 revealed the patient was brought to the PACU at 8:06 AM. Registered Nurse (RN) #4 documented that Patient #2 was administered a "neb" (breathing) treatment at 8:16 AM and 8:26 AM. RN #4 documented at 8:34 AM that Physician #6 was informed of Patient #2 remaining short of breath after the breathing treatment. RN #4 documented that Physician #6 was "at bedside" at 8:36 AM and orders to use an incentive spirometer were received. RN #4 documented that Physician #6 was notified due to the patient's "congestion" and "decrease in O2 saturation." At 9:05 AM RN #4 documented that Physician #6 was at the patient's bedside and a chest x-ray was ordered. Per RN #4's documentation, Physician #6 phoned and spoke with Physician #4. RN #4 documented at 9:36 AM that Patient #2's vital signs were 88/49, 88, 18, and O2 saturation of 92% on 2 liters of oxygen. Continued review revealed Patient #2 was complaining of chest pain and Physician #6 was notified. RN #3 documented that Patient #2 was moved to outpatient recovery from the PACU at 10:45 AM on 04/18/19. RN #3 documented that Patient #2 denied pain, had decreased lung sounds, slight rhonchi was noted, occasional coughing was noted, and a dark stain was noted to the corner of the patient's mouth/chin. RN #3 documented at 10:55 AM, that Physician #4 came to Outpatient, O2 was decreased to 1 liter per nasal cannula, Physician #4 was aware of the stain to the corner of the mouth, and an order was given for the patient to receive further monitoring with the option of discharge later. RN #3 documented that the patient had a decrease in O2 saturation at 11:05 AM (88% on 1 liter of O2), and at 11:10 AM O2 saturation was at 87%. At 11:15 AM the RN documented that the patient's O2 saturation was at 78% and RN #3 increased the O2 to 2 liters. At 11:20 AM RN #3 documented that Patient #2 was "asking for pain medication for chest pain with coughing and movement" and that Physician #6 was notified and an order was given. RN #3 documented at 12:25 PM that Patient #2 was transferred from "outpatient recovery" to the medical surgical floor and received by RN #2. At 12:41 PM, nursing staff documented that Patient #2 was moved to the medical surgical floor in stable condition with O2 at 2 liters via nasal cannula with O2 saturation at 88%. Further review revealed the patient's O2 was increased to 2.5 liters via nasal cannula. RN #2 documented at 5:32 PM that Patient #2 was stable, O2 saturation was at 90% on room air, and the patient refused oxygen setup. Per the RN documentation, Physician #4 was aware and the physician said the patient was okay for discharge. The physician directed the patient to follow up with her as needed.

Review of a "Chest X-Ray, Single View," dated 04/18/19 at 10:03 AM revealed the impression was "new patchy left lung opacity with right basilar airspace disease, could represent pneumonia. Aspiration not excluded."

Interview with RN #4 on 11/13/19 at 11:00 AM revealed he was the PACU nurse that provided care to Patient #2 on 04/18/19. RN #4 stated he recalled Patient #2 as a patient that came to the PACU and could not hold his/her "O2 sats." RN #4 stated he informed Physician #6 (Anesthesiologist) who was working that particular day of his concerns. RN #4 stated that Physician #6 ordered an EKG and contacted the surgeon (Physician #4) to inform her of concerns regarding Patient #2. RN #4 stated Physician #4 ordered a chest x-ray and then the patient was moved from the PACU to the outpatient recovery unit.

Interview with RN #3 on 11/13/19 at 10:40 AM revealed that she recalled Patient #2 and "we couldn't get [the patient] off oxygen." RN #3 stated she recalled that Patient #2 wanted to go home and Physician #4 stated the patient could discharge if his/her oxygen was okay. RN #3 stated she was unaware that a chest x-ray was ordered or completed. RN #3 stated if she had been aware that a chest x-ray was completed she would have looked for the results in the medical record.

Interview with RN #2 on 11/13/19 at 10:05 AM revealed that she recalled Patient #2 was "outpatient in a bed" which means a patient was never "admitted;" however, they were on the medical/surgical unit in an inpatient bed. RN #2 stated outpatients still had "paper records" and documentation had to be entered on those papers, and she could not document on those patients in the electronic system like other patients. RN #2 stated that Patient #2's O2 saturation would decrease whenever the patient fell asleep and then increase with activity. RN #2 stated that Physician #4 informed her that Patient #2 could discharge if the patient was off oxygen. RN #2 stated that the best she could recall was that Patient #2 had no concerns or complaints regarding care or treatment and did not have any complaints about pain. RN #2 stated no one informed her that Patient #2 had a chest x-ray conducted. RN #2 stated if she had been aware, she would have looked for the results and contacted Physician #4 and verified that she had seen them.

Interview with Physician #3 on 11/13/19 at 11:25 AM revealed she read the chest x-ray of Patient #2 on 04/18/19. Physician #3 stated that the radiology group only phoned physicians with "life threatening" results of tests. Physician #3 stated that Patient #2's results were not "life threatening" so the results were not called to Physician #4.

Interview with Physician #6 on 11/13/19 at 1:30 PM revealed that he did not recall a chest x-ray being ordered on Patient #2. Physician #6 stated that he did recall Patient #2 having difficulty being weaned from oxygen after the procedure. Physician #6 stated he discussed his concerns with Physician #4 and let her make the final call regarding the care and treatment for Patient #2.

Interview with Physician #4 on 11/13/19 at 11:45 AM revealed that she was the admitting physician for Patient #2 and did perform the procedures on 04/18/19 for Patient #2. Physician #4 stated that she did recall that Patient #2 had a difficult time being taken off oxygen after his/her procedure. Physician #4 stated she did recall being at the bedside when radiology staff were conducting the chest x-ray. Continued interview revealed Physician #4 stated that she did not recall seeing the results of the chest x-ray or following up with staff to check to see if the results of the chest x-ray were back prior to Patient #2's discharge.

Review of the medical record for Patient #2 from Facility #2 revealed Facility #2 admitted Patient #2 on 04/19/19 with a diagnosis of "Bilateral Pneumonia clinical history suggest aspiration as it occurred after an endoscopy."

Interview with the Chief of Staff on 11/13/19 at 12:30 PM revealed that if a physician ordered a test, the expectation of the facility is for the physician to follow up to ensure the test was performed and to review the results of the test. The Chief of Staff stated if the physician was not going to consider the results of the test in the treatment of the patient then why order the test in the first place.

Interview with the Quality Manager on 11/13/19 at 1:15 PM revealed the facility had reviewed Patient #2's medical record for process improvement purposes and had found issues. The Quality Manager stated that the facility had determined when a patient was "outpatient" in an inpatient bed there was no place to document notifications, charting for nursing staff, or assessment documentation to mimic what nursing staff documents on the inpatient unit. Continued interview revealed the facility had also identified that the only nursing staff aware of a chest x-ray performed was RN #4. The Quality Manager stated the facility was working on a process and it was in "draft" form to correct issues identified.