HospitalInspections.org

This CONDITION is not met as evidenced by:

Based on interview and record review, the hospital failed to provide a safe environment for Patient (P) #1, after staff failed to fully investigate an incident of neglect when a nurse from the Intensive Care Unit (ICU) did not report P #1's declining status to a doctor for 6 hours, and failed to integrate Emergency Department (ED) services with other departments delaying care (refer to A0144). It was also determined that the hospital failed to ensure P #1 was free from all forms of abuse, neglect, or harassment (refer to A0145). The cumulative effect of these systemic practices resulted in the hospitals inability to ensure patients are being provided treatment in a safe environment.

Based on record review and interview, the hospital failed to provide a safe environment for 1 (Patient (P) #1) of 10 (P#1 through #10) patients sampled by failing to fully investigate a substantiated incident of neglect by nurse to P#1 when an Intensive Care Unit (ICU) Nurse did not report to the patient's medical provider (doctor) a decline in the patient's neurological assessment for 6 hours, and failing to integrate services with other departments resulting in the failure to provide needed treatment and appropriate transfer when required for 1 (P#1) of 10 patient records reviewed. This deficient practice prevents the hospital from knowing the root cause and analysis of patient care (method of problem solving used for identifying the root causes of faults or problems) after an incident and has the potential to result in adverse outcomes for critically ill patients presenting to the emergency department. The findings are:

A. Record review of New Mexico Department of Health (DOH) Health Facility Incident Report (HFIR) completed on 01/08/19 for P #1 revealed the following:

1) Time of the incident on "01/04/19 AM unknown": "Patient arrived at the hospital's Intensive Care Unit (ICU) on 01/03/19 at 1700 (5:00 am) with "some agitation and very high blood pressure, 237/166, which had been her BP range since arrival in Emergency Room (ER) on 01/3/19 at 0042 (12:42 am). Midnight on 01/04/19, a nurse noted in her neuro (neurological) assessment that patient's pupils were non-reactive and there was no movement to painful stimuli but the nurse failed to notify provider (medical doctor). The nurse noted the same on a neuro assessment at 2:00 am and again did not notify the provider. The doctor was notified at 0615 (6:15 am) that patient was unresponsive. The doctor saw the patient at 0645 (6:45 am). Patient remained in a deep coma without sedation, pupils non-reactive, and her oxygen levels began to de-saturate (delcine in the ability to transport oxygen to organs of the body) on 01/06/19. She was determined to be brain dead, family withdrawn [sic] care, and patient was pronounced at 2124 (9:23 pm) on 01/06/19."

2) "Risk Management became aware of the event on 01/07/19 and was informed that the RN was suspended pending completion of review and investigation."

3) Record review of hospital's policy and procedure: Document Number P-QM-1010.4, effective 02/27/19, Risk Management - Incident Management System revealed the following: "[Name of facility] will report abuse, neglect, exploitation, and injuries of unknown origin or other reportable incidents to the bureau within a twenty-four hour period, or the next business day when the incident falls on a weekend or holiday." The incident report was not filled out by hospital staff (Risk Manager Manager) until 01/08/19 at 12:30 pm., did not list a physician, and was not reported to DOH until 01/09/19.

4) On 03/19/19 at 11:05 am during interview, Quality Director (QD) stated, he had not read the incident report that was submitted to the State DOH and confirmed that the facility did not complete a Root Cause and Analysis regarding the incident with P #1.


B. Record review of hospital's "DOH Complaint Narrative Investigation Report (5 day)" concluded, "Facility Action after the incident: "Nurse was suspended pending completion of investigation" and was placed on a written correction action plan. The Conclusion: "Following interviews of the nurse as well as other staff and supervisory personnel present during the night shift, no abuse, rough handling or inappropriate actions were found. The allegations could not be substantiated." The next line of the form reads: "If allegations of abuse/neglect/exploitation: Substantiated or Unsubstantiated." Substantiated was underlined.

C. On 03/18/19 at 4:50 pm during interview, Risk Management Director (RMD) was asked for all the information the hospital had completed regarding their investigation of P #1's incident. RMD stated, "We did not do anything and even if we did, we couldn't give it to you."

D. On 03/19/19 at 8:00 am during interview, RMD confirmed, she filled out the HFIR and that it was reported via on-line reporting system on 01/09/19. RMD further confirmed that the report she completed was substantiated for neglect for P #1.

E. On 03/19/19 at 8:25 am during interview, ICU Director confirmed that the hospital's Risk Management concluded the incident was substantiated for neglect. ICU Director also stated, "My nurse made an error. It is not appropriate nursing (failure to report mental status to provider when the patient was unresponsive through the night)."

Based on record review and interview, the hospital failed to ensure that patients are free from all forms of abuse in 1 (P#1) of 10 patients reviewed. This deficient practice has the potential to negatively affect all patients when staff fail to fully assess indicators in the Emergency Department (ED).
The findings are:

A. Record review of P#1's "ED to Hosp [sic]Admission documentation" revealed, on 01/03/19 at 0055 (12:55 am), P#1 answered "yes" to 2 indicator questions: 1) "Safe in Home: No (doesn't feel safe due to being alone) and "Have there been threats or direct abuse of you or your children? Yes." There was no other documentation regarding P #1's answer.

B. Record review of hospital policy number P-NS-1095.2, dated 10/26/16 rvealed, Emergency Department - documentation on the Emergency Department Nursing Record states "this guideline is intended for the nursing staff in the ED and is intended as a guide for documentation on the nursing record. Procedure: Initial Documentation: Abuse Screening question and or observed objective abuse information."

C. Record review of hospital policy number PR-1011.2, dated 04/17/216 revealed, "Risk Management - Suspected Abuse/Neglect Guidelines and Reporting Process states the purpose of the policy is to recognize the right to be fee from all forms of abuse or harassment and to prohibit abuse, neglect, and harassment . To protect patients from abuse, neglect or exploitation from anyone; (Please see the Procedure section in this policy for criteria for identifying victims of physical assault, rape, sexual molestation, domestic abuse, elder neglect or abuse and child neglect or abuse). Procedure, utilizing the criteria developed below, staff will screen patients at entry into the system on an ongoing basis. Initial patient screening will include obtaining a history and performing a physical assessment/examination that will include observation for signs and behaviors of abuse."

D. Record review of P#1's medical chart revealed no on-going documentation or physical assessment documentation was in the ED medical chart.

E. Review of P#1 ICU chart revealed two entries for an observed burn: 1) "large burn to buttocks, heat grid looking burn, bruise", and 2) "Date of First Assessment : 01/03/19 Time First Assessed: 1830 (6:30 pm), Burn Type: Buttocks, Degree of Burn: Deep partial thickness (2nd), Present on Admission? Yes: Orientation: Right Wound Description: Grate pattern from heater."

F. On 03/21/19 at 4:40 pm during interview, Intensive Care Unit (ICU) Director was asked if a "yes" answer was given on an Abuse Indicated Screening, should it be questioned further? ICU Director stated, "That should have been an indicator of abuse" indicative of further investigation. There was no other documentation in P #1's chart to indicate any type of a follow up.

G. On 03/19/19 at 3:32 pm during interview, MD #4 confirmed that P#1 had a burn on her buttocks, "that looked like somebody sat on a radiator, it did not look infected" MD#4 further stated that the Nurse Practitioner also noted bruising on her side, which was observed in ICU and not the ED.

Based on interview, the hospital failed to include performance improvement activities to track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital, based on chart reviews in 1 (P#1) of 10 (P#2-P#10) patients reviewed. This deficient practice has thelikelihood to result in the failure of the hospital to recognize and respond to incidents that could result in harm or death to patients. The findings are:

A. On 03/19/19 at 8:02 am, during interview, the Risk Manager (RM) stated that she wrote, the "Health Facility Incident Report" dated 01/08/19 from the investigation information provided to her from the Intensive Care Unit (ICU) director. The findings in the incident report was substantiated for neglect by the nurse who provided care in the ICU. She confirmed not remembering if this incident was sent to the Quality Improvement Program.

B. On 03/19/19 at 9:23 am, during interview, Emergency Department Director (EDD) confirmed that he was notified last week of the care provided to P# 1 in the ED by the Risk department.

C. On 03/19/19 at 11:04 am, during interview with the Quality Director (QD), the QD confirmed not doing a Root Cause Analysis (method of problem solving used for identifying the root causes of faults or problems,RCA) on P #1. He further confirmed that the Quality Committee meets monthly and this case did not meet criteria for a Root Cause Analysis (RCA).

D. On 03/19/2019 at 3:56 pm, during interview with Risk Management Director (RMD), the RMD confirmed discussing the incident for P #1 with the QD and he informed her he did not feel an RCA was needed because it was a personnel issue for the ICU director. The RMD further confirmed that she spoke with the Vice President (VP) of Quality from the hospital corporate office out of concern for P #1's blood pressure, the VP advised her to look into the care provided in the ED. As a result, the RMD sent an email to the QD on March 4, 2019 to do a process report. The RMD reported that she was told by the QD to contact the EDD stating "I don't have the folks to do a process right now so send an email to the EDD to do an investigation." The RMD lastly confirmed as of 03/19/19 a response had not been returned from the EDD or the QD.

This CONDITION is not met as evidenced by:

Based on interview and record review, the hospital failed to:

1) Ensure non-physician practitioners are determined to be eligible for appointment by the governing body in 1 (NP#2) of 2 non-physician practitioners reviewed (refer to A0339).

2) To adopt and enforce bylaws to carry out its responsibilities for 1 (NP#2) of 7 medical staff records reviewed (refer to A0353).

The cumulative effect of these systemic practices resulted in the hospital's inability to ensure patients are being provided patient care by medical staff who are qualified, trained, and competent in the areas of specialty when they are treating patients.

Based on record review and interview, the medical staff failed to ensure non-physician practitioners are determined to be eligible for appointment by the governing body in 1 (NP#2) of 2 non-physician practitioners reviewed. This failed practice has the potential to cause harm to patients when practitioners are not reviewed for competency, skills, and expertise to provide care in the intensive care unit (ICU). The findings are:

A. Record review of NP #2 medical staff credential file revealed, no evidence of NP #2 being "recommended as requested, with changes as noted below, or not recommended."

B. Record review of NP#2's credential record revealed the following:

1. Resume- Master of Science, Nursing, Nurse Practitioner graduation date of 05/2018. Employment history as a Family Nurse Practitioner began June 2018-current.

2. Appointment letter dated 10/17/18: "Effective 10/17/2018 this appointment grants you provisional active status in the medicine department with privileges in Critical Care Medicine, as specified in your individual application, for a period of 6 months. You may provide clinical services only with your approved scope of practice; only while you have active privileges; and in accordance with applicable Federal Law, New Mexico Law, and [name of hospital] bylaws, policies and procedures."

3. Record review of NP #2's"Request for Privileges Mid-level Practitioner revised 07/18/11 revealed, no signatures recommending privileges granted and is dated by NP #2 on 02/11/19.

C. Record review of State Board of Nursing website on 03/26/19 revealed, NP #2's verification report "Advanced Practice license/recognition information as: population focus/specialty: Family, original issue date 07/16/2018."

D. Record review of [name of facility] "Request for Privileges Mid-level Practitioner revised 07/18/11 revealed, "Previous Experience: The applicant must be able to demonstrate that he/she has provided at least 12 months of clinical experience and expertise in the area of specialization in the past five (5) years."

E. On 3/21/19 at 9:04 AM during interview, the ICU director confirmed NP #2 was a different circumstance due to the fact she had been employed as an RN (registered nurse) before in the ICU but she could see how a new NP could struggle without an appropriate, supportive on boarding plan to follow due to the lack of experience in providing care in the ICU.

Based on record review and interview, the medical staff failed to adopt and enforce bylaws to carry out its responsibilities for 1 (NP#2) of 7 medical staff records reviewed. This failed practice has the potential for staff to provide inadequate care for critically ill patients. The findings are:

A. Record review of NP #2's medical staff credential file revealed, no evidence of NP being "recommended as requested, with changes as noted below, or not recommended." according to the approval form.

B. Record review of [name of facility] "Medical Staff Bylaws, Part III: Credentials Procedure Manual 1.3 Responsibilities: 1.3.2" dated 10/20/2016 revealed, "to review and recommend action on all request for privileges for practitioners granted privileges at [name of facility]."

C. Record review of "Nurse Practitioner (NP) On-Boarding Plan (equipping new hires with the tools necessary to succeed in their new positions)" date stamped August 3, 2018, provides no evidence the governing body approved the plan validating it to be considered effective in meeting the needs of the critically ill patients.

D. Record review of "Midlevel On Boarding and Assessment" undated, revealed, "New Graduate Mid-levels, for 4 weeks discuss all patients with Captain, 4-6 weeks monitor daily, discuss work-ups with Captain, Captain signoff protocols as necessary."

E. Record review of [name of facility] "Medical Staff Bylaws" amended 10/2016 revealed, previous Chief Medical Officer (CMO). It further revealed, "4.11 Provisional Status 4.11.1 Initial Appointments a. the appointee meets all of the qualifications, has discharged all of the responsibilities, and has not exceeded or abused the prerogatives of the staff category to which he/she was provisionally appointment; b. the appointee has demonstrated his/her ability to exercise the clinical privileges approvingly granted for."

F. On 03/20/18 at 5:10 PM, during interview, CMO, confirmed "11. quarterly report card with Intensive Care Unit (ICU) director and manager on the "NP on Boarding Plan" signed 07/25/18 by CMO date stamped August 3, 2018 "fallen by the wayside." CMO also confirmed there was no documentation of who the assigned mentor was for NP#2 and to show progress during the orientation process.

40549

Based on record review and interview, the hospital failed to ensure the medical record contained information to describe the patient's progress and response to medications and services provided for 3 Patients (P #1,#9, & 10) of 10 (P#1 through #10) patients sampled. This deficient practice does not allow the medical provider to review the entire record for patient's progress or degree of changes which could result in harm or death. The findings are:

A. Record review of P#1, P#9, & P#10's medical record revealed, orders for inpatient Hemodialysis (process of purifying the blood of a person whose kidneys are not working normally) were included in the hospital electronic record. However, documentation found in the medical chart documenting a hemodialyis treatment was incomplete and the records did not contain a "Inpatient Services Dialysis Treatment Summary" for P#1, P#9 or P#10.

B. Record review of [name of agency] "Medical Staff-Medical Record Completion" policy dated 03/11/2016 revealed, "Policy: 1.1 The medical record must contain information to justify admission and continued hospitalization, support, the diagnosis, and describe the patient's progress and response to medications and services. 1.3 All records must document the following as prorogate: 1.3.3 Results of consultative evaluations by clinical and other staff involved in the care of the patient."

C. On 03/19/19 at 10:30 am, during interview, Emergency Room Director confirmed no hemodialysis notes from the RN (registered nurse) in the dialysis (the process of removing excess water, solutes, and toxins from the blood) unit of the hospital were found in the medical record for P #1.

D. On 03/19/19 at 4:34 PM, during interview, Director of Nursing Operations (NOP) confirmed, he is the liaison between the dialysis contracted provider and the hospital. He also confirmed not having knowledge that the dialysis nursing notes were not in the medical charts until the day of the interview with the surveyors. NOP also confirmed that some of the documentation is included in the hospital electronic record, but the record is incomplete without the "Inpatient Services Dialysis Treatment Summary."

E. On 3/20/19 at 8:56 PM during interview, Director of Regional Operations for the dialysis contracted provider stated, "progress notes (Inpatient Services Dialysis Treatment Summary) are given to the RN on the unit to be scanned into the medical record. We document during treatment and give the flow sheet at hand off (patient returned from dialysis to hospital unit)."

This CONDITION is not met as evidenced by:

Based on record review and interview, the hospital failed to integrate services with other departments of the hospital by 1) failing to provide needed treatment (control of BP and dialysis) and 2) facilitate transfer (from ED to ICU) when required for 1 (P #1) of 10 patient records reviewed (see tag A1103)

40207


Based on record review and interview, the hospital failed to integrate services with other departments of the hospital resulting in the failure to provide needed treatment (control of BP and dialysis) and facilitate transfer (from ED to ICU) when required for 1 (P #1) of 10 patient records reviewed. This failed practice resulted in an adverse outcome for a critically ill patient who presented to the emergency department for care. The findings are:

Control of BP

A. Record review of P #1's "Emergency Medicine Note" dated 01/03/19 at 12:50 am revealed, "On evaluation the patient is significantly hypertensive (high blood pressure) with a blood pressure in the 220s over 130s" and "Per recommendation of renal, she will be admitted to inpatient for fistulogram, symptom control, blood pressure control, and hemodialysis." Recorded in the "Number of Diagnoses or Management options" section (exact time unknown) "Patient demonstrates a marked renal azotemia with a creatinine of 21.8 and a BUN of 117. As the patient has significant symptoms related to the renal azotemia including nausea, vomiting, headache and severely elevated blood pressure, she will need emergent dialysis."

B. Record review of P #1's "Vital Signs" dated 01/03/19 revealed, P#1's BP recorded at time of arrival in the ED (12:49 am) was 226/114, at 2:17 am BP was 220/134, at 3:19 am BP was 217/119, at 5:30 am BP was 234/124, at 7:10 am BP was 226/114, and at 7:20 am BP was 208/115.

C. Record review of "American Academy of Family Physicians" journal article dated 2019 reveals normal BP is 119/79 or lower for a person 22 years of age.

D. Record review of facility "Completed Medications" revealed P#1 received Hydralazine 10 mg IV (medication used to control BP intravenously (via a tube inserted into vein) at 7:05 am on 01/03/19. The only other medication P#1 was given from time of arrival until 7:05 am on 01/3/19 was Tylenol 650 mg (medication used to treat pain and fever). Hydralazine 15 mg was again administered at 10:40 am on 01/03/19 when BP was 239/119 (10:28 am). At 11:08 am BP was 190/91. All of the BPs on 01/03/19 were recorded in red and as "(Abnormal) !". The final BP recorded in the ED prior to transfer to ICU (at 1:53 pm) was 195/105.

E. Record review of "Completed Medication" revealed, P #1 received Tylenol 650 mg (milligrams) at 2:14 am on 01/03/19.

F. Record review of "ED Quick Updates" (RN note) dated 01/03/19 at 3:20 am revealed, "pt continues to c/o (complain) of headache" documented as a 10 out of 10 for severity.

Dialysis Treatment

G. Record review of P #1's hospital record revealed patient arrived in the ED at 12:41 am on 01/3/19 via ambulance and was triaged by RN #9 at 12:51 am. RN #9 documented P #1 was experiencing "bloody emesis (vomiting blood), blackouts and abdominal pain". Also documented is, P #1 was a dialysis patient with end stage renal failure and an admission blood pressure of 195/105. Lab report dated 01/3/19 at 12:57 am revealed P #1's BUN was 117 mg/dL (hospital reference range 6-27 mg/dL) and Creatinine was 20.8 mg/dL (hospital reference range 0.55-1.02 mg/dL) .

H. Record review of MD#1's "Emergency Medicine Note" dated 01/03/19 at 2:31 am revealed, "Spoke with [name of physician (Nephrologist,MD #6] who will dialyze pt. in next 2-3 hr. Recommended inpatient admission for symptom control and wants fistulogram by IR."

I. Record review of MD #6's "Inpatient Services Dialysis Treatment Summary" dated 01/03/19 at 0700 (7:00 am) revealed MD ordered a 4 hour dialysis treatment.

J. Record review of P #1's "Inpatient Services Dialysis Treatment Summary" dated 01/03/19 revealed, the dialysis treatment was started at 8:24 am on 01/03/19 and was discontinued after 18 minutes . Record indicates P #1's BP was 181/126 at 8:20 am in the dialysis multi-suite and patient initially consented to dialysis. In the "Post-Treatment" section of the record the dialysis technician/nurse (credentials unknown) stated P #1's treatment was discontinued early because "Patient Refusal-MD Notified". Also documented in the record is, "Pt. needs to be transferred to ICU to complete ordered dialysis, did not tolerate dialysis in multi-suite."

K. On 03/19/19 at 4:34 pm, during interview, the Director of Operations for the contract dialysis company was asked about the rationale for discontinuation of dialysis treatment after 18 minutes ("did not tolerate dialysis in multi-suite") and stated, "It is not very descriptive, I would expect to see something more descriptive."

Transfer to ICU

L. Record review of MD #1's "Emergency Medicine Note" dated 01/03/19 at 7:20 am revealed, "[name of physician, MD #6 Nephrologist] was down to eval (evaluate) patient. Recommended inpatient admission for symptom control and wants fistulogram by IR".

M. On 03/21/19 at 9:16 am, during interview, ED MD #7 was asked if he received a call from dialysis personnel to report P #1 was too agitated to continue dialysis and stated: "do not think they called me, but they called the ED to let us know she was agitated and coming back. I ordered a CT of the head at that point due to a decreased mental status. If someone had called I would have considered Haldol (medication used to treat agitation and anxiety)." When asked why the patient was not transferred to ICU at 8:30 am, MD #7 stated, "I wanted to get her dialyzed first and then she would be appropriate for the floor." MD#7 confirmed that he wanted to send the patient to a hospital area that did not require intensive care. MD #7 also confirmed that he called the ICU Intensivist (MD #4) and was instructed that MD #4 wanted to get the patient dialyzed 1st (prior to hospital admission).

N. On 03/19/19 at 3:10 pm, during interview, RN #10 stated the reason given to her for discontinuation of the dialysis treatment after 18 minutes was, the patient was "too agitated, almost infiltrated her fistula". RN #10 also stated P #1 was "calm and cooperative" in the room (ED). RN #19 stated, "Dialysis wanted a sedation nurse because she (P #1) was too agitated." RN #10 confirmed that a transfer to anywhere other than ICU would probably not be justified since it would be very difficult to pull an RN from a step down unit (4th floor) to provide sedation in the dialysis unit (1st floor).

O. Record review of MD #7 "Emergency Medicine Note" dated 01/03/19 at 7:36 am, revealed, "Spoke with [name of physician (MD #2 Hospitalist)]. He will not accept patient at this time, but will accept to step down once systolic BP (amount of pressure that blood exerts on vessels while the heart is beating. In a blood pressure reading (such as 120/80), it is the number on the top) below 200, but preferably below 180. The patient has just received hydralazine and is now going to dialysis." (at 7:10 am P #1's BP was documented as 226/114).

P. Record review of Head CT (ordered by MD #7) dated 01/03/19 at 10:48 am, revealed, "No acute intracranial (space between the skull and the brain) abnormality. No hemorrhage (bleeding), infarction (clotting of the blood), or abnormal fluid collection."

Q. Record review of MD #1's "ED Provider Note" (written by) dated 01/03/19 (exact time unknown) revealed, "Neurological: She is alert and oriented to person, place and time. No cranial nerve deficit."

R. Record review of MD #6's "Renal Medicine Associates Progress Note" dated 01/03/19 at 7:38 am, revealed, "She is alert and oriented to person, place and time. She has normal range of motion."

S. Record review of "Nursing Note" (ICU) dated 01/03/19 at 7:15 pm, revealed, "Patient had a sudden drop in O2 sat (level of oxygen in the blood). Providers notified. Pt bagged (given oxygen). Intubated (breathing tube placed) by React RN, (RN#11) Documentation revealed the reason for intubation was "impending respiratory failure."

T. Record review of "Completed Medications" revealed that on 01/3/19 patient was given multiple medications to control BP after transfer to ICU (at 3:48 pm) including "Labetalol 10 mg (medication used to control BP) at 4:20 pm, Fentanyl 25 mcg (pain medication) at 4:36 pm, Labetalol 20 mg. at 6:07 pm, Ativan 1 mg (medication to control anxiety) at 6:23 pm, Morphine 1 mg (medication for BP and pain control) at 6:23 pm, and Ativan 4 mg. at 6:55 pm. In addition a NiCARdipine (BP control) infusion was started (time unknown) and stopped at 7:05 pm.

U. Record review of NP #2's "Significant Event" note dated 01/03/19 at 7:26 pm revealed, "Patient was receiving dialysis-she was not having any fluid removed (dialysis initiated 16 hr 45 min after patient arrival in ED). Her blood pressure remained with systolic > 200 despite efforts to decrease blood pressure with labetolol and hydralazine. She was also given Ativan as she was becoming diaphoretic (sweating) and restless. She was started on a nicardipine gtt (drip infusion, intravenous medication used to control BP). The RN asked for a provider and stated the patient was agonal breathing (abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing). Upon arrival in the room, sats were dropping, staff started to bag patient and her sats improved. She was unresponsive and unable to maintain airway (unable to breathe on her own).

V. Record review of NP #2 note "24 hour subjective" dated 01/04/19 at 9:17 am, revealed, "Her blood pressure came down under 140 systolic after intubation. It is unclear whether she became responsive at all last night. RN reported she was only on propofol (used to induce or maintain anesthesia during certain surgeries, tests, or procedures) for 10 minutes. The day RN was told she was unresponsive throughout the night. Her blood pressure remained stable throughout the night. Upon assessment this morning her pupils were 6 non reactive-(dilated and not reactive to light) will order STAT (urgent) head CT and MRI", and neurologically "she is unresponsive."

W. Record review of MRI of the brain done 01/04/19 at 10:48 am, revealed, "brain edema (swelling with fluid collection) with tonsillar herniation (abnormal fluid collection pushing the brain out into areas of the skull)."

X. Record review of NP #2's note "24 hour subjective" dated 01/5/19 at 12:30 pm, revealed, "neurologic testing to determine that there is no neurological response and informed the family the patient was not likely to recover."

Y. Record review of "Discharge Summary" dated 01/06/19 revealed, "Family made decision to withdraw support (breathing tube). Patient did not initiate any breaths. She was pronounced at 9:24 pm (time of death)."

Z. On 3/19/19 at 9:35 am, during interview, ED Director confirmed that review of P#1's record was just being done and a report was made that there was an issue with this patient. ED director confirmed that built into the electronic record are BP parameters. P#1's BP should have come up as red, and alerted staff to the fact that P#1's BP was out of range. In addition, ED Director confirmed staff needed to look at care in ED and how timely it was. P#1's length of time in ED was more than 200 minutes and ED Director confirmed P#1's length of stay in the ED was a problem.

AA. On 03/19/19 at 3:22 pm during interview, Intensivist (MD#4) confirmed receiving a call from ED at 7:00 am on 03/19/19 about needing a bed for a patient who needed dialysis, but the patient got agitated during the dialysis treatment, "so [name of ED MD] wanted to admit her to the ICU so she could get dialysis", but we were short on beds and [name of ED MD] also did not think agitation was an appropriate reason for ICU admission.

BB. On 03/20/19 at 7:50 am during interview, MD#6, Nephrologist, confirmed that when he spoke with the ED MD at 9:00 am on 03/19/19 he said the "floor is never an appropriate place to dialyze a patient who may have dialysis disequilibrium syndrome." (occurrence of neurologic signs and symptoms, attributed to cerebral edema [swelling of the brain], during or following shortly after intermittent hemodialysis) and the patient needed to go to the ICU.



An Immediate Jeopardy was identified and presented to hospital administration on 03/21/19 at 9:50 am. Hospital staff presented a Plan of Removal on 03/21/19 at 1:20 pm. Below is the plan of removal accepted on 03/21/19 at 1:20 pm.

Plan of Removal

COMMUNICATION

Medical Doctor

-Initiated 3/21/2019 - Chief Medical Officer - Evaluate current policy for provider to provider communication when a change in care or patient condition occurs, including documentation of reasoning. Evaluate current practice against policy and take appropriate action such as notifying the responsible person, notifying supervisors or submitting the event to peer review by May 20, 2019.

-Initiated 3/21/2019 - Chief Medical Officer - Clearly define which provider is responsible for the patient from the time the admit order is written until patient is transferred to next level of care by May 20, 2019.

Registered Nurse

-Initiated 3/21/2019 - Chief Nursing Officer - Develop Situation Background Assessment Recommendation (SBAR) process between dialysis registered nurse and Registered Nurse (Emergency Department). The name of the responsible Medical Doctor will be included by May 20, 2019.

-Initiated 3/21/2019 - Chief Nursing Officer - Fresenius -educate, implement, and evaluate existing Lovelace Medical Center Verbal Order Policy with Fresenius staff by May 20, 2019.

-Initiated 3/21/2019 - Chief Nursing Officer - Develop, approve, implement and evaluate policy on the rationale of early termination of dialysis by May 20, 2019.

DOCUMENTATION

-Initiated 3/21/2019 - Corporate Chief Information Officer - Investigate EPIC interface with Fresenius system-long term solution by May 20, 2019.

-Initiated 3/21/2019 - Clinical Operations Director - Develop Standard Work process for documentation in both electronic systems-standard document process-immediate action by May 20, 2019.

CONTRACT MANAGEMENT

-Initiated 3/21/2019 - Clinical Operations Director - Weekly meetings with Fresenius and Lovelace Medical Center Joint Operating Committee with metrics reported by May 20, 2019.

-Initiated 3/21/2019 - Clinical Operations Director/Quality Director - Define metrics and report weekly service level agreement measures such as response time from dialysis order to dialysis treatment, staffing as required in contract, and other metrics (To Be Determined) associated with this contract by May 20, 2019.

-Initiated 3/21/2019 - Clinical Operations Director - Review and evaluate Fresenius Policies for termination of dialysis by May 20, 2019.

-Initiated 3/21/2019 - Clinical Operations Director - Evaluate current Fresenius onboarding process and revise as needed (including event reporting) by May 20, 2019.

-Initiated 3/21/2019 - Chief Operating Officer - Validate/revise Fresenius contractual obligations to include timeliness of treatment, complete documentation in the electronic medical record provided to Lovelace Medical Center. [Name of Contractor] to provide remediation plan for any deficiencies related to this by May 20, 2019.

-Initiated 3/21/2019 - Chief Nursing Officer - Evaluate the appropriateness of the number of contracted nurses for the volume of dialysis patients in relationship to current Fresenius staff by May 20, 2019.

TIMELINESS OF CARE

-Initiated 3/21/2019 - Chief Nursing Officer/Quality Director - Develop real-time monitoring process and standard work flow for managing timeliness of emergent dialysis treatments. Metrics, including but not limited to timeliness of initiation of renal consult by emergency department provider, renal provider, response time, timeliness of dialysis order, and initiation of dialysis treatment will be developed and reported as described below by May 20, 2019.

QUALITY MANAGEMENT OVERSIGHT

-Initiated 3/21/2019 - Chief Executive Officer/Quality Director - The Quality Department will be responsible for oversight of all metrics. A data collection plan will be developed which includes, the measure definition, the owner, the frequency and trigger events. Data will be analyzed and presented/discussed at the Joint Operating Committee by May 20, 2019.

-Initiated 3/21/2019 - Chief Executive Officer/Quality Director - All metrics and reports will be discussed with senior leadership weekly for at least six weeks, then monthly or as needed thereafter. Metrics and reports may be altered after five months until standardized audit of all dialysis patients from Emergency Department to Fresenius service level times by May 20, 2019.

-Initiated 3/21/2019 - Quality Director - All metrics will be discussed with Lovelace Medical Center's Performance Excellence council, and Medical Executive Committee for at least six months by May 20, 2019.

HYPERTENSION

-Initiated 3/21/2019 - Chief Medical Officer - The Chief Medical Officer will coordinate with Renal and Emergency department to develop and deliver education for early detection and treatment for hypertensive emergency and indications of acute dialysis Emergency Department at section meeting by 3/28/2019.

-Initiated 3/21/2019 - Chief Medical Officer - The Chief Medical Officer in coordination with the quality department develop and perform audit of all patients with a diagnosis of hypertensive emergency for appropriate treatment for the next 60 days. Deficiencies will be handled through peer review and/or other mean necessary by May 20, 2019. Reports will be sent and reviewed by the Medical Executive Committee.

TIMELINESS OF CARE

-Initiated 3/21/2019 - Quality Director or designee will audit Emergency Department decision to admit to Intensive Care Unit arrival time for last 30 days to determine baseline and identify opportunities for improvement and determine the need to continue audits. Ownership of these improvements will be overseen by the Chief Nursing Officer by May 20, 2019.

-Initiated 3/21/2019 - Chief Nursing Officer - Continue the Patient-Care Aligned Throughput Huddle (PATH) project, already underway to improve patient flow supporting the admission of emergency room patients by May 20, 2019.

-Initiated 3/21/2019 - Chief Medical Officer - Initiate an audit of 10 patient emergency department charts to look at provider timeliness and clinical decision making. This will be reviewed by the Emergency Department directors and the Chief Medical Officer. Deficiencies will go to the general peer review with results provided back to the correct providers over the next 60 days and continued as needed by May 20, 2019.



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