HospitalInspections.org

Based on policy and procedure review, medical record review, review of incident reports and staff interviews hospital staff failed to ensure tracking and trending of medical errors by failing to document an incident for improvement opportunities for 2 of 4 incidents reviewed. (Patient #1 and Patient #9)

The findings included:

Review of a policy titled "Incident Occurrence Reports", effective date 04/14/2020, revealed "...Workforce members should complete an Incident/Occurrence Report on any unexpected or unintended incident/accident/occurrence relating to patients....whether or not injuries are sustained....(Hospital) encourages incident reporting as an important component of maintaining a safe and high-quality environment for our patients....The goal of incident reporting is identification and correction of potential risks. ..."

Review of an Emergency Department Provider Note, dated 02/23/2022 at 1023, revealed "...Medical Decision Making (name of Patient #1) is a 80 y.o. (year old).... with acute on chronic dyspnea (labored breathing)....will likely require admission....11:51 AM Worsening anemia, hemoglobin 8.9 (Reference range [RR] 11.4-15.0), hematocrit 28 (RR 31-42) . She does report some bright red blood in stool several days ago....Rectal exam reveals brown Hemoccult (test that checks for presence of blood) positive stool....1:04 PM.... Discussed with hospitalist who accepted admission....plan to trend H&H's (hemoglobin, hematocrit). ..." Review of physician orders revealed an order for "Hemoglobin and Hematocrit....Order Date/Time 02/23/2022 1502.... Every 8 hours.... 4 occurrences... ." Review of provider orders also revealed an order for "CBC (Complete Blood Count [which would include a H&H])....Order Date/Time 02/23/2022 1815 Start Date/Time 02/24/2022 0605....Daily....7 days... ." Review of Lab results revealed H&H results on 02/23/2022 at 1701 of Hemoglobin 8.1 and Hematocrit 24. Review revealed another result at 02/24/2022 at 0056 (7 hours 55 minutes later) which revealed a Hemoglobin of 8.2 and Hematocrit of 25. Review of Lab testing did not reveal an H&H completed 8 hours later and did not reveal a CBC around 0605. At 1230 on 02/24/2022 a RN Note revealed "Lab made aware that pt has labs due to be drawn. ..." Review revealed the next documented H&H result was 02/24/2022 at 1426 (13 hours 22 minutes after the last H&H ). Review failed to reveal testing as ordered.

Request for incident reports for Patient #1 did not reveal an incident report related to missed/ late laboratory testing.

Interview with Administrative Staff #4 on 07/28/2022 confirmed no incident report was found related to the late/ missed lab and acknowledged the error made.

Review of information prepared and received from the facility on 07/28/2022 revealed a new document titled "Lab Collection Process for ED patients and ED Boarders.... Current State Nurses collect lab specimens for ED Boarders. Support is available if the nurse calls the lab to let them know labs need to be drawn. Non-ED RNs may not realize this is an expectation... ."

Interview with the Director of the Labs and Lab Staff #5, on 07/28/2022 at 1100, revealed that within the lab computer system there were automatic system changes that occurred behind the scenes in an effort to avoid duplicate labs and prevent unnecessary sticks for patients. Interview revealed the serial lab (the order for the every 8 hour H&H for 4 draws) was auto cancelled in the system because the daily morning lab "took its place." Interview revealed lab did track/ audit morning labs to be sure they were collected and to the lab by 0830 but this tracking only occurred for inpatients, it was not done for ED patients boarding. Interview revealed this "fell through the cracks."



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2. Review on July 26, 2022 of policy, "Tracheostomy suctioning" revised November 19, 2021, "Critical Notes .... In the event of accidental decannulation (accidental tracheostomy tube removal): ...Complete an Incident Report in RL Solutions ..."

Closed medical record review on July 26, 2022 revealed, on September 26, 2021, Patient #9 presented to the emergency department, via medical transport, secondary to a motor vehicle collision. While in the emergency department, the patient received multidisciplinary care. Once stabilized, the patient was admitted to an in-patient bed in the intensive care area. While in the intensive care area, the patient continued to receive multidisciplinary care, including a tracheostomy, a surgical procedure. On October 12, 2021 at 11:43 AM, the patient received a medical order to transfer to a step-down/intermediate area. On October 13, 2021 at 9:27 AM, the patient was transferred to and located on a step/intermediate area and tracheostomy care was provided. On October 28, 2021 at 7:40 PM, the patient decannulated the tracheostomy and an occlusive dressing was placed over the trach site. At that time, oxygen saturation was 96% via one-liter nasal cannula. Continued review revealed, the patient remained on the step-down/intermediate area. On November 12, 2021, the patient was weaned from the nasal cannula to room air where oxygen saturation level varied from 93% to 100%. On December 21, 2021, the patient was discharged from the hospital to a rehabilitation hospital of choice. Review revealed, during the hospitalization, the patient decannulated the tracheostomy.

Request on July 26, 2022 of an incident report for Patient #9 revealed, the hospital staff failed to enter an incident report for the October 28, 2021 decannulation occurrence.

Interview on July 27, 2022 at 1:55 PM with Nurse Manager of [the step-down/intermediate area] revealed, lapses in documentation was no surprise, however, documentation of patient care, the hospital staff was still expected to perform even during the pandemic.

Based on policy review, medical record review and staff interviews facility staff failed to ensure orders for hemoglobin and hematocrit were carried out timely as ordered for 1 of 4 ED patients boarding waiting admission. (Patient #1)

The findings included:

Review and request for policies on 07/28/2022 did not reveal a policy on nursing responsibility for lab draws for patients boarding in the Emergency Department awaiting inpatient admission.

Review of an "...Emergency Department Provider Note, dated 02/23/2022 at 1023, revealed "...Medical Decision Making (name of Patient #1) is a 80 y.o. (year old).... with acute on chronic dyspnea (labored breathing)....will likely require admission....11:51 AM Worsening anemia, hemoglobin 8.9 (Reference range [RR] 11.4-15.0), hematocrit 28 (RR 31-42) . She does report some bright red blood in stool several days ago....Rectal exam reveals brown Hemoccult (checks for presence of blood) positive stool....1:04 PM....Discussed with hospitalist who accepted admission....plan to trend H&H's (hemoglobin, hematocrit). ..." Review of physician orders revealed an order for "Hemoglobin and Hematocrit....Order Date/Time 02/23/2022 1502.... Every 8 hours.... 4 occurrences... ." Review of provider orders also revealed an order for "CBC (Complete Blood Count [which would include a H&H])....Order Date/Time 02/23/2022 1815 Start Date/Time 02/24/2022 0605....Daily....7 days... ." Review of Lab results revealed H&H results on 02/23/2022 at 1701 of Hemoglobin 8.1 and Hematocrit 24. Review revealed another result at 02/24/2022 at 0056 (7 hours 55 minutes later) which resulted a Hemoglobin of 8.2 and Hematocrit of 25. Review of Lab testing did not reveal a H&H completed 8 hours later as ordered and did not reveal a CBC around 0605. At 1230 on 02/24/2022 a RN Note revealed "Lab made aware that pt has labs due to be drawn. ..." Review revealed the next documented H&H result was 02/24/2022 at 1426 (13 hours 22 minutes after the last H&H ). Review failed to reveal testing as ordered.

Review of a document prepared and received from the facility 07/28/2022 revealed "Lab Collection Process for ED patients and ED Boarders Current State Nurses collect lab specimens for ED Boarders. Support is available if the nurse calls the lab to let them know labs need to be drawn. Non-ED RNs may not realize this is an expectation. ..."

Interview with ED Director #1 on 07/28/2022 at approximately 1000 while on tour of the ED revealed that a section of the ED (E Bay)currently served as a holding area for boarding patients, patients who were admitted but waiting for an inpatient bed to become available. Interview revealed they tried to staff the unit with inpatient float pool nurses when available since these were admitted patients just waiting for a bed.

Interview on 07/28/2022 at 1025 with RN #2 in the Emergency Department area where patients were boarded revealed the RN was an inpatient Float Pool Nurse. Interview revealed RN #1 did not draw blood, interview revealed "the lab staff draws bloods."

Interview with the Director of the Labs and Lab Staff #5, on 07/28/2022 at 1100, revealed the serial lab for Patient #1 in the morning of 02/24/2022 was auto cancelled in the system because the daily morning lab order "took its place." Interview revealed the lab fell through the cracks and neither lab was drawn that morning as ordered. At 1300, another phlebotomist came on duty and was assigned to the ED. That phlebotomist could see the lab had not been drawn for Patient #1 and completed it at around 1400. Interview with the Lab Director confirmed an error was made and it was "not good care."

Interview with Lab Manager #3, on 07/28/2022 around 1130, when the Manager joined with the Director of the Labs and Lab Systems Analyst, revealed all labs in the Emergency Department were "Nurse Collects." Interview revealed when ED patients were in boarding status phlebotomy staff could not see that a lab had not been collected. The labs were considered "Nurse Collect" so only the nurses could see them. When the Phlebotomy Staff member came in at 1300 and was assigned to the ED, that staff member was assigned a nurse role and could then see the pending labs.

NC00186518, NC00185512, NC00182316, NC00182454, NC00188320, NC00179145, NC190243