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Based on review of medical record, facility policy and staff interviews, the governing body failed to ensure its medical staff followed the Hospital Medical Staff Bylaws and were accountable for the quality of care provided when the declining state of one out of one patient (#1) was not addressed in a timely manner.

Findings:

El Paso Childrens Hospital Staff Bylaws last revised on 11/30/22:

Article I,
1.2 Purposes are:
1.2.1 To oversee the quality of care, treatment, and services provided by Practitioners who are credentialed and privileged;
1.2.2 To provide a uniform standard of quality patient care, treatment, and services;...
1.2.5 To monitor the care for all patients admitted to, or treated in any Department or service of the Hospital, to assure that the care is appropriate and provided in a manner that meets or exceeds the applicable standard of care and that each member of the Medical Staff conducts himself in a professional and ethical manner;
1.2.6 To engage in a systematic and continuous review, evaluation and improvement of patient care and the processes by which patient care is delivered by the Medical Staff and others in the Hospital;
1.2.7 To provide a means by which the Medical Staff reports to the Board of Directors and the Chief Executive Officer regarding the discharge of its responsibility to provide appropriate patient care and to support the operation of the Hospital; ...



Refer to A0049
A0083
A0084

Based on review of medical record, facility policy and staff interviews, the governing body failed to ensure its medical staff was accountable for the quality of care provided when the declining state of one out of one patient (#1) was not addressed in a timely manner. The lack of action resulted in an emergency surgery with the ultimate death of the patient #1.

Findings:

A. Status-post exploratory laparotomy on 09/05/23, Patient #1 was admitted to the Pediatric Intensive Care Unit [PICU] at 07:45 am with vital signs [VS] of: Heart Rate [HR] 135; Respiration Rate [RR] 24; Blood Pressure [BP] 133/80; SpO2 [oxygen saturation] 95% on Room Air [RA]

The initial admission assessment on Patient #1 was performed when admitted to PICU by the attending physician (Staff #6), 2 resident physicians, bedside nurse and charge nurse performed the initial assessment. Although the attending MD received report from the bedside nurse, the Resident MDs and the Charge Nurse of the patient's decline and unrelieved pain, Staff Member # 6 did not personally assess the patient. as noted in the medical record:

08:00 am the nurse [Staff #7] documented Patient #1 complained of moderate abdominal pain and was frowning, grimacing, and had anxiety and rated pain 5 out of 10. A PCA [Patient Controlled Analgesic] pump of Morphine was ordered by the physician to control pain.
09:38 am Morphine 2 mg IVP [milligrams intravenous push] was given for pain
09:39 am PCA Morphine started with a continuous rate of 1mg/mL with a bolus dose of 1 mg every 30 minutes started
Approx[imately] 10:30 am - Staff #9's [medical resident's] late entry dated 9/12/23 for 9/5/23 stated, "Performed H&P [history and physical] with medical student ... Vitals showed heart rate in the 130s and blood pressure with MAPs [mean arterial pressures] > 65. -Presented to [Staff #6]."
11:00 am Staff #7 documented pain interventions response was mildly effective and documented patient pain at 4. VS: HR 118, RR 25, BP 125/81
11:30 am Staff #7 nursing progress note stated, "MD updated about patient status to include abdominal distension, unrelieved pain after giving morphine X 2. MD ordered to obtain a KUB [Kidney, ureter, and bladder Xray]."
12:00 pm - KUB resulted "no bowel obstruction or free air" Staff #7 documented pain at 6 with crying and verbal outbursts. VS: HR 122; RR 22; SpO2 95% RA Nursing progress note stated, "[Staff #6] notified that patient is restless and agitated. MD updated about abnormal vital signs to include high blood pressure and high heartrate, MD ordered to give Versed 1mg IV push."
Approx 12:00 - Staff #9 late entry, "I was called to bedside by nurse due to patient being awake and in pain ... I discussed concerns and exam with [Staff #6]."
12:30 pm - Nursing note "Mom called nurse to bedside, verbalized concern about the pain not being under control. [Staff #6] notified and ordered to administer Versed one time dose and ordered to increase frequency of the PCA pump"
12:35 pm - Nursing Note "[Staff #6] ordered to start Precedex drip. Mother refused to start Precedex drip due to multiple PRNs given at this time. Patient was calm after Versed was administered." VS: HR 151; BP 132/84; SpO2 92 % RA
01:00 pm Staff #7 documented no pain. VS: HR 154; RR 21; BP 128/99
01:30 pm Nursing progress note stated, "resident physician (Staff #9) was updated about abnormal vital signs to include high heart rate and abdominal distension. No new orders received."
Approx 01:30 pm - Staff #9 late entry, "I entered the room to reevaluate patient. Heart rate in 140s ..."
02:00 pm VS: HR 149; RR 23; BP 110/74; SpO2 92%
03:00 pm VS: HR 150; RR 22; BP 90/50; SpO2 93%; nursing progress note described extremities as "cold" Mucus membrane color as "Cyanotic"
Approx 03:00 pm - Staff #9's late entry, "-Called in by bedside nurse due to mother's concerns. -Vitals showed hypotension and tachycardia. Patient's lower extremities showed mottling. Extremities were cold and increase in capillary refill > 3 seconds. Pulses were diminished. Abdomen was distended and rigid at this time with a mild increase in serosanguineous drainage to dressing. -IV fluid bolus started. I called PICU attending and reached Staff #10 (an attending physician who just arrived for the shift). He arrived quickly to bedside and started to give orders. PICU charge nurse was already in the room along with multiple nurses and other PICU resident. I was asked to notify the surgeon of the situation and she arrived within a few minutes. -Patient taken down to OR emergently."
03:10 pm - nursing progress note, "Patient's vital signs suddenly changed: HR 145, RR: 22, BP 85/51 MAP: 62. [Staff #6], residents at bedside at this time. Physician ordered to change BP cuff location and retake BP and MD ordered to keep monitoring." In an interview on 9/19/23, VP of Quality and Patient Safety stated, "This entry is being corrected/amended as [Staff #6] never entered the patient's room as she was departing for the day. [Staff #6] herself confirmed. The conversation actually took place outside of the patient's room. [Staff #6] instructed the nurse to change BP cuff to the other arm and repeat the BP.")
04:00 pm VS: HR 152; RR 19; BP 98/71; SpO2 99%
04:10 pm Pt transport to OR [operating room]. VS HR 138; RR 18; BP 107/57 - extremities "cold" mucus membrane color "Pale"
Patient #1 ultimately passed in the OR suite and was pronounced on 9/5/23 at 6:01 pm.

B. Despite the patient #1's rapid decline, no staff member of the interdisciplinary team activated Pediatric Rapid Response Team as required by facility policy:

Facility policy entitled "Pediatric Rapid Response Team" stated in part "The Pediatric Rapid Response Team (PRRT) of critically trained staff at El Paso Children's Hospital (EPCH), will assist with and evaluate any patient in the hospital who has clinically compromised values. The PRRT may be summoned at any time by anyone in the hospital if there is a question or concern regarding the patient's condition ...

Significant changes in the assessment of the patient's medical condition may include the following, but will not be limited to:

1. Acute change from baseline in vital signs or saturations.
2. Signs of respiratory distress.
3. Altered conscious state or change from baseline state.

Upon identifying a pediatric patient in need of the PRRT:

1. Any staff member of the interdisciplinary team may activate the PRRT without penalty. The patient's primary nurse or charge nurse will be responsible for notifying the patient's primary team.
a) Any family member can initiate or request initiation of the PRRT
b) The registered nurse caring for the patient shall educate the patient's family to notify the nursing staff regarding changes in the patient's condition.
2. The PRRT will be activated by dialing the hospital's emergency number (5555) and stating, "Pediatric Rapid Response Room__" Caller will identify themselves. Operators must be informed of the exact location where the rapid response is occurring.
3. The Hospital PBX operator will be responsible for notifying the PRRT members via page and text. The AOD will be notified by phone and/or text message.
4. The PRRT will immediately respond to the emergency location. The team will assess the patient and will implement treatment per PALS and further interventions under the direction of the physician on the team.
5. The AOD will verify that the patient's attending physician has been notified.
6. Disposition of the patient will be decided by the physician on the PRRT."

C. Interview conducted September 9/19/23 with the VP of Quality and Patient Safety (staff Member #5) confirmed the lack of hands-on care and assessment by the patient's attending physician.

Staff Member # 5 stated "the patient was continually assessed the nearly 8 hours post-surgery by the bedside nurse, the Charge Nurse and the two resident MDs on duty. Each had reported the patient's decline to the attending MD (Staff Member # 6). Although Staff member # 6 was only assigned to care for one patient that day (Patient # 1), after the initial admission, she did not go into the patient's room to personally assess her. The patient continued to decline and complain of unrelieved pain throughout the day."
Staff Member # 5 continued "when shift change took place, the night shift attending doctor, Staff Member # 10, arrived and determined that there was an emergency and Patient # 1 was rushed back into surgery where she expired as a result of abdominal compartment syndrome and hypovolemic shock."

Staff Member # 5 further confirmed that the involved staff did not follow its Pediatric Rapid Response policy. The rapid response could have been initiated when the mother expressed concern about the patient's abnormal vitals or when the nurse observed the abnormal vitals and uncontrolled pain, but it was not.

Based on review of documentation and interview, it was revealed that the faciliy's governing body did not ensure that the hospital's contracted services permitted the hospital to comply with all applicable conditions of participation and standards for the contracted services.

Findings were:

The contractual agreement with Texas Tech stated in part:

"EPCH contracts with Texas Tech University Health Sciences Center at El Paso for intensivist services. The services are required to be performed by pediatric critical care board eligible/certified physicians with hospital pediatric intensivist privileges. The agreement calls for 24/7/365 in-house coverage.

EPCH does not independently employ any physicians. EPCH does not directly supervise any physician, including the TTUHSC physicians providing intensivist services in the PICU. All TTUHSC physicians are independent contractors.

All physicians are monitored and evaluated by the Medical Staff in cooperation with the hospital via various Medical Staff committees and the FPPE/OPPE process."

Refer to A049 Medical Staff Accountability.

Based on review of medical records, facility policy and staff interviews, it was determined the governing body did not ensure that the services provided to patient # 1 were provided in a safe and effective manner. The hospital failed to provide proper management of pain by not responding reasonably to the parent's request for treatment for her child; failed to provide a safe setting when The Pediatric Rapid Response Team was not activated when a change in condition was noted by the interdisciplinary team; failed to provide a regular communication from the treatment team when the attending physician did not enter the patient's room after the initial admission despite being notified of condition changes.

Findings were:

The contractual agreement with Texas Tech stated in part:
"EPCH contracts with Texas Tech University Health Sciences Center at El Paso for intensivist services. The services are required to be performed by pediatric critical care board eligible/certified physicians with hospital pediatric intensivist privileges. The agreement calls for 24/7/365 in-house coverage.

EPCH does not independently employ any physicians. EPCH does not directly supervise any physician, including the TTUHSC physicians providing intensivist services in the PICU. All TTUHSC physicians are independent contractors.

All physicians are monitored and evaluated by the Medical Staff in cooperation with the hospital via various Medical Staff committees and the FPPE/OPPE process. "

Refer to A0049 Contracted Services