HospitalInspections.org

Based on an interview and documentation review, it was determined the Hospital had not (yet) completed its Internal Investigation related to Patient #1's care/death.

Findings included:

Please see Initial Comments for information related to Patient #1.

A review of the Hospital Internal Investigation related to Patient #1's care/death revealed it was underway, but not (yet) completed. Staff and physicians involved in the Patient's care had not been formally interviewed and the Patient's ICU care had not been reviewed.

A review of the Hospital Internal Investigation to-date revealed it identified issues related to the application of a FemoStop, occurrence reporting and documentation.

Documentation indicated Patient #1's case/death was reviewed by the Interventional Cardiologists. The Interventional Cardiologists noted Patient #1's multiple severe vascular problems and thought his/her lower extremity ischemia and probable mesenteric ischemia were due to thrombic or atherosclerotic plaque emboli secondary to the cardiac cath and a lower extremity angioplasty and stenting procedure performed to address the lower extremity ischemia. The Interventional Cardiologists also thought it was appropriate to perform Patient #1's diagnostic cardiac cath at the (community) Hospital and that a post-cardiac cath right groin hematoma and/or the improper application of a FemoStop did not contribute to his/her outcome.

The Hospital's Risk Manger said the Hospital Internal Investigation was ongoing and would soon be completed.

Based on interviews and documentation review, it was determined the Hospital had not (yet) completed its Internal Investigation related to Patient #1's care/death and therefore had not fully developed and implemented a Corrective Action Plan.

Findings included:

Please see Initial Comments and Tag A 287 for information regarding Patient #1 and the Hospital's Internal Investigation regarding his/her care and death.

The Hospital Internal Investigation was underway, but not (yet) completed. Staff and physicians involved in Patient #1's care had not been formally interviewed and Patient #1's ICU care had not been reviewed.

A review of the Hospital Internal Investigation to-date revealed it identified issues related to the application of a FemoStop, occurrence reporting and documentation. The physician who applied the FemoStop to Patient #1 and the ICU Nursing Staff were educated regarding FemoStop application. Corrective actions related to the occurrence reporting and documentation issues had not (yet) been developed and implemented.