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Based on record review, physician and staff interview the Hospitalist failed to document a significant change in condition for one of one Patient's after a fall on the inpatient unit with a head injury. The Physician did not re-examine nor document the Patient's deteriorating medical condition which required an emergent surgical evacuation of a subdural hematoma in April 2010.

The findings are as follow:

Review of the Variance Report and as reported, indicated the Patient was found on the floor next to a chair lying face down on 04/27/10 at 7:30 PM. The Patient sustained a laceration on the left side above the eyebrow and a hematoma on the left side of the head. The nursing staff returned the Patient to bed and dressed the laceration. The Patient's vital signs were recorded as blood pressure of 168/78, heart rate of 89 beats per minute and oxygen saturation level was recorded as 93%. on room air.

Review of the Hospitalist Progress Note (mistakenly dated 04/26/10 instead of 04/27/10) at 8:20 PM indicated the Hospitalist documented the Patient fell and RN (#1) reported hearing a noise and the Patient was laying on the floor (words unknown). The Patient had a cut over the left eye and swelling of the eye. The Patient complained of having a headache with no other complaints. The Hospitalist indicated the Patient was already identified as a fall risk and the (safety) protocol was in place (call bell within reach, yellow dot ID band and frequent checks). The Patient pulled out the intravenous needle. The Hospitalist indicated the Patient's neurological examination was unchanged. The Patient moved all extremities. The Hospitalist notified the Patient's spouse by telephone of the fall. The Hospitalist indicated the Patient had head trauma and ordered a head computerized tomography (CT)scan. The Hospitalist indicated surgery could be consulted for the laceration of the Patient's left eye brow. The Hospitalist recommended neuro checks and monitoring the Patient.

The Hospitalist was interviewed in person on 05/11/10 at 3:30 PM. The Hospitalist said after the Patient's fall ,the Patient was unchanged from the night before when the Patient was admitted. The Hospitalist said the Patient would need surgical services for the laceration over the left eye. The Hospitalist was not sure if the Patient's spouse was informed for the need for a head CT. The Hospitalist said the Patient's spouse was told the Patient looked okay.

Review of the Neurological Nursing Assessment dated 04/27/10 at 8:05 PM indicated the Patient's neurological signs were within normal limits with the exception the Patient was disoriented to time. The Patient was alert, awake and conversant. The Patient's pupils were equal and reactive. The Nursing Assessment indicated there was no drift with the Patient's motor function.

Continued review of the Patient's medical record and as reported, the Rapid Response Nurse said the Patient was taken for the head CT at approximately 9 PM. Review of the Patient's head CT indicated positive for a subdural hematoma. The report was dated 04/27/10 as dictated by the radiologist at 9:10 PM.

Review of the Nursing Progress Note dated 04/27/10 at 9:30 PM indicated the Patient had facial droop, equal but weak grasp, drowsy but conversant and arousable. The Nursing Note indicated the Hospitalist notified the family of the Patient's fall. The Patient's vital signs were recorded as a blood pressure of 179/101, heart rate 109 beats per minute. There were no recorded respirations or oxygen saturation level recorded.

The Rapid Response Nurse said on return to the inpatient unit, the Patient was placed onto the cardiac monitor. The Rapid Response Nurse said the Patient was hard to arouse and not following commands for eye opening and calling out the name of a sitter or a female friend.

Review of the Paging System Records indicated the Rapid Response Nurse placed a call to the Neurosurgeon on 04/27/10 at 10 PM, the message read Patient more nauseous, more lethargic. The Neurosurgeon responded at 10:22 PM to report there would be no need to transfer the Patient out and the Neurosurgeon was coming in to take the Patient into the operating room. The Rapid Response Nurse sent another page to the Neurosurgeon on 04/27/10 at 10:23 PM, the message read the Patient was deteriorating quickly, tachycardiac, hypertensive, lethargic and no long moving the left arm.

The Hospitalist said the Neurosurgeon responded to the call out. The Hospitalist said the Patient was not re-examined after the head CT because the Patient was being transferred to the service of the Neurosurgeon. The Hospitalist was seeing patients in the ED. The Hospitalist said the Neurosurgeon reported the Patient needed to be brought to the operating room. The Hospitalist said there may have been another conversation about other options being considered and taking the Patient to the operating room with the Patient's spouse. However, the Hospitalist did not specifically recall the conversation and said the discussion would have been very general. The Hospitalist said the Neurosurgeon would have to provide the Patient's spouse with the specific details about the risks and benefits of the surgical procedure and to obtain consent for the surgical procedure.

Review of the Patient's Medical Record lacked physician documentation in a written progress note on 04/27/10 between the hours of 9:10 PM to 10:40 PM following the Patient's head CT and the Patient's decline in mental status and unresponsiveness. The Patient's Medical Record lacked documentation for the options as stated by the Hospitalist which included consideration to transfer to another hospital and the transfer of care to the services of a Neurosurgeon. There was no physician documentation the Patient's spouse had been contacted or documentation for an attempt to contact the Patient's spouse of the Patient's deteriorating medical condition and the need for emergent surgery.

Review of the Nursing Progress Note dated 04/27/10 at 10:37 PM indicated the Patient was unresponsive. The Patient's vital signs were recorded as a blood pressure of 179/110, heart rate of 110 beats per minute. The Patient was transported to the Operating Room.

The Rapid Response Nurse said the Patient was brought into the Holding Area and care was transferred to the circulating RN. The Rapid Response Nurse said the Anesthesiologist planned on immediately intubating the Patient to maintain the Patient's airway.

Review of the Anesthesia Intra-Operative Record dated 04/27/10 at 10:55 PM, indicated the Patient was intubated in the operating room.

Review of the Intraoperative Record dated 04/27/10 at 11:20 PM indicated the Patient's surgery began.

There was no physician documentation for the change in the Patient's medical condition on 04/27/10 after the head CT was obtained and the Patient became unresponsive.

Refer to A-Tag 0395, A-Tag 0449, A-Tag 0461, and A-Tag 0959.

Based on record review, physician and staff interview indicated the nursing staff failed to adequately assess one of one Patient's after a fall in April 2010.

The findings are as follow:

Review of the Admission Nursing Assessment dated 04/27/10 at 12 AM indicated the Patient was placed on cardiac telemetry. The Patient's heart rate was regular, at a rate of 96 beats per minute. The Patient's neurological assessment indicated the Patient had no drift in motor function of the extremities and pupil measurement was 4 on the right and left with brisk reaction. The Patient had no identified limitations with bed mobility and able to sit with minimal assistance. The Patient was identified as needing maximum assistance with bathing and minimum assistance of two with bed to chair transfer. The Patient was identified as being at risk for falls with a score of 35.

Review of the Hospital's Policy for Falls Injury and Post-Fall indicated the purpose was to define the standard of care and nursing practice who are at risk for falls/injury and provide strategies for responsible first line management and intervention. The Policy indicated patients identified with a fall risk score of 50 or higher on the Morse Fall Scale Risk Assessment required the implementation of a plan that included alternative strategies to minimize falls and injury. The Interventions included: safety alarm when a patient was unable to understand or follow directions and other less restrictive alternatives have been unsuccessful.

Review of the Nursing Note dated 04/27/10 at 1:26 AM indicated the Patient complained of getting weaker and could not stand or walk. The Patient reported not being able to get the right words out.

Review of the Nursing Note dated 04/27/10 at 4:10 AM indicated the Patient was disoriented to time and place but easily reoriented. The Patient denied being nauseous or having a headache. The Patient complained of feeling weak. The Nursing Note indicated the left hand grasp was stronger than on admission (approximately three hours earlier).

Review of the Fall Risk Assessment dated 04/27/10 at 8 AM indicated the Patient's level of risk for falls was increased to a score of 70 secondary to the Patient's impaired gait and forgetfulness about limits. The Patient was issued a mobility monitor/ a bed alarm.

Review of the Physical Therapy Consultation dated 04/27/10 at 4:20 PM indicated the Physical Therapist documented the Patient demonstrated decreased strength and impaired balance without equilibrium or protective reactions. The Physical Therapist indicated the Patient demonstrated decreased insight into deficits and decreased safety awareness and emotional lability throughout evaluation. The Physical Therapist recommended the use of a rolling walker for increased stability at the time for all ambulation. The Physical Therapist indicated the nursing staff were made aware of the results of the evaluation.

Review of the Variance Report and as reported, the Patient was found on the floor, next to a chair lying face down on 04/27/10 at 7:30 PM. The Patient sustained a laceration on the left side above the eyebrow and a hematoma on the left side of the head. The nursing staff returned the Patient to bed and dressed the laceration. The Patient's vital signs were recorded as blood pressure of 168/78, heart rate of 89 beats per minute and oxygen saturation level was recorded as 93%. on room air.

Review of the Hospital's Policy for the Management of the Patient at Risk for Falls/Injury Post-Fall indicated the interventions included for less severe injury or no obvious injury, conduct neurological and vital signs every two hours times four; then every four hours. The Policy indicated for more severe injury requiring frequent assessments consider transfer to the critical care area and for suspected head injury consider transfer to the Intensive Care Unit. The Patient sustained head trauma.

On 04/27/10 at 7:30 PM, the Registered Nurse indicated the Patient was found lying on the floor. The Nursing Note indicated the Patient had a laceration and swelling above the left eye and a dressing was applied to the area. The Nursing Note indicated the Patient's neurological signs and vital signs were monitored.

Review of the Neurological Nursing Assessment dated 04/27/10 at 8:05 PM indicated the Patient's neurological signs were within normal limits with the exception the Patient was disoriented to time. The Patient's pupils were equal and reactive. The Nursing Assessment indicated there was no drift with the Patient's motor function. The Nursing Assessment Note indicated the Patient was alert, awake and conversant.

Review of the Fall Risk Assessment dated 04/27/10 at 8:05 PM indicated despite the Patient's fall. The Patient's Fall Risk Assessment score was lowered to a score of 35. The Patient was issued a one to one sitter and a bed alarm.

The Registered Nurse who documented the nursing notes and was assigned to the Patient was out of the country and not available for an interview during the days of survey. The Nurse Manager said the Registered Nurse would not be returning to work for approximately five weeks.

The Nursing Note dated 04/27/10 at 8:45 PM indicated the Rapid Response Nurse was aware of the Patient's fall.

The Rapid Response Nurse was interviewed in person on 05/11/10 at 7:15 AM. The Rapid Response Nurse said rounds were made to each inpatient unit. The Rapid Response Nurse said the nursing staff reported the Patient fell and the Patient was okay. The Rapid Response Nurse said the nursing staff called to report Radiology was ready to take the Patient at approximately 9:30 PM. The Rapid Response Nurse said the Patient was talking, appropriate and able to follow commands. The Rapid Response Nurse said the Patient started to vomit in Radiology. The Rapid Response Nurse said many patients get motion sickness when being transported. The Rapid Response Nurse said on the Patient's return to the inpatient unit, the Patient was very different and something was wrong,and abnormal. The Rapid Response Nurse said the Patient became frigidity and moved all arms and legs in a uncoordinated fashion. The Rapid Response Nurse said the Hospitalist was paged and informed of the change of condition.. The Rapid Response Nurse said the head CT scan showed a subdural hematoma. The Rapid Response Nurse said the scan was read virtually by the Radiologist. The Rapid Response Nurse said the Hospitalist had the results and a Neurosurgeon was called. The Rapid Response Nurse said the initial plan was to transfer the Patient to a Boston hospital but the Patient began to deteriorate to quickly.

Continued review of the Patient's medical record and as reported by the Rapid Response Nurse, the Patient was taken for the head CT at approximately 9 PM.

Review of the Neurologic Assessment Flow Sheet dated 04/27/10 indicated the registered nurse documented at 8 PM and 9 PM, the Patient's eyes opened spontaneously and the pupils were reactive. The Patient was oriented and conversant. The Patient obeyed verbal commands and lifted both the right and left arm.

Review of the Nursing Progress Note dated 04/27/10 at 9:30 PM indicated the Patient had facial droop, equal but weak grasp, drowsy but conversant and arousable. The Patient's vital signs were recorded as a blood pressure of 179/101, heart rate 109 beats per minute. There were no recorded respirations or oxygen saturation level recorded for the Patient with a deteriorating mental status. There was no recording for the Patient's Glasgow Coma Scale.

Review of the Neurologic Assessment Flow Sheet dated 04/27/10 at 10 PM indicated the Patient's assessment remained the same and the Patient was oriented and conversing, opening eyes spontaneously and obeying verbal commands. The Registered Nurse's unsigned hand written assessment was in contradiction to the statement made by the Rapid Response Nurse.

The Rapid Response Nurse said on return to the inpatient unit, the Patient was hard to arouse and not following commands and calling out the name of a sitter or a female friend.

Review of the Nursing Progress Note dated 04/27/10 at 10:37 PM indicated the Patient was unresponsive. The Patient's vital signs were recorded as a blood pressure of 179/110, heart rate of 110 beats per minute. The Patient was transported directly to the Operating Room.

Review of the Anesthesia Intra-Operative Record dated 04/27/10 at 10:55 PM indicated the Patient was intubated by the Anesthesiologist.

Both the assigned RN and Rapid Response Nurse failed to clearly document the events of the evening and the observations made as to the Patient's change in condition, physician contact, arrangements for physician consultation and the transfer of the Patient for emergency surgery.

The Nursing Supervisor was interviewed in person on 05/10/10 at 3:45 PM. The Nursing Supervisor said the Patient fell and sustained an eye injury a laceration over one eye. The Nursing Supervisor said the unit secretary reported the Patient was fine and a head CT was going to be done. The Nursing Supervisor denied speaking with the nursing staff directly. The Nursing Supervisor said the Rapid Response Nurse was handling the arrangements and speaking with the Hospitalist. The Nursing Supervisor said the expectation for a patient with a head injury is to document the patients neurological signs every fifteen minutes. There was no documentation for frequent vital or neurological signs in the Patient's record.

There was no documented Plan of Care for the Patient. There was no initiation of the Plan of Care following the Patient's fall with injury nor an outline of the interventions necessary to monitor the Patient with a Head Injury.

Refer to A-tag 0449.

Based on record review, physician and staff interview the Hospitalist failed to document a significant change in condition for one of one Patient's after a fall on the inpatient unit with a head injury. The Physician did not re-examine nor document the Patient's deteriorating medical condition which required an emergent surgical evacuation of a subdural hematoma in April 2010.

The findings are as follow:

The Hospitalist was interviewed in person on 05/11/10 at 3:30 PM. The Hospitalist said after the Patient's fall the Patient was unchanged from the night before when the Patient was admitted. The Hospitalist said the Patient would need surgical services for the laceration over the left eye. The Hospitalist said the Patient's spouse was notified of the fall but the Hospitalist was not sure; if the Patient's spouse was informed of the need for a head CT. The Hospitalist said the Patient's spouse was told the Patient looked okay.

The Rapid Response Nurse was interviewed in person on 05/11/10 at 7:15 AM. The Rapid Response Nurse said rounds were made to each inpatient unit. The Rapid Response Nurse said the nursing staff reported the Patient fell and okay. The Rapid Response Nurse said rounds were made on 04/27/10 at approximately 8:30 PM. The Rapid Response Nurse did not assess the Patient. The Rapid Response Nurse said the nursing staff called to report Radiology was ready to take the Patient at approximately 9:00 PM. The Rapid Response Nurse said the Patient was talking, appropriate and able to follow commands. The Rapid Response Nurse said the Patient started to vomit in Radiology while being placed on the table. The Rapid Response Nurse said many patients get motion sickness when being transported. The Rapid Response Nurse returned the Patient to the inpatient unit. The Rapid Response Nurse said the Patient was very different and something was wrong and abnormal. The Rapid Response Nurse said the Patient became frigidity and moved all arms and legs in a uncoordinated fashion. The Rapid Response Nurse said the Hospitalist was paged. The Rapid Response Nurse said the head CT scan showed a subdural hematoma. The Rapid Response Nurse said the scan was read virtually. The Rapid Response Nurse said the Hospitalist had the results and a Neurosurgeon was called. The Rapid Response Nurse said the initial plan was to transfer the Patient to a Boston hospital however, the Patient deteriorated too quickly.

The Hospitalist said the Patient was not re-examined after the head CT because the Patient was being transferred to the service of the Neurosurgeon. The Hospitalist was seeing patients in the ED. The Hospitalist said the Neurosurgeon reported the Patient needed to be brought to the operating room. The Hospitalist said there may have been another conversation about other options being considered and taking the Patient to the operating room with the Patient's spouse. However, the Hospitalist did not specifically recall the conversation and said the discussion would have been very general. The Hospitalist said the Neurosurgeon would have to provide the Patient's spouse with the specific details about the risks and benefits of the surgical procedure and obtain consent.

Review of the Patient's Medical Record lacked physician documentation in a written progress note on 04/27/10 between the hours of 9:10 PM to 10:40 PM following the Patient's head CT and the Patient's decline in mental status and unresponsiveness. The Patient's Medical Record lacked documentation for the options as stated by the Hospitalist which included consideration to transfer to another hospital and the transfer of care to the services of a Neurosurgeon. There was no physician documentation the Patient's spouse had been contacted or documentation for an attempt to contact the Patient's spouse of the Patient's deteriorating medical condition and the need for emergent surgery.

Review of the Nursing Progress Note dated 04/27/10 at 10:37 PM indicated the Patient was unresponsive. The Patient's vital signs were recorded as a blood pressure of 179/110, heart rate of 110 beats per minute. The Patient was transported to the Operating Room.

Review of the Anesthesia Intra-Operative Record dated 04/27/10 at 10:55 PM, the Patient was intubated.

Review of the Intraoperative Record dated 04/27/10 at 11:20 PM indicated the Patient's surgery began.

Based on record review, physician and staff interview the Hospitalist failed to document a significant change in condition for one of one Patient's after a fall on the inpatient unit with a head injury. The Physician did not re-examine nor document the Patient's deteriorating medical condition which required an emergent surgical evacuation of a subdural hematoma in April 2010.

The findings are as follow:

The Hospitalist was interviewed in person on 05/11/10 at 3:30 PM. The Hospitalist said after the Patient's fall the Patient was unchanged from the night before when the Patient was admitted. The Hospitalist said the Patient would need surgical services for the laceration over the left eye. The Hospitalist said the Patient's spouse was notified of the fall but the Hospitalist was not sure if the Patient's spouse was informed of the need for a head CT. The Hospitalist said the Patient's spouse was told the Patient looked okay.

The Hospitalist said the Patient was not re-examined after the head CT because the Patient was being transferred to the service of the Neurosurgeon. The Hospitalist was seeing patients in the ED. The Hospitalist said there may have been another conversation about other options being considered and taking the Patient to the operating room with the Patient's spouse. However, the Hospitalist did not specifically recall the conversation and said the discussion would have been very general. The Hospitalist said the Neurosurgeon would have to provide the Patient's spouse with the specific details about the risks and benefits of the surgical procedure and obtain consent.

Review of the Patient's Medical Record lacked physician documentation in a written progress note on 04/27/10 between the hours of 9:10 PM to 10:40 PM following the Patient's head CT and the Patient's decline in mental status and unresponsiveness. The Patient's Medical Record lacked documentation for the options for the Patient which included consideration to transfer to another hospital and the transfer of care to the services of a Neurosurgeon. There was no physician documentation the Patient's spouse had been contacted or documentation there was an attempt to contact the Patient's spouse of the Patient's deteriorating medical condition and the need for emergent surgery.

Review of the Anesthesia Intra-Operative Record dated 04/27/10 at 10:55 PM indicated the Patient was intubated.

Review of the Intraoperative Record dated 04/27/10 at 11:20 PM indicated the Patient's surgery began.

The Neurosurgeon was interviewed in person on 05/11/10 at 4:50 PM. The Neurosurgeon said the Patient had a fall and as reported initially looked fine. The Neurosurgeon said the Patient was sent for a head CT and then quickly decompensated. The Neurosurgeon said it became clear the Patient's deteriorating condition was an emergent situation. The Neurosurgeon said the Hospitalist reported the results of the Patient's head CT by telephone. The Neurosurgeon then came into the Hospital and prepared for surgery. The Neurosurgeon said the Patient was a full code.

Refer to A-tag 0359, A-tag A-0449, A-tag , A-tag 064 and A-tag 0955.

Based on record review, physician and staff interview, the Hospitalist and Rapid Response Nurse failed to document the Patient's change in condition after a fall in April 2010.

The findings are as follow:

The Hospitalist was interviewed in person on 05/11/10 at 3:30 PM. The Hospitalist said after the Patient's fall the Patient was unchanged from the night before when the Patient was admitted. The Hospitalist said the Patient would need surgical services for the laceration over the left eye. The Hospitalist said the Patient's spouse was notified of the fall but the Hospitalist was not sure if the Patient's spouse was informed of the need for a head CT. The Hospitalist said the Patient's spouse was told the Patient looked okay.

The Rapid Response Nurse was interviewed in person on 05/11/10 at 7:15 AM. The Rapid Response Nurse said rounds were made to each inpatient unit. The Rapid Response Nurse said the nursing staff reported the Patient fell and okay. The Rapid Response Nurse said rounds were made on 04/27/10 at approximately 8:30 PM. The Rapid Response Nurse did not assess the Patient. The Rapid Response Nurse said the nursing staff called to report Radiology was ready to take the Patient at approximately 9:00 PM. The Rapid Response Nurse said the Patient was talking, appropriate and able to follow commands. The Rapid Response Nurse said the Patient started to vomit in Radiology. The Rapid Response Nurse said many patients get motion sickness when being transported. The Rapid Response Nurse said the Patient became frigidity and moved all arms and legs in a uncoordinated fashion. The Rapid Response Nurse said the Hospitalist was paged. The Rapid Response Nurse said the head CT scan showed a subdural hematoma. The Rapid Response Nurse said the scan was read virtually. The Rapid Response Nurse said the Hospitalist had the results and a Neurosurgeon was called. The Rapid Response Nurse said the initial plan was to transfer the Patient to a Boston hospital but the Patient deteriorated too quickly.

Continued review of the Patient's medical record and as reported by the Rapid Response Nurse, the Patient was taken for the head CT at 9:00 PM

Review of the Nursing Progress Note dated 04/27/10 at 9:30 PM indicated the Patient had facial droop, equal but weak grasp, drowsy but conversant and arousable. The Patient's vital signs were recorded as a blood pressure of 179/101, heart rate 109 beats per minute. There were no recorded respirations or oxygen saturation level recorded.

The Rapid Response Nurse said on return to the inpatient unit, the Patient was hard to arouse and not following commands for eye opening and calling out the name of a sitter or a female friend.

The Hospitalist said the Patient was transferred to the service of the Neurosurgeon. The Hospitalist was seeing patients in the ED. The Hospitalist said the Neurosurgeon reported the Patient needed to be brought to the operating room. The Hospitalist said there may have been another conversation about other options being considered and taking the Patient to the operating room with the Patient's spouse. However, the Hospitalist did not specifically recall the conversation and said the discussion would have been very general. The Hospitalist said the Neurosurgeon would have to provide the Patient's spouse with the specific details about the risks and benefits of the surgical procedure and obtain consent.

Review of the Patient's Medical Record lacked physician documentation in a written progress note on 04/27/10 between the hours of 9:10 PM to 10:40 PM following the Patient's head CT and the Patient's decline in mental status and unresponsiveness. The Patient's Medical Record lacked documentation for the options as stated by the Hospitalist which included consideration to transfer to another hospital and the transfer of care to the services of a Neurosurgeon. There was no physician documentation the Patient's spouse had been contacted or documentation for an attempt to contact the Patient's spouse for the Patient's deteriorating medical condition and the need for emergent surgery.

Review of the Nursing Progress Note dated 04/27/10 at 10:37 PM indicated the Patient was unresponsive. The Patient's vital signs were recorded as a blood pressure of 179/110, heart rate of 110 beats per minute. The Patient was transported to the Operating Room.

The Rapid Response Nurse said the Patient was brought into the Holding Area and care was transferred to the circulating RN. The Rapid Response Nurse said the Anesthesiologist planned on immediately intubating the Patient to maintain the Patient's airway.

Review of the Anesthesia Intra-Operative Record dated 04/27/10 at 10:55 PM indicated the Patient was intubated.

Review of the Intraoperative Record dated 04/27/10 at 11:20 PM indicated the Patient's surgery began.

Refer to A-tag 0359, A-tag 0449, A-tag 0461 and A-tag 0955.

Based on record review, physician and staff interview one of one Patient's taken to the Operating Room for an emergent evacuation of a subdural hematoma, sustained after a fall while hospitalized evidenced documentation for surgical consent from a comatous Patient. The Operative Report was corrected during the course of survey on 05/11/10.

The finding are as follow:

Review of the Patient's medical record indicated the Patient was emergently transferred to the Operating Room on 04/27/10 at 10:37 PM in a unconscious/unresponsive state for the evacuation of a subdural hematoma confirmed by head CT taken approximately one and one half hours earlier.

There was no documented evidence for an attempt to obtain consent by a physician from the Patient's spouse for the emergent surgical procedure prior to the transfer of the Patient to the operating room.

According to the Hospitalist and Rapid Response Nurse, the Neurosurgeon was contacted outside of the Hospital by telephone to consult with the Patient's change in mental status, decreased level of consciousness and unresponsiveness. According to interview, the Neurosurgeon responded promptly and after consideration decided the best option for the Patient's survival was to take the Patient into the operating room.

Review of the Anesthesia Intra-Operative Report dated 04/27/10 indicated at 10:55 PM indicated the Patient was intubated.

Review of the Surgeons Operative Report dated 04/28/10 indicated the Patient presented with some leg weakness and some vague neurological complaints. The initial head CT scan was unremarkable following placement of a ventricular peritoneal shut earlier this year. During the course of the admission, the Patient fell became nauseated and drowsy and this led to a second CT dated 04/27/10 which showed an acute subdural hematoma with shift. Following discussion of the pros and cons of surgery, the Patient requested and the Surgeon agreed to proceed.

The Chair of the Surgical Services was interviewed in person on 05/11/10 at approximately 10:50 AM. The Chair of the Surgical Services was unaware of the emergent surgery for the Patient until apprised during survey by the Department. The Chair of the Surgical Services was informed by the Surveyor that the Surgeon was called and informed by the Hospitalist of the results of the Patient's head CT which was done approximately one and one half hours after the Patient had a fall. The Chair of the Surgical Services was informed by the Surveyor that the Patient was not capable of signing for consent for the surgical procedure as the Patient was unresponsive when transported to the operating room and immediately intubated by Anesthesia.

Despite the urgency of the Patient's need for surgery, the Surgeon did not speak with the Patient as documented for consent of the surgical procedure.

Review of the corrected Operative Report provided to the Surveyor on 05/11/10 at 12 PM indicated the Surgeon amended the report for the surgical procedure dated 04/28/10 on 05/11/10 at 11:26 AM. The Surgeon documented the Patient was wide awake immediately after the fall then became nauseated and drowsy. A second CT scan dated 04/27/10 showed an acute subdural hematoma with midline shift. The Surgeon indicated the Hospitalist reported that the family wanted to proceed with surgery. The Patient was a full code and because of the urgent life threatening nature of the situation, the Surgeon did not take the time to obtain the explicit consent from the family.

The Neurosurgeon said the final operative report was electronically signed during survey. The Neurosurgeon said it would have been inappropriate to reach the family under the circumstances and given the urgent nature of the surgery to try to get a hold of the family for consent. However, the issue was not attempting to contact the Patient's spouse but documenting the Patient explicitly provided consent for surgery.

The Hospitalist said the Patient was not re-examined after the Head CT because the Patient was being transferred to the service of the Neurosurgeon. The Hospitalist was seeing patients in the ED. The Hospitalist said the Neurosurgeon reported, the Patient needed to be brought to the operating room. The Hospitalist said there may have been another conversation with the Patient's spouse about other options being considered and taking the Patient to the operating room. However, the Hospitalist did not specifically recall the conversation and said the discussion would have been very general. The Hospitalist said the Neurosurgeon would have to provide the Patient's spouse with the specific details about the risks and benefits of the surgical procedure and obtain consent.