HospitalInspections.org

Based on review of hospital policies, closed medical record review, and staff and physician interviews the hospital's governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient rights, failed to ensure an organized nursing service to supervise and oversee care, and failed to ensure a patient received the imaging services required to diagnose and treat a patient's condition.

The findings include:

1. The hospital failed to protect and promote patients' rights by failing to ensure care was provided in a safe setting related to nursing staff failing to supervise and evaluate patient care and hospital staff failing to ensure a patient received imaging services required to diagnose and treat a patient's condition.

~cross refer to 482.13(c)(2) Patient Rights Standard: Tag A0144

2. The hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations to ensure registered nursing staff supervised and evaluated patient care.

~cross refer to 482.23 Nursing Condition: Tag A0395

3. The hospital failed to ensure diagnostic radiological services that met the needs of patients by failing to ensure a patient received imaging services required to effectively diagnose and treat a patient's condition.

~cross refer to 482.26(a) Radiologic Services Standard: Tag A0529

Based on review of hospital policies, medical record reviews, and staff and physician interviews, the hospital failed to protect and promote patients' rights by failing to ensure care was provided in a safe setting related to nursing staff failing to supervise and evaluate patient care and hospital staff failing to ensure a patient received imaging services required to diagnose and treat a patient's condition.

The findings include:

1. The hospital failed to ensure care in a safe setting by failing to ensure hospital nursing staff supervised and evaluated patient care by failing to assess and reassess a patient after a significant change in condition and by failing to ensure a patient received the imaging services required to effectively diagnose and treat a patient's medical condition for 1 of 1 patient's found unresponsive (Patient #2).

~cross refer to 482.13(c)(2) Patient Rights Standard: Tag A0144

Based on review of hospital policies, medical record reviews, and staff and physician interviews, the hospital failed to ensure care in a safe setting by failing to ensure hospital nursing staff supervised and evaluated patient care as evidenced by failing to assess and reassess a patient after a significant change in condition and by failing to ensure a patient received the imaging services required to diagnose and treat a patient's medical condition for 1 of 1 patient's found unresponsive (Patient #2).

The findings include:

1. Review of Progressive Care Unit [PCU] Guidelines "Assessment/Reassessment of Patients in PCU", effective 06/26/2017, revealed "... IV. Standards....C. A complete physical assessment must be completed once each shift. A cardiac and respiratory assessment must be completed every 4 hours. Assessments can be completed more often as the patient condition warrants. D. Vital signs will be taken on all patients every 4 hours or as often as the patient's condition warrants. ..." Guideline review did not reveal reassessment expectations with significant condition changes and did not indicate when more frequent neurological checks should be initiated.

Review of Policy and Clinical Practice Guidelines "HAND-OFF COMMUNICATION", reviewed/ revised 08/2016, revealed "...Hand-off communication utilizing the Situation, Background, Assessment and Recommendations (SBAR) format will be completed as a way to provide consistent and standardized communication between staff....VI. NOTE....D. The communication should address pertinent up-to-date information regarding the patient's treatment, any pending orders incomplete tasks. ..." Policy review did not reveal required documentation related to SBAR.

Review of a policy titled "Rapid Response Team Utilization", dated 06/03/2016, revealed "...POLICY....G. Criteria for Rapid Response Team utilization could include but not limited to the following:....9. Acute mental status change....H. When patient has been determined to meet any of the above criteria, the Rapid Response Team will be notified. ..."

Review of Medical Staff Rules and Regulations "Orders for Treatment", approved 08/2013, revealed "...To set forth guidelines for a standardized method of managing physician orders....III. STANDARDS ....F....2. Orders not related to medications must be reviewed and modified or unchanged as indicated:....b) At the time of admission to special care/intensive care units c) Before transferring to a nursing unit (including the Progressive Care Unit) from critical care units. ..."

Request for a Radiology Policy related to completing ordered radiology studies, on 08/23/2018 on 1730, revealed there was no policy.

Medical record review, on 08/22/2018, revealed Patient #2, a 54 year old male, arrived to the Emergency Department [ED] on 06/10/2018. Review of ED Documents revealed an ED Physician Note, at 0420, which stated Patient #2 had a past medical history that included Chronic Obstructive Pulmonary Disease [COPD], diastolic heart failure, and morbid obesity and he "...presented for evaluation of shortness of breath, swelling, and falls. He has had multiple falls over the last several days. He has some abrasions over his right head. Complains of worsening lower extremity and abdominal swelling, weeping, increased shortness of breath. Patient cannot lay back flat. ..." Review of "Medical Decision Making" revealed "...Differential includes traumatic injury, CHF [Congestive Heart Failure], COPD, PE [Pulmonary Embolus - clot in the lungs]. D-dimer [blood test] is elevated. ..." Further ED record review revealed " ...Assessment /Plan Ordered....CT Angiography [CTA - visualizes arteries and veins through the body] Chest...CT Head Scan w/o [without] contrast. ..." Lab results review, collected at 0415, showed an abnormal D-Dimer result of 3.10 [Reference range <0.52]. Review of results revealed the clinical cut-off to exclude a pulmonary embolus was <0.50.

Review of Electronic Orders revealed a physician order for "CT Head Scan w/o [without] Contrast", ordered STAT, on 06/10/2018 at 0457, for the reason of "Head trauma, headache". Order review did not reveal any reviews, modifications, or a cancellation of the order prior to Patient #2's transfer to a tertiary hospital on 06/13/2018. Electronic Order review also revealed a physician order was entered, at 0648 on 06/10/2018, for a "CT Angiography Chest", reason "PE [Pulmonary Embolus -blood clot in the lungs] suspected, high pretest prob [probability]. ..." Review of CT Angiography order comment, on 06/10/2018 at 0743 revealed a comment by a Radiology Tech that stated "...Pt to be put on Bi-pap machine and have treatments before having CT scans per ED. ..." Further review revealed another Radiology note, at 1419, "...Spoke with pt's ED nurse and she stated that pt was still unable to lie flat for longer than 30 seconds and was still unable to be still. Pt to be admitted. Will let us know if pt can be done. ..." Order review did not reveal any modifications or a cancellation of the order prior to Patient #2's transfer to a tertiary hospital on 06/13/2018.

Review of an Addendum by a second ED physician, signed 06/10/2018 at 1657, revealed "... Patient did improve with BiPAP. His d-dimer was significantly elevated but unfortunate the patient was unable to lie flat. We did discuss with the hospitalist who agreed to perform a VQ scan rather than attempt to lay the patient flat for CT and risk further respiratory decompensation. ..." Record review did not reveal any consideration of transfer to another hospital.

Review of the History and Physical [H&P], signed 06/10/2018 at 1615, noted Patient #2 fell "on his face and chest" the day before. H&P Review revealed "...Assessment/Plan ...Plan....Patient will be admitted to ICU for close monitoring of respiratory status. ..." Plan review did not reveal any notation related to the CT of the Head. Review of an H&P Addendum, at 2010, revealed "...Plan is to get VQ scan. In the mean time, We will start Lovenox [blood thinning medication] therapeutic dose for suspected PE. ..." Review of Physician Orders revealed an order, on 06/10/2018 at 2012, for Enoxaparin [Lovenox]Treatment, 190 mg [milligrams] subcutaneous injection every 12 hours. Review of the MAR [Medication Administration Record] revealed the first dose of Lovenox was given on 06/10/2018 at 2121 and it was then administered twice on both 06/11/2018 and 06/12/2018.

Record review revealed a Physician Consult Note signed 06/11/2018 at 1610, that stated Patient #2 "...had fallen prior to admission on the concrete stubbing his left great toe and then the next day fell on the carpet in him home tearing part of his RIGHT great toenail. We have been consulted to evaluate. He remains in ICU, off BiPAP, now on nasal cannula, and managed by hospitalists awaiting CT....On Lovenox and ASA [aspirin]. ..." Further review of the Consult Note revealed Patient #2 was given Morphine and then a portion of the right great toenail was cut away/ removed. Bacitracin and a dry dressing were applied to the wound bed. Review of a Provider Notification note by a RN, recorded 06/11/2018 at 1815, revealed "Discuss [as written] with provider pt unable to stand and get on stretcher for for [as written] xray. Ok to wait until tomorrow." Review of a Physician Progress Note, signed 06/11/2018 at 1919, revealed Patient #2 was placed on Lovenox as "empiric therapy" [based on experience and relevant clinical observation, not a definitive diagnosis] for PE. The Progress Note also stated Patient #2 was too large for a VQ scan and could not lie flat for the CT angiography. It revealed a plan to "...CT angio when pain level is controlled. Continue lovenox for suspected PE ....falls precautions. ..." Progress Note review did not reveal a plan related to the Head CT. Record review did not reveal any notations from Radiology or Nursing related to the Head CT. Review did not reveal any documentation to indicate if there was consideration of transfer to another hospital.

Review of a Physician Progress Note, signed 06/12/2018 at 1337, revealed " ...Patient transferred out of the ICU [Intensive Care Unit] to PCU [Progressive Care Unit] today ....Prior to going down for a CT of his chest will administer morphine and Toradol [pain medications] for better pain control And to maximize success with laying flat. ..." Progress Note review did not reveal any notation about the Head CT. Review of Physician Orders on 06/12/2018 at 1134, revealed an order for Morphine and Toradol to be given IV push on-call 10 minutes before the CT. Review of the MAR failed to reveal the Morphine or Toradol were given and failed to reveal a CT was done. Record review did not reveal any notations from Nursing, Radiology, or Physicians to indicate whether attempts were made to transport Patient #2 for the CT angiogram or the Head CT.

Record review did not reveal any additional documentation by Radiology related to the CT Angio or the Head CT after 06/10/2018. Further record review failed to reveal either the Head CT or the Chest CT Angiogram were performed prior to Patient #2 being found unresponsive on 06/13/2018

Review of a Nursing Neurological Assessment on 06/13/2018 , computer timed as 0700, revealed "Neurological Symptoms....Drowsiness ....Responds To....No response ....Level of Consciousness....Unable to arouse....Change in Mental Status....Acute Change from baseline.... PERRLA....Yes....Eye Opening Response Glasgow....No response....Best Verbal Response Glasgow....No response....Best Motor Response Glasgow....No response....Glasgow Coma Scale....3 [low score]. ..." Review of vital signs at 0725 revealed a Pulse Rate of 98, Respiratory Rate of 16, BP 131/70, Nasal Cannula oxygen at 3 liters, and an SpO2 of 94%. Record review revealed a note at 0730 that "pt unresponsive to touch and voice. vital signs stable. [Name] RN and [Name] Respiratory at bedside. Dr. [Name] notified and abg [arterial blood gas] ordered." Record review did not reveal a rapid response was called. Review revealed the blood gases were collected at 0744. Results of blood gases, no result time given, were " ...pH 7.5 [reference range {RR} 7.35-7.45] ... PCO2 39 [RR 3-45] ... PO2 74 [RR 80-100] .... HCO3 31 [RR 22-26] .... Base Excess 6.9 [0], O2 Sat 96.6 [>95] ... ." Record review did not reveal the physician was notified of results. At 0915, [approximately 1.75 hours after the patient was found unresponsive and 1.5 hours after the blood gases were drawn] documentation stated "...Pt continues to be unresponsive to touch and voice. vital signs stable. Pt on bipap. Family at bedside. [Name of Respiratory Therapist] at bedside. Dr. [Name] paged." At 0930, review revealed "Dr [Name] notified that patient is still unresponsive" and at 0942 "Dr [Name] at bedside. orders to call code fast [code stroke]. pt transported to CT." Record review failed to reveal evidence of if blood gas results were called to the physician and failed to reveal evidence of any additional neurological assessments. Review of a Rapid Response record, dated 06/13/2018 at 0945, revealed "code stroke" was called at 0947 at the request of the physician [more than two hours after Patient #2 was found unresponsive]. Patient #2 was sent for a stat CT of the head which showed "...Large left subdural hematoma causing right to left subsubfalcine herniation [displacement of the brain]... ." Review of a Telestroke consult, signed at 1036, revealed "...Recommendations: Transfer to center with neurosurgery back-up once patient is stabilized ....Intubate patient ....Stop Lovenox and Reverse anticoagulation as per protocol. ..." Record review revealed Patient #2 was transferred to a hospital with Neurosurgical capabilities around 1225.

Staff interview with RN #1, on 08/22/2018 at 1500, revealed RN #1 was assigned to Patient #2 on 06/13/2018 at 0700. Interview revealed she got report from RN #3 at 0700. Patient #2 looked asleep, RN #1 stated, so they did not wake the patient or walk up to the immediate bedside. Interview revealed RN #1 decided to let Patient #2 sleep and checked on her other patients. Interview revealed RN #1 returned to Patient #2's bedside around 0730-0735. RN #1 stated Patient #2 moved a little but did not wake. RN #1 stated the BiPAP was not on the patient and she thought Patient #2's CO2 [carbon dioxide level] might be elevated so she went out of the room and got a nurse supervisor and a Respiratory Therapist. Interview revealed RN #1 paged the physician [MD #4] who ordered BiPAP and blood gases, which were done. RN #1 stated she did not ask the doctor to come in to see the patient, stating the MD had given orders. Interview revealed RN #1 did not remember how she found out about the blood gas results. Interview revealed about 0915, a family member was in the patient's room and asked if the doctor had come. RN #1 stated she said she would call the physician again. RN #1 stated she paged [per medical record approximately 1 1/2 hours after the first call] MD #4 at 0915. Interview revealed, after RN #1 paged MD #4 around 0915, she saw MD #4 on the unit at 0930, and stated to MD #4 "you need to come in here." Interview revealed the MD went to the patient's bedside [per medical record review at 0942] after which a code stroke was called. RN #1 stated she did not call a Rapid Response when she first discovered the change in condition. Interview revealed RN #1 called a rapid response when the physician arrived and told her to call the code stroke. Interview revealed RN #1 was not aware the patient hit his head in a fall prior to admission and was not aware a head CT had been ordered in the ED. Follow-up interview on 08/23/2018 at 1455 revealed it was around 0735 when RN #1 first attempted to wake Patient #2. Interview revealed Patient #2 was not struggling to breathe, his color was good, he would not wake up. RN #1, after review of the medical record, stated she did a Neurological assessment at 0742 and got a Glasgow Coma Scale [GCS] result of 3. Interview revealed RN #1 did not know what led to a result of 3, stating the computer calculated it, but knew it "was not good". RN #1 stated even after the blood gases resulted, she still thought the patient's unresponsiveness was from a respiratory issue. RN #1 stated she did not recall doing any additional neuro assessments. Interview revealed RN #1 had "no idea" if the patient's pupil response was normal or slow, it was the first time she had checked this patient's pupils.

Interview with RN #2, a Clinical Supervisor on PCU, on 08/23/2018 at 1145, revealed she was called into Patient #2's room by RN #1. Interview revealed she was told Patient #2 "wouldn't wake up that well." Interview revealed RN #2 was not aware the patient had fallen prior to admission. RN #2 stated she did not assess Patient #2 and did not call a Rapid Response.

Interview with RN #3, on 08/22/2018 at 0920, revealed she was the night nurse on 06/12/2018 who cared for Patient #2. Interview revealed he came in with a CHF exacerbation, was not compliant with using his BiPAP, had an elevated D-Dimer, and was on a blood thinner. Interview revealed RN #3 did not recall hearing anything about a fall. RN #3 stated she knew the patient was supposed to be getting a test done, but did not recall what test. Further interview revealed RN #3 did a complete neuro assessment once per shift, which was completed early in the shift. After that, interview revealed, a complete neuro reassessment was not done if there were no changes noted. Interview revealed Patient #2 complained of a headache, Pain Score 6, around 2312 and was medicated with Hydrocodone. On reassessment, RN #3 stated, the patient's pain level was a 2. Later, around 0300, RN #3 said she spoke with Patient #2 and he stated he had no pain. RN #3 indicated she talked with the patient again at 0500 when she gave medications. Interview revealed he was awake and swallowed the medicine without difficulty. Interview revealed Patient #2 stood up to use the urinal and was kind of "wobbly" but RN #3 was not surprised because she had been told in shift report not to try and walk him to the bathroom. Interview revealed RN #3 saw the patient again about 0600 and he appeared to be sleeping. At 0700, RN #3 stated, she gave report to RN #1. They stood inside the doorway, did not go over to the patient's bed because he appeared to be sleeping. RN #3 stated when she left her shift, she did not know Patient #2's condition had changed, she was called later. Interview revealed "I wish I knew about the falling" stating it might have helped them think more about the blood thinner and to get the CT sooner.

Interview with MD #4, on 08/22/2018 at 1320, revealed MD #4 was Patient #2's physician on 06/12-13/2018. MD #4 stated the plan was for Patient #2 to receive Morphine and Toradol on call to Radiology on 06/12/2018 to see if the medication would help him lie flat for the CTs. Interview revealed that since the patient did not go down for the testing, MD #4 assumed he was not able or they did not send for him. Interview revealed MD #4 could not recall the specific statement but stated RN #1 called her on the morning of 06/13/2018 and said Patient #2 was not responding as usual. Interview revealed the MD thought it was respiratory issue and ordered to put the BiPap on Patient #2 and draw blood gases. Interview revealed when MD #4 reviewed the blood gas result it was not an indication for the altered mental status. MD #4 stated when she arrived to the bedside [per medical record review at 0942] the patient's pupils seemed a little sluggish and Patient #2 was withdrawing from pain so MD #4 called a code stroke to get more help and testing to rule out a stroke. Further interview revealed the CT showed a bleed.

Interview with RN #4, an ICU nurse, on 08/22/2018 at 1100 revealed RN #4 cared for Patient #2 on 06/11/2018 and until his transfer out to the PCU on 06/12/2018. Interview revealed Patient #2 was in for "shortness of breath". RN #4 stated they were trying to get a CT of the chest. Interview revealed RN #4 was not aware the patient had fallen shortly before admission and was not aware the patient had a head CT ordered. Interview revealed that in completing the fall risk assessments on patients during assessments, staff members sometimes look back on the previous falls assessment to answer the question related to recent falls.

Telephone interview with MD #1, the first ED physician who saw Patient #2 when he arrived on 06/10/2018, revealed Patient #2 had been falling and was complaining of shortness of breath. Interview revealed it was "challenging" to get a history or a good timeline. Interview revealed there was a small abrasion on the patient's right forehead. Interview revealed MD #1 ordered a Head CT because of the falls, and stated she was "probably being over conservative". Interview revealed there were no head complaints and no vomiting. MD #1 stated BiPAP was started more for comfort, and stated the patient's "work of breathing" improved with BiPAP. Interview revealed Patient #2 went for the head CT but came back because he could not tolerate laying flat. MD #1 stated Patient #2's D-dimer lab test resulted as positive and PE was a possible diagnosis, and a CT Angiogram [CTA] was ordered. MD #1 put Patient #2 on BiPAP, admitted him, and planned to get him more comfortable so he could lie flat for the radiology studies to be done later. At the time Patient #2 left the ED, the patient was getting more comfortable and MD #1 thought the chances of getting the CTs were good. Interview revealed MD #1 did not think they needed to intubate the patient to get either CT, and stated she did not think the benefits of the tests outweighed the risks of intubation.

Telephone interview with PA #1, on 08/22/2018 at 1430, revealed they were waiting on testing when PA #1 took over Patient #2's care. Interview revealed Patient #2's main complaint was shortness of breath. PA #1 stated the family was concerned about Patient #2's multiple falls over the past few days. Interview revealed the Head CT order was a "conservative measure" as there were no acute neuro symptoms. The more acute issue at the time was the shortness of breath. In relation to intubating the patient for testing, interview revealed they did not want to intubate because of concern they would not be able to get Patient #2 off the ventilator. Interview revealed the patient did not meet the requirements for an emergent CT. The Head CT, PA #1 stated, was more of a completeness issue, at the time there was no bleeding from the nose or ears, pupils were reactive, there was no periorbital bruising, and no big obvious hematoma. At that point, the plan was to get the patient admitted and then see what imaging could be done. At the time the patient was admitted to the unit, PA#1 stated, all CTs were still ordered. Further interview revealed PA #1 did not recall any requests to transfer the patient.

Interview with MD #3, on 08/22/2018 at 1135, revealed he cared for Patient #2 in the ED. Interview revealed Patient #2 had significant respiratory distress and was on BiPAP in the ED. MD #3 stated he "went with Heart Failure" as the issue but discussed alternate testing with the family. Interview revealed it seemed like Patient #2 was improving. Once there was an elevated D-Dimer, MD #3 stated, "you must treat". In the ED, MD #3 stated, respiratory status was the main issue. If they had taken Patient #2 off the BiPAP he would have needed to be intubated. In the ED, he stated, the priorities are to handle the most life threatening issue, which was respiratory at the time. The patient was being admitted. In relation to the Head CT, MD #3 stated his recollection was vague, but he knew a CT of the head was ordered. MD #3 did not recall any requests to transfer Patient #2.

Telephone interview with MD #5, the admitting physician, revealed Patient #2 had multiple medical problems and on admission had symptoms of a CHF exacerbation. MD #5 stated he was aware Patient #2 had fallen at home and knew the Head CT and CTA had been ordered. MD #5 stated Patient #2 could not lay flat for the CTs. They were going to do a VQ scan, but the Patient was too large. Interview revealed Patient #2 had a complex history and multiple problems. MD #5 stated he did not see a reason to transfer Patient #2, the hospital had the resources to care for him.

Interview with the CNO, on 08/22/2018 at 1645, revealed a Rapid Response should have been called when the doctor was notified after Patient #2 was discovered unresponsive. Subsequent interview revealed neuro status should have been reassessed. The CNO stated staff nurses were trained in stroke awareness and care, stating "we are Stroke Certified." Interview revealed Radiology orders are "hidden" after 24 hours. The CNO stated the orders can be found, but are not easily accessible. Further interview revealed Medical Staff Rules and Regulations stated orders should be reviewed on transfer of care but it was not clear if this happened. Interview revealed processes were not followed.

Based on review of hospital policy, closed medical record review and staff interviews, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations to ensure registered nursing staff supervised and evaluated patient care.

The findings include:

1. The nursing staff failed to supervise and evaluate patient care by failing to recognize, assess and reassess a patient's status after a critical change in patient condition, and failing to ensure immediate notification of a rapid response for 1 of 1 patients found unresponsive (Patient #2).

~cross refer to 482.23(b)(3) Nursing Standard: Tag A0395

Based on review of hospital policies, closed medical record review and staff interviews, the hospital's nursing staff failed to supervise and evaluate patient care by failing to recognize, assess and reassess a patient's status after a critical change in patient condition, and failing to ensure immediate notification of a rapid response for 1 of 1 patients found unresponsive (Patient #2).

The findings include:

Review of Progressive Care Unit [PCU] Guidelines "Assessment/Reassessment of Patients in PCU", effective 06/26/2017, revealed "... IV. Standards....C. A complete physical assessment must be completed once each shift. A cardiac and respiratory assessment must be completed every 4 hours. Assessments can be completed more often as the patient condition warrants. D. Vital signs will be taken on all patients every 4 hours or as often as the patient's condition warrants. ..." Guideline review did not reveal reassessment expectations with significant condition changes and did not indicate when more frequent neurological checks should be initiated.

Review of Policy and Clinical Practice Guidelines "HAND-OFF COMMUNICATION", reviewed/ revised 08/2016, revealed "...Hand-off communication utilizing the Situation, Background, Assessment and Recommendations (SBAR) format will be completed as a way to provide consistent and standardized communication between staff....VI. NOTE....D. The communication should address pertinent up-to-date information regarding the patient's treatment, any pending orders incomplete tasks. ..." Policy review did not reveal required documentation related to SBAR.

Review of a policy titled "Rapid Response Team Utilization", dated 06/03/2016, revealed "...POLICY....G. Criteria for Rapid Response Team utilization could include but not limited to the following:....9. Acute mental status change....H. When patient has been determined to meet any of the above criteria, the Rapid Response Team will be notified. ..."

Medical record review, on 08/22/2018, revealed Patient #2, a 54 year old male, arrived to the Emergency Department [ED] on 06/10/2018. Review of a Triage Note, at 0406, revealed a stated complaint of "I fell yesterday morning and this morning. my wrist hurts and my left side". Review of ED Documents revealed a Physician Note by MD #1 [Medical Doctor], at 0420, which stated Patient #2 had a past medical history that included Chronic Obstructive Pulmonary Disease [COPD], diastolic heart failure, and morbid obesity and indicated he "...presented for evaluation of shortness of breath, swelling, and falls. He has had multiple falls over the last several days. He has some abrasions over his right head. Complains of worsening lower extremity and abdominal swelling, weeping, increased shortness of breath. Patient cannot lay back flat. ..." Review revealed lab work, wrist and chest X-rays were done and Patient #2 was treated with BiPAP, breathing treatments and medications. Review of "Medical Decision Making" revealed "...Differential includes traumatic injury, CHF [Congestive Heart Failure], COPD, PE [Pulmonary Embolus - clot in the lungs]. D-dimer [blood test] is elevated....Assessment/ Plan Ordered....CT Angiography [CTA - visualizes arteries and veins through the body] Chest...CT Head Scan w/o [without] contrast. ..."

Review of Electronic Orders revealed a physician order for a "CT Head Scan w/o [without] Contrast", on 06/10/2018 at 0457, for "Head trauma, headache" and an order at 0648, for a "CT Angiography Chest", reason "PE suspected, high pretest prob [probability]. ..." Record review noted the CT's were not able to be performed in the ED due to pain and Patient #2's inability to lie flat. Order review revealed the orders for the Head CT and the CT Angiogram were not canceled. Documentation in the record indicated Patient #2 was admitted to the ICU [intensive care unit] on 06/10/2018 around 1850. Review of a History and Physical [H&P], signed on 06/10/2018 at 1615, noted Patient #2 fell "on his face and chest" the day before. Review did not reveal documentation related to the CTA or the CT of the Head. Review of a H&P Addendum by a different MD, at 2010, revealed "I was called by [virtual critical care doctor] that pt [patient] has elevated D-Dimer & pt. could not lay flat, so can't get CT. Plan is to get VQ scan [scan that looks at blood and airflow in lungs]. In the mean time, we will start Lovenox [blood thinning medication] therapeutic dose for suspected PE. ..." Review of the MAR [Medication Administration Record] revealed Enoxaparin [Lovenox] 190 mg subcutaneously was started 06/10/2018 at 2121. Review of a Physician Progress Note, signed 06/11/2018 at 1919, revealed Patient #2 still could not lay flat for the CT angiography and revealed he was too big for the VQ scan. Review revealed the Patient was "...placed on Lovenox as empiric therapy [based on experience and relevant clinical observation, not a definitive diagnosis] for PE. ..." Review of the Progress Note's Assessment/Plan did not indicate any plans related to the Head CT. Review of a Physician Progress Note, signed 06/12/2018 at 1337, revealed a plan to medicate Patient #2 with Morphine and Toradol prior to the Chest CT Angiography for pain control and to maximize the potential to lay flat. Progress Note review did not reveal a note related to the Head CT. Review of Physician Orders on 06/12/2018 at 1134 revealed orders for Morphine and Toradol. Review revealed both orders were reviewed by a RN at 1337 on 06/12/2018. Review of the MAR failed to reveal the Morphine or Toradol were given and record review failed to reveal the CT's were ever done. Medical record review did not reveal any notations from Nursing, Radiology, or Physicians on 06/12/2018 to indicate whether attempts were made to transport Patient #2 for either the CT angiogram or the Head CT. MAR review revealed Lovenox was administered approximately every 12 hours on 06/11/2018 and 06/12/2018.

Review of Nursing documentation of a Neurological Assessment on 06/12/2018 at 1900 revealed the neurological exam was "within defined limits" and the Glasgow Coma Score [GCS] was 15 [range 3-15 with 15 being normal]. On 06/12/2018 at 2300 and 06/13/2018 at 0300 review of the Neurological Assessment revealed "Reassessed, no change". At 2312 on 06/12/2018, record review revealed Patient #2 complained of a headache with a pain score of 6 out of 10 [0 is no pain, 10 is the worst pain], and received Norco for pain. Reassessment at 2342 on 06/12/2018 revealed the Patient's head pain had decreased to a pain score of 2 out of 10. Review of a Respiratory Therapy Note, on 06/13/2018 at 0330, revealed "...Breath Sounds - COPD: Normal/Clear....Dyspnea [difficulty breathing]....Slight. ..."At 0700 on 06/13/2018, record review revealed a change of shift report from one RN to another. Review of a Neurological Assessment, timed at 0700, revealed "Neurological Symptoms....Drowsiness ....Responds To....No response ....Level of Consciousness....Unable to arouse....Change in Mental Status....Acute Change from baseline.... PERRLA....Yes....Eye Opening Response Glasgow....No response....Best Verbal Response Glasgow....No response....Best Motor Response Glasgow....No response....Glasgow Coma Scale....3 [low score]. ..." Review of vital signs at 0725 revealed a Pulse Rate of 98, Respiratory Rate of 16, BP 131/70, Nasal Cannula oxygen at 3 liters, and an SpO2 of 94%. Record review revealed a note at 0730 that "pt unresponsive to touch and voice. vital signs stable. [Name] RN and [Name] Respiratory at bedside. Dr. [Name] notified and abg [arterial blood gas] ordered. Record review did not reveal a rapid response was called. Review revealed the blood gases were collected at 0744. Results of blood gases, no result time given, were " ...pH 7.5 [reference range {RR} 7.35-7.45] ... PCO2 39 [RR 3-45] ... PO2 74 [RR 80-100] .... HCO3 31 [RR 22-26] .... Base Excess 6.9 [0], O2 Sat 96.6 [>95] ... ." Record review did not reveal the physician was notified of results. At 0915, [approximately 1.75 hours after the patient was found unresponsive and 1.5 hours after the blood gases were drawn] documentation stated "...Pt continues to be unresponsive to touch and voice. vital signs stable. Pt on bipap. Family at bedside. [Name of Respiratory Therapist] at bedside. Dr. [Name] paged." At 0930, review revealed "Dr [Name] notified that patient is still unresponsive" and at 0942 "Dr [Name] at bedside. orders to call code fast [code stroke]. pt transported to CT." Record review failed to reveal evidence of if blood gas results were called to the physician and failed to reveal evidence of any additional neurological assessments. Review of a Rapid Response record, dated 06/13/2018 at 0945, revealed "code stroke" was called at 0947 at the request of the physician [more than two hours after Patient #2 was found unresponsive]. Patient #2 was sent for a stat CT of the head which showed "...Large left subdural hematoma causing right to left subsubfalcine herniation [displacement of the brain]... ." Review of a Telestroke consult, signed at 1036, revealed "...Recommendations: Transfer to center with neurosurgery back-up once patient is stabilized ....Intubate patient ....Stop Lovenox and Reverse anticoagulation as per protocol. ..." Record review revealed Patient #2 was transferred to a hospital with Neurosurgical capabilities [Hospital B] around 1225.

Review of Patient #2's medical record from Hospital B, on 08/30/2018, revealed Patient #2 arrived to Hospital B at 1325. Review of the Neurosurgical Nurse Practitioner note dated 06/13/2018 at 1416 revealed " ...On arrival to the NSICU (Neurosurgical Intensive Care Unit), patient intubated off of all sedation. Received no sedation in route or for intubation. Vital signs notable for heart rate 50-60, blood pressure 140/70, SPO2 100%. On exam, pupils 4mm (millimeters) and fixed. No corneal reflex. Weak cough. No gag. Withdrawal bilateral lower extremities to noxious stimuli. Extend left upper extremity. No response right upper extremity. Neurosurgery evaluated at bedside and are attempting to contact family ..." Review revealed Patient #2 was taken to the operating room for an emergency right craniotomy. Review of the discharge summary dated 06/15/2018 revealed " ...Patient exam continued to deteriorate postoperatively. Repeat head Ct shows adequate decompression of subdural but radiographic finding of post herniation stroke and brainstem hemorrhage. Given these findings and decline in exam patient deemed to have sustained a nonsurvivable injury. This was discussed with family and he was made comfort measures and died ..." Further review revealed Patient #2's time of death was 06/14/2018 at 1218 with a " ...Preliminary Cause of Death: brain herniation, acute subdural hematoma ..."

Staff interview with RN #1, on 08/22/2018 at 1500, revealed RN #1 was assigned to Patient #2 on 06/13/2018 at 0700. Interview revealed she got report from RN #3 at 0700. Patient #2 looked asleep, RN #1 stated, so they did not wake the patient or walk up to the immediate bedside. Interview revealed RN #1 decided to let Patient #2 sleep and checked on her other patients. Interview revealed RN #1 returned to Patient #2's bedside around 0730-0735. RN #1 stated Patient #2 moved a little but did not wake. RN #1 stated the BiPAP was not on the patient and she thought Patient #2's CO2 [carbon dioxide level] might be elevated so she went out of the room and got a nurse supervisor and a Respiratory Therapist. Interview revealed RN #1 paged the physician [MD #4] who ordered BiPAP and blood gases, which were done. RN #1 stated she did not ask the doctor to come in to see the patient, stating the MD had given orders. Interview revealed RN #1 did not remember how she found out about the blood gas results. Interview revealed about 0915, a family member was in the patient's room and asked if the doctor had come. RN #1 stated she said she would call the physician again. RN #1 stated she paged [per medical record approximately 1 1/2 hours after the first call] MD #4 at 0915. Interview revealed, after RN #1 paged MD #4 around 0915, she saw MD #4 on the unit at 0930, and stated to MD #4 "you need to come in here." Interview revealed the MD went to the patient's bedside [per medical record review at 0942] after which a code stroke was called. RN #1 stated she did not call a Rapid Response when she first discovered the change in condition. Interview revealed RN #1 called a rapid response when the physician arrived and told her to call the code stroke. Interview revealed RN #1 was not aware the patient hit his head in a fall prior to admission and was not aware a head CT had been ordered in the ED. Follow-up interview on 08/23/2018 at 1455 revealed it was around 0735 when RN #1 first attempted to wake Patient #2. Interview revealed Patient #2 was not struggling to breathe, his color was good, he would not wake up. RN #1, after review of the medical record, stated she did a Neurological assessment at 0742 and got a Glasgow Coma Scale [GCS] result of 3. Interview revealed RN #1 did not know what led to a result of 3, stating the computer calculated it, but knew it "was not good". Interview revealed RN #1 "possibly" had GCS training. RN #1 stated even after the blood gases resulted, she still thought the patient's unresponsiveness was from a respiratory issue. RN #1 stated she did not recall doing any additional neuro assessments. Interview revealed RN #1 had "no idea" if the patient's pupil response was normal or slow, it was the first time she had checked this patient's pupils. Further interview revealed RN #1 received annual stroke training.

Interview with MD #4, on 08/22/2018 at 1320, revealed MD #4 was Patient #2's physician on 06/12-13/2018. Interview revealed MD #4 could not recall the specific statement but stated RN #1 called her on the morning of 06/13/2018 and said Patient #2 was not responding as usual. Interview revealed the MD thought it was respiratory issue and ordered to put the BiPap on Patient #2 and draw blood gases. Interview revealed when MD #4 reviewed the blood gas result it was not an indication for the altered mental status, therefore MD #4 stated she had to look at other causes. MD #4 stated when she arrived to the bedside [per medical record review at 0942] the patient's pupils seemed a little sluggish and Patient #2 was withdrawing from pain so MD #4 called a code stroke to get more help and testing to rule out a stroke. Further interview revealed the CT showed a bleed.

Interview with RN #2, a Clinical Supervisor on PCU, on 08/23/2018 at 1145, revealed she was called into Patient #2's room by RN #1. Interview revealed she was told Patient #2 "wouldn't wake up that well." RN #2 stated she went into Patient #2's room, called the patient's name, and rubbed his face with a washcloth. Interview revealed when she washed the patient's face, there was some slight moaning but Patient #2 did not wake. Interview revealed Patient #2 did not open his eyes while RN #2 was in the room. Interview revealed Patient #2 was a "big guy" and wasn't wearing his "CPAP". RN #2 stated she knew the patient was in the hospital for respiratory issues and thought Patient #2 was retaining CO2. Interview revealed RN #2 did not realize this was a big change for the patient. Interview revealed RN #2 rounded on Patient #2 the previous day and he was sleeping. Further interview revealed RN #2 was not aware the patient had fallen prior to admission. Interview revealed RN #2 did not assess Patient #2 and did not call a Rapid Response. Interview revealed RN #2 was stroke trained.

Interview with Respiratory Therapist [RT] #1, on 08/22/2018 at 1730, revealed the RT went into Patient #2's room on 06/13/2018 around 0725. The patient, he stated, would not awaken. Interview revealed RT #1 and RN #1 spoke with the physician and the physician ordered BiPAP and a blood gas. RT #1 and a computer navigator reviewed the computerized medical record during interview and stated the blood gas was drawn at 0744, results were in the system at 0800, and results were reviewed by RN #1 at 0802. Interview revealed the blood gas result showed Patient #2 was not in respiratory failure. RT #1 stated he discussed it with RN #1 and stated it was not a blood gas problem. Further interview revealed RT #1 gave a breathing treatment after the blood gas and the patient's effort through the BiPAP was "good". Interview revealed RT #1 did not call the physician. "If blood gas results are not critical", RT #1 stated, they "speak to the nurse."

Interview with RN #4, an ICU nurse, on 08/22/2018 at 1100 revealed RN #4 cared for Patient #2 on 06/11/2018 and until his transfer out to the PCU on 06/12/2018. Interview revealed Patient #2 was in for "shortness of breath". RN #4 stated they were trying to get a CT of the chest. Interview revealed RN #4 was not aware the patient had fallen shortly before admission and was not aware the patient had a head CT ordered. Interview revealed that in completing the fall risk assessments on patients during assessments, staff members sometimes look back on the previous falls assessment to answer the question related to recent falls.

Interview with RN #3, on 08/22/2018 at 0920, revealed she was the night nurse on 06/12/2018 who cared for Patient #2. Interview revealed he came in with a CHF exacerbation, was not compliant with using his BiPAP, had an elevated D-Dimer, and was on a blood thinner. Interview revealed RN #3 did not recall hearing anything about a fall. RN #3 stated she knew the patient was supposed to be getting a test done, but did not recall what test. Interview revealed RN #3 did not recall an obvious injury to the face. Further interview revealed RN #3 did a complete neuro assessment once per shift, which was completed early in the shift. After that, interview revealed, a complete neuro reassessment was not done if there were no changes noted. Interview revealed Patient #2 complained of a headache, Pain Score 6, around 2312 and was medicated with Hydrocodone. On reassessment, RN #3 stated, the patient's pain level was a 2. Later, around 0300, RN #3 said she spoke with Patient #2 and he stated he had no pain. RN #3 indicated she talked with the patient again at 0500 when she gave medications. Interview revealed he was awake and swallowed the medicine without difficulty. Interview revealed Patient #2 stood up to use the urinal and was kind of "wobbly" but RN #3 was not surprised because she had been told in shift report not to try and walk him to the bathroom. Interview revealed RN #3 saw the patient again about 0600 and he appeared to be sleeping. At 0700, RN #3 stated, she gave report to RN #1. They stood inside the doorway, did not go over to the patient's bed because he appeared to be sleeping. RN #3 stated when she left her shift, she did not know Patient #2's condition had changed, she was called later. Interview revealed "I wish I knew about the falling" stating it might have helped them think more about the blood thinner and to get the CT sooner.

Interview with the CNO, on 08/22/2018 at 1645, revealed a Rapid Response should have been called when the doctor was notified after Patient #2 was discovered unresponsive. Subsequent interview revealed neuro status should have been reassessed. The CNO stated staff nurses were trained in stroke awareness and care, stating "we are Stroke Certified." Interview revealed processes were not followed.

Based on review of policies, medical record reviews, and staff and physician interviews, the hospital failed to ensure diagnostic radiological services that met the needs of patients by failing to ensure a patient received imaging services required to diagnose and treat a patient's condition.

The findings include:

1. Hospital staff failed to ensure radiology services met the needs of patients by failing to ensure needed imaging studies were completed as ordered for 1 of 10 patients reviewed (Patient #2).

~cross refer to 482.26(a) Radiologic Services Standard: Tag A0529

Based on policy review, medical record review and physician and staff interviews, the hospital failed to ensure radiology services met the needs of patients by failing to ensure needed imaging studies were completed as ordered for 1 of 10 patients reviewed (Patient #2)

The findings include:

Review of Medical Staff Rules and Regulations "Orders for Treatment", approved 08/2013, revealed "...To set forth guidelines for a standardized method of managing physician orders....III. STANDARDS ....F....2. Orders not related to medications must be reviewed and modified or unchanged as indicated:....b) At the time of admission to special care/intensive care units c) Before transferring to a nursing unit (including the Progressive Care Unit) from critical care units. ..."

Request for a Radiology Policy related to completing ordered radiology studies, on 08/23/2018 on 1730, revealed there was no policy.

Medical record review, on 08/22/2018, revealed Patient #2, a 54 year old male, arrived to the Emergency Department [ED] on 06/10/2018. Review of ED Documents revealed a Physician Note, at 0420, which stated Patient #2 had a past medical history that included Chronic Obstructive Pulmonary Disease (COPD), diastolic heart failure, and morbid obesity and he "...presented for evaluation of shortness of breath, swelling, and falls. He has had multiple falls over the last several days. He has some abrasions over his right head. Complains of worsening lower extremity and abdominal swelling, weeping, increased shortness of breath. Patient cannot lay back flat. ..." ED record review revealed " ...Assessment /Plan Ordered....CT Angiography [CTA - visualizes arteries and veins through the body] Chest...CT Head Scan w/o [without] contrast. ..." Lab results review, collected at 0415, showed an abnormal D-Dimer result of 3.10 [Reference range <0.52]. Review of results revealed the clinical cut-off to exclude a pulmonary embolus was <0.50. Review of Electronic Orders revealed a physician order for "CT Head Scan w/o [without] Contrast", ordered STAT, on 06/10/2018 at 0457, for the reason of "Head trauma, headache". Order review did not reveal any reviews, modifications, or a cancellation of the order prior to 06/13/2018. Electronic Order review also revealed a physician order was entered, at 0648, for a "CT Angiography Chest", reason "PE [Pulmonary Embolus -blood clot in the lungs] suspected, high pretest prob [probability]. ..." Review of CT Angiography order comment, on 06/10/2018 at 0743 revealed a comment by a Radiology Tech that " ...Pt to be put on Bi-pap machine and have treatments before having CT scans per ED. ..." Further review revealed another Radiology note, at 1419, " ...Spoke with pt's ED nurse and she stated that pt was still unable to lie flat for longer than 30 seconds and was still unable to be still. Pt to be admitted. Will let us know if pt can be done. ..." Order review did not reveal any modifications or a cancellation of the order prior to 06/13/2018.

Review of an Addendum by a second ED physician, signed 1657, revealed "... Patient did improve with BiPAP. His d-dimer was significantly elevated but unfortunately the patient was unable to lie flat. We did discuss with the hospitalist who agreed to perform a VQ scan rather than attempt to lay the patient flat for CT and risk further respiratory decompensation. ..." Review of a History and Physical [H&P], signed 06/10/2018 at 1615, noted Patient #2 fell "on his face and chest" the day before. ..." H&P Review revealed " ...Assessment/Plan ...Plan ....Patient will be admitted to ICU for close monitoring of respiratory status. ..." Plan review did not reveal any notation related to the CT of the Head. Review of an H&P Addendum, at 2010, revealed " ...Plan is to get VQ scan. In the mean time, We will start Lovenox [blood thinning medication] therapeutic dose for suspected PE. ..." Review of Physician Orders revealed an order, on 06/10/2018 at 2012, for Enoxaparin (Lovenox) Treatment, 190 mg [milligrams] subcutaneous injection every 12 hours. Review of the MAR [Medication Administration Record] revealed the first dose of Lovenox was given on 06/10/2018 at 2121 and it was then administered twice on 06/11/2018 and 06/12/2018. Review of a Physician Progress Note, signed 06/11/2018 at 1919, revealed Patient #2 was placed on Lovenox as "empiric therapy" [based on experience and relevant clinical observation, not a definitive diagnosis] for PE. The Progress Note also stated Patient #2 was too large for a VQ scan and could not lie flat for the CT angiography. It revealed a plan to "...CT angio when pain level is controlled. Continue lovenox for suspected PE ....falls precautions. ..." Progress Note review did not reveal a plan related to the Head CT. Record review did not reveal any notations from Radiology or Nursing related to the Head CT.

Review of a Physician Progress Note, signed 06/12/2018 at 1337, revealed " ...Patient transferred out of the ICU [Intensive Care Unit] to PCU [Progressive Care Unit] today ....Prior to going down for a CT of his chest will administer morphine and Toradol [pain medications] for better pain control And to maximize success with laying flat. ..." Progress Note review did not reveal any notation about the Head CT. Review of Physician Orders on 06/12/2018 at 1134, revealed an order for Morphine and Toradol to be given IV push on-call 10 minutes before the CT. Review of the MAR [Medication Administration Record] failed to reveal the Morphine or Toradol were given and failed to reveal a CT was done. Record review did not reveal any notations from Nursing, Radiology, or Physicians to indicate whether attempts were made to transport Patient #2 for either the CT angiogram or the Head CT.

Review of a Rapid Response record, dated 06/13/2018 at 0945, revealed Patient #2 was unresponsive and VCC [Virtual Critical Care] was called for "code stroke" at 0947. Review revealed Patient #2 was transported to CT for a stat CT of the head. Review of the Head CT, dated 06/13/2018 at 1024, revealed "...IMPRESSION: 1. Large left subdural hematoma ... ." Review of a Telestroke consult, signed at 1036, revealed " ...Impression: Left Subdural Hemorrhage with midline shift ....Recommendations: Transfer to center with neurosurgery back-up once patient is stabilized. ..." Medical record review revealed neither the CT Angio nor the Head CT were done prior to Patient #2 becoming unresponsive on 06/13/2018. Record review did not reveal any additional documentation by Radiology related to the CT Angio or the Head CT after 06/10/2018. Record review did not reveal further notations about the Head CT after admission until after the patient was found unresponsive.

Interview with the Director of Radiology, on 08/23/2018 at 0930, revealed when radiology orders come through to the department a hard copy of the order (a requisition) is generated. Interview revealed the Radiology Techs pull the hard copy and use it as an internal communication tool. Interview revealed Techs are supposed to attempt to get the patient study completed and document this on the requisition form every shift, until the study is completed. Interview revealed that once the study is completed, the requisition is scanned into the Radiology system and is accessible. If the test(s) are not completed, there are no images and therefore the requisition form cannot be scanned into the Radiology computer system. In that case, interview revealed, the requisition is discarded/ shred. The Director stated that some staff members did utilize the hospital computer system to make notes if a patient cannot complete an ordered radiology test, but stated it was not a requirement and not everyone did it. Further interview revealed the Director was not aware of a policy or procedure related to this. The Director stated Radiology staff should be contacting departments every shift until a study was completed but acknowledged there was not a way to validate this unless the study was completed.

Interview, on 08/22/2018 at 1320, revealed MD #4 planned for Patient #2 to receive Morphine and Toradol on call to Radiology to see if the medication would help him lie flat for the CTs. Interview revealed that since the patient did not go down for the testing, MD #4 assumed he was not able or they did not send for him.

Interview, on 08/22/2018 at 1645, with the CNO revealed Radiology orders are "hidden" after 24 hours. Interview revealed they can be found, but are not easily accessible.

NC00141752