HospitalInspections.org

Based on review of hospital documentation and staff interview, it was determined the Governing Body

1. failed to ensure there were sufficient numbers of qualified staff; equipment and supplies available, and policies and procedures for the care of a patient that required a high level of respiratory services prior to admitting the patient to the acute inpatient unit. (Patient #18).

2. failed to conduct "Regular Meetings" as defined in their Bylaws.

3. failed to ensure the medical staff followed policies and procedures approved by the Board for ordering physical restraints (Patient #1).

Findings include:

1. The "Bylaws of the Board of Douglas Community Hospital, Inc. D/B/A Cochise Regional Hospital" included: "The mission of the Hospital is to provide patient care, education and community service...The patient care mission reflects CHR's commitment to provide high quality, compassionate, competent , efficient, and cost-effective care to its patients and customers...The CEO will be employed by the Corporation as administrator of the Hospital, and will act on behalf of the Board in the overall management of the Hospital and serve as the liaison among the Board, the Medical Staff, and the employed staff. The CEO and the Chairman of the Board may be the same person. The CEO's responsibilities and authorities will include, but not be limited to...manage the Hospital all in accordance with the policies and procedures promulgated by the Board...To provide for compliance with all applicable federal, state, and local laws...To review and respond promptly to recommendations from planning, regulatory and inspecting agencies, and report findings directly to the Board...To be responsible for elimination of services or adding of new services only after careful consideration of input from the community, patients, employees and final approval of the board...."

Patient #18 was brought into the Emergency Department on 6/11/2014 at approximately 2:45 p.m. with a chief complaint of shortness of breath. The patient was evaluated by the ED Physician #1 at 3 p.m. who documented the patient was bedbound at home with "Lou Garets disease." The physician's general assessment of the patient was: "... Awake A&O (alert and oriented) x 3 pleasant to talk with not ill. Very Awake and in no distress..."

The physician admitted the patient to the acute care unit with diagnoses including Shortness of Breath, Pneumonia, and Hypoxemia. The physician's orders included telemetry and IV fluids and antibiotics. He documented her condition at that time was "Good." The patient's "Code" status was Full Code. The patient arrived on the acute care unit at 9:15 p.m. The following is the sequence of events documented by the RNs and physicians:

-6/11/2014: 9:15 p.m. RN note: "...Patient arrives to floor. On assessment the patient was quiet, unarousable, skin cool to touch. First set of vitals were as follows; t-94.0/rectal 95.6, p-78 r-22, bp-145/73, O2-99%. (Physician #2) came down to the floor to look at the patient and discuss options with the family...."

-6/11/2014 at 11 p.m. RN note: "...Patient demonstrats (sic) kussmaul breathing. Patient positioned in a 45 degree angle and covered up to retain warmth. Recommendations has been made in regard to using a OP on this patient. DON called to eval..."

"Kussmaul breathing" is defined as a deep and labored breathing pattern often associated with severe metabolic acidosis.

-6/12/2014: 12:42 a.m. Physician #2 "charting delayed": "Patient with lethargy...Called by nursing for patient less responsive at 22:00 hours 6/11/2014. Pt seen at that time and case discussed with Dr. (name) Hospitalist via telephone, plan is for PEEP if patient unable to recover using 4 LPM Oxygen by NC (nasal cannula)...Obtunded this exam...Pupils equal round and reactive to light with 2 to 1 mm reactivity; tongue dropping to posterior with supine position, elevated patient to semi-erect and tongue remains forward non-obstructing...Grimmaces (sic) to painful stimuli...History per pt's son fills more of course of events: patient breathing changed 2 weeks ago with more of a gasping and then much worse 1 week ago and was seen by PCP with order for home oxygen (oxygen has not yet arrived at home. On presentation patient had further worsened and family was concerned. Mentation has been progressively worsening since 2 weeks ago. H/O (history of) Lou Garreg's (sic) Disease with progression; also Glucose resistance on oral hyperglycemic med's...."

-6/12/2014 at 12:51 a.m. Physician #2: "Recheck exam at this time. Patient pushes away at attempts to place OPA (oral pharyngeal airway)...."

-6/12/2014 at 1 a.m. RN note: "... the patient was "non arouseable (sic)..." and 2 a.m. "...the patient's skin was "cool and clammy" and a fingerstick blood sugar was obtained...."

-6/12/2014 at 4 a.m. RN note: "...The patient was still 'diaphoretic and cool to touch' and another fingerstick blood sugar was obtained. The RN documented the patient's body temperature had risen from 93.2 to 94.7 degrees Fahrenheit (F). The day shift RN documented at 1:22 p.m. that at 7 a.m. the patient was not responsive to voice but "minimally" responsive to hard sternal rub...."

-6/12/2014 at 3:10 p.m. the RN's documentation included: "...(Physician #2) asked to see pt for unresponsiveness and breathing with retractions. (Physician #2) in to see pt at 0945 with new orders received for foley placement, tap water enema, and titrate O2 sats and placement of bear hugger for low core temp...(Physician #1) in to see pt at 1230 and placed CPAP to adjust pt O2 sats. Pt combative, order for soft restraints received and implemented at 1305 hours. Pt O2 sats not stabilized...Pt taken to ED at 1338 hours...."

-6/12/2014 at 2:13 p.m. Physician #2: "...Trial of PEEP on floor done by Doctor, Patient improved but not well tolerated...."

6/12/2014 at 2:25 p.m. Physician #1: "...Patient placed on 5 liters last night and lethargic this am. ABG showed High PCO2. Patient oxygen remove and placed on CPAP by MD. Patient started to wake up in about one hour and almost return to baseline. Patient was transferred to (name of acute care hospital in Tucson) with CPAP and helicopter....."

On 6/17/2014 at approximately 9:45 a.m., the RN on duty in the ED was asked if the hospital had a CPAP machine. She identified that they had one "transfer ventilator" in the Emergency Department which had no CPAP capability, and showed it to the surveyors. She said there was an "iVent" ventilator that was hardly every used but did have a CPAP function on it. The RN showed the location of the unit which was stored in the Respiratory Therapy closet. She was asked if the hospital had respiratory therapists staffed or on call and she responded: "... no...."

The current Director of Nursing reported during an interview on 6/17/2014 at 9:30 a.m. that he was not familiar with and had never used the iVent and did not think it was functional because it was missing a part. He turned the unit on and saw that it did have a CPAP function but was not able to locate the equipment (circuit) that would be needed to set it up for patient use. He was not able to locate a policy and procedure for CPAP.

A Cochise Regional Hospital document titled "Respiratory Clinicare and Workflow" effective 4/3/2014 included: "...Physician, Nurses and Transport Team (Flight or Ground Ambulance) are responsible for: 1. Patients with impending or in Respiratory Failure 2. Oxygenation & Ventilation of the Patient as indicated by patient condition...."

The hospital had no respiratory therapists on duty or on call. The On-site Administrator stated during an interview on 6/17/2014 that the respiratory therapists on the current employee roster were "per diem" but they were not to be called or expected to come in. She also reported the hospital had no contract with the flight and ground ambulance companies to provide and/or assist with patient respiratory needs.

The Director of Nurses at the time of the patient's admission stated in an interview on 6/17/2014 at 11:30 a.m. that she received text messages from the nursing staff on 6/11/2014 at approximately 10 p.m., with concerns about the patient's declining status and the physician(s) discussing the possibility of the patient needing a higher level of ventilatory assistance that the nursing staff did not feel they were trained to provide. The Director of Nursing reported she went to the hospital and assessed the patient's respiratory status by attempting to place a "nasal trumpet" and an oral airway. She reported the patient did not tolerate the nasal trumpet and pushed out the oral airway on her own which meant the patient's respiratory status was stable on her own. She also reported the hospital did not have the necessary equipment ("circuit") to set up the CPAP function of the hospital's ventilator.

A telephone interview was conducted with the RN on duty from 7 p.m. on 6/11/2014 to 7 a.m. on 6/12/2014. She reported the patient arrived on the unit at approximately 9 p.m. and that there had been another new admission on the unit one-hour earlier. The RN reported Patient #18 had "kussmaul breathing," was not able to be aroused, responded only to painful stimuli (sternal rub), and had a "very cool" temperature. She requested the ED physician on duty (Physician #2) come to the unit and evaluate the patient which he did. The RN reported the physician wanted the patient to be placed on CPAP but that the hospital did not have a CPAP machine and the physician wanted to use a piece of equipment she was not familiar with. At that point the RN contacted the DON with her concerns. The DON responded to the hospital and assessed the patient's airway by inserting the nasal trumpet and then the oral airway, neither of which the patient tolerated. The RN stated the physician ordered an oral airway be kept at the patient's bedside. She said she was trained and felt comfortable in inserting an oral airway and added that if a patient needs an oral airway, the next step would be to ensure appropriate respiratory services are available.

The hospital had five admissions including Patient #18 to the acute care unit on 6/11/2014:

-Patient #19 admitted at 10:06 a.m. with orders including telemetry.

-Patient #20 admitted at 10:57 a.m. The orders for this suicidal patient included seclusion and restraints. The patient was transferred to another hospital at 2 p.m.

-Patient #21 admitted at 12:12 p.m. The orders included IV fluids and medications, telemetry, sliding scale insulin, oxygen and breathing treatments.

-Patient #22 admitted at 6:06 p.m. with orders including telemetry and IV medications.

-Patient #18 admitted at 9:15 p.m. The patient was unresponsive with breathing difficulties and orders including telemetry and IV fluids and medications.

The Daily Staffing Sheet for 6/11/2014 revealed there was one RN; one CNA and one LPN assigned to the unit for the 7 p.m. to 7:30 a.m. shift. It was later reported the LPN went off duty at approximately 11 p.m.

In summary, Patient #18 was admitted to the acute care unit at 9:15 p.m. on 6/11/2014. The patient was a "full code" status, was unresponsive and having difficulty breathing. There were four other patients on the unit admitted earlier that day with one of those patients admitted just one hour prior to Patient #18. All four patients were on telemetry monitoring and receiving IV fluids/medications. The RN on duty during the evening of 6/11/2014 notified the ED physician of Patient #18's declining condition. The ED physician evaluated the patient and told the nurse of the patient possibly needing CPAP. The hospital had no Respiratory Therapists on duty or on-call. The hospital had no policies and procedures for that level of respiratory services on the acute care unit. The RN was not trained for this intervention and notified the then Director of Nursing who came in and assessed the patient's airway status. The patient remained in the hospital on the acute care unit where she continued to decline. On or around 1:08 p.m. on 6/12/2014, the patient was placed on PEEP and/or CPAP by Physician #1 and/or Physician #2. The patient was transferred to the ED at 1:40 p.m. for "stabilization" and placed on either "bi-pap" or "CPAP" by the flight transportation crew and then transferred by helicopter to an acute care hospital in Tucson.

2. The Bylaws also included: "Duties of the Board...Operate and maintain CRH to properly meet community needs...Regular meetings will be held on a quarterly basis...."

The on-site hospital administrator reported in an interview on 6/12/2014 and in a telephone interview on 6/16/2014 that there was no documented evidence of any governing board meetings after December 19, 2013 prior to the change of ownership.

3. Article VIII Administration of the Bylaws included: "...The CEO's responsibilities and authorities will include, but not be limited to: 8.1 To manage the Hospital all in accordance with the policies and procedures promulgated by the Board...."

The "Southeast Arizona Medical Center Restraint Policy (Physical/Chemical) for Behavioral Management," Policy 2.W.35, included: "...Patients will be restrained when necessary to limit their movement as means of protecting themselves and others from harm...Specific standards are followed and a guide to time limited orders for behavior management are as follows: ...PRN orders are NOT used... A specific physician's order must be received. The restraint order must contain the following specific information: A. Whether it is a physical or chemical restraint. B. Reason for restraint. C. Type of restraint: ankle, wrist, chest, etc. D. Time limit for restraint...."

Patient #9 presented to the Emergency Department on 6/3/2014 at 11:15 a.m. The elderly patient was described in the clinical record as "disoriented" and "combative." The patient was admitted as an in-patient and transferred to the acute care unit at 2:58 p.m. Documentation in the Medical Orders print-out included a verbal order at 3:40 p.m. for "Soft Restraints" and another order at 6:45 p.m. for "Soft Restraints as needed for agitation."

Nursing documentation in the Clinical-InterDisciplinary Notes revealed soft wrist restraints were applied to the patient on 6/5/2014 at 5:40 p.m. At 6:10 p.m. the left wrist restraint was removed and at 6:25 p.m. the left wrist restraint was removed.

The Administrator acknowledged the physician did not follow policies and procedures for ordering restraints.

Based on document review, and staff interviews, it was determined the facility failed to review and update policies and procedures for Medical Records.

Findings include:

The facility policy "Release of Information" includes: "...Patients can secure a copy of their own medical record upon signing an Authorization to Release Information and showing a photo ID...."

Policies in the Health Information Management Services manual were written in 12/2001 and reviewed last by the governing board in 12/2008. No additional electronic medical record policies were added since the facility changed to an electronic medical record system in 2013.

The Medical Records Clerk verified in an interview conducted on 06/11/2014, she releases medical records based on signatures and a photo ID (Identification). A review of current ED medical records revealed the patient's sign consents for treatment and admission electronically. She acknowledged the signatures did not look like handwritten signatures and the medical record did not include a photo ID.

The Medical Records Clerk acknowledged she did not have a current list of computer or other codes and written signatures to authenticate staff electronic signatures.

The Medical Records Clerk verified she did not have a policy and procedure for authentication of electronic signatures for the physicians and nursing staff in the electronic medical record.

The On-site Administrator acknowledged in an interview conducted on 06/11/2014, there were no new policies and procedures to reflect the use on the electronic medical record system in the facility.