HospitalInspections.org

Based on document review and interviews the facility staff failed to ensure the physician orders for 1 of 2 patients (Patient #1) was followed as written.

The findings include:

On 11/15/12 the medical record of Patient #1 was reviewed. On 10/20/12 at 18:10 the attending physician ordered Patient #1 be placed on a cooling device (Arctic Sun - therapeutic hypothermia equipment) and for Patient #1 to be cooled to 33 degrees Celsius (C) (91.4 degrees Fahrenheit (F)) and to maintain the target temperature for 24 hours. After being cooled for 24 hours begin rewarming at the rate of 0.5 degrees C (1 degree F) per hour to a target temperature of 36.9 degrees C (98.6 degrees F). On 10/20/12 at approximately 18:45 the cooling apparatus was attached to Patient #1 and the cooling phase was initiated.

On 10/20/11 at approximately 22:57 Staff Member #6 began rewarming Patient #1. At approximately 07:00 on 10/21/12 Staff Member #5 realized Patient #1 was being rewarmed without being cooled for 24 hours and restarted the cooling phase.
It was noted Patient #1 had become febrile and the therapeutic hypothermia was discontinued by physician order at 08:31 10/21/11.
Patient #1's physician discharge summary stated, "Aggressive intervention was continued for several days but the patient didn't show any response. (Patient #1) remained unresponsive with sever anoxic encephalopathy. Neurology was consulted and as patient's prognosis was determined to be grave palliative care was consulted. Goals of care was changed to comfort care and patient was extubated and comfort care implemented and patient died on 10/28/12 around 01:05."
The Director of Critical Care Services, Manager of ICU and Quality Manager were interviewed on 11/15/12 and all agreed that attending physician notified the administrator on call on 10/21/12 who did speak with the ICU team leader. The ICU team leader immediately began an investigation. A report was initiated in the facility's STAR program and the Director of Critical Care Services and Manager of ICU were both notified on 10/21/12.
On 10/22/12 the incident involving Patient #1 was discussed at the Leadership Meeting and a review of the incident was begun by Quality Management. Interviews with the staff involved were begun on 10/22/12. A prescheduled (10/23/12) ICU staff meeting agenda was changed to a Safety Huddle with a focus review of the protocol for using the therapeutic hypothermia (Arctic Sun) equipment. During the regularly scheduled annual skills fair (10/31 and 11/1/12) with the ICU staff the use of the Arctic Sun was reviewed again.
On 11/11/12 Patient #2 was admitted to ICU and placed on the Arctic Sun. The Nurse Specialist again reviewed the protocols for using the Arctic Sun with the nursing staff of ICU.
On 11/15/12 the Quality Management Nurse was interviewed. She stated, "Our investigation is ongoing at present. We have 45 days from the incident to complete our investigation and report to Administration our findings. We are still interviewing and collecting data. In the meantime we have instituted some double checks with 2 nurses and did a review of the use of the Arctic Sun with the ICU staff. We have not had an incident of this nature that was brought before QAPI for a long time."
On 11/15/12 the Nurse Manager of ICU was interviewed and she stated, "We do not use the Arctic Sun very much so 2 nurses have been going over the protocol together when we have used it; That is not the procedure but it may become the procedure. Normally a person is placed on the Arctic Sun when there has been a witnessed cardiac arrest and not for a drug overdose. In (Name of Patient #1) case we did not know when he suffered the cardiac arrest for sure (there was varying information given from the family) and we suspected a drug overdose). I believe the physician was just trying everything because (Name of Patient #1) was so young."