HospitalInspections.org

THE CONDITION IS NOT MET:
Based on clinical record reviews and interviews with facility personnel for one of eleven sampled patients (Patient # 18), the hospital failed to ensure the coordination of care and/or communication between departments of surgery, trauma and anesthesia in assessing Patient #18's appropriateness for surgery. Subsequently, Patient #18 was taken to surgery and during intubation aspirated and sustained an anoxic brain injury. (See A347)

Based on clinical record reviews and interviews with facility personnel for one of eleven sampled patients (Patient # 18), the hospital failed to ensure the coordination of care and/or communication between departments of surgery, trauma and anesthesia in assessing Patient #18's appropriateness for surgery. Subsequently, Patient #18 was taken to surgery and during intubation aspirated and sustained an anoxic brain injury.

The findings include:

1. Patient #18 was admitted to the hospital on 6/25/09 following a motorcycle accident. Patient #18 sustained Stage IV and Stage V lacerations to the liver, spleen and kidney and multiple fractures. Review of the progress notes and nurses notes dated 6/25/09-6/29/09 identified that the patient was complaining of abdominal pain and distention. Review of the abdominal x-ray dated 6/29/09 identified that the patient had an ileus. Review of the progress notes dated 6/29-6/30/09 identified that the patient continued to complain of abdominal distention, bloating and belching. Further review identified that the trauma-surgical team was aware of patient's current status and the plan was to watch the patient's abdominal exam and question whether the patient was to go to the operating room for hand surgery. Review of the progress note on 6/30/09 at 10:00am, identified that the patient had increased abdominal distention, increased shortness of breath, no bowel sounds with oxygen saturation levels at 88%. Patient #18's oxygen was increased to 4 liters and his oxygen levels increased to 92-94%. RN #13 reported the patient's status to the physician's assistant. Patient #18 went to the operating room at 12:46pm for a repair of a radial/ulnar fracture. Review of the clinical record failed to identify that an assessment of the patient was completed prior to surgery by the trauma or surgery service. Upon intubation, Patient #18 aspirated, suffered a cardiac arrest and sustained an anoxic brain injury. Patient #18 expired on 1/15/10. Review of hospital "medical staff code of conduct" identified that collaboration, communication and collegiality are essential elements for the provision of safe and competent patient care by the medical staff. Interview with PA #1 identified that she was aware that the patient was having medical issues and had reported it to the trauma team, however, the clinical record lacked evidence that the patient's symptoms were assessed and/or addressed by the medical staff. MD # 17 (Anesthesia) and MD #18 (Orthopedics) identified that it was never communicated to them that the patient was having medical issues prior to surgery. MD #18 (Orthopedics) identified that the trauma service was responsible for the patient's care, however review of the progress notes dated 6/29/09 identified that the patient was on the surgical service team. MD #19 (a trauma surgeon, unaffiliated with Hartford Hospital) identified upon interview and review of the clinical record on 2/4/11 that the patient was not appropriate for surgery at that time due to his unaddressed medical problems.

In addition, review of the progress notes dated 6/25/09-6/30/09 identified that although a physician assistant had evaluated the patient on numerous occassions, the clinical record failed to indicate that an attending physician had provided supervision and/or addressed the patient's medical problems prior to surgery. Interview with the Vice President of Nursing on 2/16/11 identified that the hospital practice includes morning team meetings with each service and the patient's care would be discussed at that time with the attending physician.

Assessment of Patient

Based on clinical record reviews and interviews with facility personnel for one of eleven sampled patients (Patient #18), the facility failed to ensure that medical emergency response docmentation was completed.

The findings include:

1. Patient #18 was admitted to the hospital on 6/25/09 following a motorcycle accident. Patient #18 sustained Stage IV and Stage V lacerations to the liver, spleen and kidney and multiple fractures. Review of the progress note on 6/30/09 at 10:00am, identified that the patient had increased abdominal distention, increased shortness of breath, no bowel sounds with oxygen saturation levels at 88%. Patient #18's oxygen was increased to 4 liters and his oxygen levels increased to 92-94%. RN #13 reported the patient's status to the physician's assistant. Patient #18 went to the operating room at 12:46pm for a repair of a radial/ulnar fracture. Upon intubation, Patient #18 aspirated, and resusitation efforts were started. Patient #18 was transferred to the ICU. Review of the code sheet dated 6/30/10 at 3:30pm lacked complete documentation of the code elements including airway and circulation assessments, resusication outcomes, recorders name, medication nurses signature and physician in attendance. Review of hospital "medical emergency response policy" identified an assessment of respiratory status, physical assessment and pulse oximetry will be assessed including RN documentation for accurate and complete communication with the medical team leader. Documenter is responsibe for obtaining required signatures. Interview with the Vice President of Patient Care Services on 2/1/11 identified that the code sheet was not complete and the medical emergency response team was not activated since the ICU team was able to attend to the patient when he was transferred from the operating room.

THE CONDITION IS NOT MET:

Based on clinical record reviews and interviews with facility personnel for one of eleven sampled patients (Patient # 18), the hospital failed to ensure the coordination of care and/or communication between departments of surgery, trauma and anesthesia in assessing Patient #18's appropriateness for surgery. Subsequently, Patient #18 was taken to surgery and during intubation aspirated and sustained an anoxic brain injury. (See A941)

Based on clinical record reviews and interviews with facility personnel for one of eleven sampled patients (Patient # 18), the hospital failed to ensure the coordination of care and/or communication between departments of surgery, trauma and anesthesia in assessing Patient #18's appropriateness for surgery. Subsequently, Patient #18 was taken to surgery and during intubation aspirated and sustained an anoxic brain injury.

The findings include:

1. Patient #18 was admitted to the hospital on 6/25/09 following a motorcycle accident. Patient #18 sustained Stage IV and Stage V lacerations to the liver, spleen and kidney and multiple fractures. Review of the progress notes and nurses notes dated 6/25/09-6/29/09 identified that the patient was complaining of abdominal pain and distention. Review of the abdominal x-ray dated 6/29/09 identified that the patient had an ileus. Review of the progress notes dated 6/29-6/30/09 identified that the patient continued to complain of abdominal distention, bloating and belching. Further review identified that the trauma-surgical team was aware of the patient's current status and the plan was to watch the patient's abdominal exam and question whether the patient was to go to the operating room for hand surgery. Review of the progress note on 6/30/09 at 10:00am, identified that the patient had increased abdominal distention, increased shortness of breath, no bowel sounds with oxygen saturation levels at 88%. Patient #18's oxygen was increased to 4 liters and his oxygen levels increased to 92-94%. RN #13 reported the patient's status to the physician's assistant. Patient #18 went to the operating room at 12:46pm for a repair of a radial/ulnar fracture. Review of the clinical record failed to identify that an assessment of the patient was completed prior to surgery by the trauma or surgery service. Upon intubation, Patient #18 aspirated, cardiac arrested and sustained an anoxic brain injury. Patient #18 expired on 1/15/10. Review of hospital "medical staff code of conduct" identified that collaboration, communication and collegiality are essential elements for the provision of safe and competent patient care by the medical staff. Interview with PA #1 identified that she was aware that the patient was having medical issues and had reported it to the trauma team, however, the clinical record lacked evidence that the patient's symptoms were assessed and/or addressed by the medical staff. MD # 17(Anesthesia) and MD #18 (Orthopedics) identified that it was never communicated to them that the patient was having medical issues prior to surgery. MD #18 (Orthopedics) identified that the trauma service was responsible for the patient's care, however review of the progress notes dated 6/29/09 identified that the patient was on the surgical service team.
MD #19 (a trauma surgeon, unaffiliated with Hartford Hospital) identified upon interview and review of the clinical record on 2/4/11 that the patient was not appropriate for surgery at that time due to his unaddressed medical problems.

Based on clinical record reviews and interview with facility personnel for 4 of 11 sampled patients (Patients #107, #111, #112, #109), the facility failed to ensure that history and physicials were timed and/or updated prior to surgery.

The findings include:

1. Patient #107 was admitted to the hospital on 2/1/11 for a hernia repair. Review of the history and physical 1/4/11 identified that the document was not timed. In addition, further review identified that the history and physical was not updated prior to surgery. Review of hospital "Medical Staff Bylaws" identified that an updated medical record entry is documenting an examination for any changes in the patient's condition is placed in the patient's medical record within 24 hours after admission and always prior to surgery.

2. Patient #109 was admitted to the hospital on 2/1/11 for a right knee amputation. Review of the history and physical dated 2/1/11 identified that the document was not timed.

3. Patient #112 was admitted to the hospital on 2/1/11 for a robotic prostatectomy. Review of the history and physical dated 1/18/11 identified that the document was not timed.

4. Patient #111 was admitted to the hospital on 2/1/11 for lysis of adhesions. Review of the history and physicial dated 2/1/11 identified that the document was not timed. Review of the hospital "Documentation Policy" identified that all entries are to be complete, dated and timed.

Based on clinical record reviews and interviews with facility personnel for eight of twenty-one sampled patients (Patient #40, #41, #42, #44, #106, #107, #109 and #111), the facility failed to ensure that consent for surgeries were dated and timed.

The findings include:

1. Review of the clinical records for Patient's #40. #41, #42, #44, #106, #107, #109, and #111 failed to identify that the consent for surgery was dated and timed. Review of hospital policy " Informed Consent Policy " identified that consent forms are signed by the patient and responsible practitioner and should be dated and timed. Interview with the QI Coordinator (OR) on 11/30/10 identified that all consents are to be dated and timed.

Based on clinical record reviews and interviews with facility personnel for one of twenty-one sampled patients (Patient #112), the facility failed to ensure that an operative note was timed by the physician after a procedure.

The findings include:

1. Patient #112 was admitted to the hospital on 2/1/11 for a robotic prostatectomy. Review of the brief operative note dated 2/1/11 identified that the document was not timed after the procedure. Review of hospital "Documentation Policy" identified that all entries are to be complete, dated and timed.

THE CONDITION IS NOT MET:
Based on clinical record review and interviews with facility personnel for one of eleven sampled patients (Patient # 18), the hospital failed to ensure that the patient had a complete pre-anesthesia evaluation prior to surgery as evidenced by the lack of communication between the departments of surgery, trauma and anesthesia regarding the patient's current medical problems. Subsequently, Patient #18 was brought to surgery and sustained an anoxic brain injury during intubation. (See A102)

Based on clinical record review and interviews with facility personnel for one of eleven sampled patients (Patient # 18), the hospital failed to ensure that the patient had a complete pre-anesthesia evaluation prior to surgery.

1. Patient #18 was admitted to the hospital on 6/25/09 following a motorcycle accident. Patient #18 sustained Stage IV and Stage V lacerations to the liver, spleen and kidney and multiple fractures. Review of the progress notes and nurses notes dated 6/25/09-6/29/09 identified that the patient was complaining of abdominal pain and distention. Review of the abdominal x-ray dated 6/29/09 identified that the patient had an ileus. Review of the progress notes dated 6/29-6/30/09 identified that the patient continued to complain of abdominal distention, bloating and belching. Further review identified that the trauma-surgical team was aware of the patient's current status and the plan was to watch the patient's abdominal exam and question whether the patient was to go to the operating room for hand surgery. Review of the progress note on 6/30/09 at 10:00am, identified that the patient had increased abdominal distention, increased shortness of breath, no bowel sounds with oxygen saturation levels at 88%. Patient #18's oxygen was increased to 4 liters and his oxygen levels increased to 92-94%. Review of the anesthesia pre-assessment identified that although the pre-assessment was completed on 6/29/09, the pre-assessment failed to address the patient's current status. Patient #18 went to the operating room at 12:46pm without a complete assessment by anesthesia. Upon intubation, Patient #18 aspirated, cardiac arrested and sustained an anoxic brain injury. Review of hospital policy "pre-anesthesia assessment" identified that the pre-assessment evaluation includes assessing those aspects of the patient's condition that might affect decisions regarding perioperative risk/management and the patient's condition prior to surgery. Interview with MD # 17( anesthesia) identified that it was never communicated to him that the patient was having medical issues prior to surgery.