HospitalInspections.org

A. Based on clinical record review and staff interview, it was determined that for 1 of 10 (Pt. #1) records reviewed, the Hospital failed to ensure a timely follow up was conducted after notification of deterioration of a patient's condition.

Findings include:

1. The clinical record of Pt. #1 was reviewed on 4/11/11, at approximately 10:00 AM. Pt. #1 was a 47 year old female admitted on 9/10/10 with diagnoses of Respiratory Failure, Cardiomyopathy, Pulmonary Fibrosis, Coronary Artery Disease, Hypertension, Hypothyroidism, and Acute Renal Failure on dialysis. Pt. #1 was on a ventilator with the following ordered settings: Tidal Volume- 400, Rate- 10, PEEP (positive end-expiratory pressure) - 5, pressure support - 16 and, FIO2 - 30%.

On 10/26/10, at 7:40 AM, Pt. #1 complained of shortness of breath and the FIO2 was increased to 50 %. Oxygen saturation remained in the mid 80's and the FIO2 was increased to 60 at 10:35 AM, to 80 at 11:50 AM, and 100 at 12:25 PM. The RT note indicated that a physician (pulmonary services) was notified of the FIO2 changes at 11:50 AM. The record lacked documentation of a follow up by a physician related to the increase in the oxygen level requirement until approximately 11:00 PM on 10/26/10.

2. The above findings were discussed with the VP of Patient Care Services on 4/14/10 at approximately 2:45 PM during an interview.