HospitalInspections.org

Based on the Medical Staff Bylaws, Medical Staff Rules and Regulations, policy and procedures, medical record, and interview, the Department failed to require the surgeon updated the History and Physical (H&P) to include the abnormal EKG, and abnormal stress test, before the start of surgery on Patient #1.

Findings include:

The Medical Staff Bylaws requires, "...Responsibilities: ...To develop and maintain Bylaws and policies consistent with sound professional practices, and to enforce compliance with them...."

The policy, "Pre-operative Patient Care" requires, "...Scan tests results and paperwork brought in by patient...Place all the following on the chart prior to surgery...Results of all diagnostic studies, i.e., EKG, Lab, Radiology, etc...."

The Medical Staff Rules Regulations requires, "...All History and Physical reports...must be updated...prior to surgery...shall include...patient's current medical status that may hove changed since the prior H&P or to address any areas where more current data is needed...."

Patient #1 presented to the Pre-Operative (pre-op) area on 05/19/10, at 0515, for a planned laparoscopic sigmoid resection, with a possible ostomy, due to having diverticulosis.

The Surgeon's pre-operative order's written on 04/29/10, (prior to surgery) include, "...EKG (electrocardiogram)...."

The EKG report from 02/08/10, was in the medical record, and indicated the EKG test was abnormal.

The H&P (surgeon's office notes) dated 04/27/10, revealed, "...(patient) with follow up consultation regarding diverticulosis... asked to followup for elective colon resection...presents today to discuss elective colon resection for diverticulosis having completed preoperative colonoscopy...denies any symptoms... wants to proceed with surgery. Review of systems otherwise negative."

The surgeon updated the H&P with "No changes" on 5/19/10.

The surgeon did not include the abnormal EKG results in updating H&P.

The surgeon's operative report on 05/19/10, revealed, "... Per patient report, he also was seen by cardiology and had a recent normal stress test that we found out about only after asking him about his abnormal ekg (electrocardiogram). We were able to compare it to his previous ekg from a few months ago and it was stable. We reviewed the cardiology note from the previous visit and they indicated no further inpatient workup given the lack of symptoms. Furthermore, he stated
that he ran about 2 miles daily without symptoms. We expressed the importance of the normal stress test and he again confirmed it. Anesthesia agreed with proceeding with surgery as planned but I had the preop RN obtain the report for our records and asked them to bring it to us in the OR (operating room)...

Intraoperatively we were given a report of the patient's stress test that was actually abnormal. The patient had stated that he had followed up and was told that he had a normal stress test. With these findings, we immediately called his wife and the cardiologist. His wife again stated on speaker phone and able to be heard by the entire operating room that she was told that he had a normal stress test by her husband but she did not actually go to the appointment with him...

We spoke with the patient's cardiologist who said that he failed to follow up. They checked the records and again confirmed the abnormal stress test results and stated that he would need further workup before being cleared for surgery and therefore we decided to abort the procedure...given the abnormal stress test, we had the patient be seen by cardiology post-operatively and they cleared him for discharge home with close follow-up. "

The surgeon did not ensure a copy of the abnormal stress test was in medical record.

The surgeon did not ensure the updated H&P included the abnormal stress test.

On 04/20/11, the Director of Quality Assurance confirmed the surgeon did not update the History and Physical to included the abnormal EKG results and the abnormal Stress test results.

Based on a review of the policies and procedures, medical records, and interview, it was determined the RN did not:

1) notify the physician of Patient #3's injury;

2) update the physician on Patient #5's condition prior to being discharged; and

3) complete an incident report on Patient #3.

Finding include:

1) The policy, "Incident Reporting, serious and Sentinel Event Reporting" requires: "...Incidents that results in accidental injury to a patient...Notify the attending physician...."

Patient #3 arrived to the Emergency department (ED) on 11/04/09, at 1721, via ambulance after a friend called 911. The patient found unconscious and had taken an unknown amount of Clonazepam.

A completed "Application for Involuntary Evaluation" (a petition), was submitted and accepted on the behalf of Patient #3, since the patient needed to be treated for psychiatric conditions. Once the facility accepts the petition, the determination by the psychiatrist and judge requires the Hospital to hold and protect the patient until they are transferred to UPC (Urgent Psychiatric Center).

Patient #3 attempted twice to leave the facility, security was called after the second attempt. Security had applied restraints at 1325, after receiving a doctor's order.

The nursing notes on 11/06/09 at 1059, revealed: "talked with patient about her rights during this petitioned admission to hospital. Pt calmed down...Patient says she sustained wounds from being restrained, documented neck abrasion and left wrist bruise...."

On 03/07/11, the Director of the ED reviewed the medical record, and confirmed the RN did not document notifying the physician.

2) The policy, "Discharge - Inpatient" requires: "...To notify the physician...if a change in condition is detected or if the patient develops new symptoms. Delay discharge until physician ...is informed and confirms discharge...."

The following is Patient #5's oral intake during hospitalization:

On 07/20/10, at 0700, 120 cubic centimeters (cc) (1/2 cup).
On 07/20/10, at 1100, 240 cc
On 07/20/10, at 2100, 400 cc

On 07/21/10, at 0600, 220 cc
On 07/21/10, at 0700, 60 cc
On 07/21/10, at 2300, 120 cc

On 07/22/10, at 0800, 0 cc

The following is Patient #5's meal intake during hospitalization:

On 07/20/10, at 0700, 100%
On 07/20/10, at 1100, 100 %
On 07/20/10, at 2100, 40%

On 07/21/10, at 0700, 0%
On 07/21/10, at 1500, 0%

On 07/22/10, at 0800, 0%

The physician's order on 07/22/10 at 1116, reveals, "Discharge To 'Other'."

The physician's Admission orders (for psychiatric facility) on 07/22/10, had the patient's diet as regular, with regular consistency. No mention patient has refused meals and has only taken 400 cc of fluid in last 24 hours.

The physician's admission orders did not include any IV fluids, only oral medications.

The only documented notification by the nurses to the doctor was on 07/21/10, at 1146, " Notify (doctor), as patient's family would like to talk to him," and on 07/21/10, at 1155, "Physician called back and is on-site (to) visit."

On 03/07/11, the Director of QM confirmed the nursing staff did not notify the doctor of the change in condition to include Patient #5's not taking any fluids by mouth since 2300, on 07/21/10 (approximately 18 hours before discharge), or that the patient has not eaten since 2100, on 07/20/10 (2 days before discharge).

3) The policy, "Incident Reporting, serious and Sentinel Event Reporting" requires: "...any employee...becomes aware of a patient...incident is responsible for reporting the incident...Access electronic incident report via...of Internet...enter incident...information... submit the incident (report)...."

Patient #3 attempted twice to leave the facility, security was called after the second attempt, and restraints were applied at 1325, by security, after receiving a doctor's order.

The nursing notes on 11/06/09 at 1059, revealed: "talked with patient about her rights during this petitioned admission to hospital. Pt calmed down...Patient says she sustained wounds from being restrained, documented neck abrasion and left wrist bruise...."

On 03/07/11, the Director of QM confirmed no incident report was completed on Patient #5, regarding the injury sustained during the initiation of the restraints, and an incident report should have been completed.