HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 (Pt. #1) patient records reviewed for adverse events, the Hospital failed to implement preventive actions and mechanisms that include feedback and learning throughout the Hospital after a serious patient safety event was identified.

Findings include:

1. On 3/9/2022, the Hospital's policy titled, "Patient Safety Event Reporting/Sentinel & Never Event Management (revised by the Hospital September 2020) was reviewed. The policy required, " ...3. In response to Patient Safety Events which do not meet the definition of a Sentinel Event, a root cause analysis (RCA) investigation or other form of analysis will be conducted and an action plan may be identified within 45 business days of an event or becoming aware of an event ..."

2. On 3/9/2022, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 12/8/2022 with the diagnoses of intractable nausea and vomiting, gross abnormality of electrolytes. Pt. #1 was admitted to 3 north (Medical-Surgical and Telemetry unit).

-The discharge summary dated 12/18/2021 at 2:40 PM, authored by the Attending Physician (MD #1), included, " ...Admitting diagnosis: gastric outlet obstruction - Discharge diagnosis: poorly differentiated gastric adenocarcinoma ...Hospital Course ...presented to ED [emergency department] for daily n/v [nausea and vomiting] for 3 months with severe electrolyte derangements ...Gastric outlet obstruction secondary to dx [diagnosis] poorly diff [differentiated] gastric adenocarcinoma ...CT [computed tomography], Abdo [abdomen] and pelvis w/ [with] contrast 12/8/:Findings concerning for malignancy, showing nodular thickening of mid distal stomach, extensive lymphadenopathy, and gastric outlet obstruction ...EGD [esophagogastroduodenoscopy] done 12/13 showing friable [easy to crumble] gastric mass obstructing antrum w/ malignant stricture at pylorus [valve in stomach ...Pathology report: poorly differentiated carcinoma ...performed diagnostic lap [laparoscopy - procedure to check abdominal organs] with lap GJ [gastrostomy-jejunostomy tube in stomach] and R IJ [right internal jugular] portacath [implanted central line] placement ...Discharge disposition: home ..."

-The inpatient nursing progress note dated 12/18/2021 at 8:04 PM, authored by a Registered Nurse (E #2), included, "Pt [Pt. #1] kept saying she want to go home, and notify MD [Medical Doctor] ...Paged on-call team Dr ...put discharge order. Provide discharge education to Pt, and remove IV [intravenous line] and tele [telemetry/heart monitor] box at 1910 [7:10 PM], Pt [Pt. #1] walked out to the hallway with saying her family is waiting for her at the lob[b] y. Asked Pt [Pt. #1] if she needs wheelchair but Pt [Pt #1] said, she can walk to the lob[b]y."

-The Emergency Department history and physical dated 12/18/21 at 7:54 PM, included, " ...found with a bystander in the front of the hospital. Patient [Pt. #1] did not have a pulse at that time ...code blue was code in the ...lobby. A resident from the general surgery team recognized the patient [Pt. #1] has someone that was recently seen in the hospital for gastric outlet obstruction ...recently discharged from hospital who was found pulseless in the parking lot outside the hospital, unknown downtime. No pulse/respirations or signs of trauma. CPR [cardiopulmonary resuscitation] initiated in parking lot and patient transported to ER [emergency room]. Multiple episodes of bloody emesis...ongoing resuscitation ...rhythm PEA [pulseless electrical activity]. Time of death called at 1950 [7:50 PM]. Pupils fixed and dilated, no heart/lung sounds auscultated, no spontaneous breath sounds, no pulse ...Family notified at 2005 [8:05 PM] ...provided additional history that patient was discharged from hospital earlier this evening and was waiting outside for her [Pt. #1] ride. Her [Pt. #1] ride ...found the patient foaming on the ground and called the patient's daughter ...Family was aware of the patient's recent cancer diagnosis ...Cardiopulmonary arrest ..."

3. On 3/9/2022, the post event huddle template dated 12/20/21 at 1:18 PM, was reviewed. The template identified that Pt. #1 was discharged from the unit with no escort to the lobby. The template also identified that Pt. #1 was discharged with a hemoglobin of 7.0, trending down from 7.9 and 7.5, with no caregiver interventions documented. The template included, that the Hospital's next steps: peer review related to the hemoglobin of 7.0, handoff communication between doctors and nurses on the hemoglobin and how these types of situation should be escalated beyond physicians, and from a safety perspective, all patients should be escorted by a caregiver. The template lacked dates that the steps would be implemented and if they were implemented.

4. On 3/9/2022, the Situation, Background, Assessment, and Recommendation (SBAR) dated 12/21/2021 was reviewed. The SBAR included, " ...Situation ...Health System will ensure the safety of patients throughout the care continuum. A safe discharge should be an expectation of all patients at ...Health System. Background ...Patient who have been recently hospitalized or who have undergone procedures and testing may be at risk for falls and other adverse events due to their treatment, medications, or their underlying health condition. Assessment ...All patients discharging from a ...Health System facility should be accompanied by a ...caregiver or other professional personnel (i.e. ambulance, Medicar, etc.). The patient should be accompanied until they have safely exited the ...facility. Recommendation ...Nursing and clinical leaders should review this SBAR with their respective caregivers and ensure compliance with this safety expectation." The SBAR lacked documentation if and when the changes would be implemented.

5. The Hospital did not provide a root cause analysis during the survey.

6. On 3/9/2022 at 3:10 PM, during an observational tour of 3 North (medical- surgical, telemetry), an interview was conducted with the Charge Nurse (E#5). E#5 stated that when a patient is ready for discharge, they will be offered to be escorted to the lobby/exit via wheelchair. E#5 stated that if the patient refuses a wheelchair, most of the time the patients will just go down the elevator to the lobby on their own (unaccompanied). E#5 was not aware of any changes to the process of escorting patients to the lobby/parking lot upon discharge. E#5 stated that the normal range for hemoglobin is between 11-15, anything below that will be brought to the attending physician's attention. E#5 stated that if the hemoglobin falls below 7, that is typically when a blood transfusion will be ordered.

7. On 3/9/2022 at 2:34 PM, an interview was conducted with the 3 North (medical-surgical and telemetry unit) Nurse Manager (E #3). E #3 stated that Pt. #1 was not escorted to the lobby upon discharge. E #3 stated that the Hospital does not have a policy/procedure/protocol or guideline for escorting patients to the lobby upon discharge. E #3 stated that there have not be any changes implemented since the incident with Pt. #1 on 12/18/2021.

7. On 3/9/2022 at 3:03 PM, an interview was conducted with the Manager of Quality and Patient Safety and Quality Improvement (E #7). E #7 stated that she is not sure if a root cause analysis was conducted related to Pt. #1's incident on 12/18/2021. E #7 stated that a post event huddle is completed following an event and a root cause analysis is completed if it is determined that the Hospital needs to dig deeper into the issue.

8. On 3/10/2022 at 9:12 AM, an interview was conducted with the Executive Director of Quality (E #1). E #1 stated that the incident with Pt. #1 on 12/18/2021, was considered a serious patient safety event and not a sentinel event. E #1 stated that a root cause analysis was not conducted. E#1 stated that the peer review for Pt. #1's Physician was referred on December 21, 2021, but has not yet been completed..