Bringing transparency to federal inspections
Tag No.: A0392
Based on interview, and review of hospital documents, the hospital failed to ensure adequately trained registered nurses for the post operative care of cardiovasular (open heart) surgical patients were available when a trained cardiovascular nurse was not available to work the 6 p.m. to 7 a.m. shift on 8/3/14, which resulted in the closure of the hospital cardiovascular operating room and cardiac catheterization laboratory.
Findings:
Cardiovascular surgery, "open heart" surgery means surgery on the heart or great vessels that requires opening the chest (thoracotomy) and extracorporeal circulation (a heart-lung bypass machine provides circulation while the heart is stopped and opened for a surgical procedure on the inner structure of the heart).
During an interview, on 8/11/14 at 1:25 p.m., the Risk Manager stated a registered nurse (RN), trained to recover cardiovascular surgery, (open heart surgery) patients, called a CV (cardiovascular) Nurse, was not available to work the 8/3/14 night shift, (6 p.m. to 7 a.m.). The Risk Manager stated after review of the situation, the Administrator On Call for 8/3/14, notified area hospitals and the Emergency Medical System, that the hospital was closing the cardiovascular operating room and the cardiac catheterization laboratory and diverting any patients with cardiovascular disorders to other facilities.
During an interview, on 8/11/14 at 3:30 p.m., the Chief Nursing Officer (CNO), stated she had been Administrator On Call on 8/2/14 and 8/3/14. The CNO stated the Intensive Care Unit (ICU) Assistant Manager, who did the staffing assignments for the ICU, notified her on 8/3/14 at approximately 10:30 a.m., that she was unable to find a trained CV Nurse to work the night shift (6 p.m. to 7 a.m.).
The CNO stated she could not take the risk of a patient needing a trained CV Nurse when one was not available. After discussion with the Hospital President and the Director of Cardiovascular Surgery, the CNO closed the CV operating room, as well as the cardiac catheterization (cath) lab, and potential cardiac surgery patients were diverted to other hospitals for a twelve hour period.
During an interview, on 8/12/14 at 3:45 p.m., the ICU Assistant Manager stated that the staffing schedule for the ICU was started six weeks in advance. The Assistant Manager stated that the hospital had three RNs that had achieved competency in the care of cardiovascular surgery patients. The Assistant Manager stated the ICU needed to schedule a CV nurse for every shift, every day, and in the past the CV nurses always had filled in as needed.
The Assistant Manager stated RN D had agreed to work on call on the night shift of 8/3/14, however RN D then worked several extra shifts the week prior and called himself off because he was too worn out to take call on 8/3/14. The Assistant Manager stated she texted RN D on 8/2/14 and spoke with him on 8/3/14, each time, RN D stated he could not work. The Assistant Manager stated stated she contacted the other CV nurses to see if either was available, however they were both out of the area.
The Assistant Manager stated she had informed the Nursing Supervisor on 8/2/14 and 8/3/14, of the lack of a trained CV nurse for the night shift on 8/3/14. The Assistant Manager stated the Nursing Supervisor had also called the other CV nurses but could not recruit anyone to cover the shift.
During an interview and concurrent record review, on 8/11/14 at 4:15 p.m., Intensive Care Unit (ICU) Director stated three ICU registered nurses had been trained in the immediate and ongoing post operative care of patients undergoing open heart surgery. The ICU Director stated one additional registered nurse was currently being trained, however the Director of Cardiovascular Surgery did not feel the new nurse was ready to take the lead in the care of a new open heart patient.
During an interview, on 8/13/14 at 10:30 a.m., Physician F stated the lack of a trained CV nurse was "simply burnout" of the existing staff. Physician F stated that the candidate pool was small for nurse recruitment due to the remoteness of the hospital and the limited number of jobs. Physician F stated he had been notified of the need to close the Cardiovascular Operating Room and the cath lab with which he agreed, stating, "...Need to keep the patients safe."
Tag No.: A0951
Based on interview, and review of hospital documents, the hospital failed to develop a policy to identify and define the process for closure of the cardiac catheterization laboratory. The lack of a hospital policy for when the cardiac catheterization laboratory might stay open or be closed could potentially allow a cardiac catheterization procedure that diagnosed the need for cardiovascular surgery without means of providing post operative care needs for the patient.
Findings:
Cardiovascular "open heart" surgery, means surgery on the heart or great vessels that requires opening the chest (thoracotomy) and extracorporeal circulation, (heart-lung bypass machine provides circulation while the heart is stopped and opened for a surgical procedure on the inner structure of the heart).
During an interview, on 8/11/14 at 1:25 p.m., the Risk Manager stated a registered nurse (RN), trained to recover open heart surgery patients, called a CV (cardiovascular) Nurse, was not available to work the 8/3/14 night shift (6 p.m. to 7 a.m.). The Risk Manager stated after review of the situation, the Administrator On Call for 8/3/14, notified area hospitals and the Emergency Medical System, that the hospital was closing the cardiovascular operating room and the cardiac catheterization laboratory (cath lab), diverting any patients with cardiovascular disorders to other facilities.
During an interview, on 8/11/14 at 3:30 p.m., the Chief Nursing Officer, (CNO), stated she had been Administrator On Call on 8/2/14 and 8/3/14. The CNO stated the Intensive Care Unit Assistant Manager, who did the staffing assignments for the Intensive Care Unit, (ICU), notified her on 8/3/14 at approximately 10 a.m., that she was unable to find a trained CV Nurse to work the night shift (6 p.m. to 7 a.m.).
The CNO stated she could not take the risk of a patient needing a trained CV Nurse to care for a post operative cardiovascular patient, when one was not available. After discussion with the Hospital President and the Director of Cardiovascular Surgery, the CNO closed the Cardiovascular operating room, as well as the cardiac catheterization lab, (cath lab), and potential cardiovascular surgery patients were diverted to other hospitals
During an interview on 8/13/14 at 10 a.m., the Intensive Care Unit Director, stated that cardiac catheterization could have been done on the 8/3/14 night shift, however if the findings of the cardiac catheterization were critical and the patient required immediate surgery, the hospital could not have provided the necessary care required for an open heart patient post operatively without a trained CV Nurse.
During interview on 8/13/14 at 11:30 a.m., the Hospital President indicated he thought the cardiac cath lab could possibly have been kept open to perform only certain cath lab procedures as was done in other states, but did not specify how patient needs would be met if the cardiac cath indicated the need for immediate cardiovascular surgery.
The hospital provided a policy titled, "EMTALA (Emergency Medical Treatment and Labor Act)-Screening, Stabilization, and Transfer ...with Emergency Medical Conditions, All Departments and Locations", when asked for the hospital diversion policy. The policy defined Diversionary Status as, "The hospital does not have the the staff ...to accept any additional emergency patients." No policy was available that addressed the closure of the cath lab.
During an interview on 8/13/14 at 10:15 a.m., the Area Director of Quality and the CNO discussed the need for a hospital policy that addressed closure of the cardiac catheterization laboratory. While some diagnostic cardiac catheterizations might have been performed without the availability of the CV operating room, and the trained nurse to care for the patient postoperatively, those studies were not defined, a process had not been determined, and the specific State requirements required to maintain a cath lab without a cardiovascular operating room had not been addressed.