HospitalInspections.org

Based on staff interview, medical record and document review, the hospital failed to meet a clinical need for 2 of 3 sampled patients (Patients 2, 17) when:

1. There was no evidence of the application of a sequential compression device [intermittently-inflating sleeves placed on the legs to help prevent blood clot formation] for approximately 16 hours after the physician order was written for Patient 2 on 6/14/13, and

2. There was no evidence a sepsis screen or systems assessment had been done on Patient 17 when she presented to Labor and Delivery for an obstetrical (OB) check (an assessment to rule out labor) on 6/15/13.

The failure to ensure patient needs are met by ongoing assessments and treatment resulted in the potential for complications related to the medical/obstetrical conditions of Patients 2 and 17.

Findings:

1. Patient 2 was an 88 year-old ordered for admission to the Medical-Surgical Acute Care (MSAC) Unit at 11:41 p.m., 6/14/13 with a fracture of the hip joint socket. According to RN 2, the patient had arrived on the unit "by 4 a.m.," 6/15/13. Review of Patient 2's clinical record showed a 5:03 a.m., 6/15/13 physician admission order for a sequential compression device (SCD). Application of the SCD was not documented in the record as "on" until the hour between 9:00 - 9:59 p.m., 6/15/13.

In a 2:45 p.m., 6/19/13 interview, RN 2 stated SCDs ordered on admission "should be applied within two hours."

Review of the hospital's 12/09 "Admission and Discharge Processes" policy indicated, "Admitting orders are noted and activated within the first two hours of admission...Computerized order entry facilitates rapid communication with ancillary service departments and execution of diagnostic and therapeutic measures."

2. Patient 17, a 26 year old, with a pregnancy at term (40 weeks), presented to Labor and Delivery on 6/15/13 at 9:51 a.m. for a labor check. Patient 17 stated she had had irregular contractions since the prior day. Patient 17 was observed for several hours during which time the fetal (baby) heart rate was noted to be regular and the fetus active. At 12:25 p.m., Patient 17 was discharged undelivered after it was determined she was not in active labor.

In review of the medical record, there was no evidence Patient 17 had been initially screened for sepsis (a severe infection of the blood that can be life threatening). There was no evidence Patient 17's temperature was taken during the stay for the OB check. Patient 17's heart rate was noted to be 110 at the time of admission and consistently elevated throughout the stay. There was no evidence a systems assessment had been completed, including evaluation of heart and chest sounds.

In an interview with the Director of Quality (DQ) on 6/20/13 at 10:30 a.m., she acknowledged Patient 17's medical record showed no evidence of completion of the Maternal Assessment of Sepsis, a form used to screen all OB patients for suspected or confirmed infection, during an OB check on 6/15/13. The DQ also stated there was no evidence Patient 17's temperature had been taken during this approximately three hour stay. The DQ stated the obstetrical service has been performing a sepsis screen on all OB patients who present to Labor & Delivery as part of the initial assessment. The DQ stated this was a regional initiative and there was no written protocol for this at this time.

In review of a policy titled Labor Management Policy, revised 5/12, admission assessment criteria included: "b. Maternal Blood Pressure, Temperature, pulse, respirations and Pain assessment".

In review of a policy titled Obstetric Medical Screening Exam Standardized Procedure, revised 9/12, in a section titled Screening Exam Elements, there was direction to assess "Body system(s) and signs/symptoms specific to chief complaint/history" within 20 minutes of arrival. With an elevated heart rate this would have included, at a minimum, the evaluation of heart and lung sounds.

Based on interview and document review, the hospital failed to ensure clinical records were completed within 30 days of discharge for 39 of 740 patients discharged between 4/15/13 - 5/15/13.

Findings:

During an 8:26 a.m., 6/20/13 interview, the Health Information Management Director (HIMD) presented documentation indicating discharge summaries for 39 of 740 patients discharged between 4/15/13 - 5/15/13 had not been completed within 30 days following discharge. She articulated that "CMS [Centers for Medicare and Medicaid Services] [regulation] is 30 days" but added hospital policy and State requirements called for discharge summary completion within 14 days.

Review of the hospital's 2012 medical staff "Rules and Regulations" reflected, "The discharge summary must be completed within fourteen (14) days after the patient's discharge for all patients hospitalized over forty-eight (48) hours, except for normal obstetrical deliveries, normal newborn infants."